Mental health and well-being of healthcare workers in Central Asia

Study design and procedure

A cross-sectional evaluation of Central Asian HCWs was undertaken between July and November, 2022. HCWs were invited to participate in an online survey created on 1ka.si platform. The survey was distributed via social media platforms to HCWs in Kazakhstan, Kyrgyzstan, and Uzbekistan. Participation was entirely voluntary, confidentiality and anonymity were guaranteed. All participants had the opportunity to get acquainted with the study aim and objectives. Participants were informed that by proceeding with the survey, they were confirming their informed consent to participate. Only responses from participants who confirmed their informed consent were included in the analysis, adhering to ethical guidelines for research involving human participants. Participants gave their written informed consent by proceeding with the online survey, which was explicitly stated at the beginning of the questionnaire. This approach ensured that consent was documented electronically. The ethics committees approved this method of obtaining consent, considering the online nature of the study and the need to reach a large number of healthcare workers efficiently. By blocking repeated IP addresses, the study was protected from duplicate responses.

Study participants

During the study, we received answers from 6,903 HCWs from three countries; among them, 2,685 completed the survey (response rate = 38.9%). The study involved physicians and nurses, regardless of the level of medical care and the type of financing of the healthcare organization employed.

Measures

The original questionnaire utilized in this study is provided in the Extended Data section. The questionnaire included:

Statistical analysis

Statistical analysis was performed using Jamovi version 2.2.5. Statistics included descriptive methods [frequency, means (M), and standard deviations (SD)], comparative analysis using the t-test or ANOVA with post-hoc test (when more than two groups were compared), frequency analysis, and determination of independent associations between variables using chi-square and binominal logistic regression analysis. The level of statistical significance adopted was 5% (p<0.05).

Ethics approval and consent to participate

The study was approved by the Local Ethics Committee of “University Medical Center” Corporate Fund (extract from protocol No. 11 of December 30, 2021) and by the Local Ethics Committee of I.K. Akhunbaev Kyrgyz State Medical Academy (extract from protocol No. 13 of December 08, 2021). All methods were performed in accordance with the relevant guidelines and regulations. All participants provided informed consent online before the survey. This study adhered to the principles outlined in the Declaration of Helsinki. All methods were performed in accordance with relevant guidelines and regulations to ensure the ethical treatment of all participants involved in the research.

Compliance with reporting guidelines

This study complies with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines to ensure transparent and complete reporting of observational research.

Mental health and well-being

The prevalence and level of depression, anxiety, stress and well-being of HCWs in Central Asian countries were studied. The overall prevalence of depression was 17.7%, while in Kazakhstan (13.8%, M=4.17) and Kyrgyzstan (14.2%, M=4.66) the prevalence and average level of depression were significantly lower compared to Uzbekistan (44.3%, M=8.72), p<0.001 (Table 2). Among men, depression was significantly more common than in women (24.3% vs. 16.2%, respectively, p<0.001), while the level of depression was negatively correlated with the age of the study participants (rho=-0.104, p<0.001). Doctors compared with nurses had a high prevalence of depression (25.4% vs 13.5%, respectively, p<0.001), while this pattern did not depend on gender, and was found in Kazakhstan and Kyrgyzstan. The prevalence of depression was significantly higher among senior staff (31.5%) compared to ordinary employee (16.1%), p<0.001, and was independent of gender, but was noted only among nurses. The prevalence of depression was related to marital status and having children. Thus, depression was significantly more common among single (23.5%) and widowed (22.1%) compared with married (15.2%) and divorced (15.3%), p<0.001. Having children reduced the chances of depression (27.2% vs 13.6%, OR=0.422, 95%CI 0.344-0.517, p<0.001) among respondents, and did not depend on marital status or gender.

The overall prevalence of anxiety was 24.9%, while the prevalence and average level of anxiety significantly differed between the countries: Kazakhstan (19.2%, M=3.84), Kyrgyzstan (22.7%, M=4.48), and Uzbekistan (59.3%, M=8.72), p<0.001 (Table 2). Among male (30%) HCWs, anxiety was significantly more common compared with women (23.8%), p<0.05, while the level of anxiety was negatively correlated with the age of the study participants (rho=-0.091, p<0.001). Doctors compared with nurses had a high prevalence of anxiety (33.3% vs 20.3%, respectively, p<0.001), while this pattern did not depend on gender, and was found in Kazakhstan and Kyrgyzstan. The prevalence of anxiety was more than twice as high among senior staff (49.1%) compared to ordinary employee (22.2%), p<0.001, and did not depend on gender, profession, or country. The prevalence of anxiety, as well as depression, was associated with marital status and having children. Thus, anxiety was significantly more common among single (30.5%) and widowed (33.1%) respondents compared with married (22.2%) and divorced (22.6%) respondents, p<0.001. Moreover, having children reduced the chances of anxiety (34.3% vs. 20.9%, OR=0.507, 95% CI 0.422-0.609, p<0.001) among respondents, and did not depend on gender or marital status, with the exception of single study participants.

The overall prevalence of stress was 5.2%. Although the prevalence of stress was least noted in Uzbekistan (2.7%, M=9.01), the average stress level on the DASS-21 scale was significantly lower in Kazakhstan (5.1%, M=5.12) and Uzbekistan (7.1%, M=5.72), p<0.001 (Table 2). The prevalence of stress did not differ among men (4.6%) and women (5.3%), however, men (6.31±5.10) had significantly higher stress levels compared with women (5.60±5.05), p<0.05. As in the case of depression and anxiety, stress levels were negatively correlated with the age of the study participants (rho=-0.104, p<0.001). Doctors compared with nurses had a greater prevalence of stress (8.1% vs. 3.6%, respectively, p<0.001). Having a manager position and marital status were not associated with the prevalence of stress. However, stress levels were significantly higher among managers compared to general staff (7.42±4.84 vs 5.54±5.06, respectively, p<0.001). Post-hoc test revealed significantly higher stress levels among single people compared to married respondents (6.36±5.32 vs 5.43±4.93, respectfully, p<0.001). Having children reduced the risk of stress (OR=0.556, 95%CI 0.394-0.787, p<0.001) and did not depend on the gender of the respondents.

The DASS-21 scale also allows determining the severity of depression, anxiety and stressing (DAS). Figure 1 presents the results of the distribution of the severity of depression, anxiety and stress depending on the country. The severity of DAS symptoms is also presented in Table S1 (Extended data).

Figure 1. Distribution of the severity of depression, anxiety, and stress across different countries.

The figure illustrates the comparative analysis of mental health conditions, specifically depression, anxiety, and stress, among healthcare workers in Kazakhstan (KZ), Kyrgyzstan (KG), and Uzbekistan (UZ). The severity levels are categorized and presented to highlight the differences and similarities among these three Central Asian countries.

The level of well-being of HCWs was significantly higher in Kazakhstan (14.0±6.54) and Kyrgyzstan (14.1±6.16) compared with Uzbekistan (11.9±4.99), p<0.001. As indicated in Table 3, the gender was not related to the level of well-being. At the same time, the level of well-being was significantly higher among nurses (14.3±6.54) compared with doctors (12.7±5.77), and among regular staff (13.9±6.34) compared with managers (12.1±6.02), p<0.001, however, this trend was found only among respondents from Kazakhstan, but not from Kyrgyzstan or Uzbekistan. Single people (12.9±6.39) had significantly lower well-being indicators compared to married (14.0±6.31) or divorced (14.4±6.15) respondents, p<0.05. In turn, the study participants who had children (14.2±6.31) showed a higher level of well-being compared with those who did not have them (12.7±6.26), p<0.001. As presented in Tables S2 and S3 (extended data), the levels of depression, anxiety and stress were positively correlated with each other, and negatively with the level of well-being (p<0.001).

Mental health, well-being and experience during the COVID-19 pandemic

Although current study was conducted at the end of 2022, at the time of the end of the COVID-19 Pandemic, 40% of respondents indicated that they were at the frontline during a period of increasing incidence of COVID-19. The prevalence of depression and stress did not significantly differ depending on the experience of working on the frontline during the pandemic, whereas anxiety was more common among respondents who were on the frontline (28.2%), compared with those who were not (22.7%), p=0.001. At the same time, the level of well-being was significantly lower among respondents who were on the frontline (13.3±6.47), compared with those who were not (14.1±6.22), p<0.05.

“The impact of COVID-19 on personal life and work of HCWs” scale was used to assess the impact of the COVID-19 pandemic on the lives and work of HCWs. The number and percentage of agreement with the points on the scale are shown in Table S5 (extended data). About a third of respondents indicated that due to the COVID-19 Pandemic they had to do work that they had not done before (32.7%) and had an additional workload (37.4%). While the expansion of the work area did not differ from the involvement on the frontline in the fight against the pandemic, the presence of additional workload was more often noted by HCWs who were on the frontline (42.7%), compared with those who were not (33.8%), p<0.001 (Table S4, extended data). Slightly more than a quarter (26.0%) of respondents noted that they worked overtime and there were not enough employees, so they had to cope with various requirements (25.9%), these changes in working conditions were also more often noted among frontline workers, p<0.001 (Tables S4 and S5, extended data).

The psychological situation in the workplace also differed depending on the working conditions. Thus, HCWs who worked on the frontline were more likely to note a large amount of stress at work (42.8%) and the presence of conflicts among colleagues (16.5%), compared with those who were not on the front line (35.2% and 13.1%, respectively), p<0.05 (Tables S4 and S5, extended data).

Direct contact of HCWs with patients, both with a confirmed case of COVID-19 and with any other diseases, raised fears of transmission of diseases to loved ones, and also contributed to the development of stigmas against health care providers in society. Thus, less than a quarter (22.8%) of respondents indicated that they were afraid to tell family members about the risks of contracting the SARS-CoV-2 virus, 17.7% and 12.1% noted that people and their family members, respectively, avoided them because of the nature of their work, and 18.2% of respondents indicated that they avoided telling other people about the nature of their work; these indicators were significantly higher among HCWs who worked on the frontline, compared with those who did not work in dispensary hospitals, p<0.05 (Table S4 and S5, extended data).

Less than three-tenths of respondents (28.6%) indicated that they did not feel gratitude from employers, this was more often observed among HCWs who worked on the frontline. The perceived lack of value for society and the state was indicated by 23.6% and 29.7% of respondents, respectively, and this indicator had no significant differences from the experience of working on the frontline (Tables S4 and S5, extended data).

On average, the level of well-being was lower among those respondents who were at the frontline, but when distributed to countries, reliable results were obtained only for Uzbekistan (Table 3).

Predictors of depression, anxiety and stress

Table S5 (extended data) presents the results of binomial logistic regression analysis to study predictors of depression, anxiety and stress in a general sample of participants. According to the results of the regression analysis, the country was a reliable predictor of the presence of depression, anxiety and stress. Gender was not associated with depression or stress, but women were 1.4 times more likely to experience anxiety compared to men. At the same time, age reduced the risk of having DAS symptoms (Table S5, extended data).

Significant predictors of depression that increased the chances of symptoms were: country – Uzbekistan, being a doctor, taking a managerial position, widowing, and certain changes in life and work related to the COVID-19 pandemic (more stressful work environment, conflicts with colleagues, and lack of a sense of value for the hospital and society). At the same time, having children and expanding the area of responsibility at work in connection with the pandemic reduced the risk of developing symptoms of depression (Table S5, extended data).

The presence of anxiety symptoms was positively associated with country affiliation to Uzbekistan, being a woman, being a doctor, holding a managerial position, working on the frontline to combat the pandemic, widowing, and certain changes in life and work related to the COVID-19 pandemic (more stressful work environment and conflicts with colleagues). The following variables reduced the risk of developing anxiety: older age, having children, and expanding the area of responsibility at work due to the pandemic (Supplementary Table 5, extended data).

In the current study, stress was positively associated with the medical profession and changes in life and work associated with the COVID-19 pandemic, such as a more stressful work environment, conflicts with colleagues, and the lack of a sufficient number of employees. At the same time, country affiliation to Uzbekistan, age, and the presence of children reduced the likelihood of having stress symptoms (Table S5, extended data).

Binomial logistic regression analysis of determining factors associated with DAS symptoms by country is presented in Tables S6-S8 (extended data).

Study limitations

There were several limitations in the current study. First, the results are based on a cross-sectional study, and the identification of causal relationships is not possible. Second, the socio-demographic characteristics among the participants of the three countries differed, which led to heterogeneity of the subsamples. However, the healthcare systems in these countries are mostly similar. Moreover, like a majority of studies used self-report measures which reflected probable mental health disorders it may rather than actual diagnosis. Finally, current study did not take into account the following socio-demographic factors that could potentially be predictors of DAS symptoms and well-being: COVID-19 infection history, work in a public or private clinic, employee specialization, work experience, availability and satisfaction with compensation for work on the frontline during the Pandemic, and etc.