Occupational Health of Frontline Healthcare Workers in the United Arab Emirates during the COVID-19 Pandemic: A Snapshot of Summer 2020

The study aim was to understand the availability of personal protective equipment (PPE) and the levels of anxiety, depression, and burnout of healthcare workers (HCWs) in the United Arab Emirates (UAE). This study was an online-based, cross-sectional survey during July and August 2020. Participants were eligible from the entire country, and 1290 agreed to participate. The majority of HCWs were females aged 30–39 years old, working as nurses, and 80% considered PPE to be available. Twelve percent of respondents tested positive for SARS-CoV-2. Half of HCWs considered themselves physically tired (52.2%), reported musculoskeletal pain or discomfort (54.2%), and perceived moderate-to-high levels of burnout on at least one of three burnout domains (52.8%). A quarter of HCWs reported anxiety (26.3%) or depression (28.1%). HCWs reporting not having musculoskeletal pain, having performed physical activity, and higher scores of available PPE reported lower scores of anxiety, depression, and burnout. UAE HCWs experienced more access to PPE and less anxiety, depression, and burnout compared with HCWs in other countries. Study findings can be used by healthcare organizations and policymakers to ensure adequate measures are implemented to maximize the health and wellbeing of HCWs during the current COVID-19 and future pandemics.


Introduction
Coronavirus disease 2019 , caused by SARS-COV-2, was first detected at the end of 2019 in Wuhan, Hubei province, China [1]. The outbreak was declared an international public health emergency on 30 January 2020 by the World Health Organization (WHO) [2]. In the first two months of 2020, the virus spread to over 76 countries, with 93,091 cases reported by the WHO on the 4th of March [3]. Less than 10 days later, on the 13th of March, the virus had already spread to over 139 countries with more than The online survey link was distributed by the administration of the involved healthcare facilities to reach all HCWs within their organization. This strategy aimed to maximize the representativeness of the population sample in the study. The main six healthcare providers involved in treating COVID-19 were contacted to participate in the present study, and four agreed to distribute the survey to their healthcare personnel. Participants needed to give their consent to participate in the study before accessing the study questions.

Data Sources/Measurements (Data Collection Tools)
The data collection tool was an adaptation of the developed Occupational Health Services Survey from Barómetro COVID-19, designed by investigators of the Portuguese National School of Public Health, NOVA University of Lisbon [24]. The survey was translated from Portuguese to English and adapted for the UAE health systems organization. The survey was not validated, but it was piloted in five HCWs before its dissemination, and the results of the pilot are not part of the reported results in our manuscript (Cronbach's alpha values are reported in the next section).
The data collection tool was organized into three sections: • In the first section, we asked questions to allow us to characterize the sample by sociodemographic and health and lifestyle (sex, age, specific emirate, sleeping pattern, level of tiredness, and physical activity) and to assess their job context and demands (occupation, healthcare sector, facility type, occupational health and safety, and infection control-related questions, monitoring of SARS-CoV-2 infection, availability and adequacy of PPE); • In the second section, the Hospital Anxiety and Depression Scale (HADS) [25] was used to understand the perceptions of the HCWs about their anxiety and depression thoughts. The HADS has 14 items: seven related to anxiety and the other seven to depression.

•
In the third section, we used the Maslach Burnout Inventory (MBI) [15] questionnaire with its seven-point Likert scale to assess burnout. This questionnaire has 22 items to assess three components of burnout: emotional exhaustion (nine items), depersonalization (five items), and reductions in personal accomplishment (eight items). All the items are scored using a seven-point Likert scale (from 0 (never) to 6 (always)).

Data Analysis
We used descriptive statistical techniques to describe the variables that were considered crucial for the characterization of the occupational health situation of the HCWs in the frontline of COVID-19. Similar to the original questionnaire, occupational health and safety and infection control-related questions, monitoring COVID-19, availability, and adequacy of PPE were asked using six-point Likert scales.
For the HADS analysis, we calculated the sum of each of the 7 questions to anxiety and depression and applied the cutoff of >8 to consider the participant as reporting anxiety or depression, respectively. The internal validity of the anxiety scale (Cronbach's alpha) was 0.826 and 0.779 for depression.
The Kolmogorov-Smirnov test was used to assess the normality of the data. Chisquare test and analysis of variance were used to assess the difference in the means between anxiety, depression, and burnout scores and the most relevant socio-demographic characteristics of the HCWs surveyed. Binary and logistic regression analysis was performed to determine potential risk and protective factors for anxiety, depression, and burnout. Crude odds ratio (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were reported. Statistical significance was defined by a p-value ≤ 0.05 and 95% confidence intervals. SPSS 26.0 (SPSS Inc., Chicago, IL, USA) was used to conduct the analysis. The study sample was analyzed as one group due to the study aim of understanding the availability of PPE and the levels of anxiety, depression, and burnout of HCWs in the UAE. This practice is used in similar studies of the same design, although we acknowledge that this is a non-homogeneous group in terms of sex and occupation.

Ethical Considerations
Ethical approval was granted from the Emirates Institutional Review Board for COVID-19 Research (DOH/CVDC/2020/1257), Dubai Scientific Research Committee (DSREC-07/2020_08), the Social Sciences Ethical Committee of the United Arab Emirates University (ERS_2020_6138), and the Institutional Board Research of the involved organizations.

Participants
From the 1290 HCWs that agreed to participate in this study, the majority of the study sample were females (78%) and aged 30 to 39 years old (51%) ( Table 1). Regarding the number of weekly hours in night shifts, 38.5% had worked less than 9 h, and the same proportion had worked between 9 to 18 h, while 22.9% had worked more than 18 h during the night over the past week. Half of the workers (53.8%) reported having an average sleep of 6-8 h per day, and only 20.2% of them were physically active outside of work (physical activity almost every day or every other day). Half of the HCWs (52.2%) considered themselves physically tired that day (rated 4 or above on a scale from 0 to 6), and 43.8% were more physically tired than last week (rated 4 or above on a scale from 0 to 6).

Job Context and Work Demands
Nurses constituted three-quarters of our sample, and 88% of the HCWs reported working at a publicly funded hospital. General hospitals were the most represented type of facility in our survey, and the vast majority were from the Emirate of Dubai (69%). More than half of participating HCWs (61.4%) were working with COVID-19 patients; out of those, 34.7% were dealing with potential COVID-19 cases in a medical ward, 15.7% in an intensive care unit (ICU), 14.4% in the emergency room, and 9.9% in the COVID-19 screening centers.
The vast majority of participants (89.6%) were screening themselves daily for COVID-19 symptoms, half of the participants (49.7%) had been suspected to have had contact with a SARS-CoV-2-positive case, and 78.8% of the sample had been tested (by rt-PCR) for SARS-CoV-2 between 1 (32.9%) to 5 times (8.8%). From the total number of participants, half were tested after 72 h of contact with the positive case, but this varied between the first 24 h (17.1%), 24 to 48 h (21.9%), and 48 to 72 h (9.7%). Twelve percent of HCWs tested positive for SARS-CoV-2, but we were not able to determine whether this was community-based transmission or a nosocomial infection.
Occupational health services or infections and prevention control teams managed the risk of infection of HCWs in 95.7% of the healthcare settings, and 69.0% of HCWs had a risk assessment performed.
Eighty percent of the study population rated the availability of PPEs to be 4 or above (on a scale from 0 to 6). Eighty-two percent considered that the availability of PPE over the weeks of the pandemic improved (rated 4 or above on a scale from 0 to 6), and 82.6% considered PPE to be adequate for their level of exposure (rated 4 or above on a scale from 0 to 6).

Musculoskeletal Symptoms
Half of HCWs (54.2%) reported having more than the normal musculoskeletal pain or discomfort in the past week, and from those, 59.3% identified back pain, 26.1% in their lower body, and 14.5% in their upper limbs. When asked to rate the level of pain from 0 (no pain) to 10 (extreme pain), only a minority of participants reported having average pain (4-6 scores) in the cervical spine (28.7%), low back (34.2%), shoulders (25.9%), and hands, wrists, and arms (21.1%).

Prevalence of Anxiety and Depression
Around a quarter of HCWs scored >8 for anxiety and depression, indicating a prevalence of 26.3% for anxiety and 28.1% for depression.
Anxiety scores showed a non-significant difference by sex, occupation, and healthcare sector (p > 0.05). However, differences in anxiety scores were statistically significant by the numbers of hours per night shift (p < 0.001), the number of hours of sleep (p < 0.001), physical fatigue (p < 0.001), physical activity in the past week (p < 0.001), musculoskeletal pain (p < 0.001), and perceptions on the adequate level of PPE (p < 0.001) ( Table 2). HCWs reporting no musculoskeletal symptoms, having slept more than 8 h, without intense fatigue, having performed physical activity, and higher scores of available PPE (scored 4 and above) reported lower scores of anxiety. Depression was not statistically significantly different between males and females nor between private and publicly funded healthcare. Depression varied in terms of occupation (p = 0.005), with higher levels of depression reported amongst physicians, HCWs working a greater number of night shift hours (p = 0.005), less sleep (p < 0.001), more physical fatigue (p < 0.001), less physical activity in the past week (p < 0.001), more musculoskeletal pain (p < 0.001), and a perception of less adequate PPE (p < 0.001) ( Table 2). HCWs reporting not having musculoskeletal symptoms, having slept more than 8 h, without intense fatigue, having performed physical activity, and higher scores of available PPE (scored 4 and above) reported lower scores of depression.
In the binary logistic regression model (Table 3), factors associated with anxiety and depression are presented. Physicians were more likely to develop anxiety and depression. Higher levels of physical fatigue, musculoskeletal pain, and a lack of physical activity were associated with a greater likelihood of developing anxiety and depression (anxiety:

Prevalence of Burnout
Half of the HCWs reported moderate-to-high levels of burnout in at least one of the three subcomponents, 52.8% of HCWs reported moderate-to-high levels of emotional ex-haustion, 26.6% reported depersonalization, and 30.8% low-to-moderate levels of personal achievement.
There were no statistically significant differences for emotional exhaustion, depersonalization, or personal achievement by sex or healthcare sector (p > 0.005). Occupation differed significantly for personal achievement (p = 0.004) but not emotional exhaustion or depersonalization. Similar to the factors influencing anxiety and depression, the three domains of burnout differed according to the number of hours per night shift (p < 0.005), the number of hours of sleep (p < 0.001), physical fatigue (p < 0.001), physical activity in the past week (p < 0.001), musculoskeletal pain (p < 0.001), and perceptions on the adequate level of PPE (p < 0.001) ( Table 4).  High levels of emotional exhaustion and depersonalization were reported by HCW working more night shifts, having not performed physical activity, perceiving low PPE availability, and having musculoskeletal pain. Low levels of personal achievement were reported by HCWs working less than 9 h in night shifts, not physically active, perceiving lower availability of PPE, and reporting musculoskeletal pain.
The regression model adjusted for the adequate level of PPE at the workplace showed that physical activity, sleeping hours, and adequate PPE in the workplace were significantly associated with burnout in HCWS (Table 5).

Discussion
Understanding the workload and challenges of frontline HCWs during the COVID-19 pandemic helps implement better occupational health services, infection and prevention control practices, and strategies to help them cope with these maximized work-stress conditions.

Key Findings
Three-quarters of HCWs considered PPE to be readily available and that that availability improved over time. One-quarter of HCWs reported anxiety and depression, and half of them reported high scores in at least one of the domains of burnout (emotional exhaustion, depersonalization, and personal achievement). HCWs reporting not having musculoskeletal pain, having performed physical activity, and higher scores of available PPE reported lower scores of anxiety, depression, and burnout.

Comparison of Findings with Previous Work
The level of available PPE was considered high (4-6 score, 6 is completely available) by 80% of HCWs. This finding highlights the UAE health policies and actions taken to ensure the provision of medical supplies at the beginning of the pandemic even before the first case in the country [8]. In contrast, the availability of PPEs was considered sufficient by only 21% of HCWs in Portugal [27].
The UAE HCWs were largely monitoring themselves daily for COVID-19 symptoms, as it was advised by the international and local health authorities. The UAE local health authorities implemented weekly or bi-weekly mandatory testing for all HCWs [28]. This practice was extremely important to break the chain of community-or hospital-acquired infections, as 12% of the HCWs reported testing positive for SARS-CoV-2. Our self-reported prevalence of SARS-CoV-2 infection was not based on clinical diagnosis from serology, and it was found to be higher than seroprevalence estimates in other countries, such as India (11%) [29], similar to Spain (11.2%) [30], Belgium (12.6%) [31], and New York (13.7%) [32] and lower than China (17.1%) [33], and the United Kingdom (18.0%) [34].
Comparing the findings of the present study with other cross-sectional studies [30] that have been published on psychological distress among HCWs since the beginning of the pandemic in early 2020, it is possible to observe that HCWs in the UAE had lower levels of anxiety and depression compared to the majority of other countries reported but very similar to an umbrella review that reported a prevalence of 24.9% for anxiety and 24.8% for depression [35]. This umbrella review and meta-analysis included seven studies in the meta-analysis from Brazil, China, India, and the United Kingdom [35]. In Egypt, 90.5% of HCWs reported some degree of anxiety. The same study reported that mild anxiety was identified by 40% of HCWs, moderate anxiety by 32%, and severe anxiety by 18.5%. Regarding depression, 94% of the same study population reported mild to severe depression [36]. In Wuhan (China), the prevalence of anxiety was 44.6% and depression 50.4% [37]. In Bangladesh, the prevalence of anxiety was 69.5% and depression 39.5% in a study using HADS [38]. In Portugal, the prevalence of anxiety was 79.1% [27]. In Singapore, the prevalence of anxiety was 10.8% for physicians and nurses, and the prevalence of depression for the same sample was 8.1% [39]. In the present study, physicians had higher prevalence estimates of anxiety compared to nurses (although not statistically significant), which is sometimes the opposite in other settings, like in Turkey, where nurses reported higher levels of anxiety [21].
The present study's findings for moderate-to-high levels of emotional exhaustion and depersonalization are similar to the reported ranges and scores of other studies. An international survey with 184 HCWs from 45 countries from 5 continents reported moderate-tohigh emotional exhaustion in 56.0% and moderate-to-high in 48.9% of HCWs [19].
A systematic review of burnout in Arab countries pre-COVID identified 19 studies reporting the prevalence of the three components of burnout [40]. Emotional exhaustion ranged from 20.0 to 81.0%; depersonalization ranged from 9.2 to 80.0%, and personal achievement ranged from 13.3 to 85.8% in the studies included. However, this review did not include any studies from the UAE, as there were none in 2017; however, it reports burnout in HCWs in other Middle Eastern countries: Saudi Arabia, Bahrain, Lebanon, Palestine and Egypt, Jordan, and Yemen [40]. A second systematic review of burnout in HCWs in the Middle East included 54 studies for physicians, 53 studies for nurses, and seven studies for medical residents reported a prevalence ranging from 13 to 85% [41].
The only study of burnout in the UAE that we were able to find, also included in the aforementioned systematic review [41], identified moderate-to-high levels of emotional exhaustion in 76%, high depersonalization in 84%, and low personal achievement in 70% of UAE medical residents [14]. Our results in the HCW population (not in trainees) are substantially lower, reflecting better mental health, specifically during the COVID-19 pandemic. This may suggest that experienced HCWs are more resilient and cope better with extreme situations in comparison with less experienced HCWs; this assumption is aligned with recent findings from a similar study in China [37]. Moreover, another recent systematic review identified that the levels of mental health issues in HCWs and the general population differed by only 1% (34% and 33%, respectively) [42]. On this point, there are distinct findings highlighted by research: on one hand, HCWs may be more susceptible to stress, burnout, fear of being infected and of infecting their own family members, as well as of experiencing sleep and emotional disturbances [37,42]. On the other hand, a study from Singapore at the beginning of the pandemic reported that physicians and nurses were more likely to cope better with stressful health events and show more resilience compared with allied healthcare professionals, pharmacists, and lab technicians; again, this varied with seniority [39].

Occupational Health Implications of Findings
HCWs have identified the need for better occupational health services focusing on mental health [37]. Continuous mental health services for staff are necessary, and the pandemic highlighted this need that was already felt before the pandemic. To tackle this challenge, lessons learned from the situation should be taken. Mental health specialists have advocated that mental health services should be integrated into occupational health with the establishment of community mental health teams providing both face-to-face and online health services for HCWs, especially during potentially stressful working conditions, such as the COVID-19 pandemic [27,43,44].

Strengths, Limitations, and Future Research
One major strength of this study was the use of validated and widely used scales to identify anxiety, depression, and burnout-the Hospital Anxiety and Depression Scale and the Maslach Burnout Inventory. Moreover, the Cronbach alpha coefficients showed them to be reliable in our sample. These data collection tools made comparisons possible with other international studies before and during the pandemic [19,26]. However, the burnout, anxiety, and depression scores were based on the self-reported answers from the HCWs and cannot be comparable with data from medical diagnoses of these conditions.
Our study design attempted to recruit a representative sample of HCWs from the six major health care providers in the UAE, including publicly funded healthcare and private institutions. However, only four agreed to participate in the study, which might have introduced a selection bias, and the study sample may not have been representative of the entire HCWs population in the UAE. The majority of the study population were nurses (78%), which is in accordance with the distribution of nurses and physicians in Dubai, 67% and 32%, respectively [45], and with a recent study in Abu Dhabi, where 62% of HCWs were nurses, and 20% were physicians [46]. The study also had a higher proportion of females compared to males; some similar studies acknowledge this as a limitation [21], although the natural distribution of occupations in the healthcare sector have been occupied by females, especially nursing. Although we were not able to estimate the proportions for the country in terms of sex, age, occupation, and emirate distribution of HCWs, we have performed the analysis of the study sample as a whole, heterogeneous group. Moreover, the primary inclusion criteria was any HCWs involved in the care of COVID-19 patients, and three-quarters of our study sample (n = 1290) were nurses (78.1%; n = 1007), and the majority of nurses were female (only n = 157 or 15.6% of nurses were male; data not shown), and nurses were more likely to come into contact with or be exposed to COVID-19 patients, which explains the predominance of nurses and females in our study sample. Finally, the nature of the cross-sectional study design needs to be mentioned as well, as it lacks explanations of the impact of the different variables considered on the level of anxiety, depression, and burnout due to no temporality between exposure and outcome.
Several studies have been published on the same topic, but the data collection periods vary, and for this reason, we highlight here that the comparisons made were done by the type of study and not study period, where the different stages and waves of the pandemic might have had an impact on the anxiety, depression, and burnout levels of the HCWs included in those studies [13,21,27,36,47].
Future research on this topic using longitudinal designs would be needed to identify the protective and risk factors for anxiety, depression, and burnout. Additional variables might need to be considered, as years of experience, resilience, being a parent, and family support of HCWs have also been linked to the occurrence of the psychiatric symptoms in previous research [2,37,48].

Conclusions
HCW's health should be protected by occupational health services to ensure that they can provide high-quality standard of care to all patients. The HCWs sample represented in the study reporting not having musculoskeletal pain, having performed physical activity, and higher scores of available PPE reported lower scores of anxiety, depression, and burnout. The majority of the study population were female nurses in their thirties, and these findings are fundamental to understand thee sociodemographic characteristics, lifestyle behaviors, and mindsets related to their health, musculoskeletal pain, anxiety, depression, and burnout. The study findings can be used to help formulate better health policies focusing on encouraging physical activity, monitoring the number of night shifts per week, resilience training, and occupational health services focusing on physical and mental health. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy issue.

Conflicts of Interest:
The authors declare no conflict of interest.