rmhp-13-733.pdf

O R I G I N A L R E S E A R C H

Psychological Distress Amongst Health Workers

and the General Public During the COVID-19

Pandemic in Saudi ArabiaThis article was published in the following Dove Press journal:

Risk Management and Healthcare Policy

Mohammed Khaled

Al-Hanawi1

Martin Limbikani Mwale2

Noor Alshareef1

Ameerah MN Qattan1

Khadijah Angawi1

Rasha Almubark3,4

Omar Alsharqi1

1Department of Health Services and

Hospital Administration, Faculty of

Economics and Administration, King

Abdulaziz University, Jeddah 80200, Saudi

Arabia; 2Department of Economics,

Faculty of Economic and Management

Sciences, University of Stellenbosch,

Cape Town, South Africa; 3Research and

Studies Department, Saudi Food and

Drug Authority, Riyadh, Saudi Arabia;4Sharik Association for Health Research,

Riyadh, Saudi Arabia

Background: The rapid spread of COVID-19 worldwide has confined millions of people to

their homes and has caused a substantial degree of psychological distress. This study aims to

investigate the psychological distress impact of the COVID-19 pandemic among the Saudi

population.

Methods: This is a cross-sectional study, using data collected from 3036 participants via an

online self-reported questionnaire. The psychological distress was constructed using the

COVID-19 Peritraumatic Distress Index to classify individuals in the sample as having

normal, mild or severe distress levels. The study used descriptive analysis and multinomial

logistic regressions to examine the sociodemographic factors associated with psychological

distress levels during the COVID-19 pandemic.

Results: The evidence showed that 40% of the Saudi population are distressed due to

COVID-19, of whom approximately 33% are mildly distressed, while 7% are severely

distressed. The distress levels are particularly high amongst the young, females, private

sector employees and health workers, especially those working on the frontline.

Conclusion: The COVID-19 pandemic is associated with increased distress amongst people

living in Saudi Arabia. In support of evidence found in other countries, the study has

established that the distress levels vary across different sociodemographic characteristics.

Therefore, limiting people’s psychological damage demands both medium- and long-term

policy strategies, which include mapping the rates of stress and anxiety for effective

psychological treatment allocation and establishing innovative online methods of heightening

people’s mental wellbeing.

Keywords: COVID-19, distress, health workers, psychological, public, Saudi Arabia

IntroductionCoronavirus disease 2019 (COVID-19) is a respiratory syndrome, amongst a larger

family of ribonucleic acid (RNA) viruses, that has infected humans, causing

unprecedented numbers of deaths and substantial psychological distress across the

globe.1–3 COVID-19 emerged in Wuhan, China at the end of 2019 and spread to

other countries, leading the World Health Organisation (WHO) to declare COVID-

19 a global health emergency of international concern. The WHO emphasised the

importance of compliance with infection control standards.4 Not only were the

obvious practices of hygiene and use of hygiene equipment, such as facemasks,

important but, also, limiting personal contact through social distancing became the

gold standard.5,6

Correspondence: Mohammed KhaledAl-HanawiDepartment of Health Services andHospital Administration, Faculty ofEconomics and Administration, KingAbdulaziz University, Jeddah 80200, SaudiArabiaEmail [email protected]

Risk Management and Healthcare Policy Dovepressopen access to scientific and medical research

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In response, several countries have implemented decisive

measures to contain the spread of the disease, which include

the imposition of nationwide lockdowns. China was the first

country to implement a successful lockdown to prevent the

further spread of COVID-19.7 Notwithstanding the resultant

mitigation of the pandemic in China, there has been

a deterioration in most Chinese residents’ psychological

wellbeing under the lockdown.8–10 The adverse psychologi-

cal impact includes acute stress disorder, insomnia, post-

traumatic symptoms and depression.11 Moreover, recent

evidence reveals that 35% of the Chinese population were

psychologically distressed.12

The distress caused by COVID-19 is arguably not

limited to China because the factors that could lead to

this psychological state are common. For instance, the

knowledge of coronavirus biology and transmission is

still limited, which increases panic due to the uncertainty

of its spread.7 In addition, there is a global absence of

a vaccine to control COVID-19, leading to unrest about its

containment.13 Moreover, globalisation and increased

access to information in the current era make such worry-

ing insights relating to uncertainty easily transferable,

causing increased psychological distress, including fear

and anxiety, amongst the general public.14–16

The WHO issued a COVID-19 guideline on mental

health and psychological distress in an effort to support

people’s mental and psychological wellbeing during this

outbreak.2 Nevertheless, empirical evidence on the distri-

bution of psychological distress across the public due to

COVID-19 remains sparse. Therefore, this study aims to

investigate the impact of COVID-19 on the psychological

wellbeing among Saudi adults amid the unprecedented

lockdown. Preventive measures, such as lockdown, disrupt

normal life activities, which could generate boredom and

stress. Moreover, the limited access to outdoor leisure,

combined with the uncertainty of an effective remedy to

contain the pandemic, could increase distress. However,

these potential negative effects could generate different

levels of distress conditional on people’s sociodemo-

graphic characteristics. For instance, the demand for out-

door activities could be different between older people and

the young, while fears relating to the lack of available

treatment for the pandemic could also differ depending

on whether one works in healthcare services or not.

These issues demand adequate attention and, therefore,

the study also examines the association between different

sociodemographic characteristics and psychological

distress due to COVID-19 using data from the Kingdom

of Saudi Arabia (KSA).

KSA has become a compelling case in understanding

how COVID-19 has caused psychological distress

amongst health workers and the general public for the

following reasons. First, KSA currently has the largest

confirmed number of cases in the Arabian Gulf countries,

which means that the likelihood of pressure on the health

system and fear of infection, which could cause distress,

remain high. Second, despite the potential for increased

psychological distress in KSA, no study has been con-

ducted to identify the groups that might be suffering the

most in terms of distress due to the pandemic. Third, the

Arabian Gulf region has specific unique characteristics,

such as a natural resource-financed health system,17 that

would necessitate that the public health response to

COVID-19 be different from the rest of the world, hence

the demand for special academic attention. Finally, as the

Arabian Gulf countries have similar backgrounds, culture

and religion and are facing similar challenges, this study

on KSA could inform policy design to mitigate COVID-19

related distress in the entire region.

Materials and MethodsStudy Design and SampleThis study uses data from a cross-sectional survey that was

conducted in Saudi Arabia from 3 May to 8 May 2020,

using a validated self-reported survey. The survey used the

COVID-19 Peritraumatic Distress Index (CPDI) self-

reported questionnaire that was originally employed by

a study in China to survey peritraumatic psychological

distress during the epidemic.12 The Shanghai Mental

Health Centre verified the content validity of the CPDI

as fit to be used in collecting the COVID-19 distress

information. The questionnaire is originally in English.

R.A and A.M.N.Q translated the questions into Arabic,

while M.K.A and O.A translated it back to English to

ensure that the translation preserved the meaning captured

by the original English version. The survey then used the

Arabic text to administer the study.

Data were collected online, using SurveyMonkey, tar-

geting individuals living in KSA. A link to the survey was

distributed to respondents via social media, such as Twitter

and WhatsApp groups. The link was also posted on the

King Abdulaziz University website. Online informed con-

sents were obtained before proceeding with the questions.

The informed consent provided two options of “yes”, for

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those who volunteered to partcipate in the study, and “no”,

for those who did not wish to participate. Only those who

selected the affirmative response and confirmed that they

were above the age of 18 years were taken to the ques-

tionnaire page to complete the survey. The respondents

were clearly informed about the study’s aim and objectives

and that they were free to withdraw at any time, without

giving a reason, and that all information and opinions

provided would be anonymous and confidential.

Measurement Tool and Data AnalysisThe questionnaire consisted of two main sections. The first

section gathered information on the respondents’ socio-

demographic characteristics, including age, gender, marital

status, education level, nationality, work status, whether

the participants are health workers and, if so, whether they

were working on the frontline to face the new coronavirus

pandemic. The second section collected information on

self-perceived psychological distress in relation to the

COVID outbreak.

Dependent Variable (Psychological

Distress Assessment)In this paper, psychological distress is defined as an unplea-

sant feeling or emotion that affects a human being’s general

functioning and could induce negative feelings of self, others

and the environment.18 Participants were asked to respond to

24 questions that had five scaled responses to assess their

psychological distress and the responses were used to con-

struct a CPDI. The responses to these questions include 0 =

never, 1 = occasionally, 2 = sometimes, 3 = often and 4 =

most of the time. The questions included those on the fre-

quency of anxiety, depression, specific phobias, cognitive

change, avoidance and compulsive behaviour, physical

symptoms and loss of social functioning since the appearance

of the COVID-19 pandemic. These questions encompass the

diagnostic guidelines for stress disorders and phobias speci-

fied in the International Classification of Diseases, 11th

Revision.12

To construct the CPDI, we summed the codes of the

responses of the 24 questions, meaning that the respon-

dents’ scores could range from 0 to 96. A base count of

4 was added to all respondents to enable the maximum of

the standard 100 for a CPDI. The addition of the base,

which was also done in a recent study on the effects of

COVID-19 on distress in China,12 allows our results to be

compared to previous studies that used 100 by increasing

the base without changing the gradient of the effects. The

CPDI was then classified to obtain the levels of distress, as

follows: a CPDI score between 0 and 28 indicates normal

levels, a CPDI score between 29 and 52 indicates that the

participant is mildly distressed and a CPDI score between

53 and 100 means that the respondent is severely dis-

tressed. Items were evaluated for internal reliability,

using Cronbach’s α. The Cronbach’s alpha coefficientwas 0.91 (p<0.001), indicating internal reliability.19

Independent VariablesFor the sociodemographic variables, the age variable was

divided into categories: 18 to 29 (reference category), 30 to

39, 40 to 49, 50 to 59 and 60 or above. Gender was coded as

a dummy variable with 1 for male and 0 for female. Marital

status was captured as binary and a value of 1 was used for

married and 0 for otherwise. Education was categorised into

high school or below (reference category), college/univer-

sity degree and postgraduate degree. Nationality was coded

as a dummy variable, with 1 for Saudi national and 0 for

non-Saudi. Work status was divided into categories includ-

ing government employee (reference category), private sec-

tor employee, retiree, self-employed, student and

unemployed. Health worker was coded as a dummy vari-

able with 1 if the respondent is a health worker and 0 for

otherwise. Frontline health worker against COVID-19 was

also coded as 1 for participants who were frontline health

workers and 0 for otherwise.

Statistical AnalysisDescriptive statistics were used to analyse the general data.

The respondents’ characteristics were classified by their

psychological distress through the three distress categories

and their mean and percentage composition presented per

distress group. The study used a statistical model corrected

for multiple comparisons by the Bonferroni procedure,

which divides the 0.05 p-value by the number of compar-

isons to minimise type 1 errors.20 The method allows us to

present the statistically significant differences across the

three distress categories with respective p-values depicted.

Multinomial logistic regressions were used with CPDI

as the dependent variable to examine the factors associated

with normal, mild and severe distress due to COVID-19,

while the sociodemographic characteristics are the inde-

pendent variables. The CPDI is coded with three groups –1

for normal distress (reference category), 2 for mild distress

and 3 for severe distress. Since the logistic coefficients are

composite numbers, we obtained the marginal effects

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using the first derivative method and all the results pre-

sented in the paper are the actual probabilities. Knowing

that the degree of exposure to COVID-19 could generate

variations in the distress levels, the study, besides present-

ing the full sample probabilities, includes a subsample

analysis that looks only at health workers. All analyses

were conducted using STATA 15.1 software (StataCorp

LP, Texas, USA).

Ethical ApprovalAll procedures performed in this study involving human

participants complied with the institutional and/or national

research committee ethical standards and the 1964 Helsinki

declaration, and subsequent amendments, or equivalent ethi-

cal standards. The study was designed and conducted in

accordance with the ethical principles established by King

Abdulaziz University and, therefore, ethical approval was

obtained from the Biomedical Ethics Research Committee,

Faculty of Medicine, King Abdulaziz University (Ref-

228-20).

ResultsSociodemographic Characteristics and

Distress LevelTable 1 shows the results of the descriptive analysis. In

total, 3036 participants, including 950 (31.35%) health

workers, of which 449 (14.8%) were frontline health

workers, with the remaining 2086 (68.7%) being the gen-

eral public, participated in the study from the 13 adminis-

trative regions in KSA. Of the participants, 30.9% were

aged between 18 and 29 years, 50.1% were males and

62.7% were married. In terms of education, 26% of the

participants were educated at the high school level or

below, while 54.3% had completed college or university

degrees and 19.6% had completed a postgraduate degree.

The distress distribution across the entire sample shows

that, of the 3036 individuals, 1819 (59.9%) were normal,

999 (32.9%) were mildly distressed and 218 (7.2%) were

severely distressed. Amongst health workers, the propor-

tion of respondents as a percentage of the total sample

increased as we moved from normal (28.9%), through

mild (33.7%), to severe (39.9%) distress. The result is

statistically significant (p<0.01), which provides prelimin-

ary evidence that health workers are at greater risk of

psychological distress relative to non-health workers.

A similar statistically significant trend is observed for

frontline health workers, with the percentage growing

from normal (13.4%), through mild (15.5%), to severe

(24.3%) distress.

Furthermore, there are no statistical differences in dis-

tress levels for people in the age range of 18 to 29, while

those between 30 and 39 years have a statistically signifi-

cant increased trend in the percentage of people as we

move from normal (35.8%), through mild (38.6%), to

severe distress (46.8%). On the contrary, the age group

40 to 49 has a decreasing trend in the level of distress from

normal (23.4%), through mild (18.1%), to severe (13,3%).

Those between the ages of 50 and 59 follow, with

a decreasing distress incidence of 9.8%, 7% and 6% for

normal, mild and severe distress, respectively. People aged

60 or above also show a decreasing trend, from 3.1% to

2.6% to 0.9% for normal, mild and severe distress levels,

respectively. The age distress statistics reveal that the

young, and particularly those between 30 and 39, face

the largest psychological distress risk as a result of

COVID-19. At the same time, older people are at the

lowest risk for this mental disturbance.

Across gender, males show a decreasing trend from

normal (53.2%), through mild (45.0%) to severe (42.2%)

distress levels. On the contrary, females show an increas-

ing trend from normal (46.8%), through mild (55%) to

severe (57.8%) distress, with the results illustrating that

the largest distress burden falls on females relative to

males. There are no statistical differences in distress trends

across education and nationality. Concerning employment

status, only the retired, with a trend of 5.2% normal, 3%

mild and 2.3% severe distress, and the self-employed, with

a trend of 4.3% normal, 3.6% mild and 1.8% severe

distress, become statistically significant.

The Analysis of Distress LevelsTable 2 presents the marginal effects of the multinomial

logistic regression results for the entire sample. The pre-

sented estimates, therefore, are the probabilities of belong-

ing to a particular CPDI level. Being a health worker is

significantly associated with an increased probability of

being mildly distressed by 0.041 and that of being severely

distressed by 0.028. Across ages, there is a significant

reduction in the probability of 40 to 49 year olds being

mildly and severely distressed by 0.078 and 0.032, respec-

tively, while those in the age range of 50–59 associate with

only a reduction in mild distress by 0.082. As these

cohorts are compared to a reference group of the young,

between the ages of 18 to 29, the evidence concurs with

what was observed in the sociodemographic descriptive

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analysis that older people are less susceptible to distress

relative to younger people.

Amongst these people, males are less likely to be

mildly distressed by 0.063 and less severely distressed by

0.023 indicating that the reference category, female, is at

a greater risk of being distressed. With regard to employ-

ment status, only private sector employees are more likely

to be mildly distressed, by 0.059, relative to the omitted

category of government sector employees. All the other

employment categories are not significantly different in

their susceptibility to distress in comparison to the govern-

ment sector employees. The education variable shows that

only postgraduates relate to a 0.029 reduction in the prob-

ability of being severely distressed, in relation to the

comparison group of the high school or below education

level. The results also show that nationality does not

matter in terms of distress caused by the pandemic.

The results also revealed that, amongst all social demo-

graphic characteristics, only age particularly that of 40 to

49, gender, people with postgraduate qualifications and

Table 1 Sociodemographic Characteristics and Distress Levels

Total Normal Mild Severe P-value

Overall 3036 1819(59.9) 999(32.9) 218(7.2)

Health worker

Yes 950(31.3) 526(28.9) 337(33.7) 87(39.9) 0.007***

No 2086(68.7) 1293(71.1) 662(66.3) 131(60.1) 0.007***

Frontline health worker

Yes 449(14.8) 244(13.4) 155(15.5) 53(24.3) 0.001***

No 2587(85.2) 1575(86.6) 844(84.5) 165(75.7) 0.001***

Age

18 to 29 938(30.9) 508(27.9) 336(33.6) 72(33) 0.328

30 to 39 1129(37.2) 651(35.8) 386(38.6) 102(46.8) 0.005***

40 to 49 625(20.6) 426(23.4) 181(18.1) 29(13.3) 0.001***

50 to 59 261(8.6) 178(9.8) 70(7.0) 13(6) 0.061*

≥ 60 82(2.7) 56(3.1) 26(2.6) 2(0.9) 0.038**

Gender

Male 1521(50.1) 968(53.2) 450(45.0) 92(42.2) 0.015**

Female 1515(49.9) 851(46.8) 549(55.0) 126(57.8) 0.015**

Marital status

Married 1904(62.7) 1161(63.8) 610(61.1) 135(61.9) 0.754

Unmarried 1132(37.3) 658(36.2) 389(38.9) 83(38.1) 0.754

Education

High school education or below 789(26.0) 460(25.3) 267(26.7) 61(28) 0.480

College/University degree 1651(54.3) 990(54.4) 540(54.1) 123(56.4) 0.547

Postgraduate degree 596(19.6) 369(20.3) 192(19.2) 34(15.6) 0.108

Nationality

Saudi 2836(93.4) 1704(93.7) 924(92.5) 204(93.6) 0.932

Non Saudi 200(6.6) 115(6.3) 75(7.5) 14(6.4) 0.932

Employment status

Government sector employee 1354(44.6) 839(46.1) 418(41.8) 95(43.6) 0.704

Private sector employee 498(16.4) 273(15) 185(18.5) 39(17.9) 0.524

Retiree 131(4.3) 95(5.2) 30(3.0) 5(2.3) 0.025**

Self-employed 118(3.9) 78(4.3) 36(3.6) 4(1.8) 0.052*

Student 431(14.2) 240(13.2) 155(15.5) 36(16.5) 0.334

Unemployed 504(16.6) 295(16.2) 175(17.5) 39(17.9) 0.627

Notes: Percentages in parentheses. ***p<0.01, **p<0.05, *p<0.1.

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health workers significantly relate to the severely dis-

tressed category. Furthermore, being a health worker has

the highest probability (0.028) of being severely distressed

with the highest level of significance (p<0.01) relative to

the rest in the group. Moreover, the descriptive statistics in

Table 2 revealed that health workers have an increasing

trend of distress, from mild to severe, relative to non-

health workers and, therefore, health workers could be at

relatively higher risk of distress compared to the rest of the

population. The result warrants further investigation into

the different characteristics of health workers that correlate

with the various levels of distress. The study interrogated

these health worker correlates of distress by examining the

relationship between sociodemographic variables and dis-

tress amongst only health workers and the results are

presented in Table 3.

Table 3 presents the estimates of the sample for health

workers. Knowing that not all health workers are working

in close contact with the COVID-19 infected, a variable

that separates ordinary health workers and frontline work-

ers is included in the analysis as these two groups could

have different levels of distress due to their variations in

exposure to the pandemic. Column (1) shows that being

frontline health worker increases the probability of severe

distress, by 0.049. Health workers who are between the

ages of 30 to 39 are less likely to be mildly distressed, by

0.074, while those between the ages of 40 to 49 are less

susceptible to mild distress by 0.154. In addition, those in

the age range of 50 to 59 have a reduced probability, by

0.263, of being mildly distressed. The age output reveals

that, relative to the reference category of 18 to 29 years

old, older people are less likely to be distressed.

Furthermore, male health workers are less likely to be

severely distressed, by 0.046, while students are the only

employment category less likely to be mildly distressed,

by 0.113. The results reveal that, amongst health workers,

education and nationality do not correlate with distress due

to COVID-19.

DiscussionKSA reported its first case of COVID-19 on 2 March 2020

and, by 14 May 2020, the number was at 44,830, which was

the highest in the Arabian Gulf states. Throughout the

history of emerging pandemics, it has been documented

that there is a strong association between a pandemic

event and individuals’ psychological distress. Several stu-

dies have investigated the impact of pandemics on psycho-

logical distress. The evidence dates back to the 1918

Spanish Flu pandemic, which resulted in psychiatric

complications.21 With the surge in the prevalence of

COVID-19, and the quarantine restrictions, anxiety and

stress levels rise.22 Thus, this study attempts to understand

the impact of COVID-19 on the psychological distress

among the Saudi population during the pandemic.

Understanding this impact is central in crafting effective

Table 2 The Marginal Effects of SociodemographicCharacteristics on Distress

Dependent Variable: CPDI (1) (2) (3)

Normal Mild Severe

Health worker −0.069*** 0.041** 0.028***

(0.020) (0.019) (0.010)

30 to 39 years 0.021 −0.033 0.012

(0.027) (0.026) (0.014)

40 to 49 years 0.110*** −0.078** −0.032*

(0.032) (0.031) (0.018)

50 to 59 years 0.107*** −0.082** −0.026

(0.041) (0.040) (0.024)

≥ 60 years 0.056 0.017 −0.073

(0.072) (0.068) (0.054)

Male 0.086*** −0.063*** −0.023**

(0.020) (0.019) (0.011)

Married −0.048** 0.032 0.016

(0.022) (0.022) (0.012)

College/University degree 0.030 −0.022 −0.008

(0.022) (0.021) (0.011)

Postgraduate degree 0.042 −0.013 −0.029*

(0.028) (0.027) (0.016)

Saudi national 0.034 −0.034 −0.000

(0.036) (0.034) (0.019)

Private sector employee −0.067** 0.059** 0.008

(0.027) (0.026) (0.014)

Retiree 0.075 −0.077 0.002

(0.059) (0.058) (0.036)

Self-employed 0.041 0.003 −0.044

(0.050) (0.047) (0.035)

Student −0.017 0.007 0.009

(0.036) (0.035) (0.019)

Unemployed 0.002 −0.000 −0.001

(0.030) (0.029) (0.016)

Observations 3036 3036 3036

Notes: Standard errors in parentheses. ***p<0.01, **p<0.05, *p<0.1.

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policy responses to safeguard the population’s psychologi-

cal wellbeing amidst the COVID-19 public health crisis.

The study found that about 40% of the KSA population

had psychological distress. This result is analogous to the

40% found in Italy,20 and close to that found in France,

which was that 38% of the public are distressed due to

COVID-19.23 Iran has found that 59% of its population is

distressed due to the pandemic,24 which is higher than has

been found in this study. Therefore, this study’s findings

reveal that KSA has similar levels of COVID-19 distress

as some countries, while remaining lower when compared

to other countries, such as Iran.

Nevertheless, KSA’s COVID-19 level of distress is, on

average, high considering the proactive early pandemic

control measures that KSA undertook in comparison to

Italy and France, who had less time to prepare and imple-

ment effective measures. Hence, psychological distress

remains one of the significant health problems in KSA

during the pandemic.25 Moreover, there is a particular

concern because certain groups were found to be more

affected than others in this study. Across the entire sample

of the KSA population, the results showed that health

workers have an increased probability of becoming both

mildly and severely distressed, due to COVID-19, com-

pared to the rest of the population. These health practi-

tioners are working in close contact with the people

affected by the pandemic and, hence, are highly exposed

to the risk of contracting the disease from their patients.26

Not only are the health workers distressed due to fear of

infection but, also, the increased number of patients in

healthcare facilities due to the pandemic has amplified

the caseload per health worker and number of working

hours.27

Across the age groups, the study found that older

people are relatively less stressed compared with young

people. This result supports similar evidence found in

China.28 The reason behind this could be that older people

can manage their stress due to better knowledge about the

pandemic relative to the young.29 Another explanation

could be that younger people experience the highest men-

tal distress due to COVID-19 because of their high expo-

sure to social media,30 which transmits a large amount of

information about the pandemic, some of which is neces-

sary, while some are disturbing. Previous evidence from

KSA substantiates this finding by showing that the young,

particularly those in undergraduate college levels, experi-

ence high distress due to internet addiction.31 Moreover,

a study in Pakistan found that 82.8% of the population

identified the internet as a major source of the panic that is

generated about COVID-19 fears.32 Furthermore, the

young also happen to be the group involved in the most

outdoor activities, such as attending sports events that

have been banned under lockdown due to the pandemic.

As such, the young people need to adapt to new indoor

ways of living that could be generating boredom and

Table 3 The Marginal Effects of the SociodemographicCharacteristics on Distress Amongst Health Workers

Dependent Variable: CPDI (1) (2) (3)

Normal Mild Severe

Frontline health worker −0.017 −0.033 0.049**

(0.033) (0.032) (0.020)

30 to 39 0.062 −0.074* 0.011

(0.048) (0.045) (0.028)

40 to 49 0.165*** −0.154*** −0.012

(0.058) (0.056) (0.035)

50 to 59 0.275*** −0.263*** −0.012

(0.089) (0.090) (0.052)

≥ 60 0.036 −0.033 −0.003

(0.153) (0.145) (0.095)

Male 0.067* −0.021 −0.046**

(0.035) (0.034) (0.021)

Married −0.000 −0.035 0.035

(0.039) (0.037) (0.023)

College/University degree 0.048 −0.048 0.000

(0.042) (0.040) (0.024)

Postgraduate degree 0.071 −0.044 −0.027

(0.048) (0.046) (0.029)

Saudi national 0.038 −0.034 −0.005

(0.063) (0.060) (0.036)

Private sector employee −0.074 0.064 0.009

(0.050) (0.047) (0.028)

Retiree 0.052 −0.028 −0.024

(0.145) (0.146) (0.094)

Self-employed 0.699 0.463 −1.162

(43.395) (29.108) (72.503)

Student 0.117* −0.113* −0.004

(0.065) (0.062) (0.039)

Unemployed −0.004 0.003 0.000

(0.068) (0.065) (0.038)

Observations 950 950 950

Notes: Standard errors in parentheses. ***p<0.01, **p<0.05, *p<0.1.

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frustration. Moreover, previous evidence has revealed that

prolonged quarantine restrictions generate fear and

anxiety.33

Females were more susceptible to distress relative to

males. Similarly, recent studies in China and Italy that

assessed psychological distress post the COVID-19 outbreak

found that females were more likely to develop psychologi-

cal distress, while males are less susceptible to post-traumatic

distress in responding to stressful outbreaks.12,20 This finding

could be attributed to gender differences in the hormonal

response to stress.34 Young, Korszun35 substantiate this evi-

dence that female hormones amplify the magnitude of stress

responses within this group.

Private sector employees were found to be more dis-

tressed relative to government sector workers, which could

be due to the variations in employment sector benefits in

KSA. The government sector has greater job security rela-

tive to the private sector.36 In the event that the total econ-

omy lockdowns implemented due to the pandemic lead to

loss of business, especially for non-essential services, pri-

vate sector employees could lose their jobs, which is not the

case for government employees, who have secure jobs

relative to private sector workers. Therefore, it is not very

surprising that private sector workers are more distressed

than their public sector counterparts.

In the sample of health workers, the study found simi-

lar results to those of the full sample that older people and

males are less likely to be distressed relative to the young

and females, respectively. An additional result is that,

amongst the health workers, frontline health workers face

increased chances of severe distress relative to the rest of

the health workers, which is consistent with the findings

from Italy.20 Being the first-hand attendants of the pan-

demic in the health system exposes them to the largest risk

of contracting the virus. As such, it is not surprising that

their fears and psychological breakdowns are greater than

the general public. However, the results showed that,

amongst the health workers, students are less likely to be

distressed. In KSA, students who are also health workers

are those in their final year of their studies and are con-

ducting internships. Since the lockdown in KSA, interns,

together with other scholars, were asked to suspend les-

sons, which included their work. Hence, this action

reduced their exposure to the pandemic and relieved

them of their duties relative to the full-time employees in

the health sector, which makes the students less likely to

be distressed.

These results have implications for policy. Cases of

psychological distress have been on the increase due to

abrupt changes in lifestyle, such as school lockdowns and

curfews. In China, these invasive actions were disruptive

to people’s lives.12 The resultant negative psychological

impact of COVID-19 mitigation measures demand policy

interventions to prevent the worsening of distress among

Saudi Arabians. Thus, adequate research was needed to

explore the measure of the pandemic’s psychological

effects on the community and the affected groups of

people.37 The research findings of this paper will help in

establishing both immediate actions and long-term strate-

gic plans in managing psychological distress.

In the medium term, there is a need to improve monitor-

ing and reporting of anxiety rates, depression and self-harm,

especially amongst the highly affected groups such as health-

care workers and the younger population. The information

will assist in targeting appropriate medical interventions to

help the affected individuals.37 In addition, it is necessary to

map the already existent psychological support and resources

to be used in both treatment of and prevention of such effects.

In the long term, the government needs to invest in identify-

ing the root causes of the high rates of distress and anxiety

amongst the already implemented COVD-19 prevention

measures. In addition, there is a need to develop novel inter-

ventions that safeguard people’s mental wellbeing, such as

promoting prosocial behaviour, altruism and embracing psy-

chosocial heightening online activities.37

Study LimitationsThe study is not without its limitations. First, by using an

online questionnaire, the study selects a population that has

access to the internet, which might affect its sample’s repre-

sentativeness. Nevertheless, the study received data that

encompassed all the regions of the kingdom, which might

reduce the problem with regard to geographical coverage. Of

course, the authors acknowledge that the technological selec-

tivity and the unreliability of self-administered questionnaire

issues are not completely settled. However, the online survey

is the best possible case with the current need to maximise

social distance under COVID-19 mitigation. Second, as the

study uses cross-sectional data, it could not control for unob-

served heterogeneity across the respondents. Therefore, the

estimates should be interpreted with caution, as associations

and not implying causation. Future research could perform

a follow-up on our sample once the pandemic is over to form

panel data and control for time-invariant unobserved

heterogeneity.

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DovePressRisk Management and Healthcare Policy 2020:13740

ConclusionThe COVID-19 pandemic has brought about unprecedented

changes in human lives, which could lead to serious psy-

chological distress if disregarded. Limiting such distress,

therefore, relies on identifying the groups of people that are

at the highest risk due to the pandemic. This study examined

the factors that are associated with psychological distress

during the COVID-19 pandemic in Saudi Arabia using

cross-sectional data obtained from an online survey. The

online survey has been useful as we are in the heat of the

pandemic, where the traditional physical surveys are not

allowed to prevent the spread of the virus. The study used

descriptive analysis and logistical regressions to understand

the important sociodemographic variables related to post-

COVID-19 distress. The findings showed that being

a health worker, a frontline health worker, a young person,

a female and a private sector employee are related to dis-

tress in KSA. The study further argues that increased efforts

in raising the public awareness of COVID-19 and providing

supportive psychological programs and verified social net-

works, in both the immediate and long term, remain vital in

mitigating the psychological distress amongst the affected

Saudis. The results from KSA can be applied in designing

policy response for the post-traumatic psychological disor-

ders not only in KSA but also in the other Arabian Gulf

countries that have similar backgrounds, culture and reli-

gion and are facing similar challenges.

Data Sharing StatementThe datasets generated and/or analysed during the current

study are not publicly available due to privacy and con-

fidentiality agreements as well as other restrictions, but are

available from the corresponding author (MKA) on rea-

sonable request.

Author ContributionsAll authors made substantial contributions to conception

and design, acquisition of data, or analysis and interpreta-

tion of data; took part in drafting the article or revising it

critically for important intellectual content; gave final

approval of the version to be published; and agree to be

accountable for all aspects of the work.

FundingThis project was funded by the Deanship of Scientific

Research (DSR) at King Abdulaziz University, Jeddah,

under grant no. GCV19-8-1441. The funders had no role

in study design, data collection and analysis, decision to

publish, or preparation of the manuscript. The authors,

therefore, acknowledge with thanks DSR for technical

and financial support.

DisclosureThe authors declare no conflicts of interest.

References1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients

with pneumonia in China, 2019. N Engl J Med. 2020;382:727–733.doi:10.1056/NEJMoa2001017

2. WHO. Mental health and psychosocial considerations during theCOVID-19 outbreak; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf.Accessed May 9, 2020.

3. Suresh V. The 2019 novel corona virus outbreak–An institutional guide-line. Indian J Anaesth. 2020;64(3):242. doi:10.4103/ija.IJA_104_20

4. WHO. WHO timeline – COVID-19; 2020. Available from: https://www.who.int/news-room/detail/27-04-2020-who-timeline—covid-19. Accessed May 09, 2020.

5. Ramesh N, Siddaiah A, Joseph B. Tackling corona virus disease 2019(COVID 19) in workplaces. Indian J Occup Environ Med. 2020;24(1):16. doi:10.4103/ijoem.IJOEM_49_20

6. Cirrincione L, Plescia F, Ledda C, et al. COVID-19 pandemic: pre-vention and protection measures to be adopted at the workplace.Sustainability. 2020;12(9):3603. doi:10.3390/su12093603

7. Lau H, Khosrawipour V, Kocbach P, et al. The positive impact oflockdown in Wuhan on containing the COVID-19 outbreak in China.J Travel Med. 2020;27. doi:10.1093/jtm/taaa037

8. Brodeur A, Clark AE, Fleche S, Powdthavee N. Assessing the impactof the coronavirus lockdown on unhappiness, loneliness, and bore-dom using Google Trends. arXiv Preprint arXiv:200412129. 2020.

9. Zhang J, Lu H, Zeng H, et al. The differential psychological distressof populations affected by the COVID-19 pandemic. Brain BehavImmun. 2020;87:49–50. doi:10.1016/j.bbi.2020.04.031

10. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreakof COVID-19 coronavirus and its impact on global mental health. Int J SocPsychiatr. 2020;66(4):317–320. doi:10.1177/0020764020915212

11. Brooks SK, Webster RK, Smith LE, et al. The psychological impactof quarantine and how to reduce it: rapid review of the evidence.Lancet. 2020;395:912–920. doi:10.1016/S0140-6736(20)30460-8

12. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide surveyof psychological distress among Chinese people in the COVID-19epidemic: implications and policy recommendations. Gen Psychiatr.2020;33(2):e100213. doi:10.1136/gpsych-2020-100213

13. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R.Features, evaluation and treatment coronavirus (COVID-19). In:Statpearls [Internet]. StatPearls Publishing; 2020.

14. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM.Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan:mental health consequences and target populations. Psychiatr ClinNeurosci. 2020;74(4):281. doi:10.1111/pcn.12988

15. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: addressmental health care to empower society. Lancet. 2020;395(10224):e37–e38. doi:10.1016/S0140-6736(20)30309-3

16. Sood S. Psychological effects of the Coronavirus disease-2019pandemic. Res Human Med Educ. 2020;7:23–26.

17. Al-Hanawi MK, Alsharqi O, Almazrou S, Vaidya K. Healthcarefinance in the Kingdom of Saudi Arabia: a qualitative study ofhouseholders’ attitudes. Appl Health Econ Health Policy. 2018;16(1):55–64. doi:10.1007/s40258-017-0353-7

Dovepress Al-Hanawi et al

Risk Management and Healthcare Policy 2020:13submit your manuscript | www.dovepress.com

DovePress741

18. Arvidsdotter T, Marklund B, Kylén S, Taft C, Ekman I. Understandingpersons with psychological distress in primary health care. ScandJ Caring Sci. 2016;30(4):687–694. doi:10.1111/scs.12289

19. Fetters L, Tilson J. Evidence Based Physical Therapy. FA Davis;2018.

20. Moccia L, Janiri D, Pepe M, et al. Affective temperament, attachmentstyle, and the psychological impact of the COVID-19 outbreak: anearly report on the Italian general population. Brain Behav Immun.2020;87:75–79. doi:10.1016/j.bbi.2020.04.048

21. Menninger KA. Psychoses associated with influenza: i. general data:statistical analysis. J Am Med Assoc. 1919;72(4):235–241. doi:10.1001/jama.1919.02610040001001

22. Fardin MA. COVID-19 and anxiety: a review of psychologicalimpacts of infectious disease outbreaks. Arch Clin Infect Dis.2020;15(COVID–19):e102779. doi:10.5812/archcid.102779

23. Chaix B, Delamon G, Guillemasse A, Brouard B, Bibault J-E.Psychological distress during the COVID-19 pandemic in France:a national assessment of at-risk populations. medRxiv. 2020.

24. Jahanshahi AA, Dinani MM, Madavani AN, Li J, Zhang SX. Thedistress of Iranian adults during the Covid-19 pandemic–More dis-tressed than the Chinese and with different predictors. Brain BehavImmun. 2020;87:124–125. doi:10.1016/j.bbi.2020.04.081

25. Barry M, Ghonem L, Alsharidi A, et al. Coronavirus disease-2019pandemic in the Kingdom of Saudi Arabia: mitigation measures andhospital preparedness. J Nat Sci Med. 2020;2.

26. Lu W, Wang H, Lin Y, Li L. Psychological status of medical work-force during the COVID-19 pandemic: a cross-sectional study.Psychiatry Res. 2020;288:112936. doi:10.1016/j.psychres.2020.112936

27. Verma S, Mythily S, Chan Y, Deslypere J, Teo E, Chong S. Post-SARS psychological morbidity and stigma among general practi-tioners and traditional Chinese medicine practitioners in Singapore.Ann Acad Med Singapore. 2004;33(6):743–748.

28. Guo Q, Zheng Y, Shi J, et al. Immediate psychological distress inquarantined patients with COVID-19 and its association with periph-eral inflammation: a mixed-method study. Brain Behav Immun. 2020.doi:10.1016/j.bbi.2020.05.038

29. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, attitudeand practice toward COVID-19 among the public in the Kingdom ofSaudi Arabia: a cross-sectional study. Front Public Health.2020;8:217. doi:10.3389/fpubh.2020.00217

30. Cheng C, Jun H, Liang B. Psychological health diathesis assessmentsystem: a nationwide survey of resilient trait scale for Chinese adults.Stud Psychol Behav. 2014;12:735–742.

31. Hasan AA-H, Jaber AA. Prevalence of internet addiction, its associa-tion with psychological distress, coping strategies among undergrad-uate students. Nurse Educ Today. 2019;81:78–82. doi:10.1016/j.nedt.2019.07.004

32. Balkhi F, Nasir A, Zehra A, Riaz R. Psychological and behavioralresponse to the coronavirus (COVID-19) pandemic. Cureus. 2020;12(5).

33. Taghrir MH, Akbarialiabad H, Marzaleh MA. Efficacy of massquarantine as leverage of health system governance duringCOVID-19 outbreak: a mini policy review. Arch Iran Med. 2020;23(4):265–267. doi:10.34172/aim.2020.08

34. Sareen J, Erickson J, Medved MI, et al. Risk factors for post-injurymental health problems. Depress Anxiety. 2013;30(4):321–327.doi:10.1002/da.22077

35. Young E, Korszun A. Sex, trauma, stress hormones and depression.Mol Psychiatry. 2010;15(1):23–28. doi:10.1038/mp.2009.94

36. Alkhamis A, Cosgrove P, Mohamed G, Hassan A. The personal andworkplace characteristics of uninsured expatriate males in Saudi Arabia.BMC Health Serv Res. 2017;17(1):56. doi:10.1186/s12913-017-1985-x

37. Holmes EA, O’Connor RC, Perry VH, et al. Multidisciplinaryresearch priorities for the COVID-19 pandemic: a call for action formental health science. Lancet Psychiatr. 2020;7(6):547–560.doi:10.1016/S2215-0366(20)30168-1

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