Zubia Saleem[i], Bushra Ejaz[ii], Farzana Ashfaq[iii]

DOI: 10.36283/pjr.zu.12.1/010


Background and Aims: The COVID-19 outbreak is the biggest global crisis in generations having severe and far-reaching repercussions for the health system, creating high prevalence of severe posttraumatic stress symptoms for physical therapists, highlighting the need for psychological help. Therefore, this study aimed to investigate how resilience functions as a mediator in the relationship between anxiety and personality among Karachi based physiotherapists.

Methodology: A cross-sectional study was conducted among physiotherapists of Karachi using a convenience sampling technique from August to December 2021. The data was collected using a 10-Item Personality Inventory, Brief Resilience Scale, and Hamilton Anxiety Rating Scale questionnaire.

Results: Among 70 participants, the emotional stability trait (7.6±1.4) had higher mean values on the TIPI. On the HAM-A scale, 81.4% physiotherapists had moderate to severe anxiety followed by 15.7% mild to moderate anxiety whereas 92.9% were shown to have normal resilience. Despite all correlations being negligible, only the association between agreeableness and resilience was non-significantly higher (r=0.83).

Conclusion: It was concluded that there was no association between the anxiety state and resilience among physiotherapists, although there was a non-significantly higher relationship between agreeableness and openness to experiences personality traits. A high prevalence of moderate to severe anxiety was noted while using a standard resilience strategy.


The outbreak of the COVID-19 pandemic is the biggest global crisis in generations that have severe and far-reaching repercussions for the health system, economies, and societies to date [1]. This pandemic had a profound effect on all aspects of society, including physical and mental health1. A mental disorder or mental health issues impair an individual’s intellect, and emotional control2. As per Mental health statistics, in 2019, 301 million people worldwide experienced anxiety disorders while 280 million people were afflicted with depression, its symptoms were severe enough to cause significant suffering or functional impairment3. The COVID-19 epidemic significantly increased the number of people who experience anxiety and depressive disorders. In 2021, depression represented 4.3% of all diseases’ global burden. It is also vital to note that depression is one of the top 20 causes of disability4.

The soaring COVID-19 cases placed an enormous load on healthcare professionals that imposes severe post-traumatic stress symptoms, with front-line or quarantined healthcare personnel being at higher risk5. The main challenges experienced by healthcare professionals during the COVID-19 outbreak included an excessive workload, fear to spread the disease, a sense of pressure, lack of appropriate medications, and community isolation that accentuated widespread psychological disorders including anxiety and depression related to COVID-196. Anxiety and fear of infection were shown to be the top concerns for both healthcare staff and the general public, highlighting the need for psychological help measures7. However, healthcare professionals assisting COVID-19-infected patients experience additional stress 8. On the other hand, sadness and employment insecurity appear to be strongly associated with the dread of COVID-199.

The prevalence of depression, anxiety, and distress among a sample of 1257 Chinese healthcare workers was found to be 50.4%, 44.6%, and 71.5%, respectively, with a frontline worker with COVID-19 patients in Wuhan being associated with a higher risk10. Whereas in Pakistan, depression, stress and anxiety are common among physical therapists. According to the DASS 42 score, 70.1% of research participants had depression, 53.17% had anxiety, and 60.05% had stress11. Financial challenges, less paid employment and work discontent were determined to be the main causes of depression, stress, and anxiety11. The state of one’s mental health may be influenced by a wide range of personal, familial, social, and structural elements12. Those individuals who are subjected to adversity such as poverty, violence, handicap, and inequality, including personal psychological and biological traits like emotional intelligence and genetics are at greater risk but also are more resilient13.

Resilience is the ability to recover, rebound, bounce back, adjust, or even the following misfortune, change, or adversity. It was considered an enduring personality trait in early studies but is viewed as a complex, dynamic and multi-dimensional phenomenon now14. It is possible to cultivate some traits that are associated with resilience; these traits help people withstand stress and protect them from it15. The way individuals react to stress varies greatly between individuals. Different personalities are observed to cope in different manners with stress and in certain personalities. Although there is no research on the long-term psychological effects of COVID-19, resilience can be developed; these abilities guard against stress and strengthen one’s resistance. According to studies, personality variations between people may contribute to the emergence of anxiety symptoms16. Extraversion, neuroticism, conscientiousness, agreeableness, and openness are the five general traits that make up the five-factor model (FFM) of personality traits, which acknowledges that personality traits are hierarchically arranged from many specific characteristics to five general traits17. According to past studies, anxiety has been linked to personality traits, especially neuroticism and extraversion. Extraversion in particular seems to guard against anxiety symptoms, but neuroticism has been shown to be a predictor of such symptoms for many personalities. Resilience increases one’s resistance to stress and safeguards against it.18,19. The association between personality qualities and anxiety has not yet been investigated; however, resilience may have a mediating function. Yet Studies on the mental health of healthcare professionals are still few and far between. The purpose of this study is to investigate how resilience functions as a mediator in the relationship between anxiety and personality among Karachi-based physical therapists.


A cross-sectional survey was conducted on a total of 100 physiotherapists recruited through a non-probability convenience sampling technique from primary and tertiary care settings in Karachi from August to December 2021. The sample was selected based on of following criteria.

Inclusion Criteria

Both Male and female physical therapists aged between 25 to 40 years of age, working in primary or tertiary care units during COVID-19 for > 1 year.

Exclusion Criteria

Refusal of participation, or those individuals who haven’t worked in the industry for more than six months.

Data Collection Tool

10-Item Personality Inventory (TIPI): is a self-reported scale that measures extraversion, agreeableness, conscientiousness, emotional stability and openness, which are the Big Five personality qualities. The TIPI’s items are scored on a 7-point Likert-type scale, with 1 denoting strong disagreement and 7 denoting strong agreement with a total score of 10-70. The scale has excellent test-retest reliability (ICC = 0.92, p = <0.00) [20].

The Brief Resilience Scale (BRS): measures one’s perception of their resilience under stress. It has six items to evaluate resilience with 3 potential score ranges: 1-2.99 (low resilience), 3-4.30 (normal resilience), and 4.31-5 (high resilience). The scale has an internal consistency reliability of ά = 0.80 to 0.91 [21].

HAM-A (Hamilton Anxiety Rating Scale): assesses the severity of anxiety symptoms in clinical contexts. The scale has 14 items with a total score range of 0-56 and evaluates both somatic and mental anxiety (physical complaints associated with anxiety). A score of 17 suggests mild severity, a score of 18–24 shows mild to moderate severity, and a score of 25–30 indicates moderate to severe severity. The scale has an internal consistency reliability of ά = 0.77 to 0.9222.

Data Collection Procedure

Participants were recruited through a convenience sampling technique from primary and tertiary care hospitals in Karachi. Questionnaires TIPI, HAM-A, and BRS respectively were administered after In order to give the participants thorough information about the study, an informed consent form was given to them. These self-administered Questionnaires were shared via email, and WhatsApp to analyze their response.

Ethical Considerations

The confidentiality of each participant was maintained. The confidentiality of each participant was maintained, and no information regarding the participant was shared without consent. Furthermore, all the causation of harm was avoided to the participant throughout the study.

Data Analysis

Data was entered and analyzed on SPSS (Statistical Package for Social Sciences). Mean and standard deviation descriptive statistics were used to show participant demographic information, and frequency and percentage descriptive statistics were used to show replies. For any such association with anxiety and personality traits with resilience, the Chi-square test of association was used at a significance level of p<0.05.


Out of 100, 70 physiotherapists participated, the majority of which were women (62.9%), whereas men were (37.1%), with ages ranging from 31 to 35 years (31.4%) and 25 to 30 years (28.6%), majority of which worked in private hospitals. The details are depicted in table 1.

It was found in Measures of Anxiety and Personality Traits on the TIPI in table 2 that the emotional stability trait (7.6±1.4) had higher mean values than openness to experiences (7.4±1.7) and agreeableness (7.1±1.2), which were in turn followed by extraversion and conscientiousness. On the HAM-A scale, moderate to severe anxiety was found to be common in 81.4% of physiotherapists while mild to moderate anxiety was found to be prevalent in 15.7% of physiotherapists, and 92.9% of physiotherapists were shown to have a normal resilience approach during COVID- 19 in figure 1.

The association of resilience and personality traits revealed the relationship between agreeableness and resilience was stronger, with a correlation of r=0.83, and the relationship between openness to experiences and the remaining qualities was weaker, with a correlation of r=0.15. All of the other correlations were negligible, and none of the results were statistically significant in table 3.


This study is the One of the few research that look at anxiety state and personality traits among Karachi-based physiotherapists, It evaluate the mediating role of resilience in relationships. A study concluded among a total of 476 healthcare workers including doctors, nurses, and paramedical staff participated from Pakistan, India, and Sri Lanka. A validated WHO Self-Reporting Questionnaire (SRQ-20) was used to screen for Depression. A 25.7% prevalence of depression was reported among healthcare workers 23.

A study implies that 11.9% of physical therapists and 20.7% of physical therapist students experienced moderate to severe depressive symptoms. [24] Despite the significant frequency of anxiety among physiotherapists, recent research found that anxiety was also common among medical students, with prevalence rates of 29.4% in Israel, 43.7% in Pakistan, 44% in Malaysia, and 56% in India.  Additionally, there have been more reported significant doctor-patient disputes in China in recent years, which may have a detrimental impact on medical students’ anxieties about their future careers. Additionally, there have been more reported significant doctor-patient disputes in China in recent years, which may have a detrimental impact on medical students’ anxieties about their future careers.

A study that evaluated the association between psychological resilience and mental health in the general population of China revealed that depression, anxiety, and somatization symptoms were present in 47.1%, 31.9%, and 45.9% of cases, respectively 25. Depression and anxiety symptoms were more common during the COVID-19 pandemic’s peak phase compared to non-epidemic seasons. According to recent research, public health events can contribute to poor mental health in the broader population. The study was constrained by the difficulty of ensuring the validity of the online psychological exams, which may have jeopardized the study’s findings. Similar results were obtained in our study, where the majority of physiotherapists had moderate to severe anxiety. However, because the evaluations were based on self-reported questionnaires, the validity of the responses may have been jeopardized. Similarly, Resilience partially or completely mediated the associations between all of the Big Five personalities, with the exception of subjective well-being and perceived stress at the beginning of the COVID-19 outburst, according to a study that examined the relationship between personality and psychological functioning during the COVID-19 pandemic24. The data gathering used an online survey platform, which had some reach issues with older participants who didn’t utilize the internet.

Additionally, the sample has a higher proportion of female individuals. The sample’s unequal representation of men and women had an impact on the findings. The results of our study revealed similar negligible and insignificant relationships between resilience and all variables, except for agreeableness and openness to experiences, and unequal representation of male and female physical therapists. Our findings are also consistent with a study on the impact of personality characteristics and strong social support on coping methods for the stress brought on by the coronavirus pandemic.

This study, which was done among Israeli-Palestinian college students, examined how these factors can help people manage effectively, adaptively, and actively26. Furthermore, the findings showed that high levels of openness, extraversion, agreeableness, and conscientiousness are associated with a tendency to use active problem-focused coping, whereas high levels of neuroticism are associated with a tendency to use maladaptive emotion-focused coping. The sample size was not gathered using a randomized sampling technique, which was one of the study’s weaknesses. Second, self-reported questionnaires used to collect the data could have introduced bias. Even though the majority of physiotherapists displayed resilience levels, (22.8%) had low, (74.3%) had normal and (2.9%) had high resilience. However, the sample size restriction and the use of self-reported measures may lead to some prejudice, and coping mechanisms were not examined. However, the majority of the studies cited above-used self-reporting questionnaires to gauge psychological discomfort. Since self-reporting surveys may not fully reflect individuals’ mental health, this approach has disadvantages.

Due to inter-individual variations in resilience, social support, etc., psychological distress may not always result in a mental disorder. It is necessary to acknowledge a few limitations of the current investigation. First, since the study was cross-sectional, no causal links between the variables could be established. Second, all data were collected using self-reported surveys, which may have resulted in response bias. It’s possible that the participants overestimated or underestimated the link between the variables. Thirdly among the relationships between the big five personality traits and anxiety symptoms among the study participants, resilience had a minor mediating function, which may in part limit the practical significance of our findings. Fourthly, it is important to use caution when extrapolating the findings from our study sample. Future surveys should be done across the entire country, focusing on Pakistan’s young, old, and middle-aged populations in both urban and rural locations. The population of rural areas is more susceptible to stress and anxiety disorders due to low literacy rates and low income. Additionally, schools and institutions must offer mental health programs to students. Infirmaries, workplaces, and local communities should all host awareness campaigns. In Pakistan, there is a dearth of competent health professionals. The correct education of healthcare professionals is necessary to address this issue.


It was concluded that there was no association between the anxiety state and resilience among physiotherapists, although there was a non-significant relationship between agreeableness and openness to experiences personality traits. A high prevalence of moderate to severe anxiety was noted while using a standard resilience strategy. It may be more advantageous to identify at-risk individuals and apply adequate intervention techniques that place an emphasis on personality traits and resilience in order to prevent and minimize anxiety symptoms.


  1. Auriemma V, Iannaccone C. COVID-19 pandemic: socio-economic consequences of social distancing measures in Italy. Frontiers in Sociology. 2020 Oct 16;5:575791.
  2. Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, Ballard C, Christensen H, Silver RC, Everall I, Ford T. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry
  3. Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. The Lancet. 2019 Jul 20;394(10194):240-8.
  4. Śniadach J, Szymkowiak S, Osip P, Waszkiewicz N. Increased depression and anxiety disorders during the COVID-19 pandemic in children and adolescents: a literature review. Life. 2021 Nov 5;11(11):1188.
  5. Lenzo V, Quattropani MC, Sardella A, Martino G, Bonanno GA. Depression, anxiety, and stress among healthcare workers during the COVID-19 outbreak and relationships with expressive flexibility and context sensitivity. Frontiers in Psychology. 2021 Feb 22;12:623033.
  6. Barello S, Palamenghi L, Graffigna G. Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry research. 2020 Aug 1;290:113129.
  7. Maldonato NM, Bottone M, Chiodi A, Continisio GI, De Falco R, Duval M, Muzii B, Siani G, Valerio P, Vitelli R, Scandurra C. A mental health first aid service in an italian university public hospital during the coronavirus disease 2019 outbreak. Sustainability. 2020 Jan;12(10):4244.
  8. Ramaci T, Barattucci M, Ledda C, Rapisarda V. Social stigma during COVID-19 and its impact on HCWs outcomes. Sustainability. 2020 May 8;12(9):3834.
  9. Gasparro R, Scandurra C, Maldonato NM, Dolce P, Bochicchio V, Valletta A, Sammartino G, Sammartino P, Mariniello M, Di Lauro AE, Marenzi G. Perceived job insecurity and depressive symptoms among Italian dentists: the moderating role of fear of COVID-19. International journal of environmental research and public health. 2020 Aug;17(15):5338.
  10. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open. 2020 Mar 2;3(3):e203976-.
  11. Babur MN, Liaqat M. Prevalence and factors effecting depression, stress and anxiety among physiotherapists of Pakistan. Isra Med J. 2017;9(6):427-30.
  12. Mental disorders [Internet]. 2022 [cited 9 September 2022]. Available from:
  13. Mental Health and COVID-19: Early evidence of the pandemic’s impact: Scientific brief, 2 March 2022 [Internet]. 2022 [cited 9 September 2022]. Available from:
  14. De la Fuente J, González-Torres MC, Artuch-Garde R, Vera-Martínez MM, Martínez-Vicente JM, Peralta-S’anchez FJ. Resilience as a buffering variable between the big five components and factors and symptoms of academic stress at university. Frontiers in Psychiatry. 2021 Jul 8;12:1093.
  15. Ching SS, Cheung K. Factors affecting resilience of nursing, optometry, radiography and medical laboratory science students. International journal of environmental research and public health. 2021 Apr 7;18(8):3867.
  16. Ferguson E. Personality is of central concern to understand health: towards a theoretical model for health psychology. Health Psychology Review. 2013 May 1;7(sup1):S32-70.
  17. Hopwood CJ, Zimmermann J, Pincus AL, Krueger RF. Connecting personality structure and dynamics: Towards a more evidence-based and clinically useful diagnostic scheme. Journal of Personality Disorders. 2015 Aug 1;29(4):431.
  18. Zinbarg RE, Mineka S, Bobova L, Craske MG, Vrshek-Schallhorn S, Griffith JW, Wolitzky-Taylor K, Waters AM, Sumner JA, Anand D. Testing a hierarchical model of neuroticism and its cognitive facets: Latent structure and prospective prediction of first onsets of anxiety and unipolar mood disorders during 3 years in late adolescence. Clinical Psychological Science. 2016 Sep;4(5):805-24.
  19. Yona T, Weisman A, Gottlieb U, Masharawi Y. High levels of self-reported depressive symptoms among physical therapists and physical therapist students are associated with musculoskeletal pain: a cross-sectional study. Physical Therapy. 2022 Mar;102(3):pzab278
  20. Azkhosh M, Sahaf R, Rostami M, Ahmadi A. Reliability and validity of the 10-item personality inventory among older Iranians. Psychology in Russia. 2019;12(3):28.
  21. Kyriazos TA, Stalikas A, Prassa K, Galanakis M, Yotsidi V, Lakioti A. Psychometric evidence of the Brief Resilience Scale (BRS) and modeling distinctiveness of resilience from depression and stress. Psychology. 2018 Jul 4;9(7):1828-57.
  22. Thompson E. Hamilton rating scale for anxiety (HAM-A). Occupational Medicine. 2015 Oct 1;65(7):601.
  23. Ran L, Wang W, Ai M, Kong Y, Chen J, Kuang L. Psychological resilience, depression, anxiety, and somatization symptoms. Social Science & Medicine. 2020 in response to COVID-19: A study of the general population in China at the peak of its epidemic Oct 1;262:113261.
  24. Kocjan GZ, Kavčič T, Avsec A. Resilience matters: Explaining the association between personality and psychological functioning during the COVID-19 pandemic. International Journal of Clinical and Health Psychology. 2021 Jan 1;21(1):100198.
  25. Agbaria Q, Mokh AA. Coping with stress during the coronavirus outbreak: The contribution of big five personality traits and social support. International Journal of Mental Health and Addiction. 2022 Jun;20(3):1854-72.
  26. Agbaria Q. Coping with Stress Among Israeli–Palestinian High School Students: The Role of Self-Control, Religiosity, and Attachment Pattern. Journal of religion and health. 2021 Apr;60(2):692-708.

The Ziauddin University is on the list of I4OA ( & I4OC (
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).
Conflict of Interest: The author (s) have no conflict.

[i] Occupational Therapist, Sindh Institute Of Physical Medicine And Rehabilitation, Karachi (0000-0002-4057-1268)

[ii] Occupational Therapist, Sindh Institute Of Physical Medicine And Rehabilitation, Karachi (0000-0001-6161-3079)

[iii] Senior Lecturer, Sindh Institute Of Physical Medicine And Rehabilitation, Karachi (0000-0003-1735-5337)