Prevalence and influencing factors of depressive and anxiety symptoms among hospital-based healthcare workers during the surge period of the COVID-19 pandemic in the Chinese mainland: a multicenter cross-sectional study

Summary

Background

From November 2022 to February 2023, the Chinese mainland experienced a surge in COVID-19 infection and hospitalization, and the hospital-based healthcare workers (HCWs) might suffer serious psychological crisis during this period. This study aims to assess the depressive and anxiety symptoms among HCWs during the surge of COVID-19 pandemic and to provide possible reference on protecting mental health of HCWs in future infectious disease outbreaks.

Methods

A multicenter cross-sectional study was carried out among hospital-based HCWs in the Chinese mainland from 5 January to 9 February 2023. The PHQ-9 (nine-item Patient Health Questionnaire) and GAD-7 (seven-item Generalized Anxiety Disorder Questionnaire) were used to measure depressive and anxiety symptoms. Ordinal logistic regression analysis was performed to identify influencing factors.

Results

A total of 6522 hospital-based HCWs in the Chinse mainland were included in this survey. The prevalence of depressive symptoms among the HCWs was 70.75%, and anxiety symptoms was 47.87%. The HCWs who perceived higher risk of COVID-19 infection and those who had higher work intensity were more likely to experience depressive and anxiety symptoms. Additionally, higher levels of mindfulness, resilience and perceived social support were negatively associated with depressive and anxiety symptoms.

Conclusion

This study revealed that a high proportion of HCWs in the Chinese mainland suffered from mental health disturbances during the surge of the COVID-19 pandemic. Resilience, mindfulness and perceived social support are important protective factors of HCWs’ mental health. Tailored interventions, such as mindfulness practice, should be implemented to alleviate psychological symptoms of HCWs during the COVID-19 pandemic or other similar events in the future.

Introduction

The outbreak of the coronavirus disease (COVID-19) in 2019 has posed one of the most serious hazards to public health.^1,2 According to the report of the WHO, as of 22 March 2023, more than 761 million people around the world had been infected with COVID-19, of which 6.8 million died.³ The COVID-19 pandemic not only jeopardized physical health but also had severe negative effects on mental health of people worldwide.^4,5 Worse still, studies revealed that during the COVID-19 pandemic, hospital-based healthcare workers (HCWs) suffered from more severe mental problems than general population because of their high risk of exposure to COVID-19, feelings of guilt about patients’ death, shortages of personal protective equipment, long working hours and fatigue.^6–8 Meanwhile, previous studies have found that psychiatric history, unpleasant experiences due to infection and having relatives or friends get infected also have a negative effect on mental health of HCWs during epidemic and pandemic outbreaks (i.e. SARS, MERS and Ebola).⁹

Mental health problems of HCWs have aroused wide concerns during the COVID-19 pandemic. Since the outbreak, a series of cross-sectional surveys on mental health of HCWs have been carried out globally and the results showed that depression and anxiety were the most common psychological problems among HCWs in the pandemic.^10,11 A meta-analysis reported that during the COVID-19 pandemic, the prevalence of depression and anxiety among HCWs worldwide was 24.3% and 25.8%, respectively.¹² These mental health problems may cause insomnia, cognitive decline and even suicide, which would seriously endanger the health of HCWs.¹³ They may also reduce work efficiency, increase the rate of absenteeism, and as a result, lead to a decline in the quality of medical services, which is seriously detrimental to the prevention and control of COVID-19.¹⁴ It was reported that HCWs with poor mental and physical health are more likely to make medical errors, posing a threat to patient safety.¹⁵ In addition, mental health status of HCWs is also related to occupational burnout and change of career trajectory, which may lead to workforce attrition and shortage of medical human resources in China in the future.^16,17 Therefore, more attention should be paid to HCWs’ mental health during the COVID-19 pandemic.

For a long period during the COVID-19 pandemic, the prevalence of COVID-19 in China had been kept at a stably low level due to a series of pandemic prevention and control policies.¹⁸ Longitudinal investigations have revealed that during the stable period of the COVID-19 pandemic, HCWs faced substantially lower risks of depressive and anxiety symptoms compared to the initial outbreak period. Specifically, 60.3% and 55.5% of frontline HCWs experienced depressive and anxiety symptoms during the initial outbreak of Wuhan in February 2020, which dropped to 45.4% and 38.5%, respectively, 1 month later. These figures further decreased to 23.6% and 27.4% in December 2020, which is the stable period of the COVID-19 pandemic.^19,20 However, with the emergence of the highly transmissible Omicron variant of SARS-CoV-2, there was a surge in COVID-19 infection in the Chinese Mainland from November 2022 to February 2023, with the largest infected population since the first wave of outbreak in China. During this surge, a large number of COVID-19 patients flooded into hospitals, even far more than those during the initial outbreak in Wuhan, and most departments of almost all hospitals across China were utilized to treat COVID-19 patients at that time, and the hospital-based HCWs were encountering an unprecedented psychological crisis. Under such circumstances, their mental health might be heavily influenced and require more attention, but there have been no reports on that.

This study aims to assess the prevalence of depressive and anxiety symptoms among Chinese HCWs during the surge of the COVID-19 pandemic from November 2022 to February 2023 in China, and to explore the potential factors related to depressive and anxiety symptoms. In addition, considering the COVID-19 virus is still mutating and could probably cause another pandemic, our study may provide possible reference on promoting mental health of HCWs in future infectious disease outbreaks.

Materials and methods

Sampling and participants

This multicenter cross-sectional study was carried out among hospital-based HCWs in the Chinese mainland from 5 January to 9 February 2023. Participants were recruited by convenient sampling from seven geographical regions (Northeast China, North China, East China, South China, Central China, Northwest China and Southwest China). A self-reported online structured questionnaire was designed by the expert team with epidemiologists and psychologists through several rounds of literature reviews and focus group discussion. Afterwards, the team conducted interviews and piloted questionnaire survey on HCWs eligible for the inclusion criteria, and then finalized the questionnaire based on HCWs’ constructive suggestions and practical experience. Finally, this online questionnaire was employed to investigate the demographic characteristics and assess depressive and anxiety symptoms of HCWs during the COVID-19 surge phase (from November 2022 to February 2023) in China. The online and open access survey platform ‘Wenjuanxing’ was used to deliver the questionnaire, and digital informed consent was obtained from all participants to ensure their voluntary participation. In addition, all questions were self-administered and set as mandatory to make sure that all submitted questionnaires contained complete data without any missing information. Participants must meet the following criteria: (i) over 18 years old, (ii) hospital-based HCWs in mainland China, (iii) proficiency in Chinese, (iv) able to complete the questionnaire independently, (v) have a mobile equipment such as a mobile phone and (vi) agree to participate in this study. HCWs without professional qualifications were excluded. In total, 6996 HCWs participated in this survey, and 6558 of them met the eligibility criteria. After deleting the invalid samples which finish the questionnaire within 2 min, 6522 questionnaires were retained for further analyses, with an effective rate of 99.91%. This study was approved by the Ethics Committee of Chinese Academy of Medical Science (CAMS&PUMC-IEC-2022-83) and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Measures

Demographic characteristics

Demographic characteristics include basic demographic variables and COVID-19-related information. Basic demographic variables included age, gender, occupation, educational attainment, marital status, hospital departments, years of working and income. COVID-19-related information included work intensity, perceived risk of COVID-19 infection, COVID-19 infection status during the COVID-19 surge phase, etc.

Depressive symptoms

The nine-item Patient Health Questionnaire (PHQ-9) is a self-reported nine-item scale used to screen, define and quantify depressive symptoms of varying degrees of severity during the past 2 weeks.²¹ Rated on a four-point Likert scale ranging from 0 to 3 of each item, the total scores of PHQ-9 can assess the severity of depressive symptoms of participants and higher scores indicate more serious depressive symptoms: no depressive symptoms (0–4), mild depressive symptoms (5–9), moderate depressive symptoms (10–14) and severe depressive symptoms (≥15). This instrument was validated among Chinese populations.²² The Cronbach’s alpha of the instrument in this study was 0.922.

Anxiety symptoms

Anxiety symptoms were assessed by the seven-item Generalized Anxiety Disorder Questionnaire (GAD-7), which is a self-reported scale and rated on a four-point Likert scale ranging from 0 to 3, with a total of seven items.²³ The total score range of the scale is 0–21 points, of which 0–5 points are no anxiety, 6–9 points are mild, 10–14 points are moderate, and 15–21 points are severe. The instrument was demonstrated to be valid in various Chinese populations, and the Cronbach’s alpha of the instrument in this study was 0.965.²⁴

Resilience

The 10-item Connor–Davidson Resilience Scale (CD-RISC-10) is a widely used scale to evaluate resilience, which is a four-point Likert scale from 1 to 4.^25,26 Higher total scores indicate that it is easier to recover from negative events. This instrument was demonstrated to be a valid and reliable tool among different Chinese populations, and the Cronbach’s alpha of the instrument in this study was 0.971.²⁷

Mindfulness

The five-item Mindful Attention Awareness Scale (MAAS-5) is a brief instrument for measuring the level of mindfulness and each item rated on a Likert scale of 1–4.^28,29 Higher total scores evaluate a higher level of mindfulness. In this study, the Cronbach’s alpha of the instrument was 0.933.

Perceived social support

Two-item Perceived Social Support Scale (PSSS) is a self-report measure of perceived social support, containing two items on emotional support and material support.³⁰ Each item is a 11-point Likert scale from 0 to 10, and the total scores are obtained by adding the scores of two items. Higher total scores reflect a higher level of perceived social support. In this study, the Cronbach’s alpha of the instrument was 0.858.

Statistical analysis

Descriptive analyses were performed to describe the participants’ demographic characteristics, the COVID-19-related factors and the conditions of mental health. Frequencies and percentages were reported for categorical variables and means and standard deviations for continuous variables. The Chi-square test was applied to compare the differences between different groups. One-way ANOVA test was used to compare the mean scores between groups on the same continuous and dependent variable. Ordinal logistic regression analysis or multinomial logistics regression analysis was employed according to the results of parallel lines test. Considering that properly relaxing the type I error rate in the univariate analysis can avoid omitting the possible influencing factors, statistically significant variables at the level of P ≤ 0.10 in the univariate analysis were further entered into the multivariate logistic regression analysis. Adjusted odds ratio (AOR) and the corresponding 95% confidence intervals (95% CI) were calculated to determine the influencing factors of depressive and anxiety symptoms among HCWs. Stratified analyses were used to explore and compare the influencing factors of depressive symptoms and anxiety across different classifications of gender, income and years of working. All statistical analyses were checked and verified by two researchers using SPSS 26.0 and SAS 9.4, respectively, with level of significance determined at α = 0.05.

Results

Demographic characteristics

A total of 6522 hospital-based HCWs from seven geographical regions of China were included in the analysis and the average age was 37.58. Among them, 76.65% were female; 47.72% were nurses; 65.81% were bachelor’s degree graduates; 76.57% were married; 58.62% worked in general wards; 36.02% had worked for 10–20 years; 48.99% had a monthly income of 5000–10 000 yuan; 68.49% treated COVID-19 patients in their working departments during the COVID-19 surge phase; 47.07% supported other departments which was shifted to treat COVID-19 patients; 90.43% perceived a higher risk of COVID-19 infection from November 2022 to February 2023 than before; 88.01% perceived a higher work intensity; 76.62% infected with COVID-19 once and 80.47% received three doses of COVID-19 vaccine. The results are displayed in Table 1.

Prevalence of depressive and anxiety symptoms among the HCWs

According to the cut-off values of PHQ-9 and GAD-7 used in this study, the prevalence of depressive symptoms among the HCWs was 70.75% (4614 participants in total, with 2383 [36.54%] HCWs exhibiting mild depressive symptoms, 1181 [16.10%] exhibiting moderate depressive symptoms and 1050 [18.11%] exhibiting severe depressive symptoms), and that of anxiety symptoms was 47.87% (3122 participants in total, with 1920 [29.44%] HCWs exhibiting mild anxiety symptoms, 764 [11.71%] exhibiting moderate anxiety symptoms and 438 [6.72%] exhibiting severe anxiety symptoms), as shown in Table 2.

Factors associated with depressive symptoms among the HCWs

The factors associated with depressive symptoms of the HCWs were illustrated in Tables 3 and 4. According to the result of univariate analysis, gender, occupation, education, marital status, hospital departments, COVID-19-related information, mindfulness, resilience and perceived social support were later employed in multivariate analysis. According to the result of parallel lines test (P = 0.324), ordinal logistic regression analysis was used to identify the potential influencing factors of depressive symptoms among HCWs.

Ordinal logistic regression analysis showed that female sex (AOR = 1.301, P < 0.001) and longer working years (AOR = 1.499–1.728, P < 0.001) were factors positively associated with depressive symptoms. HCWs who had been infected with COVID-19 (AOR = 1.818–2.531, P < 0.001), those who perceived a higher risk of COVID-19 infection (AOR = 1.707, P < 0.001) and those whose work intensity increased during the COVID-19 surge phase (AOR = 1.495, P < 0.001) were more likely to have depressive symptoms. In addition, higher levels of mindfulness (AOR = 0.810, P < 0.001), resilience (AOR = 0.966, P < 0.001) and perceived social support (AOR = 0.938, P < 0.001) were negatively associated with depressive symptoms. Meanwhile, participants with a monthly income of 5000–10 000 yuan (AOR = 0.787, P < 0.001) or 10 000–30 000 yuan (AOR = 0.620, P < 0.001) were less likely to suffer from depressive symptoms than those with a monthly income of <5000 yuan.

Factors associated with anxiety symptoms among HCWs

The factors associated with anxiety symptoms of the HCWs were illustrated in Tables 5 and 6. Ordinal logistic regression analysis was used as the P values of the parallel lines test were over 0.05. The results showed that HCWs who had supported other departments that have treated COVID-19 patients (AOR = 1.197, P = 0.001), those who perceived a higher risk of COVID-19 infection (AOR = 1.565, P < 0.001) and those who perceived a higher work intensity (AOR = 1.726, P < 0.001) during the COVID-19 surge phase were more likely to have anxiety symptoms. In addition, working years over 10 years was a factor positively associated with anxiety symptoms, and married HCWs were susceptible to anxiety symptoms. Higher levels of mindfulness (AOR = 0.791, P < 0.001), resilience (AOR = 0.942, P < 0.001) and perceived social support (AOR = 0.944, P < 0.001) were negatively associated with anxiety symptoms.

Stratified analysis

The results of the stratified analysis according to gender, income and years of working did not reveal obvious differences between different groups in each variable and were also similar to unstratified results analysis in Tables 4–6, which were shown in supplementary materials.

Discussion

This study investigated mental health conditions of hospital-based HCWs in the Chinese mainland during the COVID-19 surge phase (November 2022–February 2023) when China witnessed the most extensive spread of COVID-19 and recorded the largest number of COVID-19 infections since the outbreak in 2019. As we know, this study is one of the first studies to describe the mental health effects of this COVID-19 surge phase upon HCWs in the Chinese mainland. Based on a diverse sample, our study demonstrated that 70.75% of the HCWs reported depressive symptoms, which is higher than the prevalence rate of 22.8–50.4% among front-line HCWs during the early stage of the COVID-19 pandemic in 2020 and also significantly higher than the results among HCWs during the rapid spread of the SARS-CoV-2 Omicron variant in the first half of 2022.^31–35 Our study also revealed that 47.87% of the participants reported anxiety symptoms, a prevalence rate basically consistent with the results in the initial outbreak period and the Omicron wave of the COVID-19 pandemic, ranging from 40% to 46.5%, but higher than the prevalence of 22% in the stable period of the COVID-19 pandemic in China.^31,34–36 These findings suggested that during the surge phase of the COVID-19 pandemic, a considerable number of HCWs in the Chinese mainland experienced poor mental health, highlighting concerns about the psychological well-being of HCWs during this period.

This study found that COVID-19 infection and high work intensity caused by the surge of the COVID-19 pandemic in the past several months were positively associated with the occurrence of depressive and anxiety symptoms among the HCWs. Our study showed that 77.42% of the 6522 participants reported being infected with COVID-19 according to the results of nucleic acid test or antigen test. As previous studies have shown, various physical symptoms caused by COVID-19 infection could increase the risk of depressive and anxiety symptoms.^37,38 The robust immune response to COVID-19 infection and possible direct viral infections of the central nervous system could foster psychopathology, and as a result, mental illness is more likely to occur.^38,39 In addition, from November 2022 to February 2023, when the peak of the COVID-19 pandemic occurred in the Chinese mainland, the influx of COVID-19 patients into hospitals aggravated the work intensity and physical fatigue of the HCWs, which were two identified factors that may contribute to depressive and anxiety symptoms among HCWs.^40,41 This reminds us that, on the one hand, the national health system could further strengthen its early warning and evaluation capacity to precisely assess the current situation of COVID-19 infection and other emerging infectious diseases, predict possible pandemic in advance through utilizing former experiences, case reports and statistical analysis, so as to prevent the occurrence of similar pandemic or enable early preparedness. On the other hand, it would also be beneficial to provide psychological screening and counselling services to HCWs to alleviate depressive and anxiety symptoms, if possible. Meanwhile, it is necessary to reinforce the training of HCWs on knowledge and skills related to pandemic prevention, such as how to correctly use personal protective equipment, including gloves, masks and gowns, to reduce their risk of infection. A backup workforce comprising qualified healthcare professionals, such as retired medical workers and medical students, could be established to alleviate work intensity of HCWs and allow HCWs in the acute infection phase to take more rest during the surge period of COVID-19 or other infectious diseases in the future.⁴²

The results of this study revealed that risk perception was positively associated with depressive and anxiety symptoms among the HCWs. The participants who perceived a high risk of COVID-19 infection were 1.5–2 times more likely to have depressive and anxiety symptoms than those who perceived a low risk. This finding is consistent with the results of previous studies conducted in China and other countries.^43,44 According to the psychometric paradigm, risk perception can be divided into two dimensions: ‘dread’ and ‘risk of the unknown’.⁴⁵ The surge of the COVID-19 pandemic raised HCWs’ risk perception of getting infected and infecting their families and friends, and also made them more concerned about post-infection symptoms.^36,46 In this case, according to the social stress theory, the threat of pandemic will induce stress, which in turn affects mental health among HCWs.⁴⁷ Studies have shown that the HCWs often overestimated their own risk of COVID-19 infection during the pandemic, even if they had sufficient personal protective measures.^48,49 During the COVID-19 pandemic or future infectious disease outbreaks, it is vital to be mindful of HCWs’ risk perception of being infected, so as to avoid their misperceptions of the disease and relevant situation, such as overestimating or underestimating the risk caused by diseases, hence to alleviate any unnecessary depressive and anxiety symptoms among HCWs, and to improve their mental well-being during extreme scenarios alike. In addition, it is necessary to guide HCWs to correctly understand the risk posed by COVID-19 or other infectious diseases through timely and routine lectures or group discussions.

Our study also found something interesting. HCWs who had worked for over 10 years were more likely to experience depression and anxiety symptoms. Obviously, the HCWs in this category usually held higher positions in the hierarchy of job titles and bear more responsibilities in their work team than the junior staff, and were the ones expected to make prompt, accurate and professional judgments and decisions during emergencies. Previous studies also revealed that higher job titles have an severe impact on depressive and anxiety symptoms among HCWs.²⁰ Furthermore, in this survey, the HCWs who supported other wards receiving COVID-19 patients were more likely to suffer from anxiety symptoms, but whether their own working departments received COVID-19 patients or not had no significant impact on anxiety symptoms, which is inconsistent with the results of studies carried out at the early stage of COVID-19 outbreak.^31,50 This could be attributed to the fact that during the worldwide COVID-19 pandemic over the past several years, the majority of HCWs in the Chinese mainland have accumulated a certain level of experience and expertise in providing medical services and appropriate care for COVID-19 patients, and they can easily handle the workload and offer advice or clinical practice in a calm and professional manner. However, the HCWs who were appointed to support other departments during the latest surge of COVID-19 infection were more likely to suffer from anxiety symptoms due to unfamiliar working environment and new interpersonal relationships. Previous studies have shown that the unfamiliar working environment is positively related to anxiety among HCWs during the pandemic.⁵¹ Accordingly, more attention should be paid to the mental health of HCWs with higher job titles or those working in unfamiliar environments during the COVID-19 pandemic or infectious disease outbreaks in the future.

Findings of this study indicated that resilience was negatively related to depressive and anxiety symptoms, consistent with our previous studies on the first batch of COVID-19 patients in Wuhan and others’ studies conducted among HCWs.^52,53 Resilience is considered to be a dynamic process of adaptation to adversity and a protective factor for individuals in adversity.⁵⁴ Individuals with a higher level of resilience could recover more quickly from stressful events, reducing the adverse effects of such events, and were less likely to experience depressive and anxiety symptoms.^55,56 Evidence suggested that resilience can reduce stress and improve self-efficacy among HCWs, supporting them to stay healthy.^57,58 Similarly, results of this study also showed that mindfulness was a protective factor against depressive and anxiety symptoms among HCWs. This finding reaffirmed those of previous studies, indicating that individuals with higher levels of mindfulness were more likely to maintain stability and peace of mind, which can mitigate the impact of negative emotions such as stress, depression and anxiety of HCWs.⁵⁹ It is noteworthy that mobile applications of mindfulness and meditation have become increasingly popular among the Chinese population in recent years. Mindfulness practice has become more acceptable in China and is widely used among various Chinese populations.⁶⁰ Studies proved that mindfulness practice can effectively improve the resilience and peace of mind of HCWs, reduce depressive and anxiety symptoms, and improve their happiness and job satisfaction.⁶¹ In fact, a randomized controlled trial conducted among undergraduate nursing students during the COVID-19 pandemic found that mindfulness-based online intervention can effectively reduce negative emotions of nursing students and improve their mental health.⁶² Based on these results, relevant departments could consider carrying out mindfulness practice courses for HCWs in hospitals; and considering the characteristics of their work, online mindfulness practices may be a convenient and effective option.

Additionally, we found that perceived social support was also a protective factor of depressive and anxiety symptoms. Perceived social support refers to the subjective perception and experience of individuals for different types of social support, including material and emotional support.⁶³ As previously mentioned, HCWs with higher level of perceived social support were more likely to feel the support and care from families, friends and others. As a result, they could encounter negative events with a more positive attitude and were less likely to report mental health problems.⁶⁴ Consequently, social support network should be established to reduce the mental health problems of HCWs. Health authorities or hospitals should offer practical guidance and successful experience in public health emergencies and strengthen logistics support for HCWs. Social media could play a vital role in highlighting the exceptional efforts of HCWs by sharing inspiring stories with the public to foster a better understanding and support for HCWs during emergencies, such as the COVID-19 pandemic.

To date, this study is one of the first to describe the mental health impact of the surge period of the COVID-19 pandemic on a diverse sample of Chinese HCWs. In this surge period, the number of COVID-19 infections was particularly large, the situation was extremely special, and it only lasted for about 3 months, the results of this survey in such a unique and short period are of great value. Besides, this is a multicenter cross-sectional study covering all seven geographical regions and almost all provinces in the Chinese mainland, and the overall sample size is relatively large, which can help extend our results to reflect the mental health of HCWs during the surge period of the COVID-19 pandemic.

However, several limitations must be acknowledged. First, a drawback of the cross-sectional study is that no inferences can be made about the causal relationships and more studies are needed to explore the mechanism of psychological problems among HCWs. Second, although we recruited participants from different regions and purposefully sought to represent various groups, it still has limitations in terms of sample representativeness considering that there are more than 10 million HCWs working in hospitals in China. Third, since this research was carried out during the surge period of the COVID-19 pandemic, we employed convenience sampling in selecting participants, which may also limit the representativeness of the study results to the wider population of HCWs. Fourth, the link of the online survey was distributed via the Internet, and response bias might exist because those with severe mental health problems may be reluctant to fill the online survey, which may lead us to underestimate the prevalence of psychological problems among HCWs.⁶⁵ Fifth, we did not consider the preexisting mental illness of HCWs and their depressive or anxiety symptoms prior to COVID-19, which could have an essential impact on mental health during the COVID-19 pandemic. Sixth, considering that the survey started on 5 January 2023, and PHQ-9 was only valid for the past 2 weeks, the results of the study may not fully reflect the entire surge period started since November 2022. However, the number of people infected with COVID-19 reached a peak in mid-to-late December and gradually declined thereafter, and the timing of PHQ-9 and our survey just covers this phase. Therefore, we think that the findings of this study still have some reference value for reflecting the mental health of HCWs throughout the surge period. Seventh, although some studies have found that lifestyle factors are also crucial for the mental health of HCWs,^66,67 considering this study was carried out in a special period with the largest number of COVID-19 infections so far, this study focused more on intervenable occupational risk factors specific to this surge period of the COVID-19 pandemic. Eighth, more objective and specific measurement indicators, such as the length of work hours and patients received, can be used to measure the variable “Perceiving a higher Work Intensity” in the future, which can be more objective and detailed. Finally, there was no longitudinal follow-up in our study, so it remained unclear about the dynamic changes of the impact on the mental health of HCWs during the surge phase of the COVID-19 pandemic.

Conclusion

In this study, we found that a strikingly large portion of hospital-based HCWs in the Chinese mainland has been affected by the surge of COVID-19 from November 2022 to February 2023 and suffered from mental health disturbances. This multicenter cross-sectional study revealed that this surge of the COVID-19 pandemic has seriously damaged the mental health of Chinese HCWs, while resilience, mindfulness and perceived social support are important protective factors of their mental health. More attention should be paid to HCWs and tailored interventions regarding enhancing resilience or mindfulness should be taken into account to alleviate depressive and anxiety symptoms. Policymakers could consider providing comprehensive support to this population, such as institutionalizing appropriate working hours, providing professional psychological support and offering sufficient personal protective equipment. These measures are essential to protect the mental health and well-being of HCWs, who were on the frontlines of the battle against the COVID-19 pandemic or other new infectious diseases in the future.

Supplementary material

Supplementary material is available at QJMED online.

Ethics approval and consent to participate

This study has been approved by the Ethics Committee of Chinese Academy of Medical Science on 29 December 2022 (CAMS&PUMC-IEC-2022-83).

Consent for publication

We have obtained electronic informed consent from our participants.

Transparency declaration

The manuscript is an honest, accurate and transparent account of the study being reported and no important aspects of the study have been omitted.

Author contributions

X.S., S.J., Z.D. and Y.W. prepared the first draft. X.S., Z.H., Y.Q. and C.W. provided overall guidance and managed the overall project. X.L., T.R., X.L., L.Z., J.F., X.C., W.X., H.W., Y.H., Y.Q., W.W., X.G., L.M., S.Z., Y.Y. and L.L. were responsible for the questionnaire survey and data analysis.

Acknowledgements

The authors thank the Editor-in-Chief, the Guest Editor, the Associate Editor, and the anonymous reviewers for their constructive comments and suggestions.

Funding

This work was supported by the Innovative Engineering Program sponsored by the Chinese Academy of Medical Sciences (grant number 2020-I2M-2-015).

Conflict of interest

None.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

References

Author notes