Prevalence of Anxiety, Depression, and Perceived Stigma in Healthcare Workers in Nepal During Later Phase of First Wave of COVID-19 Pandemic: A Web-Based Cross-Sectional Survey

Introduction The COVID-19 pandemic has caused discrimination and social stigma among healthcare workers (HCW) causing psychological problems due to prolonged work shifts, uncertain pay, lack of personal protective equipment (PPE), added fear of infection to self or family, and so on. This online survey is directed towards the determination of anxiety, depression, and stigma among healthcare providers in Nepal during the later phase of the first wave of the COVID-19 pandemic. Materials and methods Anxiety and depression were assessed using standard Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), respectively. Data for the survey were collected from January 10, 2021, to February 6, 2021, and analyzed using Stata 15 (College Station, TX: StataCorp LLC). Results A total of 213 participants were enrolled in the study from different parts of Nepal and their mean age was 29.90±6.43 years. The prevalence of anxiety and depression among healthcare workers was 46.95% and 41.31%, respectively. A bidirectional relationship was present between GAD-7 and PHQ-9 score interpretation. About 57% of HCW experienced some form of perceived stigmatization due to COVID-19. Frontline HCW were six times more likely to be stigmatized compared to non-front line HCWs and diagnosis of COVID-19 was associated with three times higher odds of facing perceived stigmatization. Conclusion A significant number of HCW experienced symptoms of anxiety and depression during the later phase of the COVID-19 pandemic. Frontline HCW who were infected experienced a higher level of stigma.


Introduction
The outbreak of several cases of viral pneumonia occurred in January 2020 in Wuhan of China which spread globally and was declared a pandemic by WHO later on March 1 [1,2]. Nepal reported its first case of COVID-19 on January 23 and the first mortality on May 27. As of November 11, 2020, there are 202,329 confirmed cases and 1,174 deaths including deaths of HCWs [3]. With the increasing number of COVID-19 cases and mortality, frontline HCWs are under extreme conditions of discrimination and social stigma from both the community and other healthcare workers (HCWs) who are involved in non-COVID responses putting them at a higher risk of psychological problems [4].
In a cross-sectional study conducted in China, the prevalence of symptoms of anxiety, depression, insomnia, and the overall psychological problems in HCWs during the COVID-19 pandemic were 46.04%, 44.37%, 28.75%, and 56.59%, respectively [5]. In a study conducted in Nepal from April to June, 41.9%, 37.5%, and 33.9% of HCWs developed symptoms of anxiety, depression, and insomnia, respectively, with stigma shown to be significantly associated with these conditions [6].
The COVID-19 pandemic has been a life-changing experience for almost all people around the world. HCWs

Statistical analysis
The data obtained in the study were exported in Excel and data were cleaned. Then data were imported and analyzed in STATA version 15 (College Station, TX: StataCorp LLC). Simple descriptive and cross-tabulation of various studied variables were done about anxiety, depression, and stigma. Chi-square test and Fisher exact test were performed to evaluate the association among the categorical variables considering 5% standard error and p-value cut off of 0.05 as a level of significance. Logistic regression (binary and multinomial) was performed to estimate unadjusted and adjusted odds ratio taking independent variables among which the chi-square test showed an association. A Scatter plot was drawn among continuous variables (GAD-7 total score vs. age and PHQ-9 score vs. age) to check the correlation.

Results
Among a total of 215 responses, two forms were incomplete and thus excluded from the analysis.

FIGURE 2: PHQ-9 scale-based classification of healthcare practitioners
Among categorical independent variables observed, age category, gender, stigma due to COVID-19, loss of a significant one due to COVID-19, GAD-7 interpretation for anxiety were associated with depression category based on PHQ-9 interpretation (p<0.05; Table 2).  Stigmatization to the general public and healthcare practitioners was highly prevalent during the initial surge and mid-phase of the pandemic; 3.76% (n=8) did not want to mention their stigma. Among 205 respondents who disclosed their stigma status, 57% (n=116) faced some form of stigma in society due to COVID-19 ( Figure 3).

GAD-7 scale and PHQ-9 scale questionnaire response
To gauge anxiety among respondents, we used GAD-7 standard questionnaire. The consistency of the scale was tested by Cronbach's alpha which showed high internal consistency of the scale for this study (number of items in the scale: 7; scale reliability coefficient: 0.8574). Similarly, PHQ-9 was used for depression evaluation. Cronbach's alpha coefficient for PHQ-9 was 0.8721 (number of items in the scale: 9) suggesting high internal consistency of the scale. The mean GAD-7 scale score among respondents was 4.72±3.42 (range, 0-16), and the mean PHQ-9 scale score was 4.51±3.87 (range, 0-21). Response to individual scale questionnaire over last two weeks at the time of the survey was presented in Table 4.

GAD-7 scale questions
Over the last two weeks, how often have you been bothered by the following problems?

Logistic regression
Logistic regression analysis was performed among dependent and independent variables. Only those variables where the association was seen in cross-tabulation were taken for logistic regression analysis. Multinomial logistic regression analysis showed significant odds of GAD-7 score interpretation suggesting anxiety among those with PHQ-9 interpretation of depression and vice versa ( Tables 5 and 6

Relation among continuous variables
The relation between age and PHQ-9 and GAD-7 total score was evaluated by plotting a scatter plot. It showed a weak negative correlation between the age of the participants and scores (co-efficient for PHQ-9 score: −0.1811, and for GAD-7 score: −0.2201; Figure 4A and 4B). Every one-year increment in age showed 0.4133047 times decrement in GAD-7 score (CI, −0.661881 to −0.1647284; p=0.001). Similarly, one-year increment in age showed 0.3002436 times decrement in PHQ-9 score (CI, −0.5215687 to −0.0789186; p=0.008).

FIGURE 4: Correlation between the age of the participants and scores
(A) Correlation of PHQ-9 score with age and (B) correlation of GAD-7 score with age.

Discussion
Multiple studies have evaluated the impact of COVID-19 among healthcare professionals during the early stages of the pandemic in Nepal. We aimed to assess the mental health impact in the late phase of the COVID-19 pandemic because longitudinal analysis across a time period is essential to gauge the long-term effects on HCWs who act as a frontline defense against the pandemic. We found that the prevalence of anxiety and depression was 46.95% and 41.31% among healthcare professionals. Our findings were higher compared to the earlier studies done in Nepal among healthcare professionals. A study by Khanal et al. found that 41.9% of health workers had symptoms of anxiety and 37.5% had depressive symptoms while Pandey et al. reported the symptoms of anxiety and depression were present among 35.6% and 17.0% of HCWs, respectively [6,11]. Gupta et al. too reported that the prevalence of anxiety disorder was 37.3% among HCWs, with the majority of the participants having mild anxiety and 8% of the participants had depression [7]. Most of these studies were conducted from April to May 2020 at the beginning of the pandemic during which there were no mortalities and severe forms of the disease in Nepal [6,7,11]. The first mortality due to COVID-19 in Nepal was reported only in May 2020 and maximum mortalities due to COVID-19 occurred from October to December 2020 as per John Hopkins data for COVID-19 [12]. The increased prevalence seen in our study might be due to the time of our study. Our findings are significant because it highlights the mental distress evident in the health care workers even in the later phase of the first wave of the pandemic despite vaccination and therapeutics (like repurposing of drugs already used in other condition or new experimental agents) to combat the pandemic. The ever-growing news about the new B.1.351 variant and B-117 variant of COVID-19 might have also contributed to our findings because the newer strains have been found to spread more rapidly and the Astrazeneca vaccines are less efficacious especially against the South African variant [13,14]. The culmination of these events might have led to the distress because most HCWs now realize that the pandemic may last longer than previously anticipated. HCWs are more vulnerable than the general population to develop abnormal mental disorders and symptoms due to the increased risk of exposure to infected patients.
We found that age, gender, education level, stigma due to COVID-19, work experience, hospital admission due to COVID-19, PHQ-9 interpretation for depression, and health practitioner category were significantly associated with provoking/preventing anxiety disorder based on GAD-7 by running the Pearson Chi-square test and unadjusted logistic regression analysis. It is important to note that women have been found to experience more distress and anxiety compared to males in multiple studies [11,15]. Women are usually the caregivers in the family and the professional burden coupled with responsibility and social norms might lead to excessive distress and anxiety. Also, a meta-analysis by Sanghera et al. showed that less working experience was associated with worse mental outcomes among the eight included studies in the analysis [16]. Health personnel has been found to have more distress compared to the general population as per many studies done worldwide and in Nepal [6,11,15]. However, adjusting across the variables and running multinomial logistic regression analysis showed the relation holds true only for PHQ-9 interpretation for depression and anxiety disorder based on GAD-7.
of life and adverse mental outcomes like depression. Anxiety and depression have been found to exist as comorbid conditions together accounting for 23.2% in the study by Sigdel et al. [18]. This could be due to the psychological impact caused by the COVID-19 pandemic putting a mental and physical burden among healthcare professionals in addition to the increased fear of contracting the virus. This explains the association between GAD-7 interpretation of anxiety and depression category based on PHQ-9 interpretation given their presence as co-morbid conditions in the heat of the pandemic.
We found that frontline working status was associated with stigma such that frontline workers were three times more likely to experience stigma compared to those not working in the frontline. Infectious disease outbreaks have been found to cause stigma among HCWs since the past [19]. Similarly, a study in Turkey found that HCWs who had worked with COVID-19 patients with less training were found to experience more stigma [17]. Zandifar et al. reported that working in the frontline increased the odds of intrusion and hypervigilance in a study done in Iran [20]. This might explain the association between the working status of the frontline worker and stigma. Duy et al. found a moderate correlation between the stigma scale and 21item Depression, Anxiety, and Stress Scale subscale scores [21]. This finding was similar to our finding of an association of GAD-7 interpretation for anxiety and PHQ-9 interpretation for depression with stigma. Also, the diagnosis of COVID-19 among HCWs was found to be significantly associated with stigma. Stigmatization has been found among COVID-19 survivors in a study done in India and Teksin et al.
reported an increased association of stigma with HCWs who experienced COVID-19 symptoms themselves [17,22]. The fear of being infected with coronavirus and the unpredictable clinical sequelae of infection might explain why HCWs with a diagnosis of COVID-19 might likely experience stigma. We also found that living with the elderly and the availability of precautionary measures to be associated with stigma. HCWs feel protected with sufficient precautionary measures leading to a feeling of self-assurance and protection for infection with COVID-19. Decreased fear of being infected with COVID-19 with precautionary measures may lead to decreased odds of stigma because HCWs without COVID-19 do not face the same level of stigma as healthcare workers who are infected with COVID-19.
Our study has several limitations. First, the findings of our study cannot be generalized to the whole population as it is focused on HCWs. Our study is a cross-sectional study with a small sample size. There are no validated tools to assess COVID-19 related stigma, and thus, the perception of stigma experienced by health care workers was reported by individual respondents. Since our survey was web-based with only an English version of the questionnaire with the assumption of adequate education and understanding of the participants, it could have limited access and understanding to some HCWs who did not have access to the internet and limited education. Additionally, we have used PHQ-9 directly for screening depression as it is a well-validated tool to make our study simple instead of using PHQ-2 following the use of PHQ-9, which could be another limitation.

Conclusions
The prevalence of anxiety and depression was significant among healthcare professionals. There was a bidirectional relationship between GAD-7-based diagnosis of anxiety and PHQ-9 score interpretation. More than half of HCWs faced some form of stigma in society due to COVID-19. HCWs working as frontline workers and those with a diagnosis of COVID-19 have increased odds of stigma.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Nepalese Army Institute of Health Science issued approval 367. All respondents gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the protocol and approved by the Ethical Review Committee of Nepalese Army Institute of Health Sciences (NAIHS) (Reference no: 367). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.