Qom University of Medical Sciences Journal

Introduction
With the COVID-19 pandemic, healthcare workers, particularly those in hospitals, found themselves at the forefront of the fight against a novel disease. The challenging working conditions, including direct exposure to infected patients, shortages of personal protective equipment, long working hours, and fear of transmitting the virus to family members, created unprecedented psychological pressure on this group. Numerous international and national studies have shown that healthcare workers experienced high levels of depression, anxiety, and stress during the pandemic. 
Qom province, as one of the first epicenters of COVID-19 in Iran, faced a high volume of infected cases, placing additional pressure on healthcare workers in this area. Despite the critical importance of their mental health, no comprehensive study was found (at the time of conducting this research) to investigate the prevalence and contributing factors of depression, anxiety, and stress among medical staff in hospitals affiliated to Qom University of Medical Sciences. This study thus aimed to determine the prevalence and influencing factors of depression, anxiety, and stress during the COVID-19 pandemic among medical staff of hospitals in Qom, Iran.
Methods
This cross-sectional analytical study was conducted in 2022. The study population included all medical staff of hospitals affiliated to Qom University of Medical Sciences.The inclusion criteria were: willingness to participate in the study and at least three years of continuous service. Individuals who had experienced major traumatic events in the past year or were unwilling to continue participation were excluded. Participants were selected using a convenience sampling method.  
Data were collected using the depression anxiety stress scale-21 (DASS-21). This 21-item questionnaire consists of three separate subscales, each with seven items. After obtaining ethical approvals and necessary coordination, questionnaires were distributed among the participants and collected after completion. Data analysis was performed in SPSS software, employing descriptive and analytical statistics. A significance level of 0.05 was set for all tests.  

Results
The study included 150 participants (86.7% female, 13.3% male). The majority were married (66.7%) with a bachelor’s degree (59.3%). Professionally, the largest groups were healthcare providers (38%) and midwives (25.3%). Regarding working hours, most of them (74.7%) worked 41–50 hours per week at the hospital, and had less than four hours of additional work outside the hospital (78%). Notably, 84.7% had no chronic illnesses, and none of the participants were smokers or drug users. Regarding psychological status, the highest prevalence was observed for severe anxiety (52%) and moderate depression (52.7%). For stress, 29.3% fell into the moderate and severe stress categories. Gender differences were significant only for depression (P=0.001), with males showing higher rates of severe depression than females (60% vs 20%). Marital status had no significant impact on the severity of psychological disorders (P>0.05). Both single and married participants exhibited similar patterns, with moderate depression (54% singles, 52% married) and severe anxiety (50% singles, 53% married) being more common.  
Although those with a history of chronic illness had higher rates of very severe anxiety compared to those with no history (60.9% vs 50.4%), the difference was not statistically significant (P=0.093). The anxiety severity was statistically significant based on additional working hours (P=0.037), as those with longer hours had higher very severe anxiety (90% in 4–8 hours, 65.2% in >8 hours vs 46.1% in <4 hours). The scores of depression, anxiety, or stress were not significantly different based on age or working hours (P>0.05). Regarding education level, the difference was statistically significant only for anxiety (χ2=6.82, P=0.037) and stress (χ2=8.45, P=0.011). Regarding job type, the difference was statistically significant only for stress (χ²=12.34, P=0.005). Notably, strong significant correlations were reported among the three psychological disorders (0.464<r<0.709, p<0.01), suggesting frequent co-occurrence and shared underlying mechanisms.  
Conclusion
The findings highlight a high prevalence of depression, anxiety, and stress among medical staff of hospitals in Qom (52% severe anxiety, 52.7% moderate depression, 29.3% severe or moderate stress). Organizational factors, gender, and education play key roles in their psychological disorders. Males exhibited significantly higher depression levels than females. Also, those with longer additional working hours had significantly higher very severe anxiety. Education level was the effective factor of anxiety and stress. Job type was the effective factor of stress. The findings underscore the urgent need for targeted mental health support for medical staff of hospitals in Qom. Regular mental health screenings, workplace stress-reduction programs, and coping training for high-risk staff (especially males) are recommended. It is recommended that future longitudinal studies investigate causal relationships and develop culturally appropriate interventions tailored to socio-cultural characteristics. These measures could help improve the mental health of medical staff during future pandemics.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Qom University of Medical Sciences (Code: IR.MUQ.REC.1401.144).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgments
The authors would like to thank all the patients who participated in this study.