Assessing mental health status among Iranian healthcare workers in times of the COVID‐19 pandemic: A web‐based cross‐sectional study

Abstract Objectives The present study was conducted to assess 3(HCWs) during the COVID‐19 pandemic. Methods A total number of 7626 HCWs were included in this web‐based cross‐sectional study, via the convenience sampling technique. To collect the required data, the sociodemographic characteristics information form, the Depression Anxiety Stress Scale‐21 (DASS‐21), and the Corona Disease Anxiety Scale (CDAS) were also employed. In addition, data analysis was performed using the SPSS Statistics software (ver. 24), as well as descriptive statistics, Chi‐square test (χ2 ), and univariate/multivariate logistic regression models. Results The CDAS results revealed that 47.9% and 70.5% of the HCWs had experienced moderate levels of physical and psychological anxiety, respectively. Based on the DASS results, 44.8%, 43%, and 34.8% of the HCWs had been subjected to depression, anxiety, and stress symptoms during the COVID‐19 pandemic, respectively. The logistic regression models correspondingly showed that depression among the HCWs was significantly correlated with risk factors, such as the age groups of 20–30 years (p = .001), 31–40 years (p = .006), female HCWs (p> .001), history of physical illnesses (p = .004), and history of psychiatric disorders (p> .001). Moreover, factors including the age groups of 20–30 years (p < .001), 31–40 years (p < .001), 41–50 years (p < .001), female HCWs (p> .001), history of physical illnesses (p < .001), and history of psychiatric disorders (p>.001) were assumed as significant predictors of anxiety in these individuals. Besides, factors such as the age groups of 20–30 years (p = .002), 31–40 years (p = .004), female HCWs (p>.001), occupation (p = .016), history of physical illnesses (p < .001), and history of psychiatric disorders (p> .001) could significantly predict the prevalence rate of stress in the HCWs in times of this crisis. Conclusion Given the importance of mental health status among HCWs during the COVID‐19 pandemic, health administrators and policymakers of the Ministry of Health and Medical Education in Iran are suggested to provide psychological screening and supportive care programs for HCWs with the aim of enhancing their mental health and successful coping with critical circumstances.

(p = .001), 31-40 years (p = .006), female HCWs (p> .001), history of physical illnesses (p = .004), and history of psychiatric disorders (p> .001). Moreover, factors including the age groups of 20-30 years (p < .001), 31-40 years (p < .001), 41-50 years (p < .001), female HCWs (p> .001), history of physical illnesses (p < .001), and history of psychiatric disorders (p>.001) were assumed as significant predictors of anxiety in these individuals. Besides, factors such as the age groups of 20-30 years (p = .002), 31-40 years (p = .004), female HCWs (p>.001), occupation (p = .016), history of physical illnesses (p < .001), and history of psychiatric disorders (p> .001) could significantly predict the prevalence rate of stress in the HCWs in times of this crisis. China (Hall, 2020;Vindegaard & Benros, 2020). The rapid spread of the disease, the delayed onset of its symptoms, as well as the high asymptomatic carriers of this condition correspondingly transformed this disease into the main challenge facing healthcare systems worldwide (Hall, 2020;Li et al., 2020;. The World Health Organization (WHO) introduced COVID-19 as a public health emergency of international concern (Hall, 2020; Mohindra et al., 2020;Wong et al., 2020 Healthcare workers (HCWs) are vital resources in each country whose health and safety are crucial not only for providing continuous and effective care services to patients, but also keeping health warning situations, such as outbreaks under control .
Although HCWs are responsible for patient care during the COVID-19 pandemic, they are playing against numerous health concerns, such as personal protective equipment shortages, fear of mortality and morbidity caused by COVID-19, fear of infection for themselves and its transmission to family members, along with loss of coworkers due to this condition (Chew et al., 2020;Galbraith et al., 2020;Walton et al., 2020). These risk factors have potentially increased the possibility of occurrence of short-and long-term mental health problems, including depressive symptoms, anxiety, insomnia, and grief, as well as the development of post-traumatic stress disorders among these individuals (Galbraith et al., 2020;Hall, 2020;Muller et al., 2020;Shechter et al., 2020). The WHO has further put emphasis on the extremely high burden of the pandemic on different aspects of HCWs' well-being and has even called for taking the necessary actions to address their immediate needs to save their lives and to prevent a serious impact on their physical and mental health status (World Health Organization, 2020).
The prevalence of mental health problems among HCWs during the COVID-19 pandemic has been so far investigated in several studies worldwide (Gold, 2020;Hall, 2020;Lu et al., 2020;Shechter et al., 2020). In a survey on frontline HCWs in China, 50% of these individuals had levels of depression, 45% of them were suffering from anxiety, and 34% of the cases had experienced insomnia in times of this crisis (Lai et al., 2020

Instruments and data collection
The Persian version of the questionnaires was completed using an online platform, developed by Sadra Rayaneh Novin Tabarestan Engineering Co., based in Mazandaran provinces, Iran (http://psych. mazandums.ir). After designing, the web-based questionnaires were checked by this study researchers regarding its correction and then self-report web-based questionnaires were distributed via the cyberspace, including popular messaging apps, that is, WhatsApp, Telegram, Instagram, and Short Message Service among HCW groups that working in the different therapeutic settings during COVID-19 pandemic. The time for filling the questionnaires by participants was considered approximately 15-20 min. These web-based questionnaires were distributed among different groups of HCWs and they also distributed them among other groups they knew. On the first page of the online questionnaire, researchers wrote a text for participants regarding the research title and aim of this study, the confidentiality of their information and identity. Also, they explained briefly the questionnaires content and the methods of responding to the questions. Only those questionnaires were considered filled that participants filled them until the end-stage based on the instruction of the designed questionnaire. The corresponding author of this study had a username and password for checking the numbers of filled questionnaires.
In this study, three main instruments were also completed by the participants, namely, the sociodemographic characteristics informa-

Sociodemographic characteristics information form
The sociodemographic characteristics of the participants included gender, age, marital status, place of living, level of education, field of study, working position, years of work experience, history of mental and physical problems, number of children, working units (i.e., inpatient or outpatient care wards), as well as some items about the COVID-19 pandemic, evaluated in this study.

Depression Anxiety Stress Scale-21
The DASS-21, as the shortened version of the DASS-42, was developed by Lovibond et al. to assess the symptoms of depression, anxiety, and stress among adults (Le et al., 2017) in clinical or nonclinical settings (Musa et al., 2007). The DASS-21 was a self-report measure by which the participants could rate the frequency and the severity of their experiences of negative emotions over the past week on a four-point Likert-type scale from 0, which meant "did not apply to me at all," to 3 denoting "applied to me very much or most of the time." Overall, in each subscale, the score could range from 0 to 63 and the greater the score, the higher the severity of depression, anxiety, and stress (Asghari et al., 2008;Norton, 2007). Scoring for the depression subscale was also divided into 0-9 representing normal mental health status (namely, without depressive symptoms), 10-13 showing mild depressive symptoms, 14-20 standing for moderate depressive symptoms, 21-27 denoting severe depressive symptoms, and ≥28 considered as extremely severe symptoms. In terms of rating the anxiety subscale, scores 0-7 were categorized as normal mental health status (viz. without anxiety), scores 8-9 referring to mild anxiety, and the scores of 10-14, 15-19, and ≥28 implying moderate, severe, and extremely severe anxiety among participants, respectively. Moreover, the stress subscale was scored as follows, 0-14 representing normal or without stress, scores 15-18 showing mild stress, and scores 19-25, 26-33, and ≥34 denoting moderate, severe, and extremely severe stress, respectively. The internal consistency of this scale had been estimated to be good-to-excellent (Antony et al., 1998). The psychometric properties of the Malaysian version of this questionnaire had further shown its appropriate Cronbach's alpha values of 0.84, 0.74, and 0.79, respectively, for depression, anxiety, and stress (Musa et al., 2007). In another study, the reliability of this scale in the subscales of depression, anxiety, and stress had been approved with Cronbach's alpha values of 0.82, 0.90, and 0.93, respectively (Henry & Crawford, 2005). Based on the results of a study in Iran, the reliability of this instrument had been reported by 0.86, 0.76, and 0.79 for the three subscales of depression, anxiety, and stress, respectively (Jafari et al., 2017).

Corona Disease Anxiety Scale
The CDAS, designed and validated by Alipour et al., was to measure the prevalence of anxiety caused by the COVID-19 pandemic. This scale included 18 items and two subscales of psychological and physical symptoms scored on a four-point Likert-type scale from 0 meaning never or no anxiety to 3 representing always with anxiety. The total score of this scale also ranged from 0 to 54. In the subscale of psychological symptoms, scores 0-5, 6-19, and 20-27 were considered as mild, moderate, and severe psychological symptoms, respectively. As well, physical symptoms scored 0-1 showed no or mild symptoms, 2-9 indicated moderate symptoms, and 10-27 reflected severe physical symptoms. The higher scores on this questionnaire could suggest the higher level of anxiety. The reliability of this scale had been measured using the Cronbach's alpha coefficient for the first factor (α = 0.879), the second factor (α = 0.861), and the whole questionnaire (α = 0.919) (Alipour et al., 2020).

Statistical analysis
Data analysis in this study was performed using the SPSS Statistics software (ver. 24) (SPSS Inc., IBM Corp., USA). To identify the missing data, they were also checked and cleaned before analysis. To describe the quantitative variables, descriptive analyses, such as mean± standard deviation (SD), were employed. Moreover, frequency and percentage were applied to explain the qualitative variables. The prevalence rates of depression, anxiety, and stress caused by COVID-19 were correspondingly reported and the Chi-square test (χ 2 ) was utilized to compare between-group differences. Univariate/multivariate logistic regression models were further used to explore the potential predictors of anxiety in times of this crisis. p-values less than .05 were also considered statistically significant.

Sociodemographic characteristics of participants
The sociodemographic characteristics of HCWs are presented in Table 1. A total number of 7626 HCWs were accordingly included in this study and the results revealed that most of the participants (56.2%) aged 20-30 years and approximately two-thirds (73.2%) of them were females. More than half of the participants were also married and 64.7% of the cases had no children. Nearly, 70% of the HCWs were holding Bachelor's degrees and nurses were the most frequent individuals participating in this study. Within the first 2 months of the COVID-19 pandemic, nearly 45% of the participants had been working in isolation wards related to inpatient COVID-19 patients. Among different settings involved with COVID-19, more than 50% of the HCWs had been working in hospitals and 40% of them had worked 4-8 h/day in contact with COVID-19. Among the participants, 19.6% and 8.4% of them, respectively, had history of physical illnesses and psychiatric disorders based on their self-report.

Prevalence of anxiety based on the CDAS
The CDAS results are given in Tables 2 and 3. According to the CDAS, the prevalence of physical and psychological anxiety symptoms was assessed among the HCWs and the results showed that most of the participants (47.9%) had experienced moderate physical anxiety symptoms and also more than 70% of them had suffered from moderate psychological anxiety symptoms. The results also demonstrated that anxiety caused by COVID-19 was significantly correlated with gender (p < .001), age (p < .001), marital status (p = .005), level of education (p = .001), occupation (p < .001), working in isolation wards (p = .014), working units (p < .001), working hours with COVID-19 patients (p < .001), history of physical illnesses (p < .001), and history of psychiatric disorders (p < .001).

Prevalence of depression, anxiety, and stress based on the DASS-21
The DASS-21 results are listed in Tables 2 and 4. In this regard, 44.8% of the HCWs had experienced levels of depression during this pandemic and most of them had reported moderate depression (15.4%). In addition, depression was significantly correlated with age (p < .001), gender (p < .001), marital status (p< .001), having children (p < .001), level of education (p = .006), occupation (p = .020), working hours with COVID-19 patients (p = .022), history of physical illnesses (p < .001), and history of psychiatric disorders (p < .001).

3.4
Logistic regression models for predictors of depression, anxiety, and stress in HCWs during COVID-19 pandemic The predictors of depression, anxiety, and stress among the HCWs are shown in Table 5. In this regard, the multivariate logistic regression indicated that depression among the HCWs was significantly cor-

DISCUSSION
This study aimed to investigate mental health status among HCWs in all cities of Iran. Accordingly, the prevalence rates of depression, anxiety, and stress in these individuals were assessed through the DASS-21, whose results showed that 44.8% of the HCWs had experienced depression, 43% of them had reported anxiety, and 34.8% had also suffered from stress during the COVID-19 pandemic. It is obvious that frontline HCWs engaged in direct diagnosis, treatment, and care of patients with COVID-19 and physically and psychologically challenged when committing themselves to providing high-quality care for such patients are at higher risks of psychiatric disorders (Lai et al., 2020).
Consistent with the present study, the results of a survey in Nepal, assessing mental health status among HCWs during the COVID-19 pandemic, had revealed that the prevalence of anxiety and depressive symptoms in the HCWs was by 42% and 37.5%, respectively (Khanal et al., 2020). In this study, the researchers had declared that high levels of anxiety and depression among the HCWs could be attributed to factors, such as personal protective equipment shortages and resul-  (Şahin et al., 2020). In this respect, the MHME in Iran had similarly implemented specific programs for psychological counseling not only for HCWs but also for the general population through certain phone lines. In this survey, the prevalence rates of depression and anxiety had been reported to be higher than those in the present study, probably due to different sample sizes and research instruments.
The results of this study also showed that depression, anxiety, and stress among the HCWs were significantly correlated with risk factors, such as age, female gender, history of physical illnesses, and history of psychiatric disorders. Based on the results reported in some studies, history of psychiatric disorders (Khanal et al., 2020;Şahin et al., 2020), female gender (Aiyer et al., 2020;Şahin et al., 2020;Suryavanshi et al., 2020), and age (Suryavanshi et al., 2020) had been identified as risk factors for mental health problems, such as anxiety and depression among HCWs in different settings and countries. Moreover, factors such as marital status and stressful events in work environments had been assessed in the related literature, which were not significant in the present study (Suryavanshi et al., 2020). Consistently, the findings of a survey in China had reported that increased workload, physical symptoms, such as respiratory and digestive symptoms, negative coping styles, and job burnout, could be significantly associated with anxiety and depression (Chen et al., 2020).      In this study, working less than 8 h/day was a predictor of depression and anxiety among HCWs and also working less than 8 h/day and working in hospitals compared with other working units were assumed as significant predictors of stress among HCWs during the COVID-19

TA B L E 3 CDAS in participants during COVID-19 outbreak in
pandemic. The results of a study investigating the prevalence and associated factor of anxiety among HCWs in China had found that, after adjusting for sociodemographic characteristics, such as gender, age, level of education, and marital status, the cases who had experienced direct contacts in treatment of infected patients in hospitals had suffered from higher anxiety than those who had not done so . Besides, the results of another survey in China had shown that working in an isolation ward or fever clinic could be an independent risk factor of depression, anxiety, and stress (Zheng et al., 2020

CONCLUSION
The results of this study showed that the HCWs had partially experienced a high prevalence rate of psychological symptoms during the COVID-19 pandemic. As psychological well-being and mental health status among HCWs are important issues associated with quality of care given to COVID-19 patients, health administrators and policymakers of the MHME are suggested to provide psychological screening and supportive care programs for HCWs with the aim of enhancing their mental health status and successful coping with critical circumstances.

ACKNOWLEDGMENTS
This study was funded by Mazandaran University of Medical Sciences (No. 7574), Sari, Iran. We declare that the funder had no role in the study design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the manuscript for publication.

CONFLICTS OF INTEREST
All authors report no conflicts of interest. Ref.

Gender Male
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History of psychological illness Ref.

AUTHORS' CONTRIBUTION
FE designed the study and collected the data. MA and MK collected the data, wrote the paper, and contributed to the study design. MM analyzed the data. All authors made a substantial contribution to writing of the paper draft and met the four criteria for authorship recommended by the International Committee of Medical Journal Editors.

ETHICAL STATEMENT
All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

DATA AVAILABILITY STATEMENT
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.