Asian Journal of Social Health and Behavior

: 2021  |  Volume : 4  |  Issue : 4  |  Page : 163--168

Assessment of the anxiety level and trust in information resources among iranian health-care workers during the pandemic of coronavirus disease 2019

Elham Hasannia1, Fatemeh Mohammadzadeh2, Mitra Tavakolizadeh3, Najmeh Davoudian4, Mostafa Bay5,  
1 Department of Psychiatry and Behavioral Sciences, Gonabad University of Medical Science, Gonabad, Iran
2 Department of Epidemiology and Biostatistics, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
3 Department of Medical-Surgical Nursing, Clinical Research Development Unit, Bohlool Hospital, Gonabad University of Medical Sciences, Gonabad, Iran
4 Department of Internal Medicine, Clinical Research Development Unit, Bohlool Hospital, Gonabad University of Medical Sciences, Gonabad, Iran
5 AJA University of Medical Sciences, Tehran, Iran

Correspondence Address:
Mitra Tavakolizadeh
No. 84, Ghaem Street, Gonabad, 9691894794


Introduction: The psychological impacts of the coronavirus disease 2019 (COVID-19) on health-care workers (HWs) are undeniable, especially that knowledge on the disease is limited, and the credibility of some existing sources of information is questionable. We aimed to assess the level of anxiety and trust in information resources among Iranians' HWs. Methods: A web-based cross-sectional survey was conducted on 1199 HWs between March and April 2020 in Iran. Data on demographic variables, sources of information about the COVID-19, and the trust level to them were collected using online self-administered questionnaires. The anxiety severity level was assessed using the Zung self-rating anxiety scale. Data were analyzed using simple and multiple linear regression models. Results: The mean age of participants was 32.5 ± 8.79, and 65.7% (n = 763) were male. 30.4% (95% confidence interval (CI) (CI: 27.8%–33.1%) of HWs had mild to moderate, and 21.3% (95% CI: 18.9%–23.7%) had severe and extremely severe levels of anxiety. TV (83.7%) and social media networks (58.2%) were the most frequent information sources. The lowest trust level and highest anxiety levels, and in contrast, the highest trust level and lowest anxiety levels were observed among social media users and TV viewers, respectively. The results of the multiple linear analysis showed that less work experience (P = 0.003), master's degree or above (P = 0.006), being divorced or widowed (P < 0.001), higher levels of exposure to COVID-19 patients (P < 0.05), having a history of mental illness (P < 0.001), and having underlying medical conditions (P < 0.001) were associated with higher anxiety levels. Conclusion: The study results revealed that the anxiety level among the HWs is relatively significant, and the trust level in social media networks was the lowest. Further psychological assessments and more investigations regarding the reasons for the reduction of trust and the development of the appropriate approaches to improve it are required.

How to cite this article:
Hasannia E, Mohammadzadeh F, Tavakolizadeh M, Davoudian N, Bay M. Assessment of the anxiety level and trust in information resources among iranian health-care workers during the pandemic of coronavirus disease 2019.Asian J Soc Health Behav 2021;4:163-168

How to cite this URL:
Hasannia E, Mohammadzadeh F, Tavakolizadeh M, Davoudian N, Bay M. Assessment of the anxiety level and trust in information resources among iranian health-care workers during the pandemic of coronavirus disease 2019. Asian J Soc Health Behav [serial online] 2021 [cited 2022 Jun 25 ];4:163-168
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Full Text


In December 2019, the Chinese city of Wuhan reported novel pneumonia caused by the coronavirus disease 2019 (COVID-19), which rapidly crossed borders, infecting people throughout the whole world.[1] It causes a severe acute respiratory illness, and the range of symptoms includes fever, cough, and dyspnea, with chest radiographs revealing invasive lesions in both lungs.[2],[3],[4] On August 22, the cumulative number of cases reported globally is now over 211 million, and the cumulative number of deaths is just over 4.4 million. On this date, in Iran, the cumulative number of cases and deaths are reported as over 4.8 million and 105 thousand, respectively.[3]

In this emergency, to keep up the satisfaction of the human services workforce, not only a sufficient number of doctors, attendants, propelled practice clinicians, drug specialists, respiratory advisors, and different clinicians are needed but also amplifying the capacity of every clinician to thinking about a high volume of patients is required. Human services experts need to use their maximum capacity to serve patients facing the flood of patients in the coming weeks and months. Moreover, they simultaneously need to adapt to the cultural movements and stressors, massive tasks, moral difficulties, and the immediate changes in contrast with what they know about it.[4],[5],[6],[7] There was no doubt that health-care workers (HWs) play an indispensable role in this public health emergency. They are exposed to physical and psychological stress factors, in response to this emergency, and the threatening infectious disease.[4] The findings of a cross-sectional study, on 1257 HWs in 34 hospitals equipped in China, showed that a considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Furthermore, Chinese HWs who were exposed to COVID-19, women, nurses, those in Wuhan, and front-line HWs have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.[6]

Limited knowledge about the disease and lack of treatment or vaccination exacerbate the conditions. During a new pandemic, getting information from various sources, such as public health professionals, the government, and the media, can increase people's awareness about the risk, and consequently, their adoption of preventive measures.[8] During the COVID-19 pandemic, the official departments strive to improve the public's awareness of prevention and intervention strategies by providing daily updates about surveillance and active cases on websites and social media.[9] Besides, many self-media and netizens also release and transfer related information on social media, such as WeChat and Weibo. A striking particularity of this crisis is the coincidence of virology and virality. Not only did the virus itself spread very rapidly, but also did the information or misinformation about the outbreak, and thus it expanded the created panic among the public.[10],[11] The social media panic traveled faster than the COVID-19 spread.[12] Social media may lead to misinformation overload,[13] which may cause mental health problems. There is no sufficient research on the mental health of the Iranian population during the COVID-19 pandemic. Furthermore, the psychological impact of COVID-19 on HWs is undeniable, and the credibility of some information resources about COVID-19 is questionable. Therefore, this study aimed to assess the level of anxiety levels and also the trust levels in the information resources among Iranians' HWs and determine whether the anxiety level has a link with the trust levels in the information resources.


Design and participants

This cross-sectional online study was conducted from March 15 to April 15, 2020, among Iranians' HWs. An invitation link to the online webpage of the questionnaires was sent to HWs were working during the COVID-19 pandemic in governmental and private sectors through related channels or groups of Telegram and WhatsApp. The participants were requested to send that to other colleagues who they know.

Sample size

A sample size estimation of 1053 subjects was calculated based on the formula of n = and considering a 95% confidence interval (CI), 90% power, and a small effect size of E = 0.1 according to Cohen's recommendations,[14] to determine the status (mean score) of the level of anxiety during the COVID-19 pandemic among Iranians' HWs. It was increased to 1159 subjects for a possible attrition rate of 10%.

Inclusion criteria of the study were as follows: being a HW, age above 18 years, willingness to participate in the study, ability to read and write, the passage of at least 6 months of the beginning the work, and having Iranian nationality. The incomplete questionnaires were excluded from the study.


Zung self-rating anxiety scale

The Zung self-rating anxiety scale (SAS) was used in this study to assess the subjective feelings of anxiety. It has been used to screen the people who may be anxious in the research and clinical settings.[15],[16],[17] In the past 40 years, SAS has been translated into many languages and widely used in different cultures. The scale has 20 items which are rated on a 4-point Likert scale (never = 1, sometimes = 2, most often = 3, and always = 4). Five items (Nos. 5, 9, 13, 17, and 19) in the SAS scale are stated using negative words and are scored reversely. The total raw score is calculated by summing the scores of all items, and the standard score is 1.25 × total raw score. Anxiety levels are graded as follows: standard score below 45 = nonanxiety; 45–59 = mild-to-moderate anxiety; 60–74 = severe anxiety, and above 75 = extremely severe anxiety. This scale has been translated into 10 different languages for cross-cultural research. This is a self-rating questionnaire totaling 20 questions. Questions 1–5 represent the emotional symptoms of anxiety, while questions 6–20 represent the physical symptoms of anxiety. Scores range from 1 to 4 points per question. If the score is ×50, it indicates “psychological anxiety” with 50–59 indicating mild anxiety, 60–69 moderate anxiety, and ×70 severe anxiety. The scale was translated into Chinese in 1982 in Taiwan, and the test–retest reliability is 0.70, and criterion-related validity (0.60) is measured with anxiety scale in “physical and mental health score.”[17],[18] Studies show that the SAS scale is reliable and possible to use in Iran. In the study by Sahebi et al.[19] that was performed on the Iranian population, the correlation coefficient to examine the concurrent validity of the SAS scale with the DASS anxiety subscale has was 0.67. Furthermore, in several studies in Iran, acceptable reliability has been reported for the scale.[20],[21],[22] In this study, the reliability of the scale was examined by Cronbach's alpha that was acceptable (0.84).

Use of and trust in information sources

We provided two items to assess the use of and trust level for each information source (including TV, social media networks, papers, and friends/family members) about the COVID-19 as follows: (1) “I use this service to find information regarding COVID-19”, and (2) “I trust the information received by this service”. The first item was binary (yes or no), and the second item was a 5-point Likert scale (very low, low, medium, high, and very high).


The following covariates were included in this study: gender, age, work experience, occupation, level of education, the economic situation, marital status, the amount of exposure to COVID-19 patients, history of mental illness, the amount of time to get information per day, and the presence of an underlying disease.

Ethical considerations

This study has been approved by the Gonabad University of Medical Sciences (IR.GMU.REC.1398.194). The questionnaires were completed by anonymous participants and with informed consent.

Statistical analyses

Data analyses were done using SPSS software version 16.0 IBM (SPSS Inc., Chicago, Illinois, USA). Continuous variables were summarized as mean ± standard deviation. Descriptive statistics for categorical variables also described using frequency and percentage. The simple and multiple linear regression models were used to determine the factors related to anxiety levels. Variables that had a P < 0.2 in simple linear regression model was entered in the multiple regression model. The assumptions of the linear regression, including normality, and homoscedasticity of variance, and independence of errors were assessed using normal QQ-plot of residuals, scatter plot of standardized residuals and standardized predicted values, and residual time series plot. All of the assumptions were met. The statistical significance was considered as P < 0.05.


Data of 1199 HWs were collected and analyzed (response rate = 87%). The characteristics of the participants are shown in [Table 1]. The mean age of participants was 32.5 ± 8.79, with a range from 20 to 70 years. The mean work experience was 7.9 ± 7.2 years.{Table 1}

TV and social media networks were among the most frequently utilized sources of information about the COVID-19 (83.7% and 58.2%, respectively). The mean time spent obtaining information about COVID-19 was 3.1 ± 2.7 h a day. The mean of anxiety score was 47.7 ± 13.9 and based on the cutoff of the questionnaire 30.4% (95% CI: 27.8–33.1%) of the participants had mild to moderate levels, and 21.3% (95% CI: 18.9%–23.7%) had severe and extremely severe levels of anxiety. The trust level in social media networks was the lowest, such that the trust level in 72.3% (95% CI: 68.9%–75.6%) of social media network users was mild. The highest trust level was related to TV, such that the trust level in 35.6% (95% CI: 32.6%–38.6%) of TV watchers was moderate to high. In contrast, the lowest and highest anxiety levels were linked to social media users and TV viewers, respectively [Table 2].{Table 2}

The results of the multiple linear analysis revealed that for every 1-year increase in work experience the anxiety level decrease by 0.17 (P = 0.003). People with a master's degree and above were 2.63 units less anxious than others (P = 0.006). Divorced or widowed people experience more anxiety than married people by 8.06 units (P < 0.001). Furthermore, individuals with higher levels of exposure to COVID-19 patients suffered higher anxiety levels (P < 0.05). Having a history of mental illness and underlying medical condition increases the anxiety level by 5.99 and 9.39 units, respectively (P < 0.001) [Table 3]. The anxiety had no relation with age, gender, and economic status.{Table 3}


In this study, we assessed the level of anxiety and trust in information resources among Iranians' HWs.

This study showed that 30.4% of HWs had mild to moderate, and 21.3% had severe and extremely severe levels of anxiety. In one study on 1257 HWs in China, a considerable proportion of HWs reported experiencing symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Expressly, women, nurses, and those HWs who were engaged in Wuhan, or the front-line and directly involved in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19 reported more severe degrees of all measurements of mental health symptoms than other HWs.[6]

A review of 14 studies on the stress experience of HWs found a significant strain of depression and anxiety symptoms. Severe degrees of those symptoms were found in 2.2% to 14.5% of all participants.[23] In our study, 21.3% of participants had severe and extremely severe levels of anxiety. The findings of our study showed that participants with higher levels of exposure to COVID-19 patients suffered higher anxiety levels. A similar study in China during coronavirus pandemic showed that as compared to the nonclinical staff, frontline medical staff with close contact with infected patients were twice more likely to suffer anxiety and depression.[24]

In our study, TV and social media networks were the most common sources of access to information related to COVID-19, and the highest trust level was related to TV and the lowest trust level was related to social media networks. In a study conducted to examine the level of trust of Tehran residents in the health information of mass media and virtual social networks, the highest trust level was related to television (about 65%) and radio (about 56%). In their study, the trust level for virtual social networks was about 30%.[25] In another study by Brown-Johnson et al., which was aimed to investigate the level of trust in information resources, 24% of participants rated the internet as trustworthy, followed by television (21%), radio (18%), and social media (11%) obtained more trust levels, respectively.[26] One of the explanations that most viewers trust TV content is because it offers information from credible and trustworthy sources through hiring trained individuals. Another reason for TV's success in gaining people's trust is that it pays attention to the importance of or the speed of transfer news and that it provides health alerts and information to the audience as quickly as practicable. Professional performance and the correct way of expressing the content are also among the things that affect the acceptance of the message.[25] In our research, the level of trust in all coronavirus-related information sources among HWs was generally not very high. The highest trust level was related to TV, such that the only 35.6% of TV watchers had moderate to severe trust level in this source. The complex nature of coronavirus, ambiguous transmission methods, and a variety of clinical symptoms, all of which have led to conflicting information in various information sources (even reputable scientific sources), can be one of the reasons for this decline in trust.

A study in Wuhan, China, showed that more than 80% of participants reported frequently exposed to social media, and more frequent social media exposure was associated with higher anxiety and depression.[27] In our study, the highest anxiety levels were linked with social media users.

Another finding of our study was that people with more work experience showed lower level of anxiety. The increase in years of service has inevitably led to various epidemics and crises that have gradually helped people to mature. More work experience causes less anxiety in the face of a crisis. A study on the mental health of physicians during the outbreak of COVID-19 in Oman found that older physicians experience greater well-being and a lower level of stress compared to younger counterparts. Furthermore, the current study indicated that married people had lower anxiety levels than single, widowed, or divorced people. Another study also showed that married physicians reported less stress than nonmarried peers.[28] We found that having a history of mental illness or underlying disease increases the anxiety level. A study that assessed the emotional effects of coronavirus showed older adults with psychiatric conditions may be experiencing further distress.[29] This study is one of the few studies that examined the level of anxiety among Iranian HWs, and according to our knowledge, it is the first study that has examined the level of trust in information resources during the COVID-19 outbreak in Iran among HWs, which is one of its strengths.


Anxiety level and trust in information resources was measured using questionnaire, and the data relied on the ability of the individual to interpret the questions and provide accurate responses, but these responses were not verified objectively. Therefore, some causal relationships may have been missed. Further cohort studies with more samples should be performed, and nonsubjective methods should be used. The impossibility of investigating causal relationships due to the cross-sectional design of the study, selection of bias and restriction of generalizability because of the nonprobabilistic sampling, and lack of review of all available information sources were the limitations of the current study.

Further psychological assessments are required, as well as investigating the reasons for the reduction of trust and the development of the appropriate approaches to improve it.


More than one-fifth of the respondents experienced severe and extremely severe anxiety levels. Single, divorced, or widowed people with less work experience, lower educational level, higher exposure levels with the COVID-19 patients, history of mental disorders, and underlying disease are more likely to experience higher severity levels of anxiety.


The current study was approved (approval no: A-10-1409-1) and financially supported by the Clinical Research Development Unit of Bohlool hospital in Gonabad University of Medical Sciences. Moreover, all authors wish to acknowledge all participants in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
2Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
3WHO. World Health Organization Corona Virus Disease 2019 (COVID-19) Situation Report. Available from: [Last accessed on 2021 Aug 28].
4Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-6.
5Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA 2020;323:1439-40.
6Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
7Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-4.
8van der Weerd W, Timmermans DR, Beaujean DJ, Oudhoff J, van Steenbergen JE. Monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza A (H1N1) pandemic in the Netherlands. BMC Public Health 2011;11:575.
9Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: Address mental health care to empower society. Lancet 2020;395:e37-8.
10Larson HJ. The biggest pandemic risk? Viral misinformation. Nature 2018;562:309.
11McCauley M, Minsky S, Viswanath K. The H1N1 pandemic: Media frames, stigmatization and coping. BMC Public Health 2013;13:1116.
12Wilson M, Chen L. Travelers give wings to novel coronavirus (2019-nCoV). J Travel Med 2020;27:taaa015.
13Roth F, Brönnimann G. Focal report 8: risk analysis using the Internet for Public Risk Communication, Risk and Resilience Reports, ETH Zurich, The Center for Security Studies: Zurich, Switzerland; 2013.
14Cohen J. Statistical Power Analysis for the Behavioral Sciences. England, UK: Academic Press; 2013.
15Hong X, Currier GW, Zhao X, Jiang Y, Zhou W, Wei J. Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: A 4-year follow-up study. Gen Hosp Psychiatry 2009;31:546-54.
16Samakouri M, Bouhos G, Kadoglou M, Giantzelidou A, Tsolaki K, Livaditis M. Standardization of the Greek version of zung's self-rating anxiety scale (SAS). Psychiatriki 2012;23:212-20.
17Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.
18Chen R, Chou KR, Huang YJ, Wang TS, Liu SY, Ho LY. Effects of a SARS prevention programme in Taiwan on nursing staff's anxiety, depression and sleep quality: A longitudinal survey. Int J Nurs Stud 2006;43:215-25.
19Sahebi A, Asghari MJ, Salari RS. Validation of Depression Anxiety and Stress Scale (DASS-21) for an Iranian Population; 2005:36-54.
20Madjidzadeh R, Hakimjavadi M, Gholamali Lavasani M. The reduction of anxiety and blood sugar level with group cognitive-behavior therapy in men and women with type II diabetes: An experimental study. Casp J Neurol Sci 2017;3:95-105.
21Rostami-Nejad M, Taraghikhah N, Ciacci C, Pourhoseingholi MA, Barzegar F, Rezaei-Tavirani M, et al. Anxiety symptoms in adult celiac patients and the effect of a gluten-free diet: An Iranian nationwide study. Inflamm Intest Dis 2020;5:42-8.
22Khorvash F, Askari G, Vesal S, Mehrbod N, Ghasemi H, Fatehizade M, et al. Investigating the anxiety level in Iranian medical residents in 2010-2011. Int J Prev Med 2013;4 Suppl 2:S318-22.
23Bohlken J, Schömig F, Lemke MR, Pumberger M, Riedel-Heller SG. COVID-19 pandemic: Stress experience of healthcare workers – A short current review. Psychiatr Pra×2020;47:190-7.
24Lu W, Wang H, Lin Y, Li L. Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study. Psychiatry Res 2020;288:112936.
25Tavousi M, Mohammadi S, Sadighi J, Rostami R, Haeri Mehrizi AL. Trust in mass media and virtual social networks health information: A population study. Payesh 2019;18:231-40.
26Brown-Johnson CG, Boeckman LM, White AH, Burbank AD, Paulson S, Beebe LA. Trust in health information sources: Survey analysis of variation by sociodemographic and tobacco use status in Oklahoma. JMIR Public Health Surveill 2018;4:e8.
27Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, et al. Mental health problems and social media exposure during COVID-19 outbreak. PLoS One. 2020;15:e0231924.
28Badahdah AM, Khamis F, Mahyijari NA. The psychological well-being of physicians during COVID-19 outbreak in Oman. Psychiatry Res 2020;289:113053.
29Lima CK, Carvalho PM, Lima IA, Nunes JV, Saraiva JS, de Souza RI, et al. The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Res 2020;287:112915.