1. Introduction
oronavirus disease (Covid-19), caused by SARS-COV-2 virus, was first diagnosed in December 2019 in Wuhan, China [1]. The lack of any definitive treatment or preventive method, and the prediction of some epidemiologists that at least 60% of the population is infected with Covid-19, has caused a lot of stress and anxiety in people [2]. Fear and anxiety caused by a disease are destructive and can lead to mental disorders. Fear and stress by stimulating the hypothalamus in the brain and subsequently increasing the secretion of cortisol from the adrenal gland and stimulating the sympathetic nerves throughout the body in the short term is beneficial for the body to deal with stressors [3], but if this fear and stress and the body’s response (increased cortisol levels and sympathetic stimulation) continue for a long time, it is destructive and can lead to a weakened immune system and reduced ability of the body to fight diseases such as Covid-19 [4].
2. Materials and Methods
In this descriptive cross-sectional study, 402 medical and administrative staff working in hospitals and health centers of Jahrom city in Iran who were exposed to or not exposed to Covid-19 were selected for the study using census method. Researchers first visited the health centers and hospitals in Jahrom city, and after obtaining permission from them, data were collected by using a demographic form (surveying age, gender, marital status, level of education, occupation, place of residence, workplace department, work experience, number of people living together at home, history of domestic or international travel in the past month, having/not having Covid-19, and type of employment), and the Corona Disease Anxiety Scale (CDAS). Collected data were analyzed in SPSS V. 21 software by using descriptive statistics (frequency, mean, percentage) and statistical tests including ANOVA, considering a significance level of P<0.05.
3. Results
As shown in Table 1, the mean overall score of anxiety in the medical staff (16.12) was higher than in the administrative staff (14.46) during the Covid-19 pandemic in Jahrom city. 


The mean score of mental symptoms in the medical staff (46.91) was also higher than in the administrative staff (42.63) as well as the mean score of physical symptoms (12.80 vs. 10.94).There was a significant difference between medical and administrative staff in terms of mean anxiety (P=0.030). Comparison of the estimated marginal means showed that the mean score of anxiety in the medical staff (17.68) was higher than in the administrative staff (14.049). The estimated marginal mean of anxiety in female medical staff was higher than in female administrative staff, and was higher in male medical staff than in female administrative staff. Comparison of the estimated marginal means showed that the mean score of mental symptoms in the medical staff (12.59) was higher than in the administrative staff (11.12). The estimated marginal mean of physical symptoms in female medical staff was higher than in female administrative staff, and was higher in male medical staff than in male administrative staff. In the age groups of <30 years and 31-40 years, there was no significant difference in the physical symptoms between the medical and administrative staff, but in the age groups of 41-50 years and >50 years, the mean anxiety of medical staff was significantly higher than that of administrative staff (Table 2). 


4. Discussion and Conclusion
The present study compared the level of anxiety in medical and non-medical staff to identify risk factors and their level of anxiety. The results of the present study showed that working in a hospital and caring for patients with Covid-19 was a risk factor for increasing anxiety scores in the medical staff compared to non-medical staff. The results of the present study showed that there was a significant difference between the medical and administrative staff in terms of Covid-19-induced anxiety. Benjamin et al. (2020) conducted a study to investigate the psychological impact of COVID-19 on 470 health care workers in Singapore. Their results showed that the non-medically trained hospital personnel experience more anxiety than the medically trained hospital personnel during the Covid-19 outbreak [28]. This is against our results. In our study, the anxiety level of medical staff was higher than that of administrative staff. The level of anxiety reported in the present study is lower than in the studies conducted in this field [32، 31، 20، 13], and higher than the level presented in other study [21]. This difference in anxiety may be due to the use of different tools to measure anxiety. Moreover, the time of the present study coincided with the second wave of COVID-19 outbreak in Iran, while the above studies were conducted before the second wave. At this time, the Iranian Ministry of Health and Medical Education and the Coronavirus Disease Control Headquarters took more precautions to prevent the disease. This resulted in a higher level of anxiety among the medical staff. Considering the importance of mental health including anxiety in the medical staff and the important role it plays in strengthening safety, special measures should be taken to reduce anxiety among health care providers.

Ethical Considerations
Compliance with ethical guidelines
This study was extracted from a research proposal and approved by the Jahrom University of Medical Sciences (Code: IR.JUMS.REC.1399.046).

Funding
This study was supported by the Clinical Research Development Unit of Peymaniyeh Hospital in Jahrom, Iran.

Authors' contributions
Conseptualization, problem design, writing – review & editing: All Authors; Methodology and data analysis: Navid Kalani, Nasser Hatami and Mohammad Heidarnejad.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Clinical Research Development Unit of Peymaniyeh Hospital in Jahrom, Iran for their support and cooperation.


References

1. Farnoosh G, Alishiri G, Hosseini Zijoud S R, Dorostkar R, Jalali Farahani A. [Understanding the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) and Coronavirus Disease (COVID- 19) based on available evidence-a narrative review (Persian)]. J Mil Med. 2020; 22(1):1-11. [DOI:10.30491/JMM.22.1.1]
2. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020; 395(10228):931-4. [DOI:10.1016/S0140-6736(20)30567-5]
3. Barrett K, Barman S, Yuan J, Brooks H. Ganong’s review of medical physiology. 26^th ed. New York: McGraw-Hill Education; 2019. https://www.amazon.com/Ganongs-Review-Medical-Physiology-Twenty/dp/1260122409
4. Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A. The impact of stress on body function:A review. EXCLI J. 2017; 16:1057-72. [DOI:10.17179/excli2017-480] [PMID]
5. Bajema KL, Oster AM, McGovern OL, Lindstrom S, Stenger MR. Persons evaluated for 2019 novel Coronavirus - United States, January 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(6):166-70. [DOI:10.15585/mmwr.mm6906e1] [PMID] [PMCID]
6. To KK-W, Tsang OTY, Yip CC-Y, Chan KH, Wu T-C, Chan JM-C, et al. Consistent detection of 2019 novel Coronavirus in Saliva. Clin Infect Dis. 2020; 71(15):841-3. [DOI:10.1093/cid/ciaa149] [PMID] [PMCID]
7. Alipour A, Ghadami A, Alipour Z, Abdollahzadeh H. [Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in the Iranian sample (Persian)]. Health Psychol. 2020; 8(32):163-75. [DOI:10.30473/HPJ.2020.52023.4756]
8. Azad-Marzabadi E, Salimi SH. [Study on Job stress in a military unit (Persian)]. J Mil Med. 2005; 6(4):279-84. http://militarymedj.ir/article-A-10-1-10-1-fa.html
9. World Health Organization. The world health report 2001 - mental health:New understanding, new hope [Internet]. 2001 [Updated 2001]. Availeble from: https://www.who.int/whr/2001/en/
10. Ryan ME, Wibell RS. Concerns, values, stress, coping, health and educational outcomes of college students who studied abroad. Int J Intercult Relat. 2000; 24(4):409-35. [DOI:10.1016/S0147-1767(00)00014-6]
11. Gammon J, Morgan-Samuel H. A study to ascertain the effect of structured student tutorial support on student stress, self-esteem and coping. Nurse Educ Pract. 2005; 5(3):161-71. [DOI:10.1016/j.nepr.2004.09.003] [PMID]
12. Paul E, Pector S. Industrial and organization psychology. Department of psychology, university of Florida. Florida: John Wiley and Sons; 2000.
13. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factorsassociated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020; 3(3):e203976. [DOI:10.1001/jamanetworkopen.2020.3976] [PMID] [PMCID]
14. Poon E, Liu KS, Cheong DL, Lee CK, Yam LY, Tang WN. Impact of severe acute respiratory syndrome on anxiety levels of front-line Health care workers. Hong Kong Med J. 2004; 10(5):325-30. [PMID]
15. Lee SA, Mathis AA, Jobe MC, Pappalardo EA. Clinically significant fear and anxiety of COVID-19: A psychometric examination of the Coronavirus Anxiety Scale. Psychiatry Res. 2020; 290:113112. [DOI:10.1016/j.psychres.2020.113112] [PMID] [PMCID]
16. McGrandles A, Duffy T. Assessment and treatment of patients with anxiety. Nurs Stand. 2012; 26(35):48-58. [DOI:10.7748/ns2012.05.26.35.48.c9082] [PMID]
17. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. J Am Med Assoc. 2020; 323(21):2133-34. [DOI:10.1001/jama.2020.5893] [PMID]
18. Chen KY, Yang CM, Lien CH, Chiou HY, Lin MR, Chang HR, et al. Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci. 2013; 10(11):1471-78. [DOI:10.7150/ijms.6743] [PMID] [PMCID]
19. Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry. 2004; 185(2):127-33. [DOI:10.1192/bjp.185.2.127] [PMID]
20. Goulia P, Mantas C, Dimitroula D, Mantis D, Hyphantis T. General hospital staff worries, perceived sufficiency of informa¬tion and associated psychological distress during the A/H1N1 influenza pandemic. BMC Infect Dis. 2010; 10:322. [DOI:10.1186/1471-2334-10-322] [PMID] [PMCID]
21. Liu CY, Yang YZ, Zhang XM, Xu X, Dou QL, Zhang WW, et al. The prevalence and influencing factors for anxiety in medical workers fighting COVID-19 in China:A cross-sectional survey. Epidemiol Infect. 2020; 148:1-7. [DOI:10.1017/S0007485320000413]
22. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Exp Ther Med. 2020; 38(3):192-95. https://doi.org/10.3760/cma.j.cn121094-20200219-00063
23. Cheong D, Lee C. Impact of severe acute respiratory syndrome on anxiety levels of front-linehealth care workers. Hong Kong Med J. 2004; 10(5):330-25.
24. Zhong NS, Zheng BJ, Li YM, Poon LLM, Xie ZH, Chan KH, et al. Epidemiology and cause of Severe Acute Respiratory Syndrome (SARS) in Guangdong, People’s Republic of China, in February 2003. Lancet. 2003; 362(9393):1353-8. [DOI:10.1016/S0140-6736(03)14630-2]
25. Leung GM, Ho LM, Chan SK, Ho SY, Bacon-Shone J, Choy RY, et al. Longitudinal assessment of community psycho behavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in Hong Kong. Clin Infect Dis. 2005; 40(12):1713-20. [DOI:10.1086/429923] [PMID]
26. Brooks SK, Dunn R, Amlôt R, Rubin GJ, Greenberg N. A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak. J Occup Environ Med. 2018; 60(3):248-57. [DOI:10.1097/JOM.0000000000001235] [PMID]
27. Li S, Wang Y, Xue J, Zhao N, Zhu T. The impact of COVID-19 epidemic declaration on psychological consequences:A study on active Weibo users. Int J Environ Res Public Health. 2020; 17(6):2032. [DOI:10.3390/ijerph17062032] [PMID] [PMCID]
28. Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, et al. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore. Ann Intern Med. 2020; 173(4):317-20. [DOI:10.7326/M20-1083] [PMID] [PMCID]
29. Bostan S, Akbolat M, Kaya A, Ozata M, Gunes D. Assessments of anxiety levels and working conditions of health employees working in COVID-19 pandemic hospitals. Electron J Gen Med. 2020; 17(5):em246. [DOI:10.29333/ejgm/8228]
30. Li S, Li L, Zhu X, Wang Y, Zhang J, Zhao L, et al. Comparison of characteristics of anxiety sensitivity across career stages and its relationship with nursing stress among female nurses in Hunan, China. BMJ Open. 2016; 6(5):1-7. [DOI:10.1136/bmjopen-2015-010829] [PMID] [PMCID]
31. Labrague LJ, De los Santos JA. COVID-19 anxiety among front-line nurses:Predictive role of organisational support, personal resilience and social support. J Nurs Manag. 2020; 28(7):1653-61. [DOI:10.1101/2020.07.16.20141069]
32. Amin F, Sharif S, Saeed R, Durrani N, Jilani D. COVID-19 pandemic-knowledge, perception, anxiety and depression among frontline doctors of Pakistan. BMC Psychiatry. 2020; 20:459. [DOI:10.1186/s12888-020-02864-x]
33. Shahyad S, Mohammadi MT. Psychological impacts of Covid-19 Outbreak on mental health status of society individuals:A narrative review. J Mil Med. 2020; 22(2):184-92. [DOI:10.30491/JMM.22.2.184]
34. Rajkumar RP. COVID-19 and mental health:A review of the existing literature. Asian J Psychiatr. 2020; 52:102066. [DOI:10.1016/j.ajp.2020.102066] [PMID] [PMCID]
35. Guo J, Liao L, Wang B, Li X, Guo L, Tong Z, et al. Psychological Effects of COVID-19 on hospital staff:A national cross-sectional survey of China mainland [Internet]. 2020 [Updated 2020 March 13]. Available from:https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3550050 [DOI:10.2139/ssrn.3550050]
36. Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak. Asian J Psychiatr 2020; 51:102080. [DOI:10.1016/j.ajp.2020.102080] [PMID] [PMCID]
37. Banerjee D. The COVID-19 outbreak:Crucial role the psychiatrists can play. Asian J Psychiatr. 2020; 50:102014. [DOI:10.1016/j.ajp.2020.102014] [PMID] [PMCID]
38. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. J Am Med Assoc. 2020; 323(15):1439-40. [DOI:10.1001/jama.2020.3972] [PMID]
39. Saqlain M, Munir MM, Rehman SU, Gulzar A, Naz S, Ahmed Z, et al. Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19:A Cross-sectional survey from Pakistan. J Hosp Infect. 2020; 105(3):419-23. [DOI:10.1016/j.jhin.2020.05.007] [PMID] [PMCID]
40. Chen KY, Yang CM, Lien CH, Chiou HY, Lin MR, Chang HR, et al. Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci. 2013; 10(11):1471-8. [DOI:10.7150/ijms.6743] [PMID] [PMCID]
41. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. J Am Med Assoc. 2020; 323(15):1439-40. [DOI:10.1001/jama.2020.3972] [PMID]
42. Chen 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(4):E15-6. [DOI:10.1016/S2215-0366(20)30078-X]
43. Cohen IG, Crespo AM, White DB. Potential legal liability for withdrawing or withholding ventilators during COVID-19:Assessing the risks and identifying needed reforms. JAMA. 2020; 323(19):1901-2. [DOI:10.1001/jama.2020.5442] [PMID]
44. Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al. The experiences of health-care providers during the COVID-19 crisis in China:a qualitative study. Lancet Global Health. 2020; 8(6):e790-8. [DOI:10.1016/S2214-109X(20)30204-7]