Anxiety and associated factors among Ethiopian health professionals at early stage of COVID-19 pandemic in Ethiopia.

INTRODUCTION: In late 2019, a new coronavirus disease known as COVID-19 (novel coronavirus disease 2019) was identified. As there is no any drug to treat this pandemic, the healthcare professionals are disproportionately at higher risk. The mental health outcome is expected to be high. Anxiety is expected to have a significant impact on health professionals, especially among those who work without adequate resources for self-protection.
OBJECTIVES: The objectives of this research was to assess self-reported anxiety symptoms and associated factors among Ethiopian healthcare professionals in the early stages of the pandemic.
METHODS: We have conducted an online cross-sectional study to collect information from healthcare professionals in Ethiopia during the early stage of the outbreak from April 7, 2020 to May 19, 2020. GAD-7 was used for measurement of anxiety. We have used a cut of point of 10 and above to report anxiety symptoms. We have used Google Forms for online data collection and SPSS-22 for analysis. To determine associated factors for anxiety, a binary logistic regression model was used. Variables with p-value < 0.2 during the bivariable binary logistic regression were exported for further analysis in the multivariable binary logistic regression. Finally, variables with p-value <0.05 were considered as significantly associated with the outcomes.
RESULTS: Three hundred and eighty-eight healthcare professionals filled the online questionnaire; Majority (71.1%) were males. Significant number of respondents (78.9%) reported lack of adequate personal protective equipment (PPE) at the work place. The prevalence of anxiety was 26.8%. Being female (AOR: 1.88; 95% C.I:1.11, 3.19), visiting/treating 30-150 patients per day (AOR: 3.44; 95% C.I:1.51, 7.84), those employed at private healthcare institutions (AOR: 2.40; 95% C.I:1.17, 4.90), who do not believe that COVID-19 is preventable (AOR: 2.04; 95% C.I:1.04, 4.03) and those who reported lack of PPE (AOR: 1.98; 95% C.I:1.04, 3.79) were more likely to be anxious.
CONCLUSIONS: The anxiety prevalence among healthcare professionals in Ethiopia during early stage of COVID-19 pandemic was high. This study shows that lack of preventive equipment, being female, contact with many patients, low self-efficacy and working in private health facilities were risk factors for anxiety. Anxiety prevention among health professionals during COVID-19 pandemic requires a holistic approach including provision of sufficient PPE, improving self-efficacy and addressing problems both at public and private institutions and focusing more on female health professionals.

Introduction

The Coronavirus Disease 2019 (COVID-19) epidemic emerged in Wuhan, China, and spread to other countries [1]. COVID-19 is a cluster of acute respiratory illness characterized by fever, cough, myalgia or fatigue, pneumonia, dyspnea, headache, diarrhea, hemoptysis, runny nose, and phlegm- producing cough [2, 3]. Because of the sudden nature of the outbreak and the infectious power of the virus, it will inevitably cause serious threats to people’s physical health and lives. It has also triggered a wide variety of psychological problems, such as anxiety [1, 4, 5]. The COVID-19 pandemic has been attributed to a range of anxiety and mental illness exacerbation [6, 7]. A recent umbrella review showed that the prevalence of anxiety among healthcare workers during the COVID-19 pandemic was 24.94% [8]. Another systematic review also showed that the pooled prevalence of anxiety was 30% [9]. An anxiety prevalence of 19.8% was reported among frontline and second line healthcare workers in Italy [10]. The overall prevalence of anxiety disorder among the healthcare workers in Nepal during the COVID-19 pandemic was 37.3% [11]. The prevalence of anxiety among China’s healthcare workers before the peak time of COVID-19 was 40% [12]. A prevalence of 46.7% anxiety was reported among health workers in Libya during the civil war and COVID-19 pandemic [13]. About 54.2% of healthcare workers in China had symptoms of anxiety [14]. Another study conducted among healthcare workers on the frontlines in Egypt and Saudi Arabia revealed that 58.9% of study participants had symptoms of anxiety [15]. Several predisposing factors are identified for anxiety during COVID-19. These factors include excessive working hours [16], lack of/insufficient personal protective equipment [17, 18], contact with patients with suspected COVID-19 [19], age, department, years of experience, working hours per week, internal displacement, stigmatization [13], being married, not living alone [20], and female sex [21-25].

Anxiety affects the outcome of chronic diseases such as diabetes, cardiovascular diseases, cancer, and obesity [26]. It also affect performance of job, quality of sleep, routine activities, and productivity of the affected individual [27].

Although pandemics including COVID-19 can trigger a significant human toll as well as public anxiety, economic loss, and other adverse consequences, it is common for health practitioners and administrators to fully concentrate on disease prevention and care, abandoning the psychological and mental consequences secondary to the case. As a result, there is a deficit of coping mechanisms, which increases the burden of related diseases [28].

Understanding and researching the psychological conditions of health workers during this turbulent period is therefore crucial. As a result, the objective of this study is to assess prevalence of anxiety and its contributing factors among healthcare professionals during the early stages of the COVID-19 outbreak. This research will provide evidence for tailoring and implementing appropriate mental health care policies to effectively deal with the outbreak’s challenges.

Methods and materials

Study design, area and period

We adopted cross-sectional study design through online survey, to assess symptoms of anxiety and associated factors among health care professionals in Ethiopia. The survey was conducted from April 7, 2020 to May 19, 2020.

Population and inclusion criteria

All health care professionals living in Ethiopia and who were Ethiopian nationals were used as study population. We included all health care professionals who were social media (Facebook, Twitter, Email and Instagram) users, and who were volunteer to fill the survey. We have excluded health professionals who had no access to internet during the study period due to different reasons. We preferred to use social media users because it enables us to collect the data without direct contact with the study participants, which is crucial to reduce the rate of spread of the COVID-19 pandemic.

Sample size determination and sampling technique

Due to the lack of published literature investigating the anxiety during the pandemic COVID -19 in Ethiopia as well as in the study area, in the present study, we calculated the maximum possible sample size. To achieve this, 50% proportion, 5% margin of error, a 95% confidence level and 5% for the non-response rate was considered during the sample size calculation. The final sample size was 404. The snow ball sampling technique was used to access health care professionals.

Data collection instrument and measurement

We used generalized anxiety disorder 7 items scale to assess level of anxiety [29, 30]. The GAD-7 scale was reliable with Cronbach’s alpha of 0.92 and test re-test reliability (intra class correlation = 0.83) with good validity [31]. Questions related to socio-demographic information were incorporated. Participants were asked how often they were bothered by each symptom during the last 2 weeks. Response options were “not at all,” “several days,” “more than half the days,” and “nearly every day,” scored as 0, 1, 2, and 3, respectively. A score of 10 or greater represents a reasonable cut point for identifying cases of anxiety as explained elsewhere [31]. Similar cut of point was also used previously [17]. Even though there are different tools to assess anxiety, we have used GAD-7 as it has been found to have great psychometric properties and is short and easy to administer [32].

Data processing and analysis

As this was an online data collection in the form of CSV (excel file), there was no need of data entry. The excel form data were imported into SPSS version 22 for analysis. All assumptions for binary logistic regression were checked. Bi-variable and multivariable logistic regressions were computed to determine predictor variables for symptoms of anxiety. Variables with a p-value <0.2 during the bivariable binary logistic regression analysis were included in the multivariable logistic regression analysis. In multivariable binary logistic regression, variables were considered as significant at a p-value of < 0.05. Hosmer and Lemeshow goodness- of -fit test (p>0.05) was used to check model fitness. Descriptive and inferential statistics were performed.

Ethical approval and consent to participate

Ethical approval was obtained from the Ethical Review Committee of Environmental and Occupational Health and Safety department, the University of Gondar. Respondents were communicated via social media. After explaining the purpose of the study, respondents were asked to fill and submit their responses. Any potential identifiers were eliminated to ascertain confidentiality.

Results

A total of 388 health professionals with a response rate of 96% participated in the study. Majority (71.1%) were males. Nine out of ten of the participants were public (government employees). Above half (53.1%) of the participants were medical doctors. Majority (88.1%) believe that COVID-19 is preventable. Most of the health professionals (69.1%) live at least with one family member. Significant number of respondents (78.9%) reported lack of sufficient personal protective equipment (PPE) at the work place (Table 1).

Table 1

Socio-demographic characteristics of health professionals screened for anxiety symptoms in Ethiopia during an early stage of COVID-19 pandemic (n = 388).

Variables	Category	Frequency (n)	Percent (%)
Sex	Male	276	71.1
	Female	112	28.9
Age in years	23–26	92	23.7
	27–28	92	23.7
	29–31	103	26.5
	32–55	101	26.0
Educational status	Diploma/degree	233	60.1
	MSc and above	155	39.9
Current marital status	Married	159	41.0
	Unmarried	229	59.0
Work experience	Junior (0–2 years)	127	32.7
	Mid-level (3–5 years)	117	30.2
	Senior (>5 years)	144	37.1
Organizational affiliation	Governmental	347	89.4
	Private	41	10.6
Average patients per day (n = 387)	≤9	71	18.3
	10–19	122	31.5
	20–29	92	23.8
	≥30	102	26.4
Profession	Human medicine	206	53.1
	Other health science	182	46.9
Living with at least one family member	No	120	30.9
	Yes	268	69.1
Sufficient PPE availability	No	306	78.9
	Yes	82	21.1
Do you think that COVID-19 is preventable?	No	46	11.9
	Yes	342	88.1

Prevalence of anxiety among health professionals in Ethiopia during an early stage of COVID-19 pandemic

The prevalence with 95% confidence intervals of anxiety among health professionals in Ethiopia during an early stage of COVID-19 pandemic was 26.8% (22.4%, 30.9%).

Factors associated with anxiety among health professionals in Ethiopia during an early stage of COVID-19 pandemic

Sex, living with at least one family member, average number of patients visited per day, organizational affiliation, whether professionals think that COVID-19 is preventable and sufficient availability of PPE were candidate variables (with p-value<0.2) during the bivariable binary logistic regression. Except living with at least one family member, all of these variables were significantly associated with anxiety among healthcare professionals in the final multivariable binary logistic regression model. Female study participants were 1.88-folds (AOR: 1.88; 95% C.I:1.11, 3.19) at higher adjusted odds of developing anxiety as compared to males. Healthcare professionals who visited above 30 patients per day were 3.44-times (AOR: 3.44; 95% C.I:1.51, 7.84) at higher odds of developing anxiety than those who visited less than an average of nine patients per day. Health professionals employed at private healthcare institutions were 2.4 times (AOR: 2.40; 95% C.I:1.17, 4.90) more likely to be anxious compared to those working at public healthcare institutions. Study subjects who do not believe that COVID-19 is preventable were 2.04 times (AOR: 2.04; 95% C.I:1.04, 4.03) and those who reported lack of PPE were 1.98 times (AOR: 1.98; 95% C.I:1.04, 3.79) more likely to develop anxiety (Table 2).

Table 2

Factors associated with anxiety among health professionals in Ethiopia during an early stage of COVID-19 pandemic (n = 388).

Variables	Anxiety			COR 95% CI	AOR 95% CI
		No (%)	Yes (%)
Sex	Female	72(25.4)	40(38.5)	1.84(1.14,2.96)	1.88(1.11,3.19)*
	Male	212(74.6)	64(61.5)	1	1
Presence of family member living with	No	82(28.9)	38(36.5)	1.42(0.88,2.28)	1.42(0.86,2.36)
	Yes	202(71.1)	66(63.5)	1	1
Average number of patients visited per day	≤9 patients	62(21.9)	9(8.7)	1	1
	10–19 patients	84(29.7)	38(36.5)	3.12(1.40,6.92)	2.22(0.97,5.11)
	20–29 patients	71(25.1)	21(20.2)	2.04(0.87,4.78)	1.89(0.80,4.50)
	30–150 patients	66(23.3)	36(34.6)	3.76(1.67,8.43)	3.44(1.51,7.84)*
Organization	Public	260(91.5)	87(83.7)	1	1
	Private	24(8.5)	17(16.3)	2.12(1.09, 4.12)	2.40(1.17,4.90)*
Do you think that COVID-19 is preventable?	No	26(9.2)	20(19.2)	2.36(1.26,4.45)	2.04(1.04,4.03)*
	Yes	258(90.8)	84(80.8)	1	1
PPE availability	No	218(76.8)	88(84.6)	1.66(0.91,3.03)	1.98(1.04,3.79)*
	Yes	66(23.2)	16(15.4)	1	1

1 = Reference group,

* Significant at p < 0.05,

** Significant at p < 0.001, Hosmer and Lemeshow goodness of fit test (p = 0.338).

Discussion

Anxiety was found to be present in 26.8% of the population with 95% confidence intervals (22.4%, 30.9%). Female healthcare staff, those who saw a higher number of patients per day, those who worked in private healthcare facilities, health professionals who believe COVID-19 is not preventable, and those who indicated a lack of personal protective equipment (PPE) at work were more likely to experience anxiety symptoms.

The prevalence of anxiety in the current study is higher than several earlier study reports from China [33-36] and Italy [10] and lower than other study reports from the China [12, 14, 37–39], Nepal [11], Libya [13], and Egypt and Saudi Arabia [15]. The disparity may be attributed to differences in the anxiety assessment instrument used, the prevalence of COVID-19 and the cut-off values used to dichotomize the outcome. However, the current prevalence of anxiety was similar with a pooled prevalence from a systematic review reported by Sofia et al. [40], a study among medical staff in a tertiary infectious disease hospital for COVID-19 [41], a report from a recent umbrella review [8] and another systematic review [9].

Healthcare professionals with higher patient load were more likely to be anxious. This is not surprising as the number of patients visited increases, healthcare professionals’ risk to COVID-19 becomes high. Healthcare practitioners will encounter shortage of time to exercise COVID-19 preventive practice as the number of patients they have to see per day is higher than the maximum standard.

Changing gloves and washing hands after each patient visit would be extremely difficult for them, especially if the resources available to them at work are limited.

Health professionals working at private settings were more likely to become anxious. No earlier study has reported the disparity in anxiety among public and private healthcare institutions so far as to our extensive literature search. However, we believe that the relative freedom to stay at home whenever possible from public healthcare setup and the strict attendance from private healthcare institutions may explain the higher anxiety level among healthcare professionals working at private settings. Further qualitative study may be needed to explore the real reasons of this discrepancy.

Study subjects who reported lack of PPE were more likely to be anxious in the current study. Similar to this finding a study in Hong Kong revealed that respondents who were more bothered by not having enough surgical masks were more likely to have poor mental health [42]. Depletion of PPE is known to contribute to psychological distress [38]. During the Ebola outbreak, many health workers worked extra-hours and settings without personal protective equipment and driven mainly by compassion resulted in mental health problems disproportionately higher than the general public [43]. A study on psychological impact and coping strategies of frontline Medical staff in Hunan, China revealed that the availability of personal protective equipment provided psychological benefits [44].

In the current study female health professionals were more likely to report anxiety as compared to males. This is in line with several previous studies conducted to see the gender difference of anxiety prevalence [1, 21–24, 40, 44–50]. Several possible explanations have been given for higher level of anxiety disorder among females as compared to their counter parts. Studies [51, 52] have reported that the female reproductive cycle may contribute to the significantly higher prevalence of anxiety in women. The intensive fluctuations in oestrogen and progesterone during the menstrual cycle, pregnancy, or postpartum periods were related to changes in the hormone’s neuroprotective effects, which might increase the chronicity correlated with anxiety occurrence [51]. A study also related the lower risk of developing anxiety in males to differential access to appropriate health services [53]. A metacognitive beliefs in uncontrollability, advantages and avoidance of worry may also contribute to the higher prevalence of anxiety in females than males [54]. So far, several environmental, genetic and physiological factors were suggested that may play a significant role in the differences between females and males in anxiety development [55-57]. A study also showed that women were more reactive than men in neural networks associated with fear and arousal responses [58]. The high prevalence of anxiety among female health professionals in Ethiopia may also be due to higher family responsibilities culturally bestowed on women. Women are usually involved in highly strenuous home activities in addition to their job at work place. A study conducted among 23 countries showed that females reported higher levels of anxiety compared to men at the aggregate data [50]. The study [50] also revealed that in some countries, there was no sex difference in the anxiety level reported. Similarly, there was no significant difference based on gender in a study conducted in China [59]. This might be due to the fact that GAD-7 rates vary by ethnic/cultural group [60].

Finally, health professionals who believe that COVID-19 is not preventable were more likely to be anxious as compared to those who believed that it can be prevented. The lack of hope in prevention of the disease may be indicative of the level of anxiety the healthcare workers are facing.

Limitation of the study

This cross-sectional study is based on self-reported data. Its sampling design is susceptible to bias as it is from internet-based surveys, and the sample does not really represent the general population. The social desirability bias is also another limitation of this study. However, the study is useful to the country for intervention as early as possible to halt the mental health impact of COVID-19 among healthcare professionals.

Conclusions

Anxiety was prevalent among healthcare professionals in Ethiopia during the early stage of COVID-19 pandemic. Patient load, lack of PPE and working in private institutions were factors for anxiety. Females and those who believed that COVID-19 prevention is impossible were more likely to be anxious. The healthcare institutions should fulfill necessary supplies of PPE and establish mental health units to deal with the prevalent cases of anxiety.

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11 Dec 2020

PONE-D-20-32653

Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

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Reviewer #1: Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

This manuscript is important as it assesses anxiety and associated factors among health professionals during COVID-19 which is crucial for developing an intervention plan that will address the problem. However, the introduction, methods, result, and discussion parts of the manuscript need more improvement. Also, the focuses of this study is not clear because the authors sometimes talk about depression the other time about anxiety in the introduction, method, and discussion part. So, this manuscript confuses its reader in its current status. Moreover, there are many grammatical errors that need to be edited by a language expert or a native language speaker.

Abstract

Line 44: “Developing the outcome” is not clear for readers. Try to make the term you use as simple as possible to reach all audiences.

Line 53: It would be better if you leave reporting 95% CI.

Line 54: What do you mean when you say “a large number of patients”? Do you mean treating many patients? It looks confusing.

Line 58-68: what are the implications of your findings?

Main document

Introduction

Line 67: Either delete this sentence or make it clear for readers.

Line 72 and 73: It would be better to delete depression and focus on the topic of your study.

Line 65-86: Less focus was given to anxiety. I was expecting detailed information regarding COVID-19 related anxiety but found very few sentences related to anxiety among health professionals. My recommendation is to make more literature reviews and come up with a strong introduction.

Material and Methods

Line 88-92: Information about study area is missed.

Line 90: Delete the sampling technique and report it under the topic of “sample size determination and sampling technique”.

Line 95: It would be better if you report the specific social media you have used to collect data.

Line 93-96: The inclusion and exclusion criteria are not reported well.

Line 98-102: The sampling technique is not clearly mentioned, and the reason why the authors used the snowball technique is not reported. If the authors have used social media, I do not think the snowball sampling technique is the appropriate method, but your justification is important.

Line 104-111. There are varieties of questionnaires to assess anxiety but there is no clear information regarding why you selected GAD-7. Also, the specificity, sensitivity, and validity of this questionnaire in the study area and other places are not mentioned.

Line 110-111: Use reference regarding the cut-off.

Line 116: If you have analyzed the data for anxiety and depression why you did not change the topic of your study?

Result

Line 131-132, table 1: What do you mean “other health professionals”?

Discussion

Line 160-161: it is a repetition of what you wrote in the introduction. So, try to rewrite this part.

Line 166 -1167: It is better if you mention the place or countries where the previous studies were done including whether it was conducted among a similar population or not.

Line 167-168: What do you mean about the difference in the study population? Also, you were mentioning depression several times including here. So, what you have assessed in this study is not clear, is that depression or anxiety?

Line 171: it is better to leave comparing your study against population-based studies.

Line 197-201: It would be better to find other more convincing explanations regarding why females have higher anxiety during this pandemic.

Line 207-208: Why your finding is different from the study conducted in China. It is better if you discuss the differences.

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Reviewer #1: No

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11 May 2021

Authors’ responses

Title: Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

Manuscript Number: PONE-D-20-32653

Dear Editor/reviewers, we are very grateful for your valid comment given regarding our revised manuscript that helped us to improve the write up. We have considered your eminent comments and suggestions and modified the manuscript accordingly. The response is indicated as authors’ response next to each issues raised.

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

An expert in the field handled your manuscript, and we are grateful for their time and contributions. Although some interest was found in your study, numerous major concerns arose that must be addressed in your revised manuscript. Please respond to ALL of the reviewer's comments.

Authors’ response: Thank you, we have gone through all the issues raised and addressed all of them accordingly.

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Authors’ response: Thank you, we have moved it to the method section.

6. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- https://www.nature.com/articles/srep28033

- https://www.researchsquare.com/article/rs-34504/v1

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Authors’ response: we have gone through the manuscript word for word and we have rephrased, cited and improved the write-up as suggested.

Reviewers' comments:

Reviewer #1: Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

This manuscript is important as it assesses anxiety and associated factors among health professionals during COVID-19 which is crucial for developing an intervention plan that will address the problem. However, the introduction, methods, result, and discussion parts of the manuscript need more improvement. Also, the focuses of this study is not clear because the authors sometimes talk about depression the other time about anxiety in the introduction, method, and discussion part. So, this manuscript confuses its reader in its current status. Moreover, there are many grammatical errors that need to be edited by a language expert or a native language speaker.

Authors’ response: Thank you for the issues raised, we have corrected the write-up and edited for editorial problems. We have meticulously corrected problems at introduction, methods, result, and discussion parts as suggested by the reviewer.

Abstract

Line 44: “Developing the outcome” is not clear for readers. Try to make the term you use as simple as possible to reach all audiences.

Authors’ response: Thank you we changed it as “being anxious”

Line 53: It would be better if you leave reporting 95% CI.

Authors’ response: Thank you, we changed it as suggested.

Line 54: What do you mean when you say “a large number of patients”? Do you mean treating many patients? It looks confusing.

Authors’ response: Thank you we meant treating many patients and we have specifically mentioned it as treating/visiting 30-150 patients per day.

Line 58-68: what are the implications of your findings?

Authors’ response: we have included the following statement as an implication and revised the conclusion section “This study shows that lack of preventive equipment, being female, contact with many patients, low self-efficacy and working in private health facilities were risk factors for anxiety. Anxiety prevention among health professionals during COVID-19 pandemic requires a holistic approach including provision of sufficient PPE, improving self-efficacy and addressing problems both at public and private institutions and focusing more on female health professionals.”

Main document

Introduction

Line 67: Either delete this sentence or make it clear for readers.

Authors’ response: we have revised it.

Line 72 and 73: It would be better to delete depression and focus on the topic of your study.

Authors’ response: Thank you, we have changed it.

Line 65-86: Less focus was given to anxiety. I was expecting detailed information regarding COVID-19 related anxiety but found very few sentences related to anxiety among health professionals. My recommendation is to make more literature reviews and come up with a strong introduction.

Authors’ response: Thank you, we have added additional literature about anxiety among health professionals during COVID-19 pandemic.

Material and Methods

Line 88-92: Information about study area is missed.

Authors’ response: we have added additional information about the study area.

Line 90: Delete the sampling technique and report it under the topic of “sample size determination and sampling technique”.

Authors’ response: Thank you, we have deleted the sampling technique mentioned in the study design, area and period section and mentioned it in the sample size determination section.

Line 95: It would be better if you report the specific social media you have used to collect data.

Authors’ response: Thank you very much we have used social media such as Facebook, Twitter, Email and Instagram

Line 93-96: The inclusion and exclusion criteria are not reported well.

Authors’ responses: Thank you, we have mentioned the following in the revised manuscript

“We have excluded health professionals who had no access to internet during the study period due to different reasons. We have used. We preferred to use social media users because it enables us to collect the data without direct contact with the study participants, which is crucial to reduce the rate of spread of the COVID 19 pandemic.”

Line 98-102: The sampling technique is not clearly mentioned, and the reason why the authors used the snowball technique is not reported. If the authors have used social media, I do not think the snowball sampling technique is the appropriate method, but your justification is important.

Authors’ responses: Thank you we have requested our study participants to send the questionnaire link to their closest friend so that he/ she will participate in the study. This is due to two basic reasons. The first is due to the busy hours they have health professionals do not usually participate in online surveys easily which may result in low response rate, the second reason is that they are more likely respond to questions when they are approached by their closest friends. Because of these reasons, we have used a targeted social networking even though we have shared the questionnaire link over social media.

Line 104-111. There are varieties of questionnaires to assess anxiety but there is no clear information regarding why you selected GAD-7. Also, the specificity, sensitivity, and validity of this questionnaire in the study area and other places are not mentioned.

Authors’ response: Thank you, we have mentioned these informations in the revised manuscript in the data collection and measurement section.

Line 110-111: Use reference regarding the cut-off.

Authors’ response: Thank you we have included reference for the cut of points.

Line 116: If you have analyzed the data for anxiety and depression why you did not change the topic of your study?

Authors’ response: Thank you for this comment, we have corrected the typos error throughout entire write-up and focused only on anxiety.

Result

Line 131-132, table 1: What do you mean “other health professionals”?

Authors’ response: we meant that health professionals other than medicine which includes Nurses, midwives, optometry, environmental health etc.

Discussion

Line 160-161: it is a repetition of what you wrote in the introduction. So, try to rewrite this part.

Authors’ response: thank you, we have removed the mentioned statement.

Line 166 -1167: It is better if you mention the place or countries where the previous studies were done including whether it was conducted among a similar population or not.

Authors’ response: Thank you, the countries and the population can be clearly observed from the references cited. However, we have mentioned the place and population as requested by the reviewer.

Line 167-168: What do you mean about the difference in the study population? Also, you were mentioning depression several times including here. So, what you have assessed in this study is not clear, is that depression or anxiety?

Authors’ response: Thank you, we have removed the term depression and we meant by difference in the study population as the population are different based on the facilities and the countries they are working in, the level of support they receive and the living standard they have as well as other socioeconomic factors even though they are both health professionals. We have rewritten this section to remove ambiguities as we have removed the population based studies as suggested by the reviewer in the forth-coming comment.

Line 171: it is better to leave comparing your study against population-based studies.

Authors’ response: Thank you, we have removed the population based study as suggested.

Line 197-201: It would be better to find other more convincing explanations regarding why females have higher anxiety during this pandemic.

Authors’ responses: we have searched additional evidences for the difference in the levels of anxiety among female health professionals and we have added the additional possible explanations. However, we believe that this study can never give a lasting solution to the different views regarding the difference as there are contradicting evidences. This requires a meta-analysis and additional holistic primary evidences.

Line 207-208: Why your finding is different from the study conducted in China. It is better if you discuss the differences.

Authors’ responses: we have mentioned the possible difference in the revised manuscript.

20 May 2021

Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

PONE-D-20-32653R1

Dear Dr. Dagne,

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31 May 2021

PONE-D-20-32653R1

Anxiety and Associated Factors among Ethiopian Health Professionals at Early Stage of COVID-19 Pandemic in Ethiopia

Dear Dr. Dagne:

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