key: cord- -xeue p authors: armour, cherie; mcglinchey, emily; butter, sarah; mcaloney-kocaman, kareena; mcpherson, kerri e. title: the covid- psychological wellbeing study: understanding the longitudinal psychosocial impact of the covid- pandemic in the uk; a methodological overview paper date: - - journal: j psychopathol behav assess doi: . /s - - - sha: doc_id: cord_uid: xeue p the covid- psychological wellbeing study was designed and implemented as a rapid survey of the psychosocial impacts of the novel severe acute respiratory syndrome coronavirus (sars-cov- ), known as covid- in residents across the united kingdom. this study utilised a longitudinal design to collect online survey based data. the aim of this paper was to describe ( ) the rationale behind the study and the corresponding selection of constructs to be assessed; ( ) the study design and methodology; ( ) the resultant sociodemographic characteristics of the full sample; ( ) how the baseline survey data compares to the uk adult population (using data from the census) on a variety of sociodemographic variables; ( ) the ongoing efforts for weekly and monthly longitudinal assessments of the baseline cohort; and ( ) outline future research directions. we believe the study is in a unique position to make a significant contribution to the growing body of literature to help understand the psychological impact of this pandemic and inform future clinical and research directions that the uk will implement in response to covid- . the psychosocial effects of the severe acute respiratory syndrome coronavirus (sars-cov- ), otherwise known as covid- are pervasive and of significant societal concern. indeed, it is likely that covid- will not only affect the mental health of the population presently, as the pandemic spreads, but that the impact may last long into the future. we would expect that many individuals will experience a rise in mental distress symptoms, such as anxiety and depression, during these unprecedented times when populations have been required to drastically change their day to day way of life. however, there is further concern that for some, particularly those with pre-existing vulnerabilities, this rise in mental distress will reach clinically significant levels and in turn affect day to day functioning. this is expected due to the rapidly changing and uncertain situation that is covid- and the very real fears that people will have for themselves and others around infection and mortality. previous research on sars, mers and h n (swine) flu, have given insight into the psychological impact of the outbreak of an infectious respiratory disease and the measures taken to curb its spread. a high degree of psychological distress was reported during such pandemics, particularly among healthcare workers, quarantined individuals, and sars survivors and their family members (brooks et al. ; gardner and moallef ; maunder ; tsang et al. ) . moreover, recent research from the initial phases of the covid- outbreak in china has suggested that there has been a significant psychological impact on the general population (qiu et al. ; wang et al. ) . in response to the covid- pandemic, the uk governments put in place several restrictions as the situation progressed. on january st , the first coronavirus case was confirmed in the uk (exactly month after the first covid- case was detected in wuhan, china). on march th , who declared covid- a pandemic. on march th the coronavirus bill - was introduced in the house of commons. on march rd , the uk prime minister boris johnston announced severe restrictions (enforceable by police), including a need for the population to stay at home unless there was an absolute necessity to leave such as shopping for food, medical emergencies, or if required to work in a government designated keyworker role (a comprehensive timeline from . . - . . can be found in mcbride et al. ; pre-print) . on april th the uk lockdown was extended for "at least" another weeks. however, by this time both wales (april th ), ni (april th ) and scotland (afternoon of april th ) had separately announced extensions to the lockdown beyond the initial three-week period. by may th , the uk's death toll was the highest in europe and the second highest in the world. on may th the uk prime minister announced an initial easing of lockdown restrictions. in this address, those in england who could not work from home were "actively encouraged" to return to work (avoiding public transport if possible and if not possible to social distance and wear face coverings), an unlimited amount of outdoor exercise was allowed, and individuals could drive to outdoor destinations. however, the administrations with scotland, wales and ni chose not to adopt the 'stay alert' strategy brought forward by the uk prime minister and set out their own plans on easing lockdown restrictions. from may th both the scottish and welsh governments eased restrictions to allow more than once daily exercise. no other changes were made to the lockdown restrictions in scotland; however, wales began opening gardening and recycling centres. the ni executive agreed a similar three-week extension and permitted garden and recycling centres to reopen (may th ). furthermore, ni also began recommending use of face masks in enclosed spaces (may th ), a measure announced in scotland weeks earlier (april th ). while there are plans in england to begin opening schools by june st , wales, scotland and ni have all indicated that schools will likely not open until the new academic year. additionally, a phased strategy to ease lockdown restrictions was outlined by the prime minister on the may th . however, the implementation of each of the phases involved in easing the population out of lockdown and the opening of various business and places is subject to continuous review based on the most up to date information regarding the virus. it is important to mention each nation within the uk differs regarding their individual phased strategy regarding the removal of lockdown restrictions. at the initiation of lockdown (march rd ), covid- deaths had been officially reported across the uk (england: , wales: , scotland: and ni: ). by the time the covid- psychological wellbeing baseline survey closed (april th ), official figures stated that , covid- deaths had taken place across the uk (england: , , wales: , scotland: , and ni: ) . at the time of writing this manuscript (may th ) there have been , covid- deaths in the uk (england: , , wales: , , scotland: , and ni: ) . moreover, as of may th , when adjusting for population, the uk had the highest rate of daily confirmed covid deaths worldwide ( day average), approximately people per million per day (our world in data ). the government restrictions, coupled with an already increasing prevalence of mental ill health in the uk (ford and mcmanus ; mcmanus et al. ) , and a known adverse psychological impact of restrictions such as self-isolation; which intensify loneliness and reduce sense of connectedness, purpose and meaning in personal lives, has the potential to accelerate the prevalence rates of mental ill health across the uk. in recognising this, a team of leading mental health scientists published a position paper detailing a number of mental health research priorities for the uk in response to the covid- pandemic. these included the need for increased monitoring and reporting of the rates of mental health issues and a need to determine the factors that adversely or positively affect mental health during this time. from a public health perspective, these priorities focused on the general population as well as specific populations (holmes et al. ) . in line with the research priorities highlighted by holmes et al. ( ) , the covid- psychological wellbeing study assessed commonly occurring mental health disorders such as anxiety and depression among all participants. furthermore, following the traumatic impact of previous outbreaks (maunder ; maunder et al. ; wu et al. ) , posttraumatic stress symptoms were measured, and, given the nature of the study and prior research having highlighted that quarantined and infected individuals and their family please note that these figures refer to deaths of people who had a confirmed positive covid test result. the actual number of deaths as a result of covid are likely much larger; the official figures, cited here, do not include individuals who had not been tested at the time of their death, those who tested positive from a non-nhs or public health laboratory, those who initially tested negative but subsequently caught the virus and died without a subsequent positive test and, as an indirect result of the virus, as seen in the large numbers of excess deaths during this time. furthermore, it is also important to note that small differences in the numbers of deaths recorded are present depending on where and when the data were sourced. there can be delays in a death occurring and it being reported in the official statistics for a number of reasons (e.g. awaiting test results). thus, the figures presented here are those that the department of health and social care had recorded by that date. subsequently these figures were revised to include additional deaths that had taken place by that date but had not been officially recorded as covid deaths. https://coronavirus.data.gov.uk/about members were at increased risk of poor mental health (brooks et al. ; gardner and moallef ; tsang et al. ), we also queried specific covid- exposure experiences. separate from mental health difficulties, a range of more practical concerns related specifically to the pandemic, such as adherence with government advice, concerns about school closures, governments perceived efficiency, job security, financial implications, the capacity of the health service, and infection concern were examined. such concerns, while distressing themselves, may also contribute to a deterioration in mental health and wellbeing. individuals who are concerned about becoming infected or about the availability of healthcare may be at risk of developing health-related anxiety or obsessive health behaviours (abba-aji et al. ; asmundson and taylor ; blakey and abramowitz ; jungmann and witthöft ) . individuals suffering from a job loss or financial instability as a result of the pandemic may be at greater risk of developing a range of mental health issues (mental health foundation ). moreover, the substantial changes to daily life as a result of lockdown restrictions has added stress to many individuals' work and family lives (e.g. school closures forcing parents to homeschool their children while working from home themselves). such disruption to normal routine, activities and livelihoods may lead to increases in depression, loneliness, self-harming and suicidal behaviour, and harmful alcohol and drug use (who ). finally, the role of media consumption in amplifying distress was included; this was subsequently highlighted as a mental health research priority (holmes et al. ) . as previously mentioned, it is important to identify groups of individuals who are most at risk of poor mental health during this time in order to help guide experts and to formulate an appropriate, proportionate response to these needs. indeed, older individuals and those with physical health problems may be at risk of more severe outcomes if infected with coronavirus and thus may also experience greater levels of concern and distress (holmes et al. ; shevlin et al ; preprint) . individuals with prior and current mental ill health concerns may have exacerbated distress due to disruption in services and increased isolation (elovainio et al. ; holmes et al. ) , and individuals with lower incomes or financial instability may have less access to technology (hernandez and roberts ) and more difficult housing situations (eurostat ) . the covid- psychological wellbeing study therefore investigated a range of sociodemographic characteristics to help understand which groups were potentially the most psychologically impacted. the primary aim of this paper is to report the study protocol and the resultant sociodemographic characteristics of the participants of the covid- psychological wellbeing baseline survey. for completeness, although never the intention, the sample proportions will be mapped to the uk adult population proportions (using data from the census). this will allow readers to determine areas where the sample data approximates and thus represents the uk general population and areas where particular sociodemographic may be over-and/or under-represented. our secondary aim was to provide a clear and concise account of the data that has been collected across the uk population and sub-divided by uk nation (england/wales, scotland, and northern ireland). we aim to conclude with a summary of the ongoing efforts for weekly and monthly longitudinal assessments of the baseline cohort. the covid- psychological wellbeing study is a longitudinal, multi-wave online survey of the adult ( years +) general population of the uk. the study was designed to rapidly assess and monitor the psychosocial impact of the covid- pandemic on uk residents. this was achieved by implementing an online survey; launched on march rd and closed on april th . participants who completed the initial survey were asked to complete follow up surveys on a weekly basis for three weeks (from their completion of the baseline survey [baseline as t + t = week , t = week , t = week ]) and then at three monthly intervals post baseline survey completion [baseline as t + t = month , t = month , t = month ]). this study design result in four waves of weekly longitudinal data during the first month of the uk lockdown and four waves of longitudinal data during the -month period from the st day of the uk lockdown. the former allows us to track mental health outcomes during an intense period of lockdown when restrictions were at their height and the latter allows us to track mental health outcomes over a longer period in which lock down restrictions are eased. participants were recruited via two avenues ( ) a large-scale social media campaign and ( ) using an online participant panel called prolific. all participants were required to be + years or older, currently resident in the uk and able to read and write in english. no other exclusion criteria were applied. participation was voluntary. those who participated via social media recruitment activities were included into a prize draw for one of six £ vouchers. participants who joined the study via prolific received between £ . and £ . depending on survey length across baseline and follow-ups. data collection commenced on march rd . this timeline corresponds with the commencement of the uk's period of lockdown whereby the uk prime minister announced that all people were required to stay at home except for specific and essential reasons to leave (march rd ; see timeline above). the survey was administered entirely online through the survey data collection platform 'qualtrics'. the study was launched initially via a variety of social media platforms (twitter, facebook). additional data was collected using a panel of uk residents hosted by prolific (https://www.prolific.co/). all participants, regardless of recruitment mode were required to complete the baseline survey. all those recruited via social media were asked to complete follow up surveys on a weekly basis for three weeks and then at monthly intervals ( month, months and months). participants recruited via prolific were asked to complete the monthly follow up surveys only due to a lack of financial resources that would have been required for such extensive weekly surveys. as surveys progressed, certain topics were added to the survey battery to answer key political and scientific topics of interest and therefore there are additions to measures and topics assessed across weeks and months. for the purpose of this paper, we focus on all measures included in the baseline data as completed by all participants. all participants received a detailed participant information sheet outlining the purpose of the study, exact details concerning participation, how information would be stored, what would happen to the information concerning onward publication of the data and the results, and the risks and benefits associated with participation. participants were informed about confidentiality and under what circumstances confidentiality would be broken. likewise, they were informed that participation was voluntary and they were free to refuse to participate at any point and therefore free to refuse to complete further surveys. participants were informed that if they wished to withdraw they had to contact the chief investigator with their email address and mobile telephone number used for the study and request that no more reminders about participation were sent to them. they were informed that the decision to withdraw would bring no negative consequences to them nor affect their relationship with the researchers, support providers, or queen's university. they were additionally provided with details on the formal complaints procedure, contact details for the researchers, ethical approval, and where they could access the most up-to-date information concerning covid- . subsequently, participants were presented with statements, which they had to confirm in order to provide full consent to participate in the study. all study procedures were in accordance with gdpr. personal contact data was separated from the survey responses and replaced with a unique identifier. personal contact data is stored in a separate database and access is restricted to two members of the research team. all data will be fully anonymised prior to being shared across researchers in the team. ethical approval for the covid- psychological wellbeing study was provided by the ethical review panel in the faculty of engineering and physical sciences at queen's university belfast (reference: eps _ ) and also glasgow caledonian university health and life sciences ethics committee, (hls/ pswahs/ / ). we are grateful to professor brendan murtagh (the chair) and additional reviewers for their rapid review and approval of this study. a number of quality control measures were applied to the survey to help ensure the authenticity of responses and screen out those did not meet the inclusion criteria. the survey was firstly piloted by the research team as a measure of quality control (n = ) before going live on social media and prolific. individuals were removed from the data if; (i) the respondent clicked into the survey link but did not complete any measures (n = ), (ii) the respondent did not provide full informed consent (n = ), (iii) the respondent did not provide information relating to the inclusion criteria (i.e. age and/or current residency; n = ), (iv) the respondent did not meet the inclusion criteria (i.e. < years or non-uk resident, n = ), (v) the respondent completed the survey in less than the minimum completion time (n = ). minimum completion time was set at s ( min, s), half of the median completion time for the sample. a series of standardised self-report measures were included in the survey. many were included in full, whereas some were included in part. the survey also included newly created questions pertaining to covid- exposures, worries, and symptoms. furthermore, we included a series of questions related to social and traditional media engagements around covid- news. this study was devised in early march and therefore there were no standardised measures available covering the covid- pandemic. to ensure our questions were robust and reliable several academics reviewed them in full and suggested modifications based on the extant knowledge of covid- at the time. this knowledge was based on reliable and trusted sources such as public health england, the national health service, and the world health organisation. these modifications were incorporated in full for the final survey. further details are below: participants provided information regarding their gender, age, marital status, ethnicity, religious status, personal income, and their highest level of educational attainment. female participants were asked to specify if they were currently pregnant. participants were also asked to provide information related to education and employment and to indicate whether they themselves or their family members were working in one of the government assigned key worker roles. if they indicated that a family member was a key worker, they were also asked to indicate if they lived as part of the same household. participants were asked several questions based on their residential status. specifically, their place of residence, residence type ('house', 'room in a shared house', 'apartment/ flat', 'student halls', 'residential home' or 'other), urban vs rural ('isolated dwelling', 'hamlet', 'village', 'small town', 'large town', 'city'), and number of bedrooms in place of residence. they were also asked to best describe their housing situation ('owned outright', 'owned with mortgage', shared ownership', rented', 'living rent free' or 'other'). finally, participants were also asked to specify the number of adults over years and children under years present in their place of residence, and whether they currently owned any pets (and were asked to specify what type or types of pets they had). the survey queried whether participants had ever suffered from a physical or mental health related concern. specifically, asthma, heart disease, cancer, diabetes, shortness of breath, post-traumatic stress disorder, major depressive disorder, phobia, social phobia, obsessive compulsive disorder, generalised anxiety disorder, psychotic disorders, eating disorders, health anxiety or another kind of chronic condition not specified. covid- living status participants were asked to indicate their current living status in relation to covid- at the time of completing the baseline survey ('i am living as normal', 'i am not self-isolating but have cut down my usual activities as a precaution', 'i am not self-isolating but have been told to work from home', 'i am self-isolating as i do not want to get ill, but i am not high risk, 'i am self-isolating as i do not want to get ill, but i am regarded as high risk', 'i am self-isolating as i do not want others to get ill', 'i have been told to selfisolate due to possible symptoms of covid- ′, 'i have been told to self-isolate due to a diagnosis of covid- ′, or 'i have been ordered by the government or local authority to selfisolate/stay home'. participants were presented with a series of questions in relation to symptom expression, testing, diagnosis (for themselves or loved ones) and exposure to covid- related deaths. specifically, they were asked (at the time of survey completion) did they know someone who currently has or had in the past been quarantined for covid- due to exposure and whether any of these people have been close family members or friends. likewise, they were asked to indicate did they know someone who currently has or had in the past been diagnosed with covid- and whether any of these people have been close family members or friends. participants were also asked to indicate if they were a carer for someone who had been diagnosed with covid- . participants were also asked whether they themselves were currently in quarantine or had been in quarantine in the past due to covid- , whether they had self-isolated in order to avoid infection and whether they were regarded as 'high risk'. participants were also asked if they had self-isolated due to government advice and whether they had self-isolated because they had symptoms. participants were also asked whether they themselves have been tested for covid- and whether they had been diagnosed with covid- . two questions pertained to whether participants had received a flu vaccination in the past year and whether they had had the flu in the past year. participants were also asked about exposure to covid- related deaths, specifically whether they had experienced the death of a close friend or family member and whether they had been exposed to covid- related deaths due to their occupational role. finally, participants were asked to indicate whether they experienced any of the following symptoms ('fever', 'cough', 'sore throat', 'headache', 'cold symptoms' or 'no symptoms') at the time of survey completion. media/information consumption a number of questions queried participants' media consumption in related to covid- . specifically, they were asked how often they were watching, reading, and hearing reports or updates about covid- on social media, on traditional media and on a dedicated app that has been set up to provide covid- updates. the possible response categories in relation to each type of media consumption were, ( ) less than once a day, ( ) - times a day, ( ) - times a day, ( ) - times a day, ( ) - times a day. and ( ) more than times a day. participants were asked to indicate how worried they were about several covid- related concerns. specifically, worries around quarantine/self-isolation, being infected with the virus by others, infecting others with the virus, stigmatisation due to exposure, job security, the financial implications of the outbreak, food shortages, the government's ability to manage the outbreak, the healthcare systems ability to care for covid- patients, border closures and the impact of school/university closures on children and young adults. each of these responses were rated on a likert scale, ranging from ('not at all') to ('extremely'). finally, participants were asked to indicate if they thought school, university or border closures were necessary. trauma exposure prior trauma exposure was assessed using the life events checklist for dsm- (lec- ; weathers et al. a ). the lec- contains items measuring trauma exposure and therefore the measure is used to assess whether an individual has been exposed a ptsd 'criterion a' traumatic event. in the current study we added an additional event of 'coronavirus'. participants were asked if any of the stressful life events, as measured by the lec- (plus our single addition), ever happened to them. the possible response categories were 'yes' or 'no'. participants were asked to keep their answers to the trauma screen in mind and indicate which event they felt was the worst. the possible options were, 'natural disaster'; 'fire or explosion'; 'transportation accident'; 'serious accident at work, home, or during recreational activity'; 'exposure to toxic substance'; 'physical assault'; 'assault with a weapon'; 'sexual assault,'; 'other unwanted or uncomfortable sexual experience'; 'combat or exposure to a war zone'; 'captivity'; 'life threatening illness (not covid- )'; 'witnessing severe human suffering'; 'sudden violent death'; 'sudden accidental death'; 'serious injury, harm, or death you caused to someone else'; 'coronavirus'; 'other'; 'none'. previous research has highlighted excellent psychometric properties of the lec- (gray et al. ). ptsd was assessed with the ptsd checklist for dsm- (pcl- ; weathers et al. b) . the ptsd checklist contains items reflect the dsm- symptom criteria for ptsd. in this study, participants were asked to think about their responses in regard to their covid- related experiences. these items are organised into one of four clusters each reflecting a different aspect of ptsd symptomatology. these clusters are 'intrusions', 'avoidance', 'negative alterations in cognition and mood' and 'alterations in arousal and reactivity'. each item of the pcl- is rated on a five-point likert scale (' = not at all' to ' = extremely'), and asks participants to indicate how much each symptom bothered them over the past month. a participant must rate a given item (or symptom) as ' = moderately' or higher in order to constitute as valid endorsement of a symptom. in order to meet the criteria for a diagnosis of ptsd, there must first of all be trauma exposure, followed by valid symptom endorsement across each of the ptsd symptom clusters. according to the dsm- , this requires valid endorsement (a score of or higher) of at least, one 'intrusions' item, one 'avoidance' item, two 'negative alterations in cognition and mood' items and finally, two 'alterations in arousal and reactivity' items (american psychiatric association [apa] ). additionally, previous empirical research suggests that a total score on the pcl- of between is indicative of 'probable ptsd' (murphy et al. ) . in line with the research outlined above, if a respondent had a score of or above on the pcl- they were classified as reporting 'probable ptsd'. a wealth of previous literature has demonstrated the excellent psychometric properties of the pcl- across various populations (blevins et al. ; bovin et al. ; weathers et al. b; wortmann et al. ) . generalised anxiety disorder the generalised anxiety disorder scale (gad- ; spitzer et al. ) is a seven-item scale (gad- ) used to measure symptoms of generalised anxiety disorder. the scores across all seven items are summed to yield a total score, with higher scores indicating higher levels of severity (range - ). the scale asks participants to reflect on the past two weeks in answering each of the seven items, with each item ranging from (not at all) to (nearly every day). furthermore, across both adult and adolescent samples, scores on the gad- have also been used to define severity of anxiety-based symptoms (spitzer et al. ) . a score of - is considered none/normal levels of anxiety, - is considered mild, - is moderate and - is severe (spitzer et al. ) . in adult samples scores of or more may be of particular clinical concern, as they are likely to meet the diagnostic criteria for an anxiety disorder. using the threshold score of , the gad- has a sensitivity of % and a specificity of % for gad (spitzer et al. ) . therefore, in the context of this study scores of or above were considered indicative of those meeting the criteria for gad. previous literature has demonstrated the excellent psychometric properties of the gad- across various clinical and non-clinical populations (kertz et al. ; lee and kim ; rutter and brown ; spitzer et al. ) . the patient health questionnaire (phq- ; kroenke et al. ) , was used to measure symptoms of major depressive disorder. the phq- asks participants to reflect on the past two weeks in their response to nine items, which are based upon the dsm-iv diagnostic criteria (apa ) used to assess mdd symptomatology, namely, sleep, fatigue, concentration, low self-esteem, anhedonia, etc. however, it also is in line with the current dsm- criteria (apa ; burdzovic and brunborg ) . each item of the phq- is scored on a -point likert scale, ranging from to . the response categories were, not at all ( ), several days ( ), more than half the days ( ) and nearly every day ( ). each item is summed to yield a total score, with a possible range of - , with higher scores reflecting greater levels of mdd. furthermore, scores on the phq- have also been used to define severity of mdd symptoms. in adults, a score of - none or mild, - is considered minimal, - is considered moderate, - is moderately severe, and ≥ is severe. furthermore, in adult samples scores of ≥ or more may be of particular clinical concern, as they are likely to meet the diagnostic criteria for an mdd. using the threshold score of ≥ , the phq- has a sensitivity of % and a specificity of % for mdd (kroenke et al. ; levis et al. ; manea et al. ) . therefore, in the context of this study scores of or above are considered as meeting the criteria for mdd. the phq- has been strongly supported for its applicability as a short screening tool (burdzovic and brunborg ) across various clinical and non-clinical contexts and support the psychometric validity of the scale (allgaier et al. ; burdzovic and brunborg ; lee et al. ; levis et al. ; titov et al. ; umegaki and todo ) . sleep quality participants were asked to rate what the quality of their sleep in general. the response categories were 'very good', 'fairly good', 'fairly bad' or 'very bad'. further participants were asked how they would rate their sleep quality as a result of the coronavirus (covid- ) situation during the past month. again, the response categories were 'very good', 'fairly good', 'fairly bad' or 'very bad'. emotional dysregulation the difficulties in emotion regulation scale-short form (ders-sf; kaufman et al. ) was used to measure deficits in emotional regulation. the ders-sf was developed from the original -item scale (ders, gratz and roemer ) . the ders-sf contains items rated on a -point likert scale, ranging from to . items , and are reverse coded. the response categories were, 'almost never' ( ), 'sometimes' ( ), 'about half of the time' ( ), 'most of the time' ( ), and 'almost always' ( ). the measure yields a total score as well as scores on six sub-scales. each subscale reflects a different aspect of emotional dysregulation. these are ( ) 'non-acceptance', ( ) 'difficulties with goal directed behaviour', ( ) 'impulse control', ( ) 'lack of emotional awareness', ( ) 'lack of clarity' and ( ) 'limited access to emotional regulation strategies'. higher scores indicate higher levels of dysregulation. in comparison to the original -item form, ders-sf has been shown to have excellent psychometric properties, with internal reliability values for both the ders-sf total scale and six subscales ranging from . to . in the original validation study (kaufman et al. ) . additionally, kaufman et al. ( ) indicated correlations between the ders and ders-sf ranged from . to . and indicated that the ders and the ders-sf shared - % of their variance. loneliness the ucla three-item loneliness scale (hughes et al. ) was used to measure subjective feelings of loneliness among the sample. the ucla item loneliness scale contains three questions derived from the full-scale ucla loneliness scale (version ; russell ) . each item measures one of three key dimensions of loneliness, ( ) social connectedness, ( ) relational connectedness and ( ) selfperceived connectedness. the response categories are ( ) 'hardly ever', ( ) 'some of the time' and ( ) 'often'. higher scores across these items reflect higher levels of loneliness. the excellent psychometric properties of the both the long and short forms of the ucla loneliness scale are well documented (hughes et al. ; russell ) . additionally, participants were asked to indicate how often they felt lonely, using the same response categories as above. this was a bespoke question. social support the perceived social support questionnaire-brief form (kliem et al. ) was used to assess participants perceived level of social support. the measure contains items which are rated on a -point likert scale ranging from ('not true at all') to ('very true'). higher scores reflect higher levels of perceived social support. previous research supports the psychometric validity of the scale across a range of diverse populations (kliem et al. ; lin et al. ) . the meaning in life questionnaire (mlq; steger et al. ) was used to measure the presence of and pursuit for meaning in life. the mlq contains items which correspond to one of two dimensions of meaning in life ( ) 'presence of meaning' (which refers to the extent to which participants feel that their lives have meaning), and ( ) 'the pursuit of meaning' (this refers to the extent to which participants try to find meaning and understanding in their lives; steger et al. ) . each item is rated on a -point likert scale ranging from ('absolutely true') to ('absolutely untrue'). our analytic plan, for the current paper, was conducted across three complimentary phases as follows: ( ) a series of descriptive analyses were conducted to present an overview of the key sociodemographic characteristics of the entire sample (n = ) for the baseline data of the covid- psychological wellbeing study. ( ) a series of descriptive analyses were conducted to present an overview of the key sociodemographic characteristics by uk nation. ( ) the sample distributions of key sociodemographic variables were examined in comparison to recent uk population distributions (gleaned from census data) by uk nation of residence; these were age, gender, ethnicity, economic activity, and household composition. the covid- psychological well-being study was designed as a rapid data collection exercise across the uk population. this work was supported in part by funds from the school of psychology at queens university belfast in northern ireland and the department of psychology at glasgow caledonian university, in scotland. the recruitment target was participants in baseline. the total response rate was and after several exclusions were applied concerning data quality control (please see above methods section) the final effective sample size was participants. table displays the key sociodemographic characteristics across both the overall sample (n = ) and by each nation. both england and wales were combined in order for census comparison (see table ). overall, the majority of the sample were female (n = ; . %). additionally, the majority of the sample were white (n = ; . %). further, the majority of the sample were employed full time (n = ; . %) and stated that they were not religious (n = ; . %). diversity was evident in relation to age, household income, marital status and educational attainment. in order to assess the representativeness of the covid- psychological wellbeing study sample to the uk general population, it was compared to data from the uk census for adults aged years + . in some cases, where estimates for those and older were not available, alternative comparisons were made (e.g. + or + years). these are noted in the table footnotes section. specifically, the sample was compared by uk country of residence, gender, ethnicity, economic activity, household composition, age and education level. although this method is inexact due to changes within the population in the past decade, the census contains publicly available information on all sociodemographic variables of interest. these results are presented in table , modelled on that of mcbride et al. ( ; preprint) . results are presented across the uk nations, however, in line with the census statistics, information on england and wales are presented together. in brief, the covid- psychological wellbeing study sample was not representative of the uk population as a whole (by country of residence) or within the uk nations (by sociodemographic characteristics). respondents from scotland and ni were oversampled in the study while those from england/wales were underrepresented. within each nation, females were oversampled and males under-sampled, particularly those from scotland and ni. ethnicity comparisons revealed that this was the variable which most closely represented the ethnic profiles across the uk nations. economic activity was difficult to compare to the census statistics due to the survey methodology. within the survey, respondents were able to endorse multiple options related to their employment and studying. as such, respondents could report being employed and a student, or being employed parttime and being self-employed. however, a crude comparison to the census data suggests that employed individuals and students were oversampled, while those who are unable to work or are retired were undersampled. this was similarly reflected in age group comparisons; younger individuals (particularly those aged - ) made up a greater proportion of the sample than expected from the population estimates, while there was a substantial deficit in the number of older adults (particularly those aged years +) within the sample. as noted by mcbride et al. ( ; preprint) , an accurate comparison of household composition was not achievable from the ni census data. however, the household composition of england/wales and scotland was similar to the census estimates. table displays summary statistics regarding the housing conditions and composition of the covid- psychological wellbeing study respondents (n = ). overall, the majority of the sample lived in a city (n = ; . %). regarding housing conditions, the majority of the sample lived in a house (n = ; . %), owned their place of residence with a mortgage (n = ; . %) or rented their place of residence (n = ; .%). in terms of housing composition, majority of respondents stated at least two adults lived in their home (including them; . %). further, most of the sample did not have any children under the age of in their place of residence (n = ; . %). finally, almost half of the overall sample did not own a pet (n = ; . %), with diversity evident across those who did own pets. table displays summary statistics regarding keyworker classification for the entire sample (n = ) and by each nation. overall, . % (n = ) of respondents stated they were employed within one of the government assigned key worker roles at the time of survey completion. of these respondents, majority were keyworkers in the area of health and social care (n = ), followed closely by education/childcare (n = ). this was consistent across each of the nations. the purpose of the current study was to provide a technical overview of the design and procedures involved in initiating the covid- psychological wellbeing study. furthermore, details of the measures utilised in the baseline survey and the sociodemographic characteristics of the sample are presented. given the expected widespread impact of the pandemic and its associated impact on mental health, the survey was implemented rapidly to allow for a comprehensive assessment of changes in mental health as situation unfolded within the uk. as previously mentioned, the current study was designed around key research priorities as identified from previous epidemic and pandemic research (e.g. sars), the broader literature surrounding the impact of traumatic events and consideration of topical issues that were of public interest. moreover, the focus of the covid- psychological wellbeing study aligns well with a recent report published in the lancet psychiatry (holmes et al. ) . although this position paper on mental health priorities during the covid- pandemic was published after the current study had been launched, many of the key areas identified by the authors are covered. holmes et al. ( ) identified a number of immediate and long-term mental health research priorities both at an individual and a population level. the nature of the current study will allow for opportunities to focus on some of these priorities, namely, monitoring and reporting of common mental health problems, identifying groups who are particularly vulnerable to psychological distress at this time, determining the mechanism which underlie these mental health problems (i.e. risk and protective factors), ascertaining the longer term consequences of the pandemic across the population and within vulnerable groups, and investigating the effect of repeated pandemic-related media consumption on mental health. such research can inform the design and development of a range of appropriate digital interventions both a population level and bespoke interventions for specific groups of individuals. mental health services have been highlighted as an essential part of governments' responses to covid- (united nations ). the uk government has published a recovery strategy for covid- (uk government ) which acknowledges the potential impact of these recent societal changes on the nation's mental health. although the strategy promises improvements to, and funding for, health and social care settings in order to facilitate safer access to services in future (e.g. delivering service digitally), at the time of writing, no specific uk mental health strategy for covid- has been put in place. a range of mental health campaigns have been launched, however, for example, every mind matters (public health england ), how are you doing? (public health wales ), clear your head (scottish government ), while the department of health in ni launched a mental health action plan (department of health ) in response to covid- on may. it is clear that a focused mental health strategy will be needed in light of the current pandemic, either uk wide or across nations. longitudinal research, such other) and are therefore not included in this comparison. please not participants were given to option to state they did not want to disclose their gender, these were excluded from the above as that of the current study, may help inform these strategies and campaigns by highlighting key areas of attention or concern and specific groups who are experiencing the most distress. the current study has many strengths, particularly in respect to study design. firstly, a large range of variables (sociodemographic, psychological, health, etc.) were covered in the initial baseline survey and followup surveys. this will yield a vast and diverse amount of information which can be used to help garner a better, more comprehensive understanding of the impact of these unique circumstances longitudinally. indeed, the topics covered within the survey were empirically derived, based on previous epidemic and pandemic research and matched many of the research priorities previously mentioned. for example, holmes et al. ( ) identified at least eight groups of individuals who may be particularly vulnerable to experiencing mental distress at this time, such as front line workers, people on low income or those with financial insecurities, children and young people, etc. therefore, the large range of sociodemographic topics covered will allow for a wide-ranging investigation of at-risk groups. additionally, psychometrically valid and frequently used measures of anxiety, depression and ptsd were included in the study which may aid future comparisons. furthermore, although no specific covid- measures were available at the time of survey design, the covid- specific items were based on reliable sources of covid- information (e.g. who) and were reviewed by several academics before being included in the study. moreover, the research team acted rapidly as the covid- context evolved to ensure topics which had not been included within the baseline survey, but subsequently became areas of interest or research priorities (e.g. attitudes towards vaccines), were included within the follow-up surveys. the multi-phase survey design aimed to facilitate a comprehensive data collection strategy and was an additional strength to the study. data were collected intensively from survey launch; all respondents completed the baseline while approximately half completed weekly follow-up surveys for the next month. this was followed by three anticipated monthly follow-up surveys for the full sample. this strategy allows for a comprehensive overview of mental health and wellbeing for the first month of the lockdown period in which most people's daily lives had changed dramatically, and also for an investigation of the more nuanced findings over time and as restrictions eased in the following months. finally, as openly acknowledged throughout, this study did not aim to collect representative uk sample. however, efforts were made post-data collection to assess the degree of representativeness within and across the uk nations. although ultimately the data was not representative, a substantial number of responses were gathered from england, scotland and ni, while few came from wales. as such, a more diverse uk sample was collected in relation to country of residence and at the time of writing, this is the largest known data collection exercise on covid- and mental wellbeing in ni. a number of limitations are important to consider in the context of the current study. arguably, the main limitation of the study is that the data is not representative of the uk population as a whole, in terms of country of residence, or of the individual uk nations in terms of their sociodemographic characteristics. therefore, the findings may not be generalisable to the wider uk population as a whole. however, as discussed above, there were certain strengths unique to the aims of the study by oversampling those from northern ireland and scotland. it is also important to note that the data pertaining to the current study is modest in nature as compared to some ongoing data collection efforts in the uk (fancourt et al. ) , but similar in sample size of others . the aim of the covid- psychological wellbeing study was to collect data on participants. this decision was based on the fact that the research was being conducted in the absence of external funding and the research team chose not to apply for external funding. additionally, while the utilisation of online survey methods was deemed the only safe way to gather such data on a large scale amidst a pandemic and has the added benefit of increasing accessibility to those groups who would be difficult to access via other means (wright ) , it is also important to mention that our sampling strategy may result in self-selection bias (bethlehem ) . all participants involved in the current study were recruited via a social media campaign or via prolific panel data, each of these options requires the participant ( ) to opt in first of all and ( ) have access to an internet connection and equipment to take the survey online. therefore, specific groups may be underrepresented because they do not have an internet connection, computer/smartphone device, social media profile or simply do not wish to take part in the research (bethlehem ) . given the unprecedented nature of this pandemic, it is important to also mention a number of important risk factors and experiences that were not queried in the baseline survey. we did not examine general physical health and exercise, abuse or maltreatment within the home, interpersonal violence, more in depth exploration of specific disorders such as ocd, health anxiety or diabetes nor peoples experiences of medical care if required for a covid diagnosis. of note, we did query note: a n = participants in the scottish sample had missing data across these variables and were therefore excluded; b n = participants in the n.i sample had missing data across these variables and were therefore excluded; c participants could choose more than one pet and n = participants has missing data across the entire sample for this question 'how worried people were about the ability of the health system to care for coronavirus patients if the situation worsens'. a large proportion of respondents were 'extremely' worried about this (n = ; . %) or quite a bit worried (n = , . %). given the nature of the pandemic, the researchers were responsive to covid- topics of public and scientific interest and inserted additional topics into future waves of data collection; for example attitudes to a covid- vaccine (if one was to become available) and problematic drinking behaviours. regarding the questions in the survey itself, it is possible that participants, when asked about 'self-isolation', may have had different interpretations regarding the specific meaning, either due to their own personal understanding or the rapidly changing government guidance as the situation progressed. finally, all measures used in relation to the current study were self-report, therefore it cannot be ruled out that the respondents may have been influenced by their willingness or indeed unwillingness to report correctly, which therefore may potentially bias the results (weiss et al. ). since the implementation of the baseline survey on the march r d substantial progress has been made. regarding the respondents who were recruited via the social media campaign, a further follow up surveys have been completed ( week, week, week and month post baseline completion). all respondents recruited via prolific have also now completed a month and month follow up survey. the circumstances surrounding this pandemic are rapidly changing and individuals are constantly adapting to change and challenges in their lives and routines: distancing from loved ones, working from home, job losses, and at times inability to grieve in the usual way. it is likely that the lasting effects of this pandemic may not become apparent until months down the line, or they may fluctuate in peaks and troughs in relation to key events. for example, a spike in poor mental health following lockdown and an ease in covid- concerns and worries with time (c prc ; fancourt et al. ) . it is therefore imperative that longitudinal and prospective research is prioritised in order to map these changes across the uk. in order to address this, as aforementioned, the covid- psychological wellbeing study aims to conduct both weekly and monthly follow-up surveys in order to provide a thorough investigation of how the mental health and wellbeing of individuals has been impacted by ( ) the outbreak itself, ( ) the first month of the lockdown period and ( ) the period following the ease of lockdown restrictions, allowing for more nuanced study. additionally, it is essential such research aims to embrace and investigate the complexity of studying mental health and none of these -i am not a keyworker . . . . a n = participant within the scottish data had missing data and therefore was excluded from the data presented; b n = participants form the n.i data has missing data and were therefore excluded from the data presented wellbeing during these unprecedented times. therefore, not only studying causal links but also the mechanisms that influence the relationship between certain risk factors and mental health problems, e.g., social isolation and loneliness, emotional regulation, coping strategies, certain demographic risks such as living alone, financial and employment concerns etc. furthermore, certain groups of individuals may need specific examination (e.g. parents, key workers, those who are shielding etc.). future research should strive to collect data allowing crossnation comparisons within the uk. this will be of interest given that various government bodies have taken different approaches within the four nations and there are varying precovid social, economic and cultural differences across the uk nations; some of which have the potential to impact on population wellbeing. moreover, this extends to cross-country comparisons given countries have varying approaches to lockdown restrictions and the ease of these restrictions. the covid- psychological wellbeing study affords the opportunity to make viable cross-country comparisons with partners in the us, israel and australia because of collaboration on and direct sharing of the study protocol and measures with incountry investigators who are undertaking their own data collection efforts. given these unprecedented times, qualitative research exploring the unique lived experiences of particular vulnerable/at risk groups such as those with pre-covid mental health concerns or those working on the front line is essential. the covid- psychological wellbeing study has acknowledged this need and has recently launched a sister qualitative study -'the caring for the covid- carers, key workers, and their families study'. this study aims to understand the perceptions and experiences of both healthcare professionals and their family members during the outbreak of covid- . at present, the data collection is nearing completion and a separate paper will be published in due course outlining the methodology and research findings regarding this. in sum, the covid- psychological wellbeing study aims to rapidly assess and monitor the psychosocial impact of the covid- pandemic on uk residents. at the time of writing, this is the largest known data collection exercise on covid- and mental wellbeing in ni. given the focus on both a quantitative longitudinal multi wave design, and a sister qualitative study we believe this programme of research is in a unique position to make a significant contribution to the growing body of literature to help understand the psychological impact of this pandemic. data availability the participants did not give consent for their data to be made publicly available. derived data supporting the findings of this study will be made available from the corresponding author on reasonable request. conflict of interest no potential conflict of interest was reported by the authors. ethical approval ethical approval for the covid- psychological wellbeing study was provided by the ethical review panel in the faculty of engineering and physical sciences at queen's university belfast (reference: eps _ ) and also glasgow caledonian university health and life sciences ethics committee (hls/pswahs/ / ). consent to participate all participants involved in the current study provided informed consent. the authors affirm that all participants provided informed consent for the findings to be published. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. covid- pandemic and mental health: prevalence and correlates of new-onset obsessivecompulsive symptoms in a canadian province screening for depression in adolescents: validity of the patient health questionnaire in pediatric care diagnostic and statistical manual of mental disorders (dsm-iv®) diagnostic and statistical manual of mental disorders (dsm- ®) coronaphobia: fear and the -ncov outbreak selection bias in web surveys psychological predictors of health anxiety in response to the zika virus the posttraumatic stress disorder checklist for dsm- (pcl- ): development and initial psychometric evaluation psychometric properties of the ptsd checklist for diagnostic and statistical manual of mental disorders-fifth edition (pcl- ) in veterans the psychological impact of quarantine and how to reduce it: rapid review of the evidence depressive symptomatology among norwegian adolescent boys and girls: the patient health questionnaire- (phq- ) psychometric properties and correlates initial research findings on the covid- and mental health in the uk contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the uk biobank cohort study. the lancet public health uk covid- social study. results release prevalence: are two-fifths of young people really 'abnormal'? psychological impact on sars survivors: critical review of the english language literature multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale psychometric properties of the leaving no one behind in a digital world multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science a short scale for measuring loneliness in large surveys: results from two population-based studies health anxiety, cyberchondria, and coping in the current covid- pandemic: which factors are related to coronavirus anxiety the difficulties in emotion regulation scale short form (ders-sf): validation and replication in adolescent and adult samples validity of the generalized anxiety disorder- scale in an acute psychiatric sample a brief form of the perceived social support questionnaire (fsozu) was developed, validated, and standardized the phq- : validity of a brief depression severity measure the psychometric properties of the generalized anxiety disorder scale (gad- ) among korean university students concordance between the phq- and the hscl- in depressed primary care patients accuracy of patient health questionnaire- (phq- ) for screening to detect major depression: individual participant data meta-analysis brief form of the perceived social support questionnaire (f-sozu k- ): validation, norms, and cross-cultural measurement invariance in the usa optimal cut-off score for diagnosing depression with the patient health questionnaire (phq- ): a meta-analysis the experience of the sars outbreak as a traumatic stress among frontline healthcare workers in toronto: lessons learned factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto monitoring the psychological impact of the covid- pandemic in the general population: an overview of the context psychological research consortium (c prc) study leeds: nhs digital the covid- pandemic, financial inequality and mental health exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of uk treatment-seeking veterans coronavirus pandemic (covid- ) -the data every mind matters how are you doing? a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations ucla loneliness scale (version ): reliability, validity, and factor structure psychometric properties of the generalized anxiety disorder scale- (gad- ) in outpatients with anxiety and mood disorders clear your head anxiety, depression, traumatic stress, and covid- related anxiety in the uk general population during the covid- pandemic a brief measure for assessing generalized anxiety disorder: the gad- the meaning in life questionnaire: assessing the presence of and search for meaning in life psychometric comparison of the phq- and bdi-ii for measuring response during treatment of depression psychosocial impact of sars our plan to rebuild: the uk government's covid- recovery strategy psychometric properties of the japanese ces-d, sds, and phq- depression scales in university students launch of the policy brief on covid- and mental health a longitudinal study on the mental health of general population during the covid- epidemic in china the life events checklist for dsm- (lec- ) the ptsd checklist for dsm- (pcl- ). scale available from the national centre for ptsd at www heterogeneity in emotion regulation difficulties among women victims of domestic violence: a latent profile analysis mental health and covid- psychometric analysis of the ptsd checklist- (pcl- ) among treatment-seeking military service members researching internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (sars) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors would like to thank each and every participant who gave up their valuable time to complete this survey during this pandemic. additionally the authors are grateful to the members of the ethical committee for their rapid review and approval of this study.author contributions ca designed the study. ca and em obtained ethical approval and collected the data. em and sb conducted the analysis and the write up of results. ca wrote early drafts of the manuscript. all authors contributed to the write up of the manuscript and various draft revisions. additionally all authors reviewed and approved the final version. key: cord- -duukt wh authors: chew, nicholas w.s.; lee, grace k.h.; tan, benjamin y.q.; jing, mingxue; goh, yihui; ngiam, nicholas j.h.; yeo, leonard l.l.; ahmad, aftab; ahmed khan, faheem; napolean shanmugam, ganesh; sharma, arvind k.; komalkumar, r.n.; meenakshi, p.v.; shah, kenam; patel, bhargesh; chan, bernard p.l.; sunny, sibi; chandra, bharatendu; ong, jonathan j.y.; paliwal, prakash r.; wong, lily y.h.; sagayanathan, renarebecca; chen, jin tao; ying ng, alison ying; teoh, hock luen; tsivgoulis, georgios; ho, cyrus s.; ho, roger c.; sharma, vijay k. title: a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak date: - - journal: brain behav immun doi: . /j.bbi. . . sha: doc_id: cord_uid: duukt wh objective: since the declaration of the coronavirus (covid- ) outbreak as pandemic, there are reports on the increased prevalence of physical symptoms observed in the general population. we investigated the association between psychological outcomes and physical symptoms among healthcare workers. methods: healthcare workers from major hospitals, involved in the care for covid- patients, in singapore and india were invited to participate in a study by performing a self-administered questionnaire within the period of february to april , . healthcare workers included doctors, nurses, allied healthcare workers, administrators, clerical staff and maintenance workers. this questionnaire collected information on demographics, medical history, symptom prevalence in the past month, depression anxiety stress scales (dass- ) and the impact of events scale-revised (ies-r) instrument. the prevalence of physical symptoms displayed by healthcare workers and the associations between physical symptoms and psychological outcomes of depression, anxiety, stress, and post-traumatic stress disorder (ptsd) were evaluated. results: out of the healthcare workers who participated in the survey, ( . %) screened positive for moderate to very-severe depression, ( . %) for moderate to extremely-severe anxiety, ( . %) for moderate to extremely-severe stress, and ( . %) for moderate to severe levels of psychological distress. the commonest reported symptom was headache ( . %), with a large number of participants ( . %) reporting more than four symptoms. participants who had experienced symptoms in the preceding month were more likely to be older, have pre-existing comorbidities and a positive screen for depression, anxiety, stress, and ptsd. after adjusting for age, gender and comorbidities, it was found that depression (or . , % ci . – . , p = . ), anxiety (or . , % ci . – . , p = . ), stress (or . , % ci . – . , p = . ), and ptsd (or . , % ci . – . , p = . ) remained significantly associated with the presence of physical symptoms experienced in the preceding month. linear regression revealed that the presence of physical symptoms was associated with higher mean scores in the ies-r, dass anxiety, stress and depression subscales. conclusions: our study demonstrates a significant association between the prevalence of physical symptoms and psychological outcomes among healthcare workers during the covid- outbreak. we postulate that this association may be bi-directional, and that timely psychological interventions for healthcare workers with physical symptoms should be considered once an infection has been excluded. on december , , the china office of world health organization (who) was notified regarding some cases of pneumonia of unknown etiology in wuhan city of hubei province. it was subsequently termed coronavirus disease (covid- ) by the who. the rapid global spread of the disease led to the declaration of covid- as a pandemic on march , (organization, ) . being a global hub with high international traffic, singapore observed an increasing spread of covid- . accordingly, the disease outbreak response system condition (dorscon) alert level was escalated to orange on february , , which indicates that the outbreak is deemed to have moderate to high public health impact, necessitating additional measures like quarantine and temperature screening to minimize risk of further virus transmission in the community (s k. singapore raises cornavirus outbreak alert to orange: what does it mean., ; sk ca-l, ). similarly, being a densely populated country, the indian authorities imposed a lockdown on march , , which involved barring of all public transport and prohibiting opening of public spaces (the times of india, ). between february to april , , singapore reported slightly over confirmed covid- cases with deaths, while india has reported > , confirmed cases with > deaths (the times of india, ; ministry of health singapore, ). much uncertainty revolved around the nature of spread of covid- , its severity, associated mortality and the availability of essential resources like facial masks, hand sanitizers and digital thermometers. widespread fear of imposed quarantine and lockdown measures led to the unusual displays of panic in the form of frenzied buying of goods by the general public observed in many countries (coronavirus: hong kong shoppers snap up rice and noodles as fears over outbreak mount., ; 'it's pandemonium': virus panic-buying hits los angeles., ; t a. coronavirus: politicians, supermarkets urge calm amid panic-buying of groceries, ). infectious disease outbreaks are known to have psychological impact on healthcare workers as well as the general population. a notable example would be the psychological sequelae observed during the severe acute respiratory syndrome (sars) outbreak in (mcalonan et al., ministry of health s, ) . studies on the sars outbreak revealed that healthcare workers experienced acute stress reactions (tam et al., ; grace et al., ) . in addition to the specific physical manifestations of various diseases, some symptoms may arise due to the psychological sequelae of these infection outbreaks. such psychosomatic symptoms have been reported with increased prevalence during and after the outbreaks, such as the sars and ebola virus (lam et al., ; lee et al., ; marco et al., ; tucker, xxxx; xiang et al., ) . the commonly reported symptoms range from more specific symptoms like pain (lam et al., ) to non-specific ones like fatigue, weakness and lethargy (leow et al., ) . in some cases, symptoms not perceived to be directly related to a particular infectious disease may be reported. for instance, some survivors of sars outbreak developed chronic extra-pulmonary symptoms during outpatient clinical follow-up (leow et al., ) . it is important to understand the prevalence and patterns of such somatic manifestations since they can lead to undesirable overcrowding of hospital emergency departments (farr, ; abelson, ) , causing additional workload to the already constrained healthcare systems. we investigate the association between various physical symptoms and psychological distress amongst healthcare workers in singapore and india during the current covid- outbreak. from february to april , , we recruited healthcare workers from major tertiary healthcare institutions in singapore and india. during the study period, the healthcare institutions were actively involved in the care of covid- patients. study participants included doctors, nurses, allied healthcare workers (pharmacists, physiotherapists, occupational therapists), technicians, administrators, clerical staff and maintenance workers. written informed consent was obtained from all participants and the study was approved by the institutional review board, in accordance to the principles in the declaration of helsinki. the study questionnaire, written in english, comprised five main components-demographic characteristics, medical history, symptom prevalence in the previous month, depression anxiety stress scales (dass- ) and the impact of events scale-revised (ies-r) instruments. baseline demographic characteristics such as gender, age, ethnicity, marital status, occupation and past medical history were recorded. participants had to indicate if they experienced any of the listed physical symptoms, general or respiratory-related symptoms, during the previous month and rated the severity of the reported symptoms (supplementary material ). the study questionnaire was adopted from our previous study related to the psychological impact on healthcare workers in singapore during the covid- outbreak (tay et al., ) . depression, anxiety and stress were assessed using dass- (lp, ls, ), which is a validated screening instrument for use among patients and general populations. it is a self-reported -item system developed by the university of new south wales, australia, which provides independent measures of depression, stress and anxiety with recommended severity thresholds for the depression, stress and anxiety subscales. the scores for each of the three components were calculated by summing up the scores for the relevant items, and multiplying by two to calculate the final score. cut-off scores of > , > and > represent a positive screen of depression, anxiety and stress, respectively. on the dass- depression subscales, scores of - were deemed as "mild", - as "moderate", - as "severe", and - as "extremely severe" depression. the dass- anxiety subscale score was assessed as "mild" ( - ), "moderate" ( - ), "severe" ( - ), and extremely severe" ( - ). the dass- stress subscale score was divided into "mild" ( - ), "moderate" ( - ), "severe" ( - ), and "extremely severe" stress ( - ) (tay et al., ) . the psychological distress of the outbreak was assessed using the ies-r , (weiss, ) , which is a validated -item self-report that measures the subjective distress caused by traumatic events. it has subscales (intrusion, avoidance and hyperarousal), which are closely affiliated with post-traumatic stress disorder (ptsd) symptoms. participants were asked to rate the level of distress for each component during the previous seven days of their interview. the total ies-r score was graded for severity from normal ( - ), mild ( - ), moderate ( - ), and severe psychological impact (> ). a cut-off score of was used to define ptsd of a clinical concern (creamer et al., ; weiss, ) . both dass- and ies-r have been validated for use in a recent chinese study investigating the psychological impact of covid- on the general population (wang et al., a; ho et al., ) . we evaluated the prevalence of physical symptoms reported by the healthcare workers during previous one month before the survey administration period. additionally, we investigated the association between the presence of various physical symptoms and psychological outcomes, namely the dass- score and ies-r score. categorical variables are expressed as absolute values (percentage) and continuous variables were expressed as mean value ± (standard deviation). student's t-test was used to examine the association between continuous variables and pearson's chi-square test (or fisher's exact test, where appropriate) was used to evaluate categorical variables. multivariable logistic regression was used to adjust for the effect of confounders when appropriate to determine independent associations of binary outcomes. linear regression was employed to evaluate for associations between baseline characteristics, risk status, physical symptoms and the mean scores for dass- and ies-r components. a p-value of < . was deemed significant for this study. all statistical analyses were performed using ibm spss statistics for windows, version . . armonk, ny. of the invited healthcare workers from the major hospitals in singapore and india, ( . %) agreed to participate in this study. of which, respondents were from singapore and from india. majority ( , . %) were female and the median age was (interquartile range: - ) years (table ) . most ( . %) of the participants were indian, followed by chinese ( . %) and malay ( . %) ethnicity. being a relatively younger study population, . % of the participants were unmarried. two hundred and five ( . %) participants had pre-existing comorbidities, migraine ( . %) being the most prevalent followed by eczema ( . %) and asthma ( . %). nurses comprised . % of the study population, followed by physicians ( . %) and allied healthcare professionals ( . %) ( table ) . the commonest reported symptoms were headache ( , . %), throat pain ( , . %), anxiety ( , . %), lethargy ( , . %), and insomnia ( , . %) (fig. ) . while ( . %) respondents did not report any symptom within the preceding -month of the survey administration date, ( . %) reported one symptom, ( . %) reported two, ( . %) reported three, and ( . %) reported more than four symptoms. importantly, the symptoms were generally mild in severity. using our predefined cut-offs for the dass- scoring system to screen for depression, anxiety and stress, we found anxiety in ( . %), depression in ( . %) and stress in ( . %) study participants. there was no difference in psychological outcomes between study participants from the two countries (table ). the overall mean dass- depression subscale score was . (sd . ). of the healthcare workers who screened positive for depression, % of them ( ) were scored as moderate to very severe depression. the overall mean dass- anxiety subscale score was . (sd . ) . of the patients who screened positive for anxiety, . % of them ( ) showed moderate to very severe anxiety. in terms of the dass- stress subscale, the overall mean score was . (sd . ). stress was moderateto-severe in of the participants ( . %) who screened positive for it (fig. ) . healthcare workers rated their levels of psychological distress according to the ies-r during the preceding days. the mean total ies-r score was . (sd . ) while the means (sd) for ies-r subsets for intrusion, avoidance and hyperarousal were . ( . ), . ( . ) . ( . ), respectively. of note, ( . %) of the study cohort screened positive for clinical concern of ptsd, of which demonstrated moderate to severe levels of psychological distress. the group which displayed presence of symptoms in the preceding month had less female participants compared to the group without symptoms (odds ratio (or) . , % confidence interval (ci) . - . , p = . ). on the other hand, participants with physical symptoms were more likely to have pre-existing comorbidities (or . , % ci . - . , p < . ) and older in age (mean difference . , % ci . - . , p = . ). in terms of study outcomes, those with physical symptoms were more likely to have a positive screening for depression (or . , % ci . - . , p < . ), anxiety (or . , % ci . - . , p < . ), stress (or . , % ci . - . , p = . ), and ptsd (or . , % ci . - . , p = . ) ( table ) . in the multivariable logistic regression model, after adjustment for table baseline characteristics of study participants (n = ) . (table ) . linear regression revealed that the presence of physical symptoms was associated with higher mean scores in the ies-r, dass- anxiety, stress and depression subscales. this association was present across the three respiratory-related symptoms (sore throat, breathlessness and cough) as well as constitutional symptoms like lethargy, myalgia, poor appetite. however, there was no statistical significance between the association of coryza and psychological distress (table ) . this multinational, multicenter study found significant association between adverse psychological outcomes and physical symptoms displayed by healthcare workers during the current covid- pandemic. our findings mirror the trend in recent studies on the psychological impact of the covid- epidemic among the general population in china during its initial stages (wang et al., a; li et al., ; kang et al., ) . we have previously reported that the psychological impact (specifically anxiety) of covid- was more common among nonmedically trained healthcare workers when compared to the medically trained personnel (tay et al., ) . symptoms of covid- infection are wide-ranging, and may be non-specific and similar to other viral infections (guan et al., ) . therefore, when healthcare workers develop any such symptoms, they often faced the dilemma of whether to apply for medical leave of absence, or to continue working alongside their over-worked colleagues categorical variables displayed as n (%). during this critical period. even though healthcare workers are entitled to take paid sick leave for a given number of days, little is known about the employment risks posed, especially to the low-paid non-medically trained healthcare contract workers in the event of a prolonged absence. psychological distress levels may also be exacerbated by the fear of being a carrier of the virus, causing transmission amongst fellow healthcare workers and their own families if they choose to continue to work. the fear of transmission is especially high due to the reports of asymptomatic transmission of covid- , including high transmission rates amongst healthcare workers during in china where as many as healthcare workers contracted the infection and of them succumbed (adams and walls, ) . such prevailing and overwhelming thoughts in the current pandemic atmosphere often have adverse psychological sequelae and may lead to various somatic symptoms (joob and wiwanitkit, ) . moderate to severe psychological symptoms were reported amongst the general population in a recent chinese study during the covid- outbreak (wang et al., a; wang et al., b) . this is in sharp contrast to a low prevalence of moderate to severe psychological impact in our study ( . % compared to % reported in the chinese study). furthermore, compared to the chinese study population, our cohort had lower prevalence rates of moderate to severe depression ( . % versus . %), anxiety ( . % versus . %) and stress levels ( . % versus . %). however, despite our lower prevalence rates of emotional distress, our study population displayed higher prevalence rates of physical symptoms such as headache ( . % versus . %) and sore throat ( . % versus . %) when compared to the chinese cohort. the true association of physical symptoms and psychological stress is indeed challenging to determine, especially in the current climate where the active infection needs to be urgently excluded in every suspected case before giving much importance to the 'non-specific' symptoms. nevertheless, somatic symptoms may be more prevalent during periods of stress and these are hypothesized to represent a way of communicating emotions (basant et al., ) . we hypothesize that the increased prevalence of self-reported physical symptoms is likely to have been contributed by the psychological impact of the outbreak. another possible contributing factor could be the social stigma associated with mental health issues, which may have resulted in individuals having a higher tendency to express their psychological distress via physical symptoms instead (yl, ) . headache was the most commonly reported symptom in this study. a recent study on headache associated with personal protective equipment (ppe) among healthcare workers during the covid- pandemic demonstrated that % of respondents reported ppe associated headaches, with a pre-existing primary headache diagnosis reported as an independent predictor for ppe associated headaches (ong et al., ) . similarly, migraine was the most commonly reported comorbidity in our study. hence, the common presenting complaint of headache may be related to the increased adverse psychological impact or an exacerbation of their pre-existing condition. notably in prior studies, fatigue was the most commonly reported symptom among sars survivors in both healthcare workers and the general public. (lam et al., ) interestingly, even in our study, lethargy was one of the most commonly reported symptom amongst healthcare workers. in a previous study from hong kong, lam et al demonstrated that the prevalence of chronic fatigue was significantly higher among sars survivors which persisted through the acute phase of infection till one month after the disease outbreak (lam et al., ) . interestingly, healthcare workers infected by sars were more likely to give up their employment, and the occupational risks faced by the healthcare workers during an epidemic may potentially lead to psychiatric morbidity, physical symptoms such as fatigue, and eventually burnout. although fatigue and headache may be vague and often unsubstantiated, it is crucial not to neglect such physical symptoms as they may be a reflection of underlying psychological distress (lam et al., ) . the association of psychological distress and physical symptoms is table linear regression of physical symptoms in the past one month associated with the psychological impact of the covid- outbreak (n = ) . * p-value < . ; ** p-value < . . n.w.s. chew, et al. brain, behavior, and immunity xxx (xxxx) xxx-xxx poorly understood. in addition to the fear of transmitting the infection to colleagues and family members coupled with the dilemma of applying for sick leave in an already strained healthcare sector, many healthcare workers develop burnout and may experience a sense of intense fear, stigmatization and ostracism when displaying physical symptoms suggestive of the virus infection, which often leads to negative psychological pain (nezlek et al., ; troyer et al., ) . this phenomenon has already been described in the studies during the current covid- outbreak (wang et al., a) as well as previous ebola crisis (matua and van der, ) . we postulate a bi-directional complex relationship between psychological distress and physical symptoms, where an inadvertent psychological distress exacerbates physical symptoms and vice versa (fig. ) . accordingly, the physical symptoms related to high levels of arousal in a stressful environment of a disease outbreak may lead to over-reporting of cardiovascular, respiratory, neurological or gastrointestinal symptoms (mcfarlane et al., ) . furthermore, a known stressor may precipitate or worsen specific physical symptoms. for example, a previous study has reported increased prevalence of respiratory symptoms seen in fire-fighters suffering from ptsd as a result of the psychological stress of smoke inhalation (mcfarlane et al., ) . we believe that various symptoms of throat pain, cough and myalgia during the current covid- outbreak may be over-represented as a result of the psychological stress, and further exacerbated by the presence of various comorbidities (mcfarlane et al., ) . this observation is also commonly evident in patients with depression, with the somatization of back pain and headache (von knorring et al., ) . this is in line with our finding of the significant association of the presence of comorbidities and physical symptoms amongst healthcare workers. targeted multidisciplinary interventions are needed to support healthcare workers by addressing both the psychological manifestations and physical symptoms. all efforts should be made to offer psychological support and interventions once an acute infection has been excluded. dedicated counselling may be arranged to allay their fear of transmitting the infection to their family members (wang et al., a) as well as to boost the confidence and morale of our healthcare workers. given that this is a multinational, multicentre study, with similar prevalence of psychological outcomes in both countries, the observed psychological and physical symptoms findings are more likely generalizable. however, our study has its limitations. firstly, the crosssectional nature of the study does not allow interpretation for causality. whilst we found a strong association between presence of physical symptoms and prevalence of psychological distress, we are unable to conclude that psychological distress had resulted in the manifestation of these physical symptoms. secondly, we did not assess if study participants had taken medical leave of absence, or if they sought the testing for covid- during the manifestation of physical symptoms. thirdly, owing to the stringent hospital infection control protocols to minimize contact between healthcare workers, the questionnaire had to be selfadministered and information provided on symptoms was not verified by a medical professional. fourthly, we did not record socioeconomic status and education level, which could have influenced our results. we intend to re-evaluate our study participants if the current covid- outbreak escalates further in the region, as well as after it subsides to obtain much reliable explanations about the association of psychological sequelae and various physical symptoms. this study describes an expansive range of physical symptoms experience by healthcare workers during the ongoing covid- outbreak. there is a significant association between the prevalence of physical symptoms and psychological distress, which is probably bi-directional. we recommend the provision for timely psychological support and interventions for healthcare workers who present with physical symptoms once an infection has been excluded. visualization, writing. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. disclosures vks is the current recipient of senior clinician scientist award from national medical research council, ministry of health, singapore. other authors have no financial disclosures. doctors and patients turn to telemedicine in the coronavirus outbreak supporting the health care workforce during the covid- global epidemic revision notes in psychiatry, rd. united states of america coronavirus: hong kong shoppers snap up rice and noodles as fears over outbreak mount psychometric properties of the impact of event scale -revised how hospitals hope to keep "worried well" from flooding emergency rooms during coronavirus outbreak the occupational and psychosocial impact of sars on academic physicians in three affected hospitals clinical characteristics of coronavirus disease in china impact of south asian haze crisis: study of physical and psychological symptoms and perceived dangerousness of pollution level traumatization in medical staff helping with covid- control impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up the experience of sarsrelated stigma at amoy gardens hypocortisolism in survivors of severe acute respiratory syndrome (sars) vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control manual for the depression anxiety stress scales ebola and psychological stress of health care professionals living under the constant threat of ebola: a phenomenological study of survivors and family caregivers during an ebola outbreak living under the constant threat of ebola: a phenomenological study of survivors and family caregivers during an ebola outbreak immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers singapore: ministry of health, singapore. ministry of health singapore. updates on covid- (coronavirus disease ) local situation ostracism in everyday life headaches associated with personal protective equipment -a cross-sectional study among frontline healthcare workers during covid- who characterizes covid- as a pandemic singapore raises cornavirus outbreak alert to orange: what does it mean? singapore ups outbreak alert to orange as more cases surface with no known links; more measures in force coronavirus: politicians, supermarkets urge calm amid panic-buying of groceries severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers psychological impact of the covid- pandemic on health care workers in singapore the times of india the times of india. govt fresh guidelines for lockdown . are we facing a crashing wave of neuropsychiatric sequelae of covid- ? neuropsychiatric symptoms and potential immunologic mechanisms psychiatric disorders seen in sars patients pain as a symptom in depressive disorders. ii. relationship to personality traits as assessed by means of ksp a longitudinal study on the mental health of general population during the covid- epidemic in china immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the impact of event scale: revised. in: cross-cultural assessment of psychological trauma and ptsd timely mental health care for the novel coronavirus outbreak is urgently needed application of mental illness stigma theory to chinese societies: synthesis and new directions no funding reported. supplementary data to this article can be found online at https:// doi.org/ . /j.bbi. . . . key: cord- -klewqw u authors: zhang, yan; xie, simiao; wang, pu; wang, guixiang; zhang, li; cao, xiaochen; wu, wenzhi; bian, yueran; huang, fei; luo, na; luo, mingyan; xiao, qiang title: factors influencing mental health of medical workers during the covid- outbreak date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: klewqw u background: since the outbreak of covid- , physical and psychological harm has been spreading across the global population alongside the spread of the virus. currently, the novel coronavirus has spread to most countries in the world, and its impact on the public is also increasing. as a high-risk group in direct contact with the virus, medical workers should be monitored, and their mental health deserves extensive attention. the aim of this study was to explore the mental health of medical workers facing the novel coronavirus and the main factors affecting it. methods: the present cross-sectional study including , eligible individuals from , hospitals in china was conducted through the network platform powered by www.wjx.cn, a platform providing functions equivalent to amazon mechanical turk. we used a self-designed questionnaire to collect demographic information and data on mental states, including gender, age (years), educational level, job rank, body and mind reaction, cognition of risk, and the judgment of the epidemic situation. independent samples t-tests and one-way (anova) analysis were carried out to compare the differences in the mental reactions according to the demographic and psychological states of the participants. results: there were males ( . %) and , females ( . %). the participants reported feeling calm ( . %), tense ( . %), scared ( . %), angry ( . %), sad ( . %), afraid ( . %), optimistic ( . %), impressed ( . %), and confident ( . %) during the epidemic. at the same time, the psychological stress responses of medical staff were significantly different according to the levels of exposure in their environments, duration and personal experience. conclusions: prolonged exposure to the virus and intense work are detrimental to the mental health of medical care personnel. it is necessary to adjust work conditions and intensity according to workers' mental state flexibly and systematically. at the end of , a large outbreak of disease that was widespread with a high speed and a large number of infected people broke out in wuhan ( , ) , hubei province, china. it spread quickly over a short period of time ( , ) , and it has been a serious threat not only to physical health ( ) but also to mental health issues throughout the population ( ) . since april, there have been no additional diagnoses for many days outside of hubei, china ( ) , and the number of additional infections in hubei has been largely in the double-digits, as if the chinese epidemic were about to end. however, since the outbreak of the global epidemic ( ) ( ) ( ) , the number of imported cases has been increasing continuously, making the slightly calmer mood tense once again. if the control of imported potential patients is not adequately strong to prevent the epidemic from spreading again, previous efforts could be in vain. according to the latest real-time statistics of johns hopkins university, as of : beijing time on march th, the cumulative number of confirmed cases of coronary pneumonia worldwide was more than , , and the cumulative number of confirmed cases outside china exceeded , . studying the novel coronavirus is not only a matter of fighting covid- in china but also an international public health crisis that needs to be fought by the whole world. since the outbreak of the epidemic, tension, anxiety and other negative emotions have spread throughout china on a large scale, so much so that people have fallen into a series of psychological crises ( ) . medical care personnel, as the backbone of the front line of epidemic prevention and control, have been taking on heavy work tasks with a high risk of infection and great work pressure ( ) . health-care workers, especially those in hospitals who take care of confirmed or suspected patients, are more vulnerable than the general population, experience a high risk of infection and negative emotional stress, and further risk spreading the virus to their family, friends or colleagues ( ) . moreover, dangerous and susceptible environments as well as traumatic experiences caused by high exposure can all have a certain impact on an individual's emotional state and induce emotional stress responses ( ) as well as severe anxiety and depressive disorders and posttraumatic stress disorder (ptsd, posttraumatic stress disorder) ( , ) . a psychological survey published in the lancet· psychiatry showed that the prevalence of depression, anxiety, insomnia and stress among medical staff involved in the prevention and control of the epidemic were as high as . , . , . , and . %, respectively ( ) . until now, despite the rudimentary principal notice issued by the china national health commission in january regarding the emergency psychological crisis intervention measures for covid- pneumonia, no one has been able to provide timely and effective psychological intervention measures for medical staff. therefore, it is urgent and important for psychological researchers to focus on the mental health problems of medical workers during the epidemic, explore the main factors affecting their psychological stability and health, and try to prevent longterm irreversible psychological trauma to medical workers. some scholars ( , ) in environmental psychology have studied the effects of the environment on the individual, especially in the face of danger. according to ecological theory, the individual behavior and environment are part of an interactive ecosystem, and individual behavior has a temporal and spatial background; that is to say, there is an integrated behavioral situation ( ) . for the same environmental phenomenon, arousal theory argues that the influence of the same spatial and temporal background on individuals is determined by the degree of arousal experienced by any particular individual ( ) . the level of arousal experienced by individuals is closely related to personal experience. inspired by this theory, this study attempted to investigate whether differences in the exposure environment, personal experience, and exposure duration of medical care personnel would lead to differences in their psychological responses, and advice and assistance were provided to personnel to prevent the development of mental health issues. the questionnaire was designed for medical workers from all provinces in china. in the formal test, , medical workers were selected from , hospitals in provinces to fill out the questionnaire, including in wuhan and , outside of wuhan; males and , females were included. among them, . % were under years of age, . % were aged - , . % were aged - , . % were aged - and . % were over years of age. the study was designed in accordance with the tenets of the declaration of helsinki. approval from the ethical authority of the school of educational science, huazhong university of science and technology, was granted. confidentiality and the statement confirming informed consent were managed by anonymous coding of the self-report questionnaires. this survey used wechat, online questionnaires and other online surveys to investigate the emotional and psychological stress states of medical staff. we used a selfdesigned questionnaire to collect demographics and mental state data including factors such as gender, age (years), educational level, job rank, body and mind reaction, cognition of risk, and the judgment of the epidemic situation, which was started in the third week after the outbreak, and the specific time is from february to february , . our team sent out questionnaires through the internet platform powered by www. wjx.cn, a platform providing functions equivalent to amazon mechanical turk. participants filled in the questionnaire on the web page through mobile phone or computer. first, information was collected through small-scale interviews; next, we compiled a stress response questionnaire and determined the questionnaire topics and factors through exploratory factor analysis (efa). data from subjects were collected as preliminary test through a web questionnaire with items, including in wuhan and outside wuhan, males and females. before the exploratory factor analysis, the results showed that the kmo (kaiser-meyer-olkin) measure of sampling adequacy was . (chi-square = . , df = , p < . ), and the bartlett's test of sphericity indicated that the correlation matrices on which the pca was based were suitable for analysis. according to the factor load matrix after the rotation axis, the analysis process of the items was as follows. first, delete three items with insufficient load and which are difficult to name on each factor; next, compare the load of each item on each factor, and delete three items with small load and similar load on different factors; third, analyze each factor, and delete the items with poor division and which are difficult to explain. as per the above principles, all nine items were retained and three factors were confirmed as the result, and the total variance was . %. the factors, which were named in turn, were cognition of danger (cd), reflecting the evaluation of the environmental risk of the subjects; judgment of the situation (js), reflecting the confidence in successfully combating the epidemic and the psychology of the anti-epidemic work; and the stress reaction (sr), reflecting the physical and mental stress response produced by the subjects' current environment. see table . after constructing a stress reaction questionnaire with good reliability and validity, we used confirmatory factors analysis (cfa) to confirm the validity of the questionnaire to provide a questionnaire that reflected the ideal standard. data from subjects were collected as cfa, including in wuhan and outside wuhan, males and females, and the fitting index tables and model diagrams drawn through amos software of cfa are shown in table and figure ; finally, we conducted a wide range of formal tests. the internal consistency reliability (cronbach α coefficient), partial reliability and the correlation between each factor score and the total score of the questionnaire were calculated by spss . , and the results showed that the overall internal consistency and reliability and the overall parity factor for both was . . see table . all data analysis was carried out using spss . (spss inc, chicago, illinois), and a two-tailed probability value of < . was considered to be statistically significant. descriptive statistics for the demographic and psychological states of the medical staff were shown as the mean, standard deviation (sd), number (n), and percentage. independent samples t-tests and one-way (anova) analysis were carried out to compare the differences in the mental reactions according to the demographic and psychological states of the participants. among the , subjects who filled in the questionnaire, the distribution was not uniform, and . % were doctors ( , in this study, the differences in the health care workers' environmental exposure were demonstrated mainly by whether they participated in the covid- resistance front and had direct contact with confirmed patients. there were significant table . the results show that those involved in the first-line response believed they were at greater risk of exposure to infection in the workplace(t = . , p < . ), and they had more anxiety about infection (t = . , p = . ), thought they were more likely to get sick (t = . , p < . ), worried more about family infection (t = . , p = . ), had lower confidence in obtaining victory over the epidemic (t = . , p = . ), had poor sleep quality (t = . , p < . ) and had a higher demand for psychological counseling (t = . , p < . ). however, there were no significant differences for the cognition of the current epidemic severity and the fear of epidemic prevention. the differences in health care workers' personal experiences were affected mainly by whether they had experienced sars or another epidemic. there were significant differences in the levels of cognition of danger, judgment of their situation and stress reactions to personal experiences. specific statistical results for the medical care personnel and group comparisons are displayed in table , which shows that medical staff involved in sars prevention believed they had a greater risk of exposure to infection in the workplace (t = . , p = . ), were more likely to be infected (t = . , p = . ), had more confidence in the success in epidemic prevention and control (t = − . , p = . ), less fear of fighting the epidemic (t = − . , p = . ), and poor sleep quality (t = . , p = . ). however, there were no significant differences for the items regarding being worried about getting infected, the cognition of the current epidemic severity and the need for psychological counseling. since the outbreak of the epidemic, medical workers have been stressed and made to work for long periods of time, with little time for rest. the difference in exposure duration was reflected mainly by the number of continuous working days. this study compared the differences in the duration of the participants' operational time in medical care work and divided the working hours into four levels for horizontal comparison, which found that the longer the working hours were, the more likely the participants believed they would be infected (f = . , p < . ), the more worried they were about family members being infected (f = . , p < . ), and the poorer their sleep-quality was (f = . , p < . ). however, the fear of epidemic prevention was lower (f = . , p < . ). furthermore, there were significant fluctuations in two dimensions, cognition of the current epidemic severity (f = . , p = . ) and confidence in anti-epidemic measures (f = . , p < . ), caused by the increase in working hours, which at first declined a certain degree, then increased significantly. see table . since the emergence of the new coronavirus pneumonia in wuhan at the end of december , numerous medical staff have been working intensively for nearly months and will continue to do so in the future. the results showed that the current mental health status of health care workers was not stable, with a general mean of more than . in terms of the cognition of danger, and most of the mean values were above (according to richter's five-point score, which gradually declined from to ). regarding the dimensions of the judgment of the situation and the stress reaction, the medical staff were optimistic, and there was no obvious negative somatization phenomenon. it was found that the exposure environment, personal experience, and exposure duration had significant effects on the psychological stress and emotional responses of medical staff. medical workers involved in the front-line of prevention were affected to different degrees in these three dimensions, and the statistical level was significantly different. this may be due to direct exposure to close contact with the virus and negative tension in their environment as well as the fear of threats to their own lives. additionally, the medical work environment is infested with patients' senses of grief and panic, resulting in a constant psychological burden for front-line medical workers. at the same time, there is no clear and targeted cure for the novel coronavirus infection. doctors and nurses are not in a position to cope with the suffering of infected patients, which is further increasing their psychological burden. the influence of medical workers who have experienced sars and other epidemic diseases was not synchronized in these three dimensions. in the dimension of the cognition of danger, employees with experience of sars and other epidemic prevention situations felt more serious psychological pressure, while for the dimension of the judgment of the situation, they had more confidence about overcoming this epidemic. this may be explained by the success of the prevention and control of infectious diseases like sars, which has enhanced the collective sense of the efficacy of health care groups in the face of similar diseases, thus enhancing their confidence. however, the difficulties of living through that process and the negative emotions experienced are difficult to describe, and the impact has not gradually disappeared over time. the outbreak of the epidemic quickly awakened the former unhappy memory, so the iteration and development of risk cognition were derived from a certain preexisting foundation. this is also a wake-up call for psychological workers to remind us to do a good job of psychological intervention and health care even after illness. as the time of exposure to the virus increases, the mental state of the medical staff deteriorates. regarding the factor of risk cognition, the negative psychological state of the medical staff gradually intensifies with the passage of time, whereas the optimistic hope dimension presents the inverted u curve change. in the physical and mental response dimension, the sleep-quality of the medical staff is generally poor, but the difference in the level of demand for psychological counseling is not significant. this may be because, in the early days of the outbreak, a large number of patients poured into hospital emergency rooms and fever outpatient departments, increasing the already heavy workload and responsibility of all medical staff. meanwhile, the high intensity of work continued without rest, there were inadequate protective supplies and protective isolation measures, the outpatient procedure organization became cluttered, and other phenomena have continually aggravated the psychological burden of medical staff, reducing the confidence of medical workers in prevention and control. as the epidemic situation gradually comes under control, medical work tends to stabilize, so the confidence in prevention and control has been steadily recovered. however, the negative feelings of health care workers have not been effectively vented, such as the grievances, fears, and powerlessness of medical staff in the face of dissatisfaction from patients and their families because of the lack of timely treatment. the inner suffering cannot slowly dissipate over time. by contrast, it is highly likely that the backlog of negative emotions causes some mental health issues, especially ptsd, requiring the attention of psychological workers. ptsd usually occurs within a few weeks of traumatic events but can also appear after a few months or even a few years, and the duration is usually half a year or more ( ) ( ) ( ) , depending on the severity of the event and the individual state of mind ( , ) . the current trend of the epidemic situation in china has been obviously controlled, and the tension of the medical staff can be relaxed in stages, which is the best time for online psychological guidance. moreover, the outbreak of foreign epidemics is rapid, and many countries lack the experience of prevention and control. china plans to send some supportive medical workers to countries where the epidemic is ongoing. the relief of tension is about to face new challenges, and it is essential to effectively perform psychological intervention and regulation for medical staff. both chinese and international mental health workers must pay attention to this problem and stabilize psychological security ( , ) . this study found that the psychological state of medical workers was significantly affected by the high-risk environment of direct contact infection, long working hours, and personal experiences. however, the only factors that can be controlled are the working environment and working hours. the authors suggests the establishment of a matching system between the psychological state and the working intensity of medical staff; after all, only upon a foundation of psychological security can the work be completed efficiently. the psychological security work needs to be carried out in a systematic and hierarchical manner from the local level to a more general investigation by utilizing close attention to ensure that every corner of the mental health of medical staff is explored. first, based on the overall comprehensive investigation, a medical staff psychological state tracking system should be established. second, all mental state files should be classified into attention levels, such as core, focus, general attention, etc. meanwhile, each health worker will be assigned a psychologist who is responsible for paying regular attention to their mental health problems. psychological workers need to evaluate whether the medical staff 's work schedule matches their psychological status and periodically review their appropriate work intensity level. finally, specific psychological interventions need to be carried out for all health workers who are marked as working at a certain level of focus and above by recording any incidents in their mental state file. by investigating the emotional and psychological stress responses of medical staff during the prevention and control of the new coronary pneumonia, it was found that the high intensity of medical work had a variety of negative effects on their risk cognition, confidence in overcoming the epidemic situation and physical and mental reactions, all of which are detrimental to the mental health of medical staff. in addition, the exposed environment, personal experiences and differences in the length of their work hours played important roles. to maintain the mental health and stability of medical staff and avoid the influence of mental health issues like ptsd, psychological workers need to take targeted measures to systematically solve the mental health problems of medical workers in the face of major infectious disease crises. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. approval from the ethical authority of the school of educational science, huazhong university of science and technology, was granted. confidentiality and the statement confirming informed consent were managed by anonymous coding of the self-report questionnaires. the patients/participants provided their written informed consent to participate in this study. yz, pw, and lz conceived and designed the questionnaire. lz recruitment and payment of participants. sx, gw, xc, yb, fh, nl, ml, and qx analyzed the data. sx wrote and revised the paper. all the authors have approved the manuscript and agreed with submission to your esteemed journal. a novel coronavirus outbreak of global health concern clinical features of patients infected with novel coronavirus in wuhan travelers give wings to novel coronavirus ( -ncov) incubation period of novel coronavirus -ncov infections among travellers from wuhan, china -novel coronavirus outbreak: a new challenge timely mental health care for the novel coronavirus outbreak is urgently needed will novel virus go pandemic or be contained? journey of a thai taxi driver and novel coronavirus importation and human-to-human transmission of a novel coronavirus in vietnam community pharmacist in public health emergencies: quick to action against the coronavirus -ncov outbreak vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control theoretical perspectives of traumatic stress and debriefings long-term psychiatric morbidities among sars survivors online mental health services in china during the covid- outbreak environmental psychology empirical research in environmental psychology: past, present, and future an ecological perspective on theory, methods, and analysis in environmental psychology: advances and challenges a problem for cognitive load theory-the distinctively human lifeform a systematic review of ptsd prevalence and trajectories in dsm- defined trauma exposed populations: intentional and non-intentional traumatic events perception counts: the relationships of inner perceptions of trauma and ptsd symptoms across time post-traumatic stress disorder and somatization symptoms: a prospective study emotional distress and positive and negative memories from military deployment: the influence of ptsd symptoms and time does acute stress disorder predict post-traumatic stress disorder in 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reproduction is permitted which does not comply with these terms. key: cord- -h qwxdtn authors: speckhard, anne title: prevention strategies and promoting psychological resilience to bioterrorism through communication date: journal: risk assessment and risk communication strategies in bioterrorism preparedness doi: . / - - - - _ sha: doc_id: cord_uid: h qwxdtn nan terrorism as a psychological weapon . dread not only in its immediate victims but in its wider witnessing audience. continually redefining itself in response to counterterrorism measures. the progress and portability of high-tech weaponry and the ability to communicate information quickly (over internet and telephone) has advanced the ability of small groups to create virtual command centers that can operate simultaneously and cover multiple world regions, and in doing so enact events of worldwide mass terrorism. moreover biological, chemical, and nuclear wmd -all previously weapons of states -are increasingly coming within the grasp of smaller groups of actors, and terrorists have made clear their desire to obtain and use such weapons. in the fight against terrorism societies must prepare themselves for all variants of terrorist attack and institute policies that prevent widespread dread and panic, and promote resilience in the larger civil society. the defense against terrorism is in reality four-tiered. firstly, it involves investing huge amounts of resources into hardening defenses in terms of securing buildings, airports, and civil military installations. this defense is important in securing key resources. yet it has been called a placebo response by some because in reality, the entire nation can be a target, total defense is illusory and any death will achieve media coverage -thereby radicalizing public opinion and demonstrating the ineffectiveness of the security forces (mackenzie, ) . secondly, tier of defense against terrorism includes infiltrating and destroying terrorist groups -by discovering and thwarting their plans ahead of time and raising questions about their methods and ideology within the groups (atran, ; post, ) . society that help shape interactions amongst the population including nongovernmental organizations (ngos), media, and those intermediary institutions (e.g., professional associations, religious groups, labor unions, citizen advocacy organizations, etc.), which build links between the population, provide information, analyses and political responses, and that give voice to various sectors of society and enrich public participation in democracies. of course civil society never acts in a vacuum or completely independent of government hence this paper focuses often upon how the two overlap, including through laws, policies, and instructions from one governing the other, as well as their interaction through the media, the public health service, hospitals, medical institutions, universities, think tanks, foundations, the legal system etc. civil society being broadly defined here as the formal and informal structures of the emerging threat of global terrorism is one that is dynamic and prevention strategies and promoting psychological resilience thirdly, for winning the "war on terrorism" societies can defend against terrorism by working to understand and diminish the reasons for popular support of terrorist groups -"debranding" the ideology and looking for and addressing the root causes. lastly and most importantly for this paper is the need for society to anticipate the responses of its own citizenry to terror attacks of all kinds and build resilience into it so that the psychological effects of terrorism are minimized. with the advent of groups like al-qaeda and the interest in creating terror attacks involving mass casualties and the use of self martyrdom missions many in the terrorism field have begun to speak of a "new terrorism". whether or not we are seeing a real break with old terrorists' methods and goals it is certainly true that today's terrorists function in a completely new global environment. with the erosion of strict borders between countries (particularly in the european union) and even world regions (since the fall of the soviet bloc), the advance and portability of high-tech weaponry including biological, chemical, and nuclear hazards, and the ease and speed of communication through the internet and telephones for purposes of recruitment, training, and planning terror attacks -terrorists now have a global playing field in which even small groups of individuals can motivate, plan, and enact mass terrorist events. moreover biological, chemical, and nuclear wmd -all previously weapons of states -not small groups, are increasingly coming within the grasp of smaller groups of actors, and terrorists have made clear their desire to obtain and use such weapons. use wmd including bioterrorism (schweitzer, ) . in addition to the much publicized words of osama bin laden in which he stated it was a sin not to make use of such weapons, shamil basayev, leader of the chechen terrorist groups has also avowed his willingness to attack his enemies with the same agents he believes his people have been attacked with including i am indebted to thelma gillen of the uk mod for this brilliant idea of attempting to "debrand" an ideology, much like one might attempt to debrand a trademark. martha crenshaw severely criticizes this conceptualization, which she credits to simon and benjamin. qaeda and its affiliates. chillingly they have avowed their willingness to the most well-known and perhaps most feared global terrorists are al-a. speckhard the new terrorism bioterrorism. abu musa'ab al suri one of the contemporary al-qaeda ideologues also advocated the use of wmd and criticized osama bin laden for not previously using them (paz, ) . likewise aum shinrikyo, a nonal-qaeda linked group, that was active in japan aimed to develop such weapons and actually shocked the world with the first mass chemical attack when they dispersed sarin gas in the tokyo subway, injuring hundreds. likewise two al-qaeda affiliate groups were thwarted in their attempts to use a ricin like substance in london and paris, and a failed biological attack was carried out in the united states when a small anti-government group attempted to contaminate a salad bar with salmonella. so clearly there is an avowed willingness by today's terror groups to resort to the use of bioterrorism. as far as intelligence analysts have been able to piece together when groups are searching for wmd they have thus far resorted to utilizing state sponsorship, trying to buy materials on the world black market, or resorted to illicit pilferage. when these activities have not worked, terror groups have adjusted their strategies by putting their resources into internal reuven paz writes, "abu mus'ab al-suri -a former leading trainer and scholar of al-qaeda, published two significant documents calling for a new organization of global jihad: "the islamist global resistance." one was a nine-page letter published in december , and the other was a huge book totaling , pages about the strategy of global jihad in his open letter to the state department, al-suri talks at length about the importance of using wmd against the united states as the only means to fight it from a point of equality. he even criticizes osama bin laden for not using wmd in the september attacks: "if i were consulted in the case of that operation i would advise the use of planes in flights from outside the u.s. that would carry wmd. hitting the u.s. with wmd was and is still very complicated. yet, it is possible after all, with allah's help, and more important than being possible-it is vital." al-suri states that "the muslim resistance elements [must] seriously consider this di cult yet vital direction." reuven paz writes, "abu mus'ab al-suri -a former leading trainer and scholar of al-qaeda, published two significant documents calling for a new organization of global jihad: "the islamist global resistance." one was a nine-page letter published in december , and the other was a huge book totaling , pages about the strategy of global jihad in his open letter to the state department, al-suri talks at length about the importance of using wmd against the united states as the only means to fight it from a point of equality. he even criticizes osama bin laden for not using wmd in the september attacks: "if i were consulted in the case of that operation i would advise the use of planes in flights from outside the u.s. that would carry wmd. hitting the u.s. with wmd was and is still very complicated. yet, it is possible after all, with allah's help, and more important than being possible-it is vital." al-suri states that "the muslim resistance elements [must] seriously consider this di cult yet vital direction." research and development (hoffman, ) . the aum shinrikyo group recruited and hired highly trained russian scientists and set up a highly specialized laboratory. likewise, information discovered in afghanistan makes clear that al-qaeda was engaged in a serious effort to develop a usable chemical and biological weapons capability. seized materials include films of tests carried out by al-qaeda operatives showing that the group achieved their goals enough to having reached the stage of limited testing of agents on live subjects. in the united kingdom and france terrorists groups have utilized crude recipes for biological agents such as ricin (hoffman, ; schweitzer, ) . in the thwarted uk case the group planned to smear small amounts of ricin on the door handles of random vehicles and thereby hoped to create mass hysteria from a few deaths rather than enact a mass killing. terrorists have certainly observed that it is possible to undermine public confidence and create mass anxiety responses by simple and even limited dispersal of a biological agent. the huge public reaction to the anthrax attacks in the united states (and indeed worldwide when one considers the providers) included: shutting down buildings; strangling the mail system; workers donning masks and rubber gloves while processing mail; quarantining areas, requiring employees to take precautionary strong antibiotics, public and private stock piling of medicines, and widespread anxiety about anthrax. these responses made clear that one could both undermine public confidence and create widespread mass distress with relatively few anthrax attacks (hoffman, ; speckhard, a) . likewise the fact that it took months and $ . million to decontaminate the hart senate office building and nearly $ million to do the same in the boca raton postal facility demonstrated the high costs of responding to the dispersal of minute quantities of a biological agent. terrorists learned from these events that rendering an important facility inoperable by virtue of biocontamination can have widespread and devastating social, psychological, and economic repercussions (hoffman, ) . the so-called chechen cell of north africans in paris were discovered preparing ricin for an attack on the russian embassy in paris and the london group had already prepared large quantities of ricin for an unspecified attack. attacks throughout europe which were taken seriously by emergency number of us embassies that were also affected, as well as the many hoax a. speckhard mass anxiety with bioterrorism . . undermining public confidence and creating ricin scandal it became apparent that the terrorists were more interested in their ability to undermine public confidence and to potentially create mass hysteria with a bioterrorism attack than in actually enacting a mass killing event. likewise the algerian cell's interest in ricin appears to be based in their inability to achieve sufficient media impact using strictly conventional attacks (hoffman, ) . terrorism relies upon making a strong media impact and bioterrorism has that potential. while the war in afghanistan made significant inroads in taking out the main al-qaeda leadership, its ideology still flourishes and in the absence of a strong centralized leadership the movement has continued unabated. recruitment, training and perhaps most important, a motivational ideology is daily transmitted globally via the internet bringing on board a disparate (but unified by a common ideology) group of disenfranchised, alienated, frustrated, and even traumatized individuals living in both conflict and non-conflict zones willing to sign on to support and even enact terrorism. in terms of western security, this is particularly troublesome in europe where radicalization among disenfranchised muslim communities appears to be a swelling phenomenon. the unresolved conflicts and human rights violations in chechnya, palestine, kashmir, and now in afghanistan, iraq, and guantanamo bay as well, all give fuel to the al-qaeda ideology, which argues that islam is under attack by corrupt western powers and militant jihad including attacks on civilians and self martyrdom operations is not only justified, but a duty. with the current ease of communication, lessening of technological barriers, convincing ideology, and a ready pool of recruits, it appears that the occurrence of a mass bioterrorism attack may simply be only a matter of time. given this state of affairs can we anticipate the responses of our citizenry to bioterrorism and if so how can government and civil society prepare and increase societal resilience to such attacks? to answer this question we must acknowledge that our citizenry is far more resilient than they are often given credit for. the common view espoused by government officials and policymakers is an expectation that people will panic in the face of a mass terrorist event and that chaos will ensue. experience with terrorism, however, does not bear that out (wessely, ) , although most of our research is based on conventional versus bioterrorism. in nearly all civil disasters that have been studied by researchers, holding aside the moments of escaping an imminent danger such as a fire, earthquake, hurricane, or bomb -researchers repeatedly have found volunteer their resources, and risk their lives to help each other. society actually becomes more civil during times of disaster as social cohesion increases rather than decreases under threat: in the short-term attachment behaviors generally increase, social cohesion increases, and the heroic is often called forth in ordinary people (speckhard, a) . we have numerous studies that bear this out. / is a good example. after-the-event interviews of persons involved revealed that people did not take a "me first attitude", disabled and injured persons were not run over by panicking hordes or left behind, abandoned (furedi, ) . on the contrary the / evacuation was self-generated, orderly, and without panic, and those who were hurt or disabled were carefully and calmly assisted and taken to emergency services (glass and schoch-spana, ) . the explosion of the chernobyl nuclear power plant gives us another window in which to view the responses of citizenry in times of mass disaster. when the reactor was about to explode the plant operators did not abandon their posts and flee like cowards to protect themselves. instead they heroically fought to the last moments to shut down the reactor, to contain the damage -many giving their lives to do so. the madrid train bombings give us another example. witnesses state that after the first explosions passengers helped one another and calmly began to exit the scene. only when repeated blasts occurred did some begin to run. even then, when it became clear that emergency vehicles were having a hard time getting to the platform, taxi drivers waiting for customers did not flee in fear, but volunteered themselves as makeshift ambulances and ferried wounded persons to emergency care (speckhard, b) . the same happened in the moscow subway bombingspeople walked calmly for long distances in the darkness, helping the wounded to evacuate. when terrorists bombed a crowded rock concert outside of moscow -the band agreed to bravely play on, the audience followed instructions not to stampede in fear and the wounded were carefully attended to. in the moscow theater where hostages were held by chechen suicide terrorists the hostages also remained calm for the most part during their ordeal and helped one another (speckhard, a; speckhard et al., ; speckhard et al., a, b) . even in the beslan hostage taking crisis where hundreds of children were held hostage, water and toilet privileges were withheld, and shooting occurred in front of the hostages -there were only limited outbreaks in times of threat. total strangers help each other, open their homes, that citizenry has become quite attachment and community-oriented extremely heroic behaviors were displayed (speckhard, c) . the london public transportation bombings also met with relative calm, with londoners quickly resuming confidence in the use of public transportation (wessely, ) . even under sustained and intense terrorist threat such as what has occurred in israel during the second intifada (uprising) we witness that the vast majority of the population there has habituated to the threat, certainly making adjustments in daily living to avoid as much as possible their potential for being killed by terrorists -but yet carrying on with life all the same. while the psychological costs of living under a sustained and intense terror threat are still not well understood (likely causing hyperarousal states in many, bodily distress, etc.) we do also see that most of the israeli population have on their own found ways to be resilient in the face of it. terrorists aim at creating widespread horror, dread, and fear, and to divide society. however, it is safe to say that despite this when under threat one can see in civil society, at least in the short term that attachment behaviors generally increase, social cohesion increases, and the heroic is often called forth in ordinary people. while this is true of terrorism that involves bombs and destruction we know less about societal responses to bioterrorism and we may find that the lessons learned from one type of terrorism may not transfer as well to another. we still have not studied well the potential effects of a mass bioterrorism event in which the dread caused by the spread of an invisible, contagious, and potentially lethal pathogen may be horrendous and in fact lead to less resilient responses. in this case the spread of horror from the terrorist attack will be amplified not only by the mass media but also by the many vectors of contagious contact all of which are difficult for ordinary individuals, much less medical professionals to understand and cope with. likewise trying to contain a potentially lethal contagious disease, that has a presymptomatic incubating period, and that can be spread through contact with others is extremely challenging and requires societal cohesion and compliance with rapidly responding and well-informed government authorities. in this case quarantines and the means of enforcing them, panic-driven hoarding of medicines and overwhelming the medical care services with "worried well" and psychosomatic individuals are issues that we know from other disasters might well occur and, which might severely impact societal resilience. thus we cannot say in all cases we expect society to be resilient. when it comes to poisons, invisible toxins, and fear inducing contagious illness, we have to look at other incidents to draw lessons. of hysteria. for the most part the adults present calmed the children and some when a threat is invisible and difficult to comprehend, some individuals may be expected to respond with fear, aggression, hysteria, and even psychosomatic symptoms if the fear of a potential toxic exposure becomes overwhelming. such responses have been witnessed in many events and are well documented in the literature. after the goiania radioactive incident (brandao mello et al., ) , following chernobyl (bromet et al., ; green et al., ; havenaar et al., ; speckhard, b) , and after the sarin attacks in the tokyo subway, medical systems were briefly overwhelmed by thousands of individuals who feared that they had the symptoms of poisoning, many who became psychosomatically ill. the explosion of the chernobyl nuclear power plant was perhaps the most serious "invisible" threat to date. likewise the bhopal and goiania and other similar incidents give us additional information making clear that there are unique psychological and fear responses to "invisible" toxins, poisons, and contaminants, as well as the widespread dread of pervasive and random threat that accompanies conventional terrorism. not only is disease contagious but psychosocial phenomena can also spread as infectiously through populations as biological agents, sometimes wreaking as much havoc with health as the disease agents themselves. the processes whereby emotions, attitudes, beliefs, and behavior are spread, transmitted, and even leap between populations, similar to other contagious outbreaks like measles, chicken pox, or even the common cold is referred to as psychological or psychosocial contagion. psychosocial contagion moves from person to person, often times requiring only a single exposure. categories of contagion important for understanding potential societal responses to bioterrorism include emotional, behavioral and aggression contagions. mood, fear, and anxiety states can be transmitted quickly through a population as humans tend to synchronize their facial expressions, voices, and postures with those in their immediate environment taking on fear and distress states when they witness these in those around them (behnke et al., ; hatfield et al., ; hsee et al., ; mcdougall, ) . this is particularly true of children. this synchronization can occur in response to viewing live footage in the mass media and may be one of the modern day mechanisms for rapid transmission of emotional contagions. behavioral contagions can also occur. for instance individuals exposed to violations of rules often increase their likelihood to engage in a similar or fear of the unseen and unknown -poisons, toxins, identical behaviors (i.e., speeding, delinquency, criminality, teenage smoking, youth sex, substance abuse) (connolly, ; ennett et al., ; jones, ; jones and jones, ; rowe et al., ) . these two contagionsemotional and behavioral likely explain the psychology behind the hysterical buy out of duct tape in the united states when word got out that the homeland defense report had made mention of duct tape as a useful means of protecting oneself from chemical and biological attacks. similarly it can explain in part why many americans were massively noncompliant and failed to heed public health officials instructions not to stockpile cipro (flaxocin) the antibiotic used to treat anthrax, instead of following a general panic among many to buy out unnecessary antibiotics and perhaps by doing so deprive those truly in need of them. if the anthrax attacks had been widespread, this may have caused significant hardship for some. as of this writing, we see the dread and dismay caused as avian flu makes its way westward, with many citizens overly worried and rejecting poultry products and others noncompliant due to economic concerns of losing livelihoods, with the long-term health and economic consequences still unknown. certainly governments must plan ahead for how they would handle issues of quarantine if it were needed and work beforehand with the public to get their participation and acceptance for plans, as well as with the media, police, military, or national guard units that would be responsible for reporting on and enforcing quarantine so that as much as possible contentious issues are dealt with and anticipated beforehand. even rehearsing how a decontamination unit would function in a mass terror setting is important for small but crucial issues like deciding does everyone who goes through the unit have to strip naked and if so can provisions be made for segregating the sexes -a difficult issue for those for whom modesty is a key value; how do decontamination units handle the need to give up contaminated items including car keys -raising the issue of how does one get home; or how to handle the surrender of contaminated mobile phones -creating stresses and tensions for family members who can no longer check on and reassure their loved ones. small but crucial issues like these if anticipated and thought through beforehand, with useful remedies built into the response scenarios can be arranged for the least stressful responses. new models of readiness are necessary to counter this threat especially when it pertains to biological terrorism because biological contamination raises unique and difficult issues, differing dramatically from other types of terrorism. as psychological contagion is a very real response to the potential of toxic exposure, medical systems should prepare ahead for massive onslaughts of the "worried well". the severe acute respiratory syndrome (sars) virus crossing from asia to canada in a very short time -shutting down an entire city; the cyrptosporidium epidemic of in the state of wisconsin; and the current epidemic with avian flu makes clear that huge number of people can be affected when a bio-threat spreads quickly through a community and that these threats raise difficult psychological and medical issues (glaser, ) . governments and media must work together preparing ahead of time on how to communicate calmly in such crises in a manner that will offer useful preventative measures, minimize the potential negative effects of psychosocial contagions (including citizenry becoming noncompliant and aggressive), prevent mass sociogenic illness from occurring, and prevent overwhelming of the medical systems by those whose emotional state has put them in need of medical care. in the case of bioterrorism as we shall see this is no easy task. in its extreme form psychosocial contagion can spawn mass hysterical contagions or mass sociogenic illness -that is, the rapid spread of illness signs and symptoms, which has no physical basis for the symptoms and no known exposure to a pathogen (bartholomew and wessely, ; cohen et al., ; kerckhoff, ; marsden, ) . hysterical contagions involve the spread by contact, including mass media exposure, of reported symptoms and experiences usually associated with clinical hysteria (hallucinations, nausea, vomiting, fainting, etc.) in the absence of exposure to a pathogen. such illnesses often begin with exposure of a limited group to a biological contagion or chemical toxin with the others around these persons or learning of them responding hysterically with some form of nervous excitation, including a significant loss or alteration of function, and physical symptoms with no basis in physical etiology. these types of illness often affect members of a cohesive group although they can leap across groups when common links are made in reality or imagination. such links are often made through the mass media in which one quite limited group of individuals is actually exposed to a biological or chemical toxin and has real symptoms but other groups fear that they too have been exposed. study of these types of contagions has found that exposure to the verbal reporting of symptoms rather than exposure to the symptoms themselves was enough to pass it on to others (colligan and murphy, ) , which makes it clear that responsible and nonhysterical news reporting is very necessary to contain such contagions. often there is a sensitizing issue that makes populations vulnerable to psychogenic illness. in belgium in , a mass sociogenic illness occurred in response to tainted coca cola that gave off harmless fumes, but caused psychogenic symptoms in schoolchildren mass sociogenic illness and members of the general public. this may have occurred because the belgian public had been sensitized by serious food scares during the previous year involving dioxin contamination in the food (nemery et al., ) . research has also shown that when one groups feels under attack by an enemy it is much easier for the symptoms to spread as the "victim" group finds it easy to believe that they have been poisoned by their enemies (bartholomew and wessely, ) . this occurred in palestine (modan et al., ) , kosovo (hay and foran, ) , and recently in chechnya. recent evidence indicates people do not even have to be present at a terrorist event to experience posttraumatic symptoms (speckhard, a, b; speckhard and mufel, (speckhard, a, b; speckhard and mufel, ) . in these studies, media and, particularly television exposure, was an important predictor of stress or traumatic symptoms in the face of terrorism second to geographic distance from the attacks. we must recognize that graphic images have the potential to be traumatic in themselves in terms of their potential to create a "witnessing" experience of trauma and their constant replay can also become traumatic as a potential victim also proved to cause stress symptoms (dixon et al., ), something that can also occur via televised images. terrorists' goals are to spread horror in behalf of their political cause and they reach their goal of maximum psychological impact through their manipulation of the mass media. the media, which is in a sense symbiotic with all the horrors of the world, generally responds within minutes of any terror attack and coverage begins immediately. in the case of a mass terror attack, the "talking heads" follow shortly thereafter. in most cases of mass terrorism it will be through these channels that the interventions to the resiliency of civil society -by what they communicate or fail to communicate. journalist robert frank points out that in a disaster situation people often "only recall from the peak moment, in the peak intensity, and far less attention is paid to the more accurate picture that emerges over time." this then according to frank, "creates a predisposition to think a certain way before the facts are fully presented and afterward then only to listen and retain those that confirm what was previously believed." unfortunately journalists are under pressure to get stories quickly and report the news with insufficient information. frank goes on to state, "it is however, very, very seductive to news-workers to appear knowledgeable when you are not" (speckhard, b) . certainly the emotional and behavioral response of citizenry to an event of bioterrorism will depend in part on how well and calmly government communicates the events to citizens and directs them in useful activities rather than leaving an information vacuum for the media experts or "talking heads" to fill with emotionally fearful information. if governments wish to avoid such consequences and compete with the unbridled freedom of mass media to form public opinions they must be prepared and have their own "sound bites" and "talking heads" prepared well ahead of a disaster, otherwise the mass media will fill the vacuum. while the practice of journalists presenting incomplete stories with only half fashioned facts is unlikely to disappear, government and the public health systems have a responsibility to prepare ahead of time and be ready to provide psychological triage -both through the media and in person for the worried well and psychosomatic individuals who will likely overwhelm the medical facilities. in the short term government and experts credibility is crucial. once that is lost it is very difficult to calm arousal states in individuals who will not believe competing information from that they already took on board. terrorists thrive on creating a mental environment in which citizens live in fear and dread of the next attack. civil society can do a lot to fight this type of psychological tactic. one of the most important ways is for those in charge of information to be well prepared and to speak in a reassuring manner about what is both known and unknown, giving essential information but not creating a sense of constant danger. this is a difficult but necessary balance to strike. in providing psychological reassurance over the media, government needs to think ahead of time to taking advantage of the new technologies as well -particularly the internet. in today's world we must recognize that many people will instantly log onto the internet in search of information and that rumors will abound. public health officials should have already prepared and be ready to launch (or have already launched) reliable and useful information via the internet and through all other channels of mass media to reassure the public and instruct them for the most protective responses. likewise government can make use of mobile phones, computers, and hand held devices that can receive transmissions with messages specifically aimed at them by virtue of where they are presently located. in the case of a contagious outbreak it is possible to transmit information regarding advisories of where not to travel and information about which hospitals and clinics in the area are free versus overwhelmed and general health care advice for that regional area (hopmeier, ) . in this case credibility is crucial. government must be very careful from the beginning to not lose the trust of the public in announcing what is known and still unknown, and to address psychosomatic responses in a meaningful way that differentiates them from the actual illness in question. while state control of media is an anathema to those who hold dear the rights of free press and freedoms of speech, the media can take actions collectively to self censure sensationalist reporting that continues to ratchet up fears. government spokespersons can put fears in perspective reminding people not to generalize from one event to all potential possibilities. for instance, following the february moscow subway suicide bombing that killed less than persons, moscow's carnegie center dmitri trenin stated, "every time i go down into the underground i wonder if i will finish my journey. now nine million people feeling they are playing russian roulette" (ostrovsky, ) . while this was a statement of his feelings, it reflects the sense of psychological contagion that can occur when nine million people fear an event that affected only a very small proportion of their total. statistically the dreaded terror event is much more unlikely to happen to them than many other ordinary horrors that they forget to fear. the same occurred with the sniper in the washington area in the fall of , with fear of a deadly but highly unlikely threat nearly paralyzing a huge metropolitan area. terrorists win when they can create a sense of dread of a pervasive and random threat -one that can strike anyone, anywhere at anytime. invisible threats -as involved in bioterrorism have the most likelihood of achieving this goal. the chernobyl disaster is probably the most well-known example of an abysmal failure by government to communicate and protect its citizenry and the effects of this failure are still felt today. twenty years later the prevention strategies and promoting psychological resilience population has still not recovered from fearing what their government failed to protect them from and many individuals disregard competing causes for illnesses such as alcoholism, pollution, stress, poor nutrition, etc., with nearly every birth defect, many serious illnesses -especially cancer, and even symptoms of minor distress in the region still suspected and blamed on chernobyl (speckhard, b, b) . most of the potential bioterrorist threats are clear -although the uncertainty lies as to where, when and how. thus it is possible for government to think ahead to what the population needs to know to respond calmly and with insight. indeed it may be wise to be already letting people know that smallpox vaccinations work even after exposure, that anthrax can be lethal upon direct exposure but is not spread infectiously. these bits of information can lay a foundation for calm responses, should the dreaded event occur, and create confidence that one could survive. in the wake of an actual mass terror event it is wise if the government has prepared ahead of time on who will speak and given some thought, not only to the facts that must be relayed, but also to that how the message is relayed is often as important as the message itself. the emotional tone of the message can create fear or calm. the israelis' success during the first gulf war ( ) when the population was being bombarded by scud missiles and directed to don gas masks (including putting them on small children), and retire to safe bio-sealed rooms in the event of a bioterror attack depended in large part on the preparation taken beforehand by government to disperse gas masks and to teach individuals how to take preventative measures to respond to bioterrorism. likewise israeli army spokesman, nahman shai, whose task it was to announce to the citizenry instructions to don gas masks and go to shelters, performed this duty in such a reassuring manner that he is still remembered fondly. in providing this anxiety inducing information at the moment of imminent attack his voice remained so calm and soothing as did his demeanor that he was later nicknamed the "the valium of the nation." likewise when the decision was made in israel to inoculate first responders (i.e., medical personnel, police officers, public health teams, and army soldiers) to a potential bioterrorism attack involving smallpox the fear surrounding doing so was addressed by the general director of the ministry of health, boaz lev, going on television and being the first to take the inoculation -showing by example that he had faith that it was worth the risks of doing so. this is a heroic example of how to communicate calmness in a crisis situation. often when a disaster or terrorist event occurs all the information is not known and the greatest psychological issue is about safety and what is next. frightened citizens want to know what to expect and they need things explained in a way they can understand. this is difficult for government officials who often do not have all the information they need to respond immediately and do not know if the threat is ongoing. in this case it is of paramount importance to tell the truth. short-term pacifications achieved with falsehood only create mistrust and blame later. it is far wiser to state clearly what is known and to admit what is still not known, making it clear that government is working hard to get the answers and nothing will be withheld to achieve maximum protection for the citizens. when explaining the risks of toxic and radioactive exposures it is important to speak in ways that put the dangers in perspective. far more people currently die in road accidents than in terror attacks, radiation exposure also occurs normally at the dentist, while flying, etc. people can understand and respond better when risks are explained in terms of comprehensible and clear comparisons. public health systems in the united states at least, have been losing funding in recent years. without the foresight of politicians, to have made preparatory investments of resources and personnel, they may not be ready to handle a huge public health epidemic, especially one caused by bioterrorism. the equipment and training alone needed to competently handle a bioterrorism attack (in terms of rapid identification and containment) must be anticipated ahead of time and the need for a central command and control, and clear lines of communication often across many agencies must also be determined well in advance. these are lessons we have learned from other terrorist and disaster events. in the japanese sarin attacks for instance the lack of emergency decontamination facilities and protective equipment resulted in a further secondary exposure of medical staff ( ambulance staff and staff in the main receiving hospital reported symptoms). the same occurred following chernobyl. in a training scenario involving multiple bombs and a potential chemical attack played out at the north atlantic treaty organization (nato) support facility in brussels in numerous personnel who were unaware it was not a real event, were called to the scene -ambulances, bomb detonation, decontamination units, etc. who interacted with guards already present at the unit. it became clear in analyzing the exercise that the various actors could not communicate well, as the handheld radios of the emergency workers did not coordinate with those in the nato support facility. it was also not clear who should take charge of the multiple units who converged upon the site and when the decontamination unit did not arrive (it went to another facility by accident) the entire "rescue" was delayed by hours. likewise the ambulatory contaminated "victims" ran to ambulances who refused to take them -because they were contaminatedand then ran through the neighborhood. had it been a real chemical or biological attack the contaminant or pathogen would likely have been widely spread. a similar public safety exercise known as topoff -for "top officials ," sponsored by the us department of homeland safety and state designed to test and improve us domestic response to terrorist incidents, carried out a fictional simultaneous attack against chicago using pneumonic plague and seattle using a radiological bomb in may . similar to the nato support facility exercise the real first responders were not alerted ahead of time that it was a fictional attack but once on the scene worked simulated crime scenes and treated volunteers pretending to be victims. nineteen federal agencies, as well as state and local emergency responders from illinois and washington, as well as from canada and the american red cross were involved. the exercise provided valuable lessons, including the realization that multiple control centers, numerous liaisons, and increasing numbers of response teams only complicated the emergency effort. likewise officials noted that it was essential to monitor and correct false media reports that might have inflamed the public to panic (miller, ) . certainly we know from such exercises that resources must be devoted not only to equipment but to careful planning of how to respond well technically and media-wise to terrorist threats, especially those involving radiological, biological, and chemical terrorism. most worrisome in a biological attack is the ability of government officials to detect unusual activity -as in new strange symptoms -and act early enough to contain the spread of lethal contagious disease within a geographical and population area in time to prevent mass casualties. this is extremely difficult to do as lethal contagious bioterrorist attacks will follow a trajectory beginning with exposure, to incubation, to latently symptomatic individuals to those who succumb and die. in the event of a biological terrorism attack public health officials working with government will be called upon to quickly identify if they are dealing with a bacteria, virus, or toxin and to identify it as quickly as possible and mount an efficient response. since biological infections have an incubation period an efficient response could mean cordoning off those who have been exposed and who are potentially dangerous transmitters (vectors) of the disease. this could mean quarantining symptomless individuals in an effort to make sure that those who have been exposed and could, but are not necessarily proven to, be incubating disease do not spread it to others. it is unclear in a liberal democracy if government officials would be able to establish quarantines that keep people in, much less out, of a zone that has been identified as "exposed" to a lethal biological agent. in these cases one might envision in the united states, the national guard or police troops called in to quarantine off a subpopulation of highly upset individuals who have families, cares, and responsibilities outside of the zone being quarantined (pollack, ) . certainly, in such a scenario, we can expect extremely strong fear and anxiety states to be transmitted quickly through the population and much rule-breaking behavior. whether or not this would mount to the point of contagious aggression is unknown as it has never been well tested. we do know, however, that the contagion of aggressive behavior has been shown to operate in both local and dispersed collectives, particularly within transitory and unpredictable angry crowds (mobs) (bandura, ; lachman, ; reicher, ) and we know from the recent riots in the islamic world that such aggressive contagions can easily be mediated and whipped up by the mass media. it is unlikely that democratic governments would ever desire or strive to shut down media reporting of a bioterrorist attack, yet we can learn from other societies that have taken this tact. after the initial stages of the beslan hostage-taking siege, ossetian authorities shut down broadcasts from the local televisions stations in an effort to defuse some of the local tension of televised broadcasting of the event. likewise psychiatric consultants brought in to help with the siege realized that mothers sitting at home with nothing more to do than agitate and shame their husbands for not going to rescue their children caught in the school building had to be addressed. they organized meaningful tasks for the mothers and opened a briefing center where every three hours or so they gave reports to the townspeople outlining everything they knew about the siege, potential negotiations, the state of the children inside, and so on. while it is unlikely that western countries would follow suit in shutting down television broadcasting, and even in beslan, cable networks, internet, and radio continued to broadcast in the area, it is useful to think ahead on how to work with the media and how to give citizens useful tasks to help them be empowered to be heroic in a crisis versus feeling helpless and frustrated with a sense of powerless inactivity. government decisions on when and what to tell, regarding attempts to contain the threat using quarantine strategies, whether or not to take action in a bioterrorism attack during the period of incubation when there are still no casualties, how to educate now and during the crisis, decisions about putting resources into the public health system, making sure medicines and vaccinations are available and dispersed fairly -are all public policy issues that should be ethically addressed well ahead of time. active public participation in such plans creates a societal investment in carrying them out. if this work has not been done ahead of time it may result in less complaint, less cohesive, and less resilient responses to terrorist threats. while civilians are more resilient that given credit for, a proportion of individuals will predictably suffer from symptoms of acute and posttraumatic stress when exposed to violence and death in a terrorist attack. while many of these responses are short-lived and resolve themselves through normal coping channels, some do not. the nature of a bioterrorism event, however, is less likely to result in acute posttraumatic stress states (unless there are massive numbers of deaths) than one might expect when the attack involves an explosion or other act of mass violence because the traumatic stressor is information versus a witnessed trauma. this is the difficulty inherent in dealing with "invisible" stressors, such as toxins, pathogens, and contaminants -they create fear, horror, and dread but there is often no clearly defined event to address, but instead an amorphous and undefined emotional horror. acute stress responses to a bioterrorism attack are much more likely to include psychosocial and behavioral contagions including hysteria, somatization, mass sociogenic illness outbreaks, and hysterical and possibly even aggressive demands for medical care, vaccines, and medicines than the acute posttraumatic responses often seen in response to an explosion or an act of violence. in all cases reassuring information and calm responses are the most helpful. there is a strong body of literature that demonstrates that intrusive psychological debriefing applied in a coercive manner in the immediate aftermath of traumas, is neither necessary or helpful, and sometimes even harmful, as most acute and posttraumatic symptoms to terror attacks decline overtime when normal coping channels are utilized (national institute of mental health, ). however, this is not to say that the "worried well" or psychosomatic individuals who appear asking for help should not receive psychological triage. in most cases traumatized individuals and those in high arousal states will respond well to having their posttraumatic and acute stress symptoms normalized -learning that it is a normal reaction to a traumatic event to feel fear, to even be dissociative if the fear is overwhelming, to experience intrusive thoughts and bodily arousal afterwards, and to engage avoidance strategies to little avail. learning that these are normal responses to trauma often helps individuals to move beyond them more easily versus get caught up in additional fears and shame over why they are not feeling or acting normal, as well as to diminish the avoidance responses that often occur in those who suffer from posttraumatic reexperiencing (speckhard, a; speckhard et al., a, b) . likewise those who have "caught" contagious psychological states and somatic symptoms are often also well served to receive medical care assuring them they are not a victim of the biological contaminate, as well as reassuring them that it is normal for some individuals to "catch" fear states and for these to evidence themselves in the body. in this way the individual is not shamed by having somatized their stress, something most individuals find distressing in itself, but also receives a logical explanation for what is happening in their body -an explanation that if judged as credible (and this is crucial) allows them to calm the bodily arousal that is supporting the negative symptoms. when a sense of humor and normality is introduced, the somatizing response often lessens. however if the person's real concerns are not taken seriously, and are ridiculed, he is accused of making up symptoms, ignored or told to go home as nothing is wrong, symptoms can often worsen. fear states can increase causing further somatization, shame can lead to strong avoidance, and isolation responses or the fear can drive aggressive responses. thus a balance must be struck between kindly understanding gentle humor to help somatizing individuals to understand how psychological contagions pass between persons, and firm reassurance that they are indeed not infected by the biocontaminate. of course those who are most distressed and less responsive to short-term triage should be identified and put in contact with helping professionals for longer term care with particular emphasis on those who are seriously dissociative and children with strongly embedded somatic symptoms. the best ways to ensure that acute stress responses to a mass terrorist event are minimized is to move survivors as quickly as possible to safety and reunite family members. this can be complicated in the event of a bioterror attack as it can be unclear for sometime if it is safe for persons to be reunited and it takes some time to establish when the critical period of attack (and ensuing contagion) is over. communications in all terror attack scenarios should be calm and clear and everything supportive that can be done to lower physiological states of arousal should be done. hyperarousal states. hence behaviors that are attachment oriented -calling family, seeking out contact with others, etc. should be encouraged in the aftermath of a terror event. the internet may also prove to be a very useful tool in this regard. following / , numerous researchers made use of the internet as a research tool and surprisingly found it also functioned as a therapeutic tool -that discussing the issues for many functioned as a social buffer. in terms of posttraumatic sequelae to bioterrorism there are unique longterm variants that must be taken into account. those exposed to poisons, invisible toxins, radiation, and so forth often worry less about their "traumatic" exposure, since that was often a non-event for them at the time it occurred, but only took on importance retrospectively when they learned since horrifying information is usually the central aspect of contamination stressor and there is often an absence of sensory details in the threat, the stressor may be said to be of a more cognitive, but equally horrifying form. indeed, victims of toxic disasters often experience horror in their imaginations of the future. for instance, the chernobyl victim who has a high radiation exposure as a child may continually see himself in the future as a cancer victim, or the pregnant woman exposed to a toxic contaminant may continually flash forward to the birth of deformed child, fearing to continue her pregnancy but loath to abort it. as a result survivors of toxic traumas develop a unique trauma-induced time distortion that is better understood as a "flash-forward" because it is the constant intrusion and reexperience in the mind of a horrifying, inescapable, and life-threatening event that the survivor expects to happen in the future as a result of having been exposed to a contaminant in the past. these flash-forwards are made up of repetitive and intrusive thoughts and images (similar to flashbacks) and create acute emotional distress and bodily agitation similar to the hyperaroused state typically observed with flashbacks (speckhard, b (speckhard, , b . this was quite common among those traumatized by chernobyl. they did not evidence clear posttraumatic arousal states to the memories of actual exposure but instead displayed them in response to involuntary horrific thinking about the future, experiencing intrusive and distressing states about getting cancer, dying young, bearing deformed children, etc. (speckhard, b (speckhard, , b . horrifying information about their potential exposure to a deadly contaminant or toxin, which now threatens to poison their entire future. pregnancy is known to often be a time fraught with worry about the health of the future child. one researcher wrote that the highest death toll from the chernobyl disaster was not caused by direct exposure to radiation but abortions were provided for many women in the direct exposure area. the decision to abort is an extremely difficult one for many persons, particularly those with a wanted pregnancy and in instances following toxic exposure is often made in a relatively short time period with the potential for deep psychological distress afterward including impacted grief, guilt, and traumatic responses (speckhard and mufel, ; speckhard and rue, ) . given that we can anticipate many of the bioterrorist threats we may face, we should prepare ahead of time, reassuring and giving accurate information concerning the potential desire to abort what may be a perfectly healthy pregnancy, so that unnecessary abortions of wanted pregnancies do not take place. researchers of toxic disasters often find that mothers are often more worried about their children's symptoms than children themselves (bromet et al., ) . finding a way to reach out to mothers and reassure them while giving them useful strategies for finding mastery for combating their fears, versus feeling powerless to protect their children, can also be very helpful. likewise we must address long-term fears of mothers-to-be when contamination of any type has occurred. girls and young women yet to bear children are often stigmatized after toxic exposures. not only do they often fear having deformed children, even many years afterwards, but they also often become the victims of the stigmatizing fears of others, which can diminish their ability to find suitable marriage partners. following chernobyl, the birthrate in contaminated areas as opposed to noncontaminated areas fell dramatically from to ; an effect which was attributed, as most likely, due to maternal anxiety about birth defects (world health organization, ) and many young men and women who had been exposed found they were shunned as marriage partners. worries of being exposed to a toxin, contaminant, or pathogen especially in girls and young women and in regard to childbirth nearly always is an issue that must be addressed even long after the fact of exposure. health-care workers are another vulnerable population. they form the front line in an often terrifying scenario caring for individuals who may in europe not directly exposed (knudsen, indeed when the israelis decided to inoculate their first responders against smallpox the only fatality was a family member of a doctor who ended up infecting his immune-suppressed wife. the horror of potentially contaminating one's own children was voiced by health-care workers after the sars outbreak, as well as by those caring for contaminated individuals directly after the chernobyl explosion, with workers saying that was the hardest part of the ordeal for them. we must take into account these very difficult situations our health-care workers will face, and consider ahead of time emergency protocols for childcare for those who take the very front lines in a serious bioterrorism threat, so that they can devote their complete energies to medical care and worry less about spreading lethal and not well understood disease at home. we must also find ways to support and honor heroic health-care workers like those who died taking care of sars patients, as well as those others who volunteered to help with the sars outbreak, knowing full well that to do so might be risking their lives. in the face of a massive bioterrorism threat we should give some thought to preparing psychological triage workers -mental health workers who have been trained ahead of time to sort through psychosomatic symptoms versus those needing immediate quarantine and treatment. given the thousands of psychosomatic and worried individuals who have overtaken the health-care systems in other similar situations, mental health-care workers can ease the burden on health-care workers and send the worried and hysterical patients home with some calming reassurance, sorting through those who also should be referred for additional psychological assistance. terrorists achieve their goals when they manage to derail political processes and move democracies to compromise their cherished values. as many terrorist attacks have been aimed at and timed with elections it is wise for governments to plan ahead how to respond when a candidate is killed, when a terror attack occurs during an election and so forth, so that the processes of democracy do not become derailed. the chaos of a bioterror attack can easily disrupt an election if voters are afraid to congregate in public places. it is wise to have thought ahead of time what the strategy would be for delaying or recounting an election in such a scenario. a. speckhard likewise when terrorists exploit the freedoms of liberal democracies it is tempting to surrender civil liberties in order to stop them. while some liberties may have to be suspended to effectively fight terrorism, it is are willing and able to do by virtue of their training, but this can be especially difficult for health-care workers who are also parents, or who have elderly relatives at home, and who fear exposing their own families. centers, such as at guantanamo bay, abusing prisoners in abu ghraib, etc. simply discredits our integrity and plays into the terrorist promoting ideologies that support violent responses against our abuses. these things unleash the terrorists' justifications for "defending" themselves through the use of wmd including bioterrorism. we need to always occupy the higher ground and continually remind, especially those who support the new "religiously" oriented terrorists, that islam in particular does not condone killing by poison and that many scholars of the koran takes a firm stance against the use of such weapons. but such statements fall on deaf ears if we ourselves are guilty of similar violations of morality and ethics. individuals need to feel that their world is somewhat predictable and that they have some mastery in it. bioterrorism involves an invisible threat that can create the opposite feelings: fear, horror, and dread as the actual contaminate spreads by biological contagion, and fear states including psychosomatic responses spread via psychosocial contagion. to defend against bioterrorism government initiatives should have been well thought out ahead of time, include preparatory education and a participatory process of the citizenry, preparation of experts who will be called on to help and work ahead of time with the media who will report the crisis, coupled with leaders whose words and actions inspire the belief that government is credible, calm, and acting in the public's behalf during a crisis. when leaders are honest, communicate calmly, and have prepared their societies ahead of time to respond well to terrorism, we can expect resilient responses. in times of threat and disaster populations often become attachment oriented and cohesive and heroic behaviors are frequently displayed. the best defense against terrorism, however, is to address first and foremost the root causes of it and end the motivations of terrorist leaders and sympathizers to kill and destroy. ultimately terrorism will not disappear until its root causes are addressed. social injustices that inflame terrorist rhetoric must be addressed as we all work for peace and security in this new uncertain world. until we achieve the ability to undermine terrorism by addressing its root causes, infiltrating terrorist groups and hardening our defenses we will have to continue to work toward strengthening civil society to be resilient to face this continuing threat. in the prevention strategies and promoting psychological resilience absence of achieving this we must prepare our societies with well thought out plans to be as resilient as possible. important to recognize that going too far in this direction -detaining thousands of aliens following / , practicing "torture lite" in detention genesis of suicide terrorism aggression: a social learning analysis protean nature of mass sociogenic illness. from possessed nuns to chemical and biological terrorism fears contagion theory and the communication of public speaking state anxiety the psychological effects of the goiania radiation accident on the hospitalized victims toxic contamination: the interface of psychological and physical health effects an investigation of job satisfaction factors in an incident of mass psychogenic illness at the workplace a review of mass psychogenic illness in work settings some contagion models of speeding school and neighborhood characteristics associated with school rates of alcohol, cigarette, and marijuana use heroes of the hour we are not immune: influenza, sars, and the collapse of the public health bioterrorism and the people: how to vaccinate a city against panic psychological effects of toxic contamination emotional contagion epilogue: lessons learned and unresolved issues in toxic turmoil: psychological and societal consequences of ecological disasters yugoslavia: poisoning or epidemic hysteria in kosovo? terrorism and the chemical, biological, radiological, nuclear risk communication and psychological impact; technological and operational methods of mitigation assessments of the emotional states of others -conscious judgements versus emotional contagion behavioral contagion and official delinquency: epidemic course in adolescence preferred pathways of behavioural contagion the june bug: a study in hysterical contagion legally induced abortions in denmark after chernobyl psychological perspective for a theory of behavior during riots terrorism and the placebo response. jane's defense weekly memetics and social contagion: two sides of the same coin the group mind communicating at topoff : a keystone in terrorism response the arjenyattah epidemic. a mass phenomenon: spread and triggering factors mental health and mass violence: evidence-based early psychological intervention for victims/survivors of mass violence: nih publication no the coca-cola incident in belgium russian authorities blame chechens as moscow subway train blast kills . financial times global jihad and wmd: between martyrdom and mass destruction risk assessment and risk communication strategies in bioterrorism preparedness social and psychological factors in the genesis of terrorism paul's riot: an explanation of the limits of crowd action in terms of a social identity model an epidemic model of adolescent cigarette-smoking the age of non-conventional terrorism innoculating resilience to terrorism: acute and posttraumatic stress responses in us military, foreign & civilian services serving overseas after toxic turmoil: psychological and societal consequences of ecological disasters soldiers for god: a study of the suicide terrorists in the moscow hostage taking siege unpublished interviews from the madrid training bombings civil society's response to mass terrorism: building resilience psycho-social and physical outcomes of technological disaster: information as a traumatic stressor unpublished beslan interviews universal responses to abortion? attachment, trauma and grief responses in women following abortion complicated mourning: dynamics of impacted post abortion grief research note: observations of suicidal terrorists in action posttraumatic and acute stress responses in hostages held by suicidal terrorists in the takeover of a moscow theater stockholm effects and psychological responses to captivity in hostages held by suicidal terrorists report on the nato russia advisory panel on mitigating the social and psychological consequences of chemical, biological and radiological terrorism. paper presented at the nato headquarters council meeting victimhood and resilience world health organization. health effect of the chernobyl accident and special health care programmes key: cord- -x h tix authors: yu, hua; li, mingli; li, zhixiong; xiang, weiyi; yuan, yiwen; liu, yaya; li, zhe; xiong, zhenzhen title: coping style, social support and psychological distress in the general chinese population in the early stages of the covid- epidemic date: - - journal: bmc psychiatry doi: . /s - - - sha: doc_id: cord_uid: x h tix background: the purpose of this study was to investigate the psychological status of the general population in mainland china during the outbreak of coronavirus disease (covid- ), and to explore the factors influencing psychological distress, in order to provide the basis for further psychological intervention programs. methods: we administered three questionnaires on-line to a convenience sample of the general population from different regions of mainland china from february to february , . we used the mandarin versions of the six-item kessler psychological distress scale (k ), the simplified coping style questionnaire (scsq), and the social support rating scale (ssrs). we also collected demographic data and other information related to the covid- outbreak. multivariate binary logistic regression analysis was used to identify factors influencing psychological distress. results: of respondents, returned valid questionnaires and were included in the analysis. nearly one quarter ( . %) had high levels of psychological distress (k score ≥ ). individuals with higher psychological distress were more likely to be unmarried, spend more than h per day searching for information about covid- , more frequently adopt a passive coping style, and report less social support than those with lower psychological distress. conclusions: the covid- outbreak in china has a great impact on the mental health status of the general population. active coping strategies and increased social support are significantly correlated with decreased psychological distress, and may serve as the basis for psychological interventions. an outbreak of infections of severe acute respiratory syndrome coronavirus (sars-cov- ), initially called novel coronavirus ( -ncov), began on december , , when several cases of pneumonia of unknown etiology were reported in wuhan in hubei province of china [ ] . in the early stages of this pneumonia, severe acute respiratory infection symptoms can occur, with some patients rapidly developing acute respiratory distress syndrome, acute respiratory failure, and other serious complications [ ] . as of march , , the total number of patients in china with confirmed coronavirus disease (covid- ) was , , of which , were in hubei province, and the total number of covid- -associated deaths was [ ] . at the end of january , the world health organization declared the covid- outbreak in china as a public health emergency of international concern. infectious diseases cause significant psychological distress, both in the general public and in health professionals [ ] . the emergence of covid- has parallels with the pandemic of human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids), the severe acute respiratory syndrome (sars) outbreak and the threat of an avian influenza pandemic, all of which caused substantial concern among health authorities, the media, and the general public [ ] . as a life-threatening disease, we can consider covid- outbreak as a specific stress. psychosocial responses towards infectious disease outbreaks are variable and can range in intensity, including feelings of anxiety, a sense of shame, failure or weakness of the individual and society; an underestimation of likelihood of survival; an overestimation of likelihood of infection [ ] ; an urge to take flight from the outbreak; excessive, inappropriate adoption of precautionary measures; and increased demand for healthcare services during a critical shortage [ ] . very few epidemiological data are available about mental health problems and psychiatric morbidity among those suspected or diagnosed with covid- , the health professionals treating them and the general population [ ] . therefore, the best strategies to respond to mental health challenges during the outbreak remain unknown. previous research has indicated that coping styles and social support are moderating variables in the relationship between stress and distress [ ] , and that the relationship among stress, coping strategy and support system is complicated [ , ] . a framework has been constructed in the support/coping field, in which social support and coping strategy have main effects on stress without a significant interaction between them [ ] . coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events [ ] . during exposure to stressors, different individuals, or the same individual under different conditions, can employ active or passive coping strategies [ ] . active coping strategies include ( ) considering ways to overcome stress and make plans for subsequent efforts, ( ) accepting the existence of stressful events, and ( ) taking full advantage of the situation by learning lessons from it. passive coping strategies include ( ) refusing to acknowledge the existence of stressful events, ( ) giving up on making efforts to pursue the goals set under stressful situations, and ( ) strengthening stressful feelings. when confronted with a single stressor or constellation of stressors, individuals are forced to consider their coping resources and select a coping response accordingly. a previous study of post-traumatic symptoms in survivors after a catastrophic earthquake associated active coping with well-being, while passive coping was often related to psychological distress [ ] . nevertheless, another study found that passive coping styles may have beneficial effects on relieving stress and temporarily coping with setbacks, suggesting that the difference between the two coping styles may be quantitative [ ] . this suggests the need to explore whether these coping styles increase or reduce psychological distress during the covid- pandemic. in addition to coping strategies, effective social support has consistently been reported to protect individuals from developing mental health problems when they experience stressors [ ] . social support can be defined as a series of support measures accessible to an individual through their social relationships with other individuals, groups, and the larger community, and can be divided into three components: subjective support, objective support, and the utilization of support [ ] . there are two possible mechanisms through which social support can influence mental and physical health. one is through main effects: social support is salutary for all individuals independent of the extent of stress that they are currently facing. the other mechanism is a stressbuffering model, in which the social support of others may have an ameliorating effect on life stressors, particularly for individuals under greater stress [ ] . the beneficial effects of social support on psychological wellbeing have been widely studied and well documented across the general population and patients with various illnesses [ , ] . the role of social support is generally beneficial and most findings demonstrate this protective role [ ] . however, social support is not always beneficial, as a study found that while asians are more likely to benefit from implicit social support (social networking), caucasians are more likely to benefit from explicit social support (event-specific advice) [ ] . the potentially complex effect of social support on psychological distress during the covid- outbreak needs to be explored. the severity of the psychological burden that covid- places on the general population was not clear at the onset of the outbreak, and a model to guide successful interventions was lacking. little is known about how chinese are coping with the covid- stressor. based on previous studies, we aimed to investigate the psychological status of the general population in the early stages of the covid- outbreak and explored factors influencing psychological distress. we further compared psychological distress, their coping style/social support and other demographic factors between the participants who did or did not suspect that they were infected. we hypothesized that an active coping style and social support were protective factors against psychological distress in the general chinese population in the early stages of the covid- epidemic. we further hypothesized that population with suspected infection would show higher psychological distress, use less active coping styles or more passive coping styles and have less social support than those without suspected infection. our results may help provide the basis for psychological intervention programs. the study population comprised chinese living in mainland china. the snowball sampling method was used to invite potential study participants. through the wechat application, which constitutes a mainstream medium in china, the investigators invited an initial group of individuals to participate. the first set of invitees then forwarded the invitations to of their contacts whom they considered suitable, and this second set forwarded the invitation in the same way. participants filled in anonymous basic information online via the questionnaire star (https://www.wjx.cn), and as long as they did not report a history of serious mental illness, they were asked to provide informed consent and were able to continue to the three questionnaires (see below). the study was approved by the ethics committee of west china hospital, sichuan university. invitees were allowed to complete the survey from p.m. on february , until midnight on february , . first, participants filled in a custom-designed questionnaire that collected sociodemographic information about sex, age, marital status, educational level, occupation, family residence location, and family income. the questionnaire also asked about infection with sars-cov- (in the respondent or relatives), time spent searching for information about the virus everyday, history of contact with the epidemic area (wuhan city), and presence of cases in the respondent's community. then participants filled out the mandarin versions of the six-item kessler psychological distress scale (k ), the simplified coping style questionnaire (scsq), and the social support rating scale (ssrs). the mandarin version of the k , which has been validated in the world mental health survey [ ] , comprises six questions that ask respondents to rate how frequently they have felt 'nervous', 'hopeless', 'restless or fidgety', 'so depressed that nothing could cheer you up', 'everything was an effort', or 'worthless' during the past days [ ] . items are rated on a five-point scale, with indicating an absence of the symptom and indicating that the symptom was always present during the past days. the final k score can range from to , with higher scores (≥ ) indicating higher levels of psychological distress [ ] . the k has shown good reliability and validity, with cronbach's α ranging between . and . [ ] . the scsq [ ] , based on the 'ways of coping' questionnaire, is a -item self-report that includes dimensions of active coping ( items) and passive coping ( items). responses are given on a four-point likert scale ( = never; = very often). the instrument has been used frequently in china, with high reliability and validity [ ] . the active coping dimension is composed of items to , which mainly reflect active coping strategies an individual uses when encountering stress, such as "trying to see things in as good a way as possible" and "identifying several different ways to solve problems." the passive coping dimension consists of items - , which mainly reflect passive coping strategies that an individual uses when encountering stress, such as "relieving troubles through smoking and drinking" and "fantasizing that some miracle may happen to change the status quo." the scsq score reflects participants' coping style preferences, with a higher score indicating a higher possibility that the participant would adopt the relevant coping style [ ] . the scsq has shown good reliability and validity, with cronbach's α ranging between . and . [ ] . the ssrs is a -item self-report that assesses the level of an individual's social support over the past year [ ] . this measure consists of three subscales: subjective support ( items), objective support ( items), and utilization of support ( items). subjective support refers to perceived social support, meaning that people feel supported, cared for and helped by family members, friends and colleagues [e.g., question: how many close friends do you have? responses: ( ) none, ( ) - , ( ) - , or ( ) or more]. objective support refers to visible, practical and direct support (e.g., financial or other tangible resources that you received when you needed help). the utilization of support reflects the degree of social support used [question: how do you get help when in need? responses: ( ) i am self-reliant, ( ) i seldom ask for help from others, ( ) i sometimes ask for help from others, or ( ) i often ask for help from relatives and friends]. the total ssrs score ranges from to points, with higher scores indicating higher level of social support. the ssrs has shown good reliability and validity, with cronbach's α ranging between . and . [ ] . only one set of surveys was accepted from the same internet protocol address, and surveys were not accepted if the time to complete all questionnaires was less than s. surveys did not request any identifying information. all statistical analyses were performed using spss (ibm, armonk, ny, usa). exploratory data analysis was conducted using frequencies for categorical variables and mean values for continuous variables. where appropriate, odds ratios (ors) were reported. differences in demographic characteristics, coping style and social support between respondents who suspected or did not suspect that they themselves had covid- were assessed for significance using the independent two-samples t test, in the case of age and family income coefficient; or the chi-squared test, in the case of sex, marital status, education levels, residence location, presence of covid- in respondent's community, and time spent searching for information about covid- . to identify predictors of high psychological distress, we classified respondents into those with high psychological distress (k score ≥ ) and those with low psychological distress (k score ≤ ) [ ] . to identify factors influencing high psychological distress among respondents who did not suspect that they had covid- , we performed binary logistic regression and backward stepwise multiple logistic regression. the dependent variable was the dichotomous classification of low or high psychological distress. the model was constructed with the following covariates: age, sex, educational level, marital status, family income coefficient (total family income/number of family members), residence location (hubei province or other), history of contact with the epidemic area (wuhan city) or not, time spent per day searching for information about covid- , and questionnaire scores for positive coping style, negative coping style, subjective support, objective support and utilization of support. the least significant variables were removed one at a time until only significant variables (p < . ) remained. supplementary tables and show the factors included and excluded, respectively, in the logical regression models. we also did group comparison to identify the risk factors associated with high psychological distress. differences in demographic characteristics between respondents with high or low psychological distress in non-suspected cases were assessed for significance using the independent two-samples t test, in the case of age and family income coefficient; or the chi-squared test, in the case of sex, marital status, education level, residence location, presence of covid- in the respondent's community, time spent per day searching for information about covid- (supplementary table ). binary and logistic regression was not performed on data from respondents who suspected that they had covid- , since only one of them showed low psychological distress. a total of participants received the invitation to the online survey, taking a mean of . ± . min to complete all questionnaires. three people finished in fewer than s, and did not finish all questionnaires. after excluding these individuals, respondents ( . % men) were included in the final analysis. their average age was . ± . years, . % were unmarried, . % had at most a senior high school level of education, . % had a technical qualification, . % had a bachelor's degree, and . % had a postgraduate qualification. a total of . % of respondents were from hubei province, the initial area of the covid- outbreak. fewer than a quarter of participants ( . %) were suspected of having covid- , . % had a history of contact with the epidemic area, and . % lived in communities where covid- cases had been reported. nearly one third ( . %) of respondents spent more than h per day searching for information about covid- (table ) . of the respondents, . % had high levels of psychological distress (k score ≥ ). mean scores were as follows: active coping style, . ± . ; passive coping style, . ± . ; subjective social support, . ± . ; objective support, . ± . ; and utilization of support, . ± . (table ) . differences in demographic characteristics, coping style and social support between respondents who suspected or did not suspect that they had covid- only one of respondents with suspected infection showed low psychological distress, indicating that suspected cases in our sample had high psychological distress. in contrast, only around % of respondents without suspected infection had high psychological distress. respondents with or without suspected infection were different in demographic characteristics: those with suspected infection were younger (mean age, . ± . ), and they had lower family income ( . ± . ), higher education level, and more contact with wuhan city. compared to respondents without suspected infection, those with suspected infection also spent more time searching for information about covid- , rarely used any coping style to deal with the stressor, and had less social support (table ) . binary logistic regression identified three factors that predicted high psychological distress among our respondents without suspected infection: spending > h daily searching for information about covid- (or for - h, . ; or for > h, . ; both p < . ), being unmarried (or . , p = . ), and using a passive coping style (or . , p = . ). the binary logistic regression also identified four factors that predicted low psychological distress: active coping style (or . , p < . ), objective support (or . , p = . ), subjective support (or . , p = . ) and utilization of support (or . , p = . ) ( table ). the following factors did not predict high psychological distress among non-suspected cases: age, sex, education level, family income coefficient, residence location, or history of contact with the epidemic area. in the group comparison, we did not find any significant differences in demographic features between participants without suspected infection who had high or low psychological distress, except for residence in hubei province (supplementary table ). to the best of our knowledge, this appears to be the first study to examine psychological distress in the general population in mainland china during the covid- outbreak, and to investigate factors associated with that distress. the results of the present study show that in february , when there were significant public concerns about the new coronavirus pandemic outbreak, . % of our participants reported high levels of psychological distress (k score ≥ ). respondents with suspected infection reported higher levels of psychological distress than those without suspected infection, and the two groups differed in several sociodemographic variables, coping styles and support systems. among those without suspected infection, factors significantly associated with high psychological distress were unmarried status, spending > h per day searching for information about covid- , a passive coping style and lower social support. the present study was conducted during the first two weeks of the covid- outbreak, since human-tohuman transmission was announced on january , [ ] . in our study, . % of participants had high psychological distress based on the cut-off score of [ ] . the prevalence of high psychological distress in our samples is lower than the . % in a retrospective survey of perceived psychological distress in the construction industry, schools, businesses and residents in urban and rural areas during the sars outbreak [ ] . our results may be more reliable than a retrospective study because our data were collected and analyzed during the stressor event. at the same time, the prevalence rate in our study is higher than the . % of health care workers in taiwan who showed significant mental symptoms during the sars epidemic [ ] . these findings suggest that the covid- outbreak places a substantial burden on the mental health of the general population in china. therefore, urgent measures are needed to enhance mental health services during the covid- crisis. in our study, nearly all the respondents with suspected infection showed high psychological distress, indicating high probability of having a severe mental illness and that specific intervention is needed for this subgroup [ ] . this subgroup, compared to respondents without suspected infection, used less active coping styles and more passive coping styles during the outbreak; they had lower objective social support, subjective social support and utilization of social support; they were younger, had less education and lower family income; and they were more likely to be residents in hubei province, to have had contact with the epidemiological area (wuhan), and to live in communities where covid- cases were present. there are several explanations for the high psychological distress. it may be due to the fear of being infectious, being placed in quarantine, or suffering financial loss, stigma or discrimination. it may be due to a sense of guilt, frustration, boredom, or a feeling of having inadequate supplies or information. all these factors are stressors during the covid- pandemic [ , ] . another potential explanation is belonging to a low-income social class, being younger, and having less education and low-skilled employment, which are risk factors for distress related to covid- . indeed, being younger, being less attached to school education and belonging to a lower-income community are risk factors for distress during exposure to acute and chronic stressors in [ , ] . these factors may also impact social support and coping strategies: low-income, lesseducated young adults are reported to lack social support and be more prone to adopting passive coping strategies, which are major risk factors for depressive symptoms in university students [ ] . finally, it is not surprising that those suspected with infection had more closely contact with wuhan city, since covid- was first observed in wuhan. news coverage of the covid- outbreak in wuhan initially focused on the high infectivity and fatality, potentially creating fear and panic. in addition, in order to decrease the risk of disease transmission, wuhan authorities suspended public transport indefinitely from january , . a range of measurements were urgently adopted, such as early identification and isolation of suspected and diagnosed cases, contact tracing and monitoring, collection of clinical data and biological samples from patients, dissemination of regional and national diagnostic criteria and expert treatment consensus, establishment of isolation units and hospitals, and prompt provision of medical supplies and dispatching of external expert teams to hubei province [ ] . the process of sars-cov- infection control and prevention involves the use of personal protective equipment, quarantine, and isolation, all of which may be further associated with fear and anxiety. it is reasonable to conclude that under these circumstances, the general population is under substantial stress and may need special care and psychological intervention. for respondents without suspected infection, an active coping style and social support were protective factors against psychological distress in our regression model. on the other hand, unmarried status, spending more than h per day searching for information about the covid- outbreak, and passive coping styles were risk factors of high psychological distress. we found that unmarried respondents were two times more likely to have increasing psychological distress in our logistic regression models. our results are consistent with a recently published analysis in china showing that marriage was a determinant of psychological distress in the general population, and that unmarried individuals showed higher psychological distress during the covid- outbreak [ ] . social support from partners and family members has been associated with well-being [ ] , and existing literature reveals considerable differences in social support among married, formerly married, and never-married people: unmarried people are less likely than married people to report having close family members or friends [ ] . in addition, married people have larger help networks than unmarried or divorced individuals [ ] . unmarried subjects often do not benefit from the support of a spouse or family [ , ] . respondents without infection who showed high psychological distress (k score ≥ ) also showed a higher frequency of passive coping style, such as problemavoidance, fantasy, and self-blame. our results are highly consistent with the findings in the subgroup of participants with suspected infection, in whom passive coping strategies were also associated with high psychological distress. our results are also consistent with a previous meta-analysis that reported a strong association between passive coping style and depression [ ] . previous research indicated that coping styles can affect how a stressful event is perceived and how it is managed [ ] . since coping can involve "all efforts to manage taxing demands, without regard to their efficacy or inherent value" [ ] , it is not necessarily associated with a good outcome. our findings are consistent with other studies that associate higher stress with greater use of emotionoriented and social diversion-oriented coping [ ] . our results emphasize the need to research coping strategies in the general population and interventions to teach coping during epidemic outbreaks. such work may lay a solid foundation for individuals to cope positively and actively with various stress factors and circumstances [ ] . our results suggest several considerations for helping the general population handle the psychological distress caused by the covid- epidemic. first, fear of covid- is common in the general population worldwide, and the best way to end fear about covid- is to learn about the disease and actual risk to others. second, we should encourage people to work with colleagues to reduce financial stress: when people were unable to work during the epidemic, they may have experienced stress related to job status or financial situation. third, providing health support, such as a telephone hotline for communication and consulting, may help reduce distress associated with social distancing, quarantine, or isolation [ ] . finally, connecting people with others for giving and receiving social support online can bolster psychological well-being. feeling lonely and isolated from others is a common feeling during lockdown, and regularly connecting with friends and family in video or phone calls may improve the level of social support [ ] . our results indicate that media reports about how the government is fighting the outbreak, how to protect oneself from covid- , and how many suspected infections and cases were reported every day may engender intense confusion and panic in the general population. we suggest that the public should limit the time they spend searching for covid- information to fewer than h per day. our results suggest that giving priority to traditional national media with direct connections to trustworthy medical decision-makers is associated with greater self-confidence in coping with covid- [ ] . second, people can prepare daily schedules in which they ensure variety in the schedule, work, leisure, exercise, and learning. they may wish to start new activities, such as home-based "exergames" (active videogames), which may be important for maintaining physical fitness and establishing long-term adherence to exercise during the covid- pandemic [ ] . there are several limitations in our study. first, the surveying was based on network invitation rather than face-toface random sampling, and participants had to be able to use internet tools. whether our results can be generalized to individuals who cannot use the internet is unclear. second, we did not assess whether and how respondents were engaging in prevention; preventive self-behaviors can also mediate stress levels [ ] . third, our study design was cross-sectional and so could not capture changes in psychological distress and its predictors over the course of the covid- outbreak. at one year after the sars outbreak, survivors still had elevated stress levels and disturbing levels of psychological distress [ ] . therefore, the long-term psychological implications of infectious disease outbreaks should not be ignored. finally, % of our respondents were women, which may reduce the generalizability of our findings to the general chinese population. the covid- outbreak in china is substantially affecting the mental health of the general population. mental health interventions should be implemented in a timely manner for individuals with suspected infection. our results showed that positive coping strategies and increased social support significantly correlated with lower psychological distress. this suggests that the general population, especially those directly affected by the pandemic, should be taught active coping strategies and be encouraged to seek and maintain social support [ ] . we believe that efficient mental healthcare in the national public health emergency system will empower china and the world during the campaign to contain and eradicate covid- [ ] . outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study who: coronavirus disease psychosocial consequences of infectious diseases wen soon s. psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease risk perception and impact of severe acute respiratory syndrome (sars) on work and personal lives of healthcare workers in singapore what can we learn? med care pneumonia causes panic in guangdong province timely mental health care for the novel coronavirus outbreak is urgently needed religious involvement, coping, social support, and psychological distress in hivseropositive african american mothers stress: appraisal and coping conservation of resources. a new attempt at conceptualizing stress methodological issues in estimating main and interactive effects: examples from coping/social support and stress field emotional intelligence and coping styles with stress you want to measure coping but your protocol's too long: consider the brief cope cb: post traumatic stress disorder and coping strategies among adult survivors of earthquake a preliminary study of the reliability and validity of the simplified coping style questionnaire psychological health and coping strategy among survivors in the year following the wenchuan earthquake social integration, social networks, social support, and health stress, social support, and the buffering hypothesis the functional effects of social relationships on chronic illnesses and disability social and emotional support and its implication for health. curr opinion psychiatry cultural differences in the impact of social support on psychological and biological stress responses screening for serious mental illness in the general population with the k screening scale: results from the who world mental health (wmh) survey initiative short screening scales to monitor population prevalences and trends in non-specific psychological distress psychological distress across the lifespan: examining age-related item bias in the kessler psychological distress scale reliability and validity of the simplified coping style questionnaire the role of active coping in the relationship between learning burnout and sleep quality among college students in china social support rating scales (ssrs) nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study the -item kessler psychological distress scale to survey serious mental illness among chinese undergraduates: psychometric properties and prevalence estimate zhonghua yu fang yi xue za zhi [chinese journal of preventive medicine the mental health of hospital workers dealing with severe acute respiratory syndrome stress and psychological distress among sars survivors year after the outbreak the psychological impact of quarantine and how to reduce it: rapid review of the evidence using social and behavioural science to support covid- pandemic response coping, stress, and social support associations with internalizing and externalizing behavior among urban adolescents and young adults: revelations from a cluster analysis what's the role of perceived social support and coping styles in depression and anxiety? sleep disturbances among medical workers during the outbreak of covid- the psychological distress and coping styles in the early stages of the coronavirus disease (covid- ) epidemic in the general mainland chinese population: a web-based survey social support and strain from partner, family, and friends: costs and benefits for men and women in adulthood family, friends, and -month ptsd among african americans stress, social support and depression in single and married mothers dyadic effects of resilience on well-being in chinese older couples: mediating role of spousal support how relevant is marital status and gender variables in coping with colorectal cancer? a sample of middle-aged and older cancer survivors risk and protective factors for depression that adolescents can modify: a systematic review and metaanalysis of longitudinal studies assessing coping strategies: a theoretically based approach correlation research on psychological health impact on nursing students against stress, coping way and social support coping with covid- : exposure to covid- and negative impact on livelihood predict elevated mental health problems in chinese adults covid- -related information sources and the relationship with confidence in people coping with covid- : facebook survey study in taiwan exergames as coping strategies for anxiety disorders during the covid- quarantine period work stress among chinese nurses to support wuhan in fighting against covid- epidemic stress, coping, and success among graduate students in clinical psychology -ncov epidemic: address mental health care to empower society publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations supplementary information accompanies this paper at https://doi.org/ . /s - - - . table . factors values assigned in the logical regression models. supplementary table . factors excluded in the logical regression models. supplementary table . differences in demographic characteristics between respondents with high psychological distress (hpd) and those with low psychological distress (lpd) in non-suspected cases. authors' contributions zl had the idea for and designed the study. zl had full access to all of the data in the study. zl took responsibility for the integrity of the data and the accuracy of the data analysis. hy and mll drafted the paper. mll did the analysis. zxl, wyx, ywy, and yyl collected the data. zzx reviewed and edited the paper. all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. all authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. none. the identified data used in this study can be made available upon necessary request. inquiries for the data should be sent to the corresponding authors. this study was conducted in accordance with the ethical standards put forth in the declaration of helsinki. an online written informed consent was obtained from the participates via the questionnaire star before they were able to continue to the survey. the study was approved by the ethics committee of west china hospital, sichuan university (reference number - ). the participants received a complete description of this survey and provided online written informed consent. a copy of the written consent is available for review by the editor of this journal. the authors declare that they have no competing interests. key: cord- -gcjgfasj authors: taylor, melanie r; agho, kingsley e; stevens, garry j; raphael, beverley title: factors influencing psychological distress during a disease epidemic: data from australia's first outbreak of equine influenza date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: gcjgfasj background: in australia experienced its first outbreak of highly infectious equine influenza. government disease control measures were put in place to control, contain, and eradicate the disease; these measures included movement restrictions and quarantining of properties. this study was conducted to assess the psycho-social impacts of this disease, and this paper reports the prevalence of, and factors influencing, psychological distress during this outbreak. methods: data were collected using an online survey, with a link directed to the affected population via a number of industry groups. psychological distress, as determined by the kessler psychological distress scale, was the main outcome measure. results: in total, people participated in this study. extremely high levels of non-specific psychological distress were reported by respondents in this study, with % reporting high psychological distress (k > ), compared to levels of around % in the australian general population. analysis, using backward stepwise binary logistic regression analysis, revealed that those living in high risk infection (red) zones (or = . ; % ci: . – . ; p < . ) and disease buffer (amber) zones (or = . ; % ci: . – . ; p < . ) were at much greater risk of high psychological distress than those living in uninfected (white zones). although prevalence of high psychological distress was greater in infected ei zones and states, elevated levels of psychological distress were experienced in horse-owners nationally. statistical analysis indicated that certain groups were more vulnerable to high psychological distress; specifically younger people, and those with lower levels of formal educational qualifications. respondents whose principal source of income was from horse-related industry were more than twice as likely to have high psychological distress than those whose primary source of income was not linked to horse-related industry (or = . ; % ci: . – . ; p < . ). conclusion: although, methodologically, this study had good internal validity, it has limited generalisability because it was not possible to identify, bound, or sample the target population accurately. however, this study is the first to collect psychological distress data from an affected population during such a disease outbreak and has potential to inform those involved in assessing the potential psychological impacts of human infectious diseases, such as pandemic influenza. equine influenza (ei) is an acute, highly contagious viral disease which can cause rapidly spreading outbreaks of respiratory disease in horses and other equine species. it does not infect humans, but the virus can be physically carried on skin, hair, clothing, shoes, vehicles and equipment and through these means can be transferred to other horses. in addition, the windborne virus can be spread for distances up to eight kilometres [ ] . australia's first outbreak of ei was confirmed on august th . it spread quickly, but was successfully contained within areas of south east queensland (qld) and new south wales (nsw). although ei was not detected in other states and territories, stringent disease control procedures were put in place across all states; which included an initial stand-still of all horse movements and subsequent controls, movement restrictions, and biosecurity requirements for many months. colour-coded ei control zones were established within four weeks of the outbreak based on the level of disease/disease risk in local government areas in nsw and qld; these were adjusted as the disease spread, and each zone was subject to specific controls and restrictions. controls were reviewed, revised and expanded as the disease spread, subsequent disease containment and control progressed, and policies were revised. these zones are summarized in table . further details of the outbreak, restrictions and zoning are available via the nsw department of primary industries (nsw dpi) and qld. department of primary industries and fisheries (dpi&f) websites [ , ] . throughout the outbreak movement restrictions and biosecurity requirements remained in place, and no (or very limited) horse movement was ever allowed from higher risk zones to lower risk zones. the disease outbreak peaked in late september/early october , and then declined as successful containment and eradication strategies were progressed. the last new infections of ei were reported in nsw and qld in december . in total approximately , properties and , horses were infected in nsw and at least , properties were infected in qld. current data from disease surveillance and monitoring indicates that no active infection is present in australia and the expectation is that australia will be declared ei-free by the end of june ; if successful, australia will be the only ei infected country in the world to have eradicated the disease. the effects of ei and the disease containment strategy, like the horse industry itself, were varied and wide-ranging; impacting differentially on horse owners and those involved with the horse industry nationally. in terms of support to those affected, a range of government financial support and assistance was available to many of those affected within a short time of outbreak onset and financial and economic impact surveys were undertaken to provide feedback information to government [ , ] . the current study was conducted to gain additional complementary data to assess the impacts of ei on the social and emotional health and well-being of those affected. this paper reports data collected on non-specific psychological distress; however the full study covered many other aspects, such as adherence to biosecurity requirements, effects of social isolation due to quarantine and the consequences of restricted horse movement and related activities, and sources of support and coping during the ei outbreak. although ei is endemic in europe and north america, and has occurred as an epidemic in many other countries, e.g. japan, south africa, hong kong, there does not appear to be any published studies of the human response or impacts to ei or the containment strategies used to control this disease. the best reported and documented research with respect to the impacts of infectious animal disease on people is the outbreaks of foot and mouth disease (fmd) in europe in , specifically in the uk and the netherlands. like ei fmd is highly contagious, however, fmd is considerably more serious as it spreads to cloven-hoofed animals including cattle, sheep, pigs, and goats. during these fmd outbreaks an estimated million livestock were slaughtered on , farms in the uk (including many healthy animals as part of 'contiguous' or preventative culling on farms neighbouring infected farms) and , were culled in the netherlands. the impacts on people were both economic, through financial/business/ tourism-related losses, and psychological, through the exposure to loss of livestock, culling, and massive funeral pyres; the latter affecting not just farmers and their families, but also the wider population through media images on the television and in newspapers [ ] [ ] [ ] . in the uk higher 'caseness' as indicated by the ghq(g) was found in farmers from 'badly infected' areas, although higher psychological morbidity generally, was reported in farmers from both badly infected and unaffected areas [ ] . in a study of dutch dairy farmers [ ] around half of those whose animals were culled suffered from severe post-traumatic distress, (identified as a clinical level of distress (> ) using the -item impact of events scale), with this reducing to one in five for those where severe restrictions were imposed (but where no culling took place). higher levels of symptoms were reported for older respondents and those with lower levels of education. in this same study differences in stress, psychological marginalization, and depression were reported for different disease control areas, i.e. culled-area, buffer-area, fmd-free area [ ] . within australia, the psycho-social impacts of ovine johne's disease have been reported [ , ] in which grief, depression, and anxiety were profound in affected farming families, and the perceptions of the management control process were the cause of much of the distress. government policies on quarantining and de-stocking farms were suspended due to mounting reports of severe emotional and social distress in farmers, rural families, and government employees implementing those policies. further discussion of stress in emergency responders managing agricultural emergencies is considered in an australian context in a recent paper by jenner [ ] . the role of the animal-human bond on disaster preparedness and response is key feature in human response to animal disease, and has been review by hall et al. [ ] . these authors report several aspects of relevance to the current study, including the increasing role of horses as companion animals as opposed to livestock or economic investments, and hence an increasing emotional attachment to horses; the complex and dynamic emotional relationship between farmers and their livestock; the emotional and practical implications of the animal-human relationship in disaster management, e.g. compliance with disaster management behaviours; and the impacts on veterinarians as first responders in disasters. these authors conclude that recognizing the mental health aspects of the animalhuman bond is an important factor in public health approaches to disaster and can be critical in promoting the resilience of individuals and communities. therefore, it follows that in an animal-centred disease outbreak, such as ei affecting horses, the potential disruption of the animal-human bond, and the impact of policies restricting animal-human activities could have significant implications for the mental health and resilience of those affected. the main outcome measure in this study is non-specific psychological distress, as measured by the kessler (k ) [ ] . the k was selected because it is a well-established and validated measure that is used widely in population research in australia, it has been used in population health surveys in nsw [ ] , victoria [ ] , south australia [ ] , and western australia [ ] , as well as in national surveys conducted by the australian bureau of statistics [ ] , and therefore state and national prevalence data are available as benchmarks for the current study. scores from the k can be related to levels of intervention, with 'very high' psychological distress scores (> ) equating to 'caseness' for a mental disorder, and high scores are strongly associated with current diagnosis of anxiety and depression using the composite international diagnostics interview (cidi) [ ] . the k is also able to discriminate between dsm-iv cases and non-cases, and is felt to be an appropriate screening instrument for identifying likely cases of anxiety and depression in the population providing a strong marker for a possible mental health disorder [ ] [ ] [ ] . in the most recent ( ) data from the nsw adult population health survey the combined proportion of the population reporting 'high' or above psychological distress ( - ) is . % [ ] . in addition, recent data collected in rural communities suggests that these figures may be slightly higher in rural-dwellers with 'very high' psychological distress of % reported in one study [ ] and . - . % for combined 'high'/'very high' psychological distress in another [ ] . these findings are of relevance in the current study as it would be expected that horse-ownership would be linked to rural and peri-urban residency. the questionnaire was designed for online completion to expedite data gathering whilst the ei outbreak was occurring. questionnaire content was reviewed by subject matter experts, including a small group of public health professionals in nsw health, some of whom had been involved in aiding the nsw dpi in disease control management, a nsw dpi local district control centre controller who was responsible for leading control activities, and representatives of the australian horse industry council (ahic). ethics approval for the study was obtained through the university of western sydney ethics committee. horse owners, and those involved in the horse industry were invited to take part in the study via an e-mail alerting service administered by ahic; using the national horse emergency contact database (hecd). the hecd had been established before the ei outbreak and was used as a network to contact and inform horse-owners during emergencies, such as bushfires, and disease outbreaks, and had been used previously by ahic for collecting financial impacts information relating to ei earlier in the outbreak. this alerting service was used regularly during the ei crisis to update registrants with government support agency communications and general industry news and support information. approximately , addressees were registered on the hecd; most were individuals, but also included were industry associations, pony clubs, and horse groups that would forward information to their own memberships nationally. horse owners in nsw were encouraged by the nsw dpi to register on the hecd to receive up to date information. the initial invitation to participate was sent to those registered on the hecd on november (week of the outbreak). the survey remained open until january (week of the outbreak) and date of completion was recorded with each respondent's data. the full survey comprised questions, covering a wide range of subject areas; those reported here include demographic information, i.e. gender, age category, number of children, highest level of educational qualification, and state/territory of residence. in addition, respondents were asked about the nature of their current main involvement with horses (i.e. their industry sector), for example breeding, equestrian, recreational; whether their primary source of income was linked to a horse-related industry, and their current colour-coded ei control zone. the main outcome measure reported in this paper is nonspecific psychological distress as measured by the k . this measure comprises questions that ask respondents how often they have experienced certain symptoms during the preceding four weeks and responses are scored on a scale of to depending on how frequently each symptom is experienced, where = 'none of the time', and = 'all of the time'. thus, a minimum score is , indicating no psychological distress, and a maximum score is , indicating the most severe level of psychological distress. scores on the k are subsequently categorized into four levels: low (scores of - ); moderate (scores of [ ] [ ] [ ] [ ] [ ] [ ] ; 'high' (scores of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and 'very high' (scores of - ) [ ] . statistical analyses were undertaken using stata, version . ( ; stata corporation, college station, tx, usa). exploratory data analysis was conducted using frequency distributions for categorical variables. in the logistic model, a binary coding of psychological distress was used in which high psychological distress was a combination of 'high' + 'very high' levels of psychological distress = (i.e. k scores of or greater) and low psychological distress was a combination of 'low' + 'moderate' levels of psychological distress = (i.e. k scores of or less). simple binary logistic regression and backward stepwise multiple logistic analyses were performed to identify factors influencing high psychological distress. all variables were entered into the model initially, with the least significant variables removed one at a time until only significant variables associated with values of p ≤ . remained. all statistical tests were two-tailed. details of the study sample are presented in table . in total, , respondents completed the online survey, and of these % were male and % were female. more than a half of the sample ( . %) had no children. a total of . % of the respondents had a tertiary level educational qualification. just under half the sample ( %) was from nsw and respondents from qld. and victoria (vic) comprised a further % of the sample ( % from each state). thirty percent of respondents were in uninfected white zones in states other than nsw and qld, and % were from the restricted high ei risk red zones in nsw and qld. around three quarters of the sample ( %) were from three industry sectors; recreational, equestrian, and breeding/stud sectors ( %, %, and %, respectively). the majority of respondents ( %) reported that their main source of income was not linked to a horse-related industry. the prevalence of the four levels of psychological distress for the whole sample during the equine influenza outbreak; were % of respondents reporting 'low', % reporting 'moderate' % reporting 'high' and % reporting 'very high' levels of psychological distress. table shows the proportion of respondents reporting each level of psychological distress for the main socio-demographic survey variables. the greatest prevalence of 'very high' psychological distress was reported for those respondents in the - age group ( . %), and the lowest prevalence was reported by those in the - age group and those under ( . % and . %, respectively). with regard to the remaining socio-demographic variables the highest prevalence of 'very high' psychological distress were recorded for those respondents who were female, those with one child, and those with no formal educational qualifications. the prevalence of 'very high' psychological distress was greater for respondents from qld. ( . %) with prevalence figures being slightly lower for respondents from nsw ( . %) and lower again for respondents from vic. ( . %). the highest prevalence of 'very high' psychological distress was found for respondents in the red zones ( . %) and lowest for those in the white zones ( . %). those whose incomes were linked to horse-related industry had a higher prevalence of 'very high' psychological distress as compared to those whose main income was not linked to a horse-related industry ( . % and . %, respectively). the four levels of psychological distress were combined in pairs ('low'/'moderate', and 'high'/'very high') to form a binary variable for subsequent statistical modelling. figure shows the prevalence of this binary high/low psychological distress variable by ei disease zones. respondents in the red and amber zones reported higher prevalence of high psychological distress ( % and %, respectively) than those in the purple, green, and white zones ( %, %, and % respectively). univariate analysis table shows the unadjusted and adjusted odds ratios (ors) for the associations between high psychological distress (≥ ) and socio-demographic variables. total count = unless otherwise given in brackets respondents whose main source of income was from horse-related industry (unadjusted: or = . , % ci: . - . ; p < . ) were at a greater risk of high psychological distress than those whose main income was not linked to horse-related industry. chological distress as compared to those whose income was not linked to horse-related industry. the most salient finding was the extremely high prevalence of high psychological distress in horse owners and those involved in the horse industry during a serious horse disease epidemic; with just over one third ( %) reporting levels of psychological distress that might require some form of external intervention, and % of these ( % of the sample) reaching levels that may be considered indicative of 'caseness' for a dsm-iv disorder. the prevalence of 'very high' psychological distress in this sample was approaching five times the level reported in recent population health data for nsw [ ] . although this prevalence is very high, and there are some methodological reasons why this may be distorted (see study limitations section) it is certainly true that many of those impacted by ei, or the threat of ei, were subject to a wide range of acute stressors over a prolonged period, in a country where ei and such rigorous disease containment and control measures were previously unknown. analysis of psychological distress prevalence within the sample indicated that ei control zone was associated with psychological distress. those in the areas where ei was present had higher risk of high psychological distress, furthermore, risks were higher in areas where ei was more active or threatening and the tightest levels of disease control were in place (i.e. red and amber/buffer zones). this finding suggests high levels of anticipatory anxiety. interestingly, the risks of higher psychological distress in the purple zone (the region in nsw with the highest infection rate and earliest infections) were lower than in the red and amber areas. it is probable that during the timing of the study ei was more of a 'known' threat to those in the purple zone and there would have been some habituation to this risk; with many properties already infected or recovering, and restrictions eased due to the decision to let ei 'run its course' in this area at that time. as disease control (and zoning) was controlled at a state level there is geographical overlap and co-linearity of the australian state/territory and ei control zone variables in the analysis; in the backward stepwise multiple logistic analyses excluding one made the other a significant factor. with regard to analysis by state, it is interesting to note the high levels of psychological distress reported in victoria. although victoria remained ei-free throughout the crisis, those in victoria were . times more likely to experience high psychological distress that those in the other uninfected states. there are probably a number of reasons for this effect: victoria has a very extensive horse industry and is geographical closer to the infected states and diseaseaffected areas of nsw and qld; there is also a high level of business interaction and physical movement of horses between victoria and nsw and qld; hence the level of proximal threat and the degree of disruption caused by disease control measures was probably experienced more widely in victoria and may explain some of this effect. it should also be noted that although the remaining states were similarly uninfected, the overall prevalence of high psychological distress in horse owners from these states was still far higher than in the general population; those uninfected were not unaffected. one of the other primary factors associated with high psychological distress was age. those in the - year age category reported the highest levels of high psychological distress and analysis indicated that although prevalence and comparative risks of high psychological distress reduced from age onwards, these reduced risks only became reliably statistically significant from age onwards, and high psychological distress was certainly still a risk to those in the - year age category. this is interesting because in the general population psychological distress is generally found to peak around middle age ( s- s). the study findings would suggest that younger people were particularly vulnerable and were coping less well with the consequences of ei. the reasons for this finding are not known, however, research literature suggests that younger people form stronger emotional attachments to animals [ ] , and they are also less likely to be resilient or practised, generally, when it comes to coping with adversity. from the general perspective of mental and physical health of younger people, it is interesting to consider the longer term consequences and potential burden of disease if these effects are enduring. it is also interesting to note here the association of psychological distress with having children. data in this study indicated that those with one child had a . times higher risk of high psychological distress than those with no children; and having three or more children appeared somewhat protective against high psychological distress. national statistics would support the suggestion that those with one child are generally younger adults and/or are 'young families' with a single younger child. in this study, . % of respondents with one child reported 'very high' levels of psychological distress (k score = - ). given these family circumstances such a finding may be a cause for concern. the final main factor associated with high psychological distress was having an income linked to horse-related industry. unsurprisingly, those with financial dependence on an industry facing such a crisis are likely to be significantly predisposed to high psychological distress. nothing has been mentioned in this paper on the industry sector from which respondents had their main involvement with horses. these data were reported as part of the sample description to illustrate the wide range of industries affected by ei and the complexity of the affected population, and to provide information to aid interpretation of the findings. the nature of the potential psychological impacts of ei on those in different sectors is extremely diverse; from purely economic impacts, to loss of leisure pursuits and disruption of social networks, to loss of futures and missed opportunities in time, and many other possible impacts. time, money and support will help most recover but it is possible that some people's mental and physical health will be permanently affected by ei and some will take many years to recover professionally if they choose to stay in these professions. given the level of psychological distress noted in the current study, it is interesting to consider the distress that might result from other epizootics, such as foot and mouth disease or avian influenza, and how this, in turn, might compare to the levels of distress resulting from human epidemics, such as sars and h n /pandemic influenza. as mentioned earlier, foot and mouth disease in europe resulted in high distress and ptsd in farmers. in relation to avian influenza, most research has focussed on risk perception and compliance with protective behaviours. a large european union project on risk perception to avian influenza in europe and asia found moderate levels of risk perception generally, with higher levels of risk perception noted in europe, and in females in most countries [ ] . considering distress and risk perception in relation to human epidemics; it is likely that psychological distress would be far greater, since these present a threat to human health and possibly death. certainly data collected during and after sars in hong kong found high levels of fear and ptsd in health care workers and hospital workers [ ] , and high levels of emotional disturbance in the general population [ ] . research in canada found enduring psychological distress, up to two years following sars, among health care workers in a hospital that treated sars patients [ ] . this study had a number of limitations that should be considered when interpreting the data. firstly, the target population; those affected by ei, is a complex, disparate, and unknown population and therefore it is difficult to comment accurately on the representativeness of the sample. all horse owners in australia are not registered on a centralized database, or otherwise controlled, and as a result, it is not possible to know how extensive the database used to access horse owners (the hecd) was. however, at a national cross-industry sector level it is believed that this was the most extensive and efficient online route to access the target population, and the use of the database as a central communication facility during the ei crisis meant that this was likely to have been a focus for those affected during the epidemic. due to demographic bias in the sample, in particular, a greater proportion of women, and those with higher levels of education it is possible that there will be response bias in the data. the high proportion of women in the sample may be due to greater interest and participation in studies of this nature, but may also be indicative of higher levels of females in the target population, in particular in the main industry sectors represented in the data, i.e. recreational and equestrian. there are no official statistics on gender breakdown across horse industry sub-populations in australia, but data indicate that the equestrian sector in the united states may comprise % women [ ] , so the gender bias may reflect a gender bias in the main industry sub-populations in our data. research data often report higher levels of psychological distress in women in the general population, and therefore, the gender demographic bias in our study might have led to an elevation in the levels of psychological distress reported in this study. however, the absence of a significant gender effect in this study, and the close matching of relative levels of psychological distress in men and women with data from the australian general population, suggests that ei, as an adversity, was exerting similar impacts on males and females. it is not possible to explain why there was an absence of a gender difference in the data. one possible explanation is that the timing of the study; around the height of the ei epidemic, and the high levels of psycho-logical distress generally, reflected peak, acute levels in which gender differences were minimised and insignificant. as with gender bias, it is hard to define the impacts of education level in the data. unlike the (female) gender bias in the data, higher levels of education offer a protective effect (as identified in the univariate analysis). therefore, this source of bias may have led to an under-reporting of high psychological distress. again, it is not possible to define or quantify the extent of this. finally, the use of an online survey imposes potential limitations. it is probable that the study findings under-represent the responses of those in certain demographics, e.g. those who are less educated (as noted), those less affluent, and older respondents. not all horse owners would have access to the internet, and online survey methodology is relatively uncontrolled, e.g. the sample was self-selected and therefore may be more prone to response bias than a sample that was randomly selected or otherwise controlled. also, those experiencing higher distress may have been more motivated to respond. the extent of this response bias on the data cannot be accurately estimated, however, in anticipation of potential response bias, actions were taken to ensure that the study was presented to potential respondents in a way that would minimize such effects; e.g. the study was presented as independent of any industry group or government organization and it was clearly identified as a university research study. it was hoped that such presentation of the study would reduce political or self-interest motivation for completing the study. despite some methodological limitations, this study was able to determine the psychological impact of australia's first outbreak of equine influenza on a substantial sample of horse owners and those involved in horse-related industry. study findings indicated that this affected population had highly elevated levels of psychological distress and that, although prevalence of high psychological distress was greater in infected ei control zones and states, elevated levels of psychological distress were experienced in horse-owners nationally, and not just in areas where equine influenza was present. statistical analysis indicated that certain groups were more vulnerable to high psychological distress; specifically younger people, those with no formal educational qualifications, and those whose main income was linked to a horse-related industry. findings from this study generate further questions: what were the determinants of elevated psychological distress? was it the risk of the disease itself, e.g. fear of the disease, or concern for horses? was it the social and emotional impacts of disease control measures and restrictions, e.g. social isolation, quarantine, loss of freedom or control, stigma of being 'infected'? was it loss of income or sporting aspirations? more importantly, how enduring is this elevated psychological distress, and what are the longer term mental or physical health consequences for those affected? the latter is of critical importance given the increased prevalence of high psychological distress reported in young people in this study. some of these questions can be addressed using additional data collected in the wider study; however, the issue of enduring psychological distress will require further assessment. publish with bio med central and every scientist can read your work free of charge online equine influenza fact sheet: queensland government department of primary industries and fisheries equine influenza outbreak: queensland government department of primary industries and fisheries australian horse industry council: equine influenza impact study results australian horse industry council: follow-up equine influenza impact study impact of the foot-andmouth disease outbreak in britain: implications for rural studies the british foot and mouth crisis: a comparative study of public risk perceptions, trust and beliefs about government policy in two communities psychological impact of the animal-human bond in disaster preparedness and response psychological impact of foot-and-mouth disease on farmers impact of a foot and mouth disease crisis on post-traumatic stress symptoms in farmers the psychological impact of the foot and mouth disease crisis on dutch dairy farmers psychosocial investigation of individual and community responses to the experience of ovine johne's disease in rural victoria the psychological impact of responding to agricultural emergencies. the australian journal of emergency management short screening scales to monitor population prevalences and trends in non-specific psychological distress report on adult health from the new south wales population health survey. sydney. nsw department of health victorian population health survey : department of human services population research and outcome studies unit: the health status of people living in south australian divisions of general practice: south australian monitoring and surveillance system (samss). in health intelligence south australian department of health our state of health : an overview of the health of the people of western australia. health information centre, department of health australian bureau of statistics: national survey of mental health and well-being of adults use of the kessler psychological distress scale in abs health surveys evaluation of measures of psychological distress as screeners for depression in the general population the performance of the k and k screening scales for psychological distress in the australian national survey of mental health and well-being screening for serious mental illness in the general population summary report on adult health by area health service from the new south wales population health survey. in sydney nsw department of health preliminary development and validation of an australian community participation questionnaire: types of participation and associations with distress in a coastal community prevalence of psychological distress, anxiety and depression in rural communities in australia interpreting scores on kessler psychological distress scale (k ) animals in the lives of children avian influenza risk perception sars-related perceptions in hong kong. emerging infectious diseases fear of severe acute respiratory syndrome (sars) among health care workers factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto equines and their human companions this study was funded by nsw health. the authors would like to acknowledge and thank g. barry smyth and the australian horse industry council for the support they provided for this study at such a challenging time; both their subject-matter expertise and practical assistance in accessing horse owners. we would also like to thank a number of horse industry groups for supporting the study, in particular, harness racing australia, the equestrian federation of australia, equine veterinarians australia, and the australian racing board. we would like to thank dr paul armstrong and staff at nsw health for their comments on the survey design. the authors declare that they have no competing interests. mt was involved in all aspects of the research project; design, conducting the research, data handling, exploratory analysis, drafting and editing the paper. gs, and br assisted with the design of the study and provided input in all aspects of the review, data interpretation and editing of the paper. ka conducted the statistical analysis and contributed to the drafting and review of the paper. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -yjn sja authors: o'connor, daryl b.; aggleton, john p.; chakrabarti, bhismadev; cooper, cary l.; creswell, cathy; dunsmuir, sandra; fiske, susan t.; gathercole, susan; gough, brendan; ireland, jane l.; jones, marc v.; jowett, adam; kagan, carolyn; karanika‐murray, maria; kaye, linda k.; kumari, veena; lewandowsky, stephan; lightman, stafford; malpass, debra; meins, elizabeth; morgan, b. paul; morrison coulthard, lisa j.; reicher, stephen d.; schacter, daniel l.; sherman, susan m.; simms, victoria; williams, antony; wykes, til; armitage, christopher j. title: research priorities for the covid‐ pandemic and beyond: a call to action for psychological science date: - - journal: br j psychol doi: . /bjop. sha: doc_id: cord_uid: yjn sja the severe acute respiratory syndrome coronavirus‐ (sars‐cov‐ ) that has caused the coronavirus disease (covid‐ ) pandemic represents the greatest international biopsychosocial emergency the world has faced for a century, and psychological science has an integral role to offer in helping societies recover. the aim of this paper is to set out the shorter‐ and longer‐term priorities for research in psychological science that will (a) frame the breadth and scope of potential contributions from across the discipline; (b) enable researchers to focus their resources on gaps in knowledge; and (c) help funders and policymakers make informed decisions about future research priorities in order to best meet the needs of societies as they emerge from the acute phase of the pandemic. the research priorities were informed by an expert panel convened by the british psychological society that reflects the breadth of the discipline; a wider advisory panel with international input; and a survey of psychological scientists conducted early in may . the most pressing need is to research the negative biopsychosocial impacts of the covid‐ pandemic to facilitate immediate and longer‐term recovery, not only in relation to mental health, but also in relation to behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we call on psychological scientists to work collaboratively with other scientists and stakeholders, establish consortia, and develop innovative research methods while maintaining high‐quality, open, and rigorous research standards. the global impact of the coronavirus disease (covid- ) is unprecedented. by the june , in excess of million cases of covid- worldwide had been confirmed and covid- -related deaths were close to half a million. however, its impact should not only be measured in terms of biological outcomes, but also in terms of its economic, health, psychological, and social consequences. the covid- pandemic is unique with respect to the ongoing risks associated with the large numbers of infected people who remain asymptomatic, the impacts of the countermeasures on societies, the likelihood of second or third waves, and the attention it has received due to its global reach (particularly in high-income countries). the effects of the covid- pandemic will likely shape human behaviour in perpetuity. psychological science is uniquely placed to help mitigate the many shorter-and longer-term consequences of the pandemic and to help with recovery and adjustment to daily life. the immediate research response to covid- was rightly to focus resources on the transmission of covid- , identify biologics with which to treat those infected with the virus, and develop vaccines to protect populations. however, biomedical science can only go so far in mitigating the severe negative health, economic, psychological, and social impacts of covid- . the future availability of a vaccine currently remains uncertain; therefore, the primary weapons to mitigate the pandemic are behavioural, such as encouraging people to observe government instructions, self-isolation, quarantining, and physical distancing. even if a vaccine becomes available, we will still require changes in behaviour to ensure its effective delivery and universal uptake, so we need to prioritize research that will make the greatest contributions to our understanding of the effects of, and recovery from, the pandemic. the important contributions made by psychological scientists to understanding the impact of previous pandemics, including the ebola disease outbreak, severe acute respiratory syndrome (sars), and the middle east respiratory syndrome (mers), are welldocumented and mean we knew already a lot about public messaging and stress among frontline workers when the covid- outbreak began (e.g., brooks et al., , holmes et al., rubin, potts, & michie, ; tam, pang, lam, & chiu, ; thompson, garfin, holman, & silver, ; wu et al., ) . however, the unique features of covid- , including its virulence, the large proportions of people who remain asymptomatic but may still spread the virus (centre for evidence-based medicine, ), the stringent lockdown procedures imposed at pace on whole societies, and its global reach mean there is an urgent and ongoing need for social science research (world health organisation, ) . the collective and individual responses to severe acute respiratory syndrome coronavirus- (sars-cov- ) and to the introduction of measures to counter it have fundamentally changed how societies function, affecting how we work, educate, parent, socialize, shop, communicate, and travel. it has led to bereavements at scale, as well as frontline workers being exposed to alarming levels of stress (e.g., british medical association, ; greenberg, docherty, gnanapragasam, & wessely, ) . there have additionally been nationwide 'lockdowns' comprising physical distancing, quarantines, and isolation with the associated effects on loneliness, forced remote working, and homeschooling (e.g., hoffart, johnson, & ebrahimi, ; holmes et al., ; lee, ) . however, as well as having adverse psychological effects, the measures introduced to fight the pandemic may have led to positive social and behavioural changes. most obvious are the remarkable levels of compassion and support that have developed among neighbours and within communities as well as positive changes in behaviours such as hand hygiene, homeschooling, and physical activity. therefore, in addition to mitigating the negative effects of the pandemic, it is important to understand how any positive effects can be maintained as restrictions ease. there are, and will undoubtedly continue to be, inequalities in the effects of the pandemic and its aftermath; recognizing these vulnerability and resilience factors will be key to understanding how the current situation can inform and prepare us for dealing with future crises. of course, while we, as psychological scientists, are interested in the general effects of the pandemic, we are acutely aware of the fact that these effects disproportionately impact on different groups (box ). the issue of inequality is of central importance and runs through the research priorities that we describe below and it is a picture is emerging of covid- not as a single pandemic, but multiple parallel pandemics with some people facing numerous severe challenges and others experiencing few or none (williamson et al., ) . for those most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. a clear priority for psychological scientists is to understand how best to help those in need and to consider the following factors in their research efforts. in western europe and the united states, the death rate among people with black, asian, and minority ethnic backgrounds is substantially higher than that of the general population. it is not known what is causing the disproportionate impact nor how it can be mitigated. psychological science is in a good position to explore the biopsychosocial antecedents and consequences of having a black, asian, or minority ethnic background in the context of covid- . individuals living in poverty face disproportionate challenges in relation to education, work, income, housing, and physical and mental health. for these most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. moreover, an impending financial crisis means that people who have never before experienced hardships may suddenly find themselves in precarious circumstances. a quarter of people in the uk experience mental health problems every year, with particularly high levels in young people (mental health foundation, ) . the changed social conditions of the pandemic may increase the severity of mental health challenges, particularly when standard (face-toface) treatment and support are difficult to access. at the same time, pregnant women and those with existing long-term conditions such as transplant patients, cancer patients, and chronic obstructive pulmonary disease patients have been designated 'extremely vulnerable' and asked to self-isolate for long periods of time with uncertainties over access to support. those individuals who have recovered from covid- might also have new biological vulnerabilities, uncertainty over immunity post-covid- , and risk stigma arising from infection. individuals with disabilities, learning disabilities, special educational needs, and developmental disorders may also be more vulnerable due to the increased psychological challenges associated with shielding and self-isolation. the challenges generated by the pandemic vary markedly across the lifespan and will influence the nature of current and future psychological needs of different groups. many young people have struggled with reductions in direct social contact, decreased motivation, and uncertainty caused by disrupted training and education. adults have experienced multiple stresses as a consequence of intensified caring responsibilities, financial concerns, job uncertainty, and health conditions. for many older people, the greatest challenges have been social isolation, disruptions in access to health and social care, and coping with bereavement. in addition to the challenges surrounding age, there are emerging data to suggest that the effects of covid- may exacerbate existing inequalities for women. for example, women are more likely to be key workers and primary caregivers, thereby being exposed to higher levels of psychological and financial stress (fawcett society, ). the covid- pandemic is likely to have had a disproportionate impact on groups with low levels of social inclusion and/or those who traditionally have declined support services, such as people living in poverty, traveller communities, and people who are homeless. being separated from wider support networks may also be particularly difficult for those living in hostile households such as victims of domestic abuse and lgbt people living with family members who are unaccepting of their identity. many of those detained in secure settings have been exposed to marked changes in service delivery and reduced social contact, increasing their vulnerability to the psychological effects of the pandemic. surely not a coincidence that the murder of george floyd during a global pandemic prompted a global civil rights movement drawing attention to inequalities. in this position paper, informed by a group of experts and a survey (box ), we highlight the many ways in which psychological science, its methods, approaches, and interventions can be harnessed to help governments, policymakers, national health services, education sectors, and economies recover from covid- (box ) and other future pandemics (if they occur). specifically, we have identified the shorter-and longerterm priorities around mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness in order to ( ) frame the breadth and scope of potential contributions from across the discipline, ( ) assist psychological scientists in focusing their resources on gaps in the literature, and ( ) help funders and policymakers make informed decisions about the shorter-and longer-term covid- research priorities to meet the needs of societies as they emerge from the acute phase of the crisis. the methodology we employed to develop the main research priority domains is described in box , and the seven priority domains are outlined below and summarized in table . how does collective identification impact on social responsibility and adherence to anti-pandemic measures? one of the most striking aspects of the covid- pandemic has been the importance of social psychology to the outcomes. given the highly differentiated nature of susceptibility to the virus (box ), one might have expected many (especially the young and fit) to conclude that they have more to lose than gain by observing the rigours of lockdown and other preventative measures. if they had acted on such an individualistic calculus, then far more people would get infected and far more (especially the old and infirm) would die. however, on the whole, people did not act on the basis of such narrow self-interest, and the vast majority supported the lockdown (e.g., duffy & allington, ) . what is more, conversely, well-functioning social support is likely to confer resilience against the negative psychological impacts of the pandemic. finally, it is important that psychological scientists consider the interconnectedness of the above factors. for example, individuals who are young and from a bame background who are also from a less affluent socio-economic background may be disproportionately impacted by the educational, economic, and other consequences of the measures taken to contain and recover from the pandemic. similarly, many of the solutions to the problems posed by the pandemic involve the use of new technologies that assume the requisite skills, access to devices, and internet connectivity meaning that the 'digital divide' will likely have been exacerbated by the pandemic (ons, ). this paper outlines research priorities for psychological science for the covid- pandemic. in april , the british psychological society convened a core group of nine experts who met regularly for weeks in order to develop the research priorities. the nine experts represent broad areas of the discipline, namely biological, clinical, cognitive, developmental, educational, health, occupational, and social, and were assisted by a wider advisory group of psychological scientists (n = ) drawn from a range of uk higher education institutions and areas of research expertise. we also received input from two international experts. briefly, we used an iterative expert consensus procedure (e.g., merry, cooper, soyannwo, wilson, & eichhorn, ) to elicit and distil the judgments of experts on the research priorities for psychological science. unlike other consensus methods, which typically start with a list of priorities that are then ranked over the course of or meetings (e.g., fitch, bernstein, aguilar, burnand, & lacalle, ; mcmillan, king, & tully, ) , the present approach both generated and judged the priorities over hour long face-to-face meetings of the core group. consensus was achieved through discussion, and the experts were encouraged to discuss with the wider advisory group and their professional networks in between meetings. given the need to establish the priorities rapidly, a lengthy consultation process or an extensive review of all relevant scientific literatures was not possible. however, a brief online survey of psychological scientists was launched early in may with the aim of ensuring that the core and advisory groups had not missed any key research priorities, and to identify the highest ranked priorities in each of the broad areas of psychology to help inform the final wider-ranging research priority domains. the online survey had two components: first, participants were asked the open-ended question, 'please can you tell us what are your priorities for psychological science research in response to the covid- pandemic?' second, participants were asked to rank order the top five research priorities identified by the core group in each of the eight broad areas of the discipline (i.e., biological, clinical, cognitive, developmental, educational, health, occupational, social). the survey was distributed to psychologists via heads of uk psychology department email lists, the social media outlets of professional psychology networks (including the british psychological society), and snowball email methods by the expert and advisory group members. we received replies from psychological scientists representing all of the main areas of the discipline. respondents were . % female, . % were aged between and years, and . % self-identified as being from a minority group. the highest ranked research priorities in each of the broad areas are presented in table (see appendix for the full list of priorities). as a result of the time constraints, a detailed qualitative analysis was not possible for inclusion in this paper; nevertheless, the core group gave consideration to all of the free responses provided. overall, there were differing degrees of specificity, and respondents provided numerous, additional, and wellspecified research questions. however, at the broadest level, respondents' priorities coalesced around the question of how do we address the negative biopsychosocial effects of the covid- pandemic? the degrees of specificity related to population (e.g., people with black, asian, and minority ethnic backgrounds, children, people with low socio-economic status, people living with long-term conditions), type of intervention (e.g., service provision, environmental/social planning), methodology (e.g., qualitative, online, survey, laboratory-based), and setting (e.g., workplace, school, prison), but there was broad agreement. perceived personal risk bears no relation to whether people adhere to government instructions: whether or not one identifies with the broader community and hence acts on the basis of the risks to the community as a whole is the key driver (jackson et al., ) . so, getting people to think in collective rather than personal terms is critical to controlling the pandemic (reicher & drury, ) . or, in the rather more forceful terms of new york governor andrew cuomo: 'yeah it's your life do whatever you want, but you are now responsible for my life. you have a responsibility to me. it's not just about you . . . we started saying, "it's not about me it's about we." get your head around the we concept. it's not all about you. it's about me too. it's about we'. how can we nurture the development and persistence of mutual aid and pro-social behaviour? the significance of such 'we-thinking' is not limited to issues of adherence and social responsibility. the literature on behaviour in disasters and emergencies (drury, ) suggests that the experience of common fate in such events leads to a sense of shared social identity that in turn underpins solidarity and cohesiveness between peopleeven strangers. we have seen numerous examples of 'we-thinking' in the time of pandemic, which have played a key role in sustaining people through difficult circumstances. these range from neighbours knocking on doors to see whether people need help to over three million people contributing to more than four thousand mutual aid groups across the uk (butler, ) . so, how can we nurture such we-thinking in order to build mutual aid in communities and ensure it endures even after the acute phase of the covid- pandemic is over? what is the relationship between group membership, connectedness, and well-being? there is growing evidence of the role of group membership in sustaining both physical and mental health (haslam, jetten, cruwys, dingle, & haslam, ) . in addition to asking in general terms about how group identities are created, sustained, or else undermined in times of crises, we also need to investigate further the interface between group processes and health during and after periods of crisis. in other words: how can we keep people psychologically together even when they are physically apart and what is the relationship between face-to-face and virtual groups in terms of their health effects? more generally, that is not to say that all research priorities were covered in the original survey. two issues in particular stood out from the comments we received. the first was the importance of dealing with inequalities and differences between groups in the experience of the pandemic. the second was the need to address the positive as well as the negative developments coming out of the response to covid- . these were both incorporated into revisions of the paper and now occupy a much more central place than before. we are thankful to all those anonymous respondents whose comments helped improve our argument. a more rigorous, thematic analysis of these data is now available (see bps, c). the picture was very similar when respondents were asked to place research priorities identified by the expert group into rank orders. that is, broadly speaking, the priorities that received the highest rankings, irrespective of area of subdiscipline, were related to the need to address the negative biopsychosocial effects of the covid- pandemic. box : psychological science: methods, approaches, and interventions to help meet the immediate and longer-term covid- research priorities the future research landscape will be challenging due to the ongoing physical distancing requirements; however, psychological scientists are equipped with a broad range of methods, approaches, and interventions that will allow these research priorities to be met. some examples are as follows: internet-mediated research will be an important approach utilized by psychological scientists to collect data in the immediate post-pandemic phase and at longer-term follow-ups. internet-mediated research can be reactive (e.g., online surveys, online interviews) and non-reactive (e.g., data mining, observations from screen-time apps) and can be integrated with objective assessments of behaviour as well as with biological and social markers of physical and mental health. internet-mediated research can also be used to run experiments with online software available such as gorilla, psychopy, and e-prime. recent work has summarized the range of software for building behavioural tasks, and their efficacy in being used online (sauter, draschkow, & mack, ) . changes in the use of research methodologies may provide a catalyst for the formation of new collaborations and training to develop research skills in the psychological science community. at the same time, trust around data security and confidentiality will need to be built between researchers and the general public from whom we sample. however, in , more than an estimated million people aged - years in the european union reported they had not used the internet in the preceding months (eurostat, ) , and researchers will need to think creatively about conducting research projects remotely. for example, participants can have study materials delivered by post (e.g., salivettes for cortisol sampling or asking participants to self-sample), replacing face-to-face communication with telephone and/or video calls, and the use of personal protective equipment when collecting data. psychological therapies and behaviour change interventions can already be delivered remotely and evidence suggests that remote delivery does not necessarily mean inferior delivery (e.g., irvine et al., ) . urgent research is needed to translate interventions that are typically delivered in-person to telephone and online delivery modalities. psychologists are well-positioned to collect valuable qualitative data concerning people's relevant experiences, perspectives, and practices associated with covid- , which could inform psychologybased interventions to improve well-being and social cohesion. multiple participant-centred qualitative research methods can be rapidly deployed to elicit first-hand accounts from members of different communities, including (online) interviews, focus groups, and qualitative questionnaires, focusing on the psychological and social impact (jowett, ) . beyond the immediate term, qualitative data can be gathered longitudinally so that insights can be generated into the experiences of diverse groups over time, identifying salient crisis points and effective resolutions. implementation science is a branch of psychological science that is dedicated to the uptake and use of research into clinical, educational, health care, organizational, and policy settings. principles of implementation science can be used to help stakeholders navigate the extensive and unwieldy psychological science research literature. to inform policymakers and support professional decisionmaking about implementation, psychological research needs to be disseminated in an accessible format. one example of a well-regarded translational system is the us institute of education sciences what works clearinghouse (https://ies.ed.gov/ncee/wwc/), which provides reviews and recommendations about evidence-based practices for professionals working in educational settings. can we learn from this in order to improve the plight of socially isolated people as we emerge from the acute phase of the pandemic? under what conditions does unity and social solidarity give way to intergroup division and social conflict? finally, in addressing the positive potential of social psychological processes, we must not forget their darker side. 'we' thinking can all too easily slip into 'we and they' thinking, where particular groups are excluded from the community and then blamedeven an important feature of the covid- pandemic has been requested by government to provide psychological science expertise at pace. the inclination of many psychological scientists is to begin designing a new study or conducting a systematic review following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, but this does not meet the needs of policymakers. it would be valuable for psychological scientists providing expert advice to acquaint themselves with the terminology and procedures that are familiar to civil servants who are more likely to have use for a quick scoping review or rapid evidence assessment (collins, coughlin, miller, & kirk, ) rather than embarking on a time-consuming systematic review of systematic reviews (keyworth, epton, goldthorpe, calam, & armitage, ) . there are many challenges involved with conducting covid- -related research including dealing with vulnerable groups, giving due consideration to ethical concerns, as well as issues around running studies in the light of physical distancing requirements. therefore, having relevant patient and public involvement and including individuals with lived experience (as appropriate) in designing studies will be of paramount importance. psychological science has been leading the way in promoting and adopting open science principles and practices. nevertheless, psychological scientists need to ensure they balance the urgency of conducting covid-related research (during and in the recovery period) with ensuring research quality and open research practices. therefore, in order to help maintain quality, openness, and rigour, we urge researchers to endeavour to use registered reports, where possible (e.g., https://osf.io/rr/), or preregister their research hypotheses and analysis plans (e.g., https://aspredicted.org/) and make their data findable, accessible, interoperable, reusable (fair) recognizing the principle of 'as open as possible; as closed as necessary' (bps, a (bps, , b norris & o'connor, ) . moreover, we urge researchers to utilize pre-print servers, such as psyarxiv, in order to ensure their latest research findings are made publicly available rapidly and at no cost. we hope that openness will drive quality, but as yet there is no substitute for articles being peer-reviewed prior to wider acceptance by the scientific community. psychological science has responded swiftly to the covid- pandemic, but there is a danger of duplication of efforts and participant fatigue in the proliferation of online surveys, experiments, and focus groups that have arisen. we need to harness the ongoing efforts of psychological scientists worldwide in a coordinated effort on the scale of the large hadron collider (cern, ) to deliver truly evidence-based interventions to help societies emerge from the covid- pandemic. this will include cross-cultural research to understand why mortality rates, mitigation measures, and adherence to government instructions have differed so markedly between countries. finally, we urge researchers to register their research studies and findings on international repositories (https://osf. io/collections/coronavirus/discover). attackedfor the crisis. thus, un head antonio guterres has warned of a 'tsunami of hate' unleashed by the pandemic (davidson, ) . this hate and violence can take different forms: of anti-authority riots as in france (willsher & harrap, ) , or of racist violence against minorities as in india (mazumdaru, ) . in sum, insights from social psychology can be a valuable resource in a crisis; it can bring people together and generate constructive social power. but equally, it can set people apart and create problems that endure well beyond the crisis itself. it is evidently of the greatest importance to understand the processes that determine whether people unite or divide in hard timesand notably to understand the role of leadership, which has been so significant and so diverse in different countries during covid- . work environment and working arrangements consistent with previous pandemics (e.g., rubin et al., ) , the work-related challenges of the pandemic have been particularly high and widely recognized for health and social what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? how will the covid- pandemic affect children's development? how will the covid- pandemic affect family functioning? how do school closures influence children's educational progress and well-being? what kinds of support improve long-term outcomes for children and young people? how can support services be effectively delivered to vulnerable children and young people, families, and schools? what are the immediate and longer-term consequences of covid- for mental health outcomes? what changes in approaches resulting from the pandemic need to be harnessed for the future? . physical health and the brain does covid- have neurological effects on the brain with consequences for mental health? what are the psychobiological impacts of the covid- pandemic on physical and mental health? how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? how do we develop new theories and tools to promote sustained behaviour change? care workers in direct contact with patients suffering the effects of covid- , leaving them vulnerable to trauma, fatigue, and other manifestations of chronic stress. what is unique about covid- is that changed working conditions and anxiety about infection have affected almost all employees, with particular challenges being faced by delivery workers, shop assistants, teachers, emergency services personnel, care home staff, transport staff, and social workers. the full economic severity of the covid-related restrictions is uncertain, although up to two million people could lose their employment in the uk alone (wilson, cockett, papoutsaki, & takala, ) . for those people still working, and those about to return to work, there are notable changes that will likely affect working practices in the foreseeable future. therefore, understanding the impact of the covid- pandemic on the work environment and new working arrangements is paramount to kick starting the economy and adjusting to daily life. what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? for many workers, particularly those in white-collar occupations, work took place entirely from home during the lockdown. it is possible that the lockdown will accelerate the general increase observed in home working practices (ons, ). a move to greater levels of remote working has clear economic benefits for employers (e.g., reduced estates costs). the flexibility to balance work and family life is also attractive to many employees (cf. strategic review of health inequalities in england, ). overall, the evidence points to positive benefits of remote working in terms of well-being (charalampous, grant, tramontano, & michailidis, ) , although these effects are not consistent. for example, it may lead to greater levels of professional isolation (golden, veiga, & dino, ). an increase in remote working will likely occur with a concomitant increase in the use of online technology to support communication and aspects of collaborative working. this has the potential to blur boundaries between work and home domains, resulting in negative impacts on well-being and productivity from work-home interference (van hoof, geurts, kompier, & taris, ) . greater use of technology may also be associated with different perceptual and cognitive demands that may affect productivity and wellbeing including social connections with work colleagues (e.g., mark et al., ) . what is the impact of physical distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? until an effective vaccine is available, physical distancing rules will need to continue to be in place in work environments and we may experience multiple stay-at-home versus return-towork cycles. there is very little research exploring physical distancing and its effect on the general workplace, but returning to work will likely be both a welcome change and a potential stressor. while we have research from teams working in difficult and extreme environments (power, ; smith, kinnafick, & saunders, ) and research on professional isolation (golden et al., ) , this is an unprecedented opportunity to study adaptation across a breadth of individuals and organizational settings. how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? the unprecedented demands that the pandemic has placed on organizations also offer a unique opportunity to understand how organizational resilience and preparedness for dealing with disruptions and emergencies can be developed. while a pandemic of this nature is rare, we can anticipate increasing periods of disruption due to covid- flareups and additionally, for example, in response to climate-induced events (e.g., recent australian fires, uk flooding), which are predicted to occur more frequently (banholzer, kossin, & donner, ) . although we know a lot about individual resilience, we know relatively little about organizational resilience, especially in the context of well-being and performance (taylor, dollard, clark, dormann, & bakker, ; fasey, sarkar, wagstaff & johnston, under review) and the ingredients such as the structures, processes, culture, and leadership that are essential for developing organizational resilience. parenting can be a challenging and anxiety-provoking experience at any time, but the covid- pandemic has brought these challenges and anxieties into sharp focus. for most families, the lockdown will represent the longest period of parenting they have experienced without ( ) the support of extended family members, friends, and childcare professionals; ( ) the routine of school and out-of-school activities; and ( ) any face-to-face social life outside the home. these changes in the social environment may have both negative and positive impacts on children and their families. at the most extreme end of the spectrum, the restrictions in place to combat the spread of the virus have been associated with worrying increases in domestic violence and child abuse. however, all families are likely to have experienced greater levels of stress (social care institute for excellence, ). the majority of carers with school-age children are dealing with homeschooling for the first time, and many carers are having to adapt to working from home while also looking after their children and older relatives. these pressures will be particularly acute for single-carer families. of course, such multi-tasking concerns apply only to carers fortunate enough to have maintained employment. it is important to support families during the current crisis, but also to understand the implications of these unprecedented changes in family life for family functioning and children's development as we emerge from the pandemic. how will the covid- pandemic affect family functioning? many effects of the pandemic on children's development are likely to be indirect, functioning through its impact on caregiving and family functioning. it is crucial for this research to include family members such as grandparents and non-resident parents and siblings. children in families who are already vulnerable due to domestic violence or abuse, social or economic disadvantage, or physical or mental ill health are likely to be most adversely affected. there is an urgent need for research to examine how these vulnerabilities moderate changes in family functioning post-pandemic and their impacts on the child. the ability to regulate behaviour and emotional responses is a key aspect of successful social interaction in individuals of all ages (e.g., baumeister & heatherton, ; kochanska, murray, & harlan, ) . family members may develop new self-regulation strategies as a result of having extended contact with the same restricted group of people. while such strategies may be adaptive, individuals facing extreme social or financial challenges may cope by psychologically distancing themselves from family members, ruminating on negative events, or engaging in behaviours that are harmful. understanding how adaptive and maladaptive self-regulation strategies change post-pandemic may prove useful in identifying individuals who need additional psychological support. school closures and social restrictions may provide a unique opportunity for family members to gain insight into each other's lives, potentially reducing disagreements and improving family functioning. research should investigate whether reporting such improvement during the crisis is associated with lower caregiving stress and better mental health. it is also important to study how families can maintain any positive aspects of functioning that have resulted from the pandemic as restrictions are eased. how will the covid- pandemic affect children's development? the effects of the pandemic will undoubtedly vary as a function of the child's age. while carers with young infants may have concerns about the negative impact of the lockdown on their babies' development, the infants themselves will be unaware of the abnormal nature of their social environment. optimal later development is predicted by caregivers' ability in the first year of life to see the world from the infant's point of view and respond appropriately to their cues (e.g., fraley, roisman, & haltigan, ; zeegers, colonnesi, stams, & meins, ) . the social restrictions do not obviously impede this type of infantcaregiver engagement, and young infants may therefore be least affected by the pandemic. older children who recognize the drastic changes in social contact may find transitioning back to pre-pandemic social behaviour difficult. it is therefore important to study how children and young people manage this transition and investigate whether the lockdown has raised the incidence of emotional and behavioural difficulties. studying the effects of the pandemic and its aftermath on particular groups that are known to be vulnerable to educational and health disadvantage (e.g., looked after children or children with developmental disorders) should be prioritized. positive effects of the pandemic on children's behaviour and social interaction are also anticipated. many children and young people will have found new ways to communicate with friends, entertain themselves, and keep themselves physically active. time away from school may have been spent learning new skills, developing new hobbies, or helping or supporting others. investigating changes in children and young people's empathy, altruism, theory of mind, creativity, innovation, problem-solving, and cognitive flexibility post-pandemic will help shed light on potential positive outcomes of the social restrictions associated with the pandemic. the challenges posed by the covid- pandemic have never been more evident than for the education and well-being of children and young people. in april , a third of the world's population were experiencing extended periods of lockdown with closure of schools and nurseries. parents, many of whom had work and other family responsibilities had to adopt the additional role of educator in home environments not set up for formalized learning. ad hoc arrangements were put in place at speed by schools with limited opportunities to develop clear definitions of learning activities, provide access to learning resources, and establish effective home-school communication. early surveys have shown wide variation in homeschooling arrangements, including stark differences between state and private schools in access to online learning and pupil-teacher communication (sutton trust, ) . there is a wealth of evidence about the factors that facilitate effective learning in schools, such as curricula and teaching strategies (hattie, ) . other studies have established that children's academic attainment and adjustment are predicted by higher caregiver education (erola, janolen, & lehti, ) and engagement in schooling (harris & goodall, ) . however, little is known on how to set up and deliver home education effectively under the unique conditions of the pandemic. while for some children the extended period at home is likely to have distinct positive benefits, research prior to covid- on substantial externally driven disruptions in schooling has shown adverse effects on child achievement and well-being (meyers & thomasson, ; sunderman & payne, ). the outcomes for the individual child are likely to depend on the capacity of families to step in and effectively support curriculum delivery at home. studies of other severe unplanned disruptions to schooling and family lives such as long-running strikes and natural disasters have shown greatest impacts on long-term educational and emotional outcomes for the most disadvantaged children (jaume & will en, ; masten & osofsky, ) . at particular risk of disproportionate adverse outcomes are children from families living in poverty, those receiving social care support, individuals with special educational needs and disabilities, and young people with mental health problems. there are high levels of concern that the recognized attainment gap for children from disadvantaged families (education in england: annual report . education policy institute) could be magnified by the pandemic conditions. there is an urgent need to identify and understand both the positive and negative factors that influence children's educational outcomes during and after the pandemic, and to use this knowledge to target support to those who need it most. the unanticipated consequences of the pandemic pose challenges for conventional designs depending on pre-intervention assessments. understanding its impacts on children's lives will require a robust body of research that draws on the diverse research methods of psychological science. this will require large-scale multidisciplinary data collection in addition to smaller-scale quantitative and qualitative approaches that will be vital for understanding the experiences of children, families, and professionals. some key questions to be addressed by this research are outlined below. in addition to collecting data on home-based support for learning, detailed contextual data are needed about social and environmental factors that are likely to interact in determining positive educational outcomes at particular educational phases (e.g., reading, writing, and maths in primary schools), as well as a range of mental health outcomes (e.g., anxiety, depression, self-harm, resilience). this will include research into the effect of social distancing on a range of social outcomes in children and young people (e.g., inclusion/ exclusion, friendships). what kinds of support improve long-term outcomes for children and young people? knowledge about the impacts of school disruptions on all children and young people will allow evidence-based interventions and resources to be targeted at those with greatest need. robust evaluations are required to scrutinize how interventions are accessed, by whom and with what degree of success. how can support services be effectively delivered to vulnerable children and young people, families, and schools? with reduced resources and restricted movement, professionals (such as practitioner psychologists) have had to adapt and develop new ways of delivering services. researchers in psychological science have a key role to play in working with practitioners and service providers to evaluate systems put in place for monitoring and delivering professional support during and in the aftermath of the pandemic. what are the immediate and longer-term consequences of covid- for mental health outcomes? there is expected to be an increase in mental health problems as a result of the covid- pandemic and the measures used to counter it. we already have evidence for the long-term mental health effects of previous pandemics and disasters (e.g., tam et al., ; thompson et al., ; wu et al., ) and an emerging literature on the near-term effects of covid- (e.g., ahmad & rathore, ; williamson et al., ) . but previous pandemics have been more localized and circumscribed making covid- different. social distancing, school closures, self-isolation, and quarantine have lasted longer than anything previously experienced. we know that these factors, together with financial uncertainty and concerns about health, are predictive of mental health difficulties, particularly anxiety. the current pandemic amplifies these factors and not only exacerbates problems in those with pre-existing mental health difficulties, but also increases the chance of new onset in those with no previous contact with mental health services. concerns about mental health effects may be particularly heightened for children, who have experienced high levels of disruption to normative developmental opportunities (including opportunities for social and outdoor play) and education, and potentially high levels of family stress (https://emergingminds.org.uk/cospace-study- ndupdate/). various poor mental health outcomes are also potentially associated with the disease itself. information about the long-term consequences comes from similar viruses such as sars and the mers. for example, many people who suffered from sars seemed to experience detrimental psychological effects even a year later (rogers et al., ; tam et al., ; thompson et al., ; wu et al., ) . therefore, we need to establish the immediate and long-term consequences of covid- on mental health outcomes in the population generally, but also in vulnerable, shielding, and self-isolating groups (box ). we urgently need to understand how all these factors interact and whether these consequences will require psychological interventions and supports not currently available. what changes in approaches resulting from the pandemic need to be harnessed for the future? even if the mental health consequences of this pandemic are not as predicted, we still expect increases in mental health problems. we know that mental health accounts for an increasing proportion of sick leave and that one in eight children and young people experience a diagnosable mental health problem (nhs digital, ) . childhood mental health problems often recur in adulthood (kessler et al., ) and are associated with physical health difficulties, poor academic, and occupational functioning, and are the primary predictor of low adult life satisfaction (layard, clark, cornaglia, powdthavee, & vernoit, ) . the increased prevalence will place a further burden on a mental health system that was already stretched and will increase waiting times and accentuate gaps in care. during the pandemic, mental health services rapidly changed. inpatients were discharged, even if they were detained in hospital because they were a risk to themselves or others. some people benefited, but we do not know how this reduction in bed use was managed. was it because the right supports and accommodation were provided? the move to remote contact in mental health services had been slow and of varied quality prior to covid- with challenges for both staff and service users. but the shift during the pandemic was swift, and although undoubtedly nhs staff felt pressure during the changeover, there now seems to be a steadier state. again, some service users may have benefited from this change with reductions in travel and, for some, better access to care and treatment. however, although the digital divide is reducing (robotham, satkunanathan, doughty, & wykes, ) , it remains highest in those who already have high unmet needs, including people in rural areas, those on lower incomes, people with lower levels of formal education, and older people. if remote working is tobe abeneficial part of an evolved mental health service, then we need to understand how to provide that 'webside' manner that will increase adherence and promote a therapeutic alliance. we also urgently need to evaluate the effectiveness of remotely delivered, digital interventions in the immediate and longer term. future interventions will need to be deliverable remotely, depending on local resources. for example, from an international perspective, many low-to-middle-income countries do not have high broadband penetration; hence, optimizing digital delivery that depends strongly on good internet connections will further widen the welfare gap. physical health and the brain the effects of covid- on health outcomes will be far-reaching and complex. for those falling ill, there are the direct consequences of the disease symptoms, such as respiratory failure in severe cases, alongside potentially direct viral effects on the brain. there are also more indirect population-wide effects of covid- pandemic-related stress and anxiety on physical and mental health, not only from the disease itself but also from changes in lifestyle including delayed treatment and screening for other known or suspected conditions. moreover, it is also likely that from an international perspective, in many lowto-middle-income countries, the pandemic will result in greater hunger/starvation, which will have severe impacts upon health. does covid- have neurological effects on the brain with consequences for mental health? at one level, covid- might alter mental health by the direct actions of the specific virus (severe acute respiratory syndrome coronavirus- ; sars-cov- ) on the brain. while neurological dysfunction is often described in covid- , including dizziness, and loss of taste and smell, these conditions are common to other respiratory tract infections and need not reflect a neurological disease per se (needham, chou, coles, & menon, ) . data from cerebrospinal fluid and post-mortem analyses will help resolve issues over the penetrance of sars-cov- . it is, however, known that the target receptor for sars-cov- is the angiotensin-converting enzyme- receptor (ace ). disruption of the blood-brain barrier during illness might enable entry of the virus, potentially aided by the presence of ace receptors in glial cells and brain endothelium. other potential routes of entry include the cribriform plate and olfactory epithelium, as well as via peripheral nerve terminals, permitting entry to the cns through synapse connected routes (ahmad & rathore, ) . at the same time, there is an array of immunological responses, including the cytokine 'storm' in severe cases, alongside non-immunological insults to the central nervous system provoked by covid- . the latter include hypoxia, hypotension, kidney failure, and thrombotic and homeostatic changes involving neuroendocrine function (needham et al., ) . together and separately, they may contribute to brain dysfunction in ways that vary with the severity of the infection, other underlying conditions (needham et al., ) , and the treatment for those other conditions (south, diz, & chappell, ) . largescale studies help confirm differential clinical risk factors for death following infection (williamson et al., ) , prompting genotype analyses, while noting that covid- might also induce epigenetic changes, including ace demethylation (sawalha, zhao, coit, & lu, ) . additional health concerns include post-viral fatigue and whether it might provoke a long-lasting syndrome. research consortia are initiating comparisons between populations that have or have not contracted covid- . challenges for psychological scientists include how to assess impacts on cognition and mental health, both in the short term and long term. a part of this challenge is how to deliver effective, online psychological testing (e.g., for 'shielded' populations), or to help follow-up large population cohorts, while not biasing the sample away from those least likely to use these platforms. an integral part of some investigations will be the inclusion of multiple neuroimaging methods, despite the era of distancing. just one of many questions would be the impact of covid- on mild cognitive impairment and its conversion to dementia. there is a premium on studying pre-existing cohorts (e.g., uk biobank, alspac), where retrospective, baseline data exist. such data are especially precious in the present landscape where everyone is, to some degree, affected by the pandemic. the power of these pre-existing cohorts will, however, be heavily influenced by the proportion of the population who contract covid- . what are the psychobiological impacts of the covid- pandemic on physical and mental health? despite the umbrella term 'stress' covering many different things, there is agreement that in its different forms, stress can lead to physiological changes (e.g., neuroendocrine, cardiovascular), with negative consequences for health (o'connor, thayer & vedhara, in press). three principal research questions can be identified: ( ) to what extent does pandemic-related stress, anxiety, and worry impact on biological mechanisms that influence health (i.e., hypothalamic-pituitary-adrenal axis regulation and cortisol dynamics, the autonomic nervous system, and gene expression) as well as on health behaviours (e.g., eating, sleep, alcohol consumption)? ( ) how best to counter their adverse effects? and ( ) how might such stress exacerbate existing medical and mental health conditions, and for how long? for all three questions, there will be considerable variations between groups and individuals (box ). one challenge will be to collate and verify relevant information, including that from 'smart' devices that can provide daily physiological data, activity information, and other measures of diurnal patterns, including sleep. one of the groups most likely to be negatively affected by stress is health care professionals. the pandemic may exacerbate the already high prevalence of secondary traumatic stress, burnout, and physical exhaustion among health care professionals, as well as impact on patient safety and medical error (e.g., dar & iqbal, ; figley, ; hall, johnson, watt, tsipa, & o'connor, ) , due to excessive workload and workplace trauma (e.g., itzhaki et al., ) . while resources such as support from managers and colleagues can help protect health care professionals against traumatic stress, the longerterm impact is likely to be substantial on individuals, their families, on the national health services and the wider care industry. amongst other groups of concern (box ) are those caring for a vulnerable relative or partner at home. one novel feature of daily life in the wake of the covid- pandemic in countries around the world are near-daily government briefings. one focus of these briefings is government instructions to the public as to how to behave. adherence to these and future instructions will be key to dealing with future crises. moreover, many sections above share in common the requirement that people adhere to instructions, whether it is practitioners delivering psychological therapies effectively over the telephone or employees continuing to maintain physical distancing at work. in the initial response to the pandemic, many governments instructed people to ( ) stay inside as much as possible; ( ) stay > m away from other people at all times; and ( ) maintain hand hygiene, among other measures such as wearing face coverings. the evidence suggests that public adherence to government covid- -related instructions worldwide has been high (ons, ), but it is not clear for how long people will continue to adhere to instructions that impinge on personal freedoms. what is clear is that there is a dearth of workers sufficiently trained to advise policymakers and to implement behaviour change interventions rapidly and at scale. the british psychological society's guidance on behaviour change is a good starting point for ensuring that instructions and messaging is clear (british psychological society, a). appointing chief behavioural science advisers to governments would ensure that cuttingedge psychological science advice is placed at the heart of policymaking. as people begin to emerge from the acute phase of the pandemic and the changes that were made to tackle it, it is important that psychological science is at the heart of ensuring that health-enhancing behaviours are sustained and that health-damaging behaviours are changed or prevented. there are numerous approaches to developing such interventions, including the behaviour change wheel (michie, atkins, & west, ) and intervention mapping (bartholomew eldrigde et al., ) , but they require the expertise of psychological scientists to deliver and to evaluate them (west, michie, rubin, & amlôt, ) . one of the main challenges now, and in the future, will be to ensure there is a workforce equipped with the competencies to develop behaviour change theory and tools that will bring about sustained changes in behaviour. taught post-graduate courses exist that could be scaled up and/or adapted to continuing professional development qualifications to meet this demand and help ensure that the changes in behaviour that will be required for the foreseeable future are sustained. how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? we sometimes forget that we have the theories and evidence for solutions that can be applied at pace to address novel problems. although we have never seen a lockdown before and so cannot predict what the outcomes will be directly, we do know what processes underpin adherence to instructions, and so can advise on the levers that can sustain adherence. in unprecedented and uncertain times now and in whatever the future might bring, the nature of psychological science allows us to make unique and invaluable contributions. if the covid- pandemic teaches us one thing, it is on the need to accelerate the translation of evidence from psychological science into practice. how do we develop new theories and tools to promote sustained behaviour change? at the same time, we should not forget the 'slow' approach to research (armitage, ) that involves addressing key research questions with multiple perspectives and methodologies, and accumulating such knowledge in prisma-guided systematic reviews. it is vital that continued investment is made into behaviour change research. only with this can we refine and develop the theories that best explain human behaviour (e.g., michie et al., ) . key research priorities include identifying which behaviour change techniques work best, for whom, in which contexts, and delivered by what means (e.g., epton, currie, & armitage, ) as well as how to counter the conspiracy theories and misinformation that arise during crises that seem to be aimed at derailing the very behaviours required to keep us safe and to reduce risk. in this position paper, we have set out seven research priority domains in which psychological science, its methods, approaches, and interventions can be harnessed in order to help governments, policymakers, national health services, education sectors, economies, individuals, and families recover from covid- . these are mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we have also highlighted that a clear overarching research priority relates to understanding the inequalities in the effects of the pandemic and recovery; recognizing the vulnerability and resilience factors that will be key to understanding how the current pandemic can inform and prepare us for dealing with future crises. we call on psychological scientists to work collaboratively with other scientists in order to address the research questions outlined, refine them and to adopt multidisciplinary working practices that combine different disciplinary approaches. an important next step will be to engage with wider stakeholders, potential users, individuals with lived experience, and beneficiaries of the research. addressing each of the research priority domains will benefit enormously from larger scale working and coordinated data collection techniques and the establishment of research consortia with their associated economies of scale. we also call on psychological scientists to further develop and adapt innovative research methodologies (e.g., remote testing and intervention delivery, online data collection techniques), while maintaining high-quality, open, and rigorous research and ethical standards in order to help with the recovery as we emerge from the acute phase of the crisis. how can we use biological markers to facilitate people's return to work? how do we link covid- -related biomarkers to existing population cohort databases? how do we address the negative biological impacts of the covid- virus on mental health? what are the impacts of covid- infection, treatment, and recovery on the brain? how do school closures influence educational progress, and physical and mental health outcomes for all children and young people? what 'homeschooling' practices are associated with positive educational and psychological outcomes? what is the effect of social distancing on a range of social outcomes in children and young people? what methods are used to track, monitor, and deliver local authority support services to vulnerable children and young people, families, and schools during lockdown, at transition back to school, and after return to school? how are educational and psychological interventions allocated, structured, delivered, and evaluated for children and young people in need, after schools have reopened? what is the impact of remote and flexible working arrangements on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what managerial behaviours are most effective to manage remote working, possible mental health issues, job insecurity, and productivity? what is the risk of longer-term mental ill health among frontline staff after the immediate crisis? how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? neurological manifestations and complications of covid- : a literature review changing behaviour, slow and fast: commentary on peters, de bruin and crutzen the impact of climate change on natural disasters planning health promotion programs: an intervention mapping approach self-regulation failure: an overview stress and burnout warning over covid- behavioural science and disease prevention taskforce. behavioural science and disease prevention: psychological guidance position statement on open data covid- research priorities for psychological science: a qualitative analysis the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid- mutual aid: how to help vulnerable people near you. the guardian lhc the guide systematically reviewing remote e-workers' well-being at work: a multidimensional approach the production of quick scoping reviews and rapid evidence assessments: a how to guide beyond linear evidence: the curvilinear relationship between secondary traumatic stress and vicarious posttraumatic growth among healthcare professionals global report: virus has unleashed a 'tsunami of hate' across world, says un chief. the guardian the role of social identity processes in mass emergency behaviour: an integrative review the accepting, the suffering and the resisting: the different reactions to life under lockdown. the policy institute, king's college london unique effects of setting goals on behavior change: systematic review and meta-analysis parental education, class and income over early life course and children's achievement what do you use the internet for? defining and characterising organisational resilience in elite sport coronavirus: urgent call for uk government to support women and girls compassion fatigue: coping with secondary traumatic stress disorder in those who treat the traumatized the rand/ucla appropriateness method user's manual the legacy of early experiences in development: formalizing alternative models of how early experiences are carried forward over time the impact of professional isolation on teleworker job performance and turnover intentions: does time spent teleworking, interacting face-to-face, or having access to communication-enhancing technology matter managing mental health challenges faced by healthcare workers during covid- pandemic healthcare staff wellbeing, burnout, and patient safety: a systematic review do parents know they matter? engaging all parents in learning the new psychology of health: unlocking the social cure visible learning, a synthesis of over meta-analyses relating to achievement loneliness and social distancing during the covid- pandemic: risk factors and associations with psychopathology multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science are there interactional differences between telephone and face-to-face psychological therapy? a systematic review of comparative studies mental health nurse's exposure to workplace violence leads to job stress, which leads to reduced professional quality of life the lockdown and social norms: why the uk is complying by consent rather than compulsion the long-run effects of teacher strikes: evidence from argentina carrying out qualitative research under lockdown -practical and ethical considerations. lse impact blog age of onset of mental disorders: a review of recent literature delivering opportunistic behavior change interventions: a systematic review of systematic reviews effortful control in early childhood: continuity and change, antecedents, and implications for social development what predicts a successful life? a life-course model of well-being mental health effects of school closures during covid- email duration, batching and self-interruption: patterns of email use on productivity and stress disasters and their impact on child development: introduction to the special section coronavirus: eu fears a rise in hostile takeovers how to use the nominal group and delphi techniques mental health statistics: children and young people an iterative process of global quality improvement: the international standards for a safe practice of anesthesia paralyzed by panic: measuring the effect of school closures during the polio pandemic on educational attainment (no. w ) the behaviour change wheel: a guide to designing interventions neurological implications of covid- infections mental health of children and young people in england - science as behaviour: using a behaviour change approach to increase uptake of open science stress and health: a review of psychobiological processes exploring the uk's digital divide coronavirus and the social impacts on great britain extreme teams: toward a greater understanding of multiagency teamwork during major emergencies and disasters the two psychologies and coronavirus. the psychologist do we still have a digital divide in mental health? a five-year survey follow-up psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid- pandemic the impact of communications about swine flu (influenza a h n v) on public responses to the outbreak: results from national telephone surveys in the uk building, hosting and recruiting: a brief introduction to running behavioral experiments online epigenetic dysregulation of ace and interferonregulated genes might suggest increased covid- susceptibility and severity in lupus patients coping strategies used during an extreme antarctic expedition domestic violence and abuse: safeguarding during the covid- crisis covid- , ace , and the cardiovascular consequences strategic review of health inequalities in england post- does closing schools cause educational harm? a review of the research. information brief covid- impacts: school shutdown severe acute respiratory syndrome (sars) in hong kong in : stress and the psychological impact among frontline healthcare workers psychosocial safety climate as a factor in organisational resilience: implications for worker psychological health, resilience, and engagement distress, worry, and functioning following a global health crisis: a national study of americans' responses to ebola work-home interference: how does it manifest itself from day to day? applying principles of behaviour change to reduce sars-cov- transmission opensafely: factors associated with covid- death in million patients in a paris banlieue, coronavirus amplifies years of inequality. the guardian getting back to work: dealing with the labour market impacts of the covid- recession. institute for employment studies coronavirus disease (covid- ) the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perfection, and altruistic acceptance of risk mind matters: a three-level meta-analysis on parental mentalization and sensitivity as predictors of infant-parent attachment christopher armitage's contribution is supported by the nihr manchester biomedical research centre and the nihr greater manchester patient safety translational research centre. the views expressed in this publication are those of the authors and not necessarily those of nihr. armitage would like to thank professors madelynne arden and alison wearden for their support in writing. til wykes would like to acknowledge the support of her nihr senior investigator award. the set of priorities utilized for the survey of the psychological community.how do we increase adherence (and ability to adhere) to uk government covid- related instructions? how do we promote maintenance of positive behaviour changes and reverse negative behaviour changes resulting from covid- -related lockdown? how do we address the negative psychological impacts of the covid- pandemic? how do we maximize recovery from covid- for those infected with the virus? what is the impact of covid- -related stress on biological processes and health outcomes? what makes people adhere to anti-covid measures? what are the bases of anti-social behaviours such as stockpiling? how do mutual aid groups form and what makes them endure? when does social cohesion give way to scapegoating, prejudice, and intergroup conflict? what creates (or prevents) the potential for protests and collective disorder in the crisis? what are the long-term mental health effects of covid- ? what coping mechanisms are useful in reducing mental health problems during a pandemic? how do we provide beneficial remote psychological therapy and maintain therapeutic alliance? has discussion of mental health during the pandemic reduced stigma and discrimination in the community? people detained in hospital under the mental health act were discharged to free up bedshow was this possible? what are the impacts of covid- infection, treatment, and recovery on cognition, behaviour, and the brain? what are the drivers of covid- -related stress and its cognitive, neural, and physiological mechanisms and consequences? what are the perceptual and cognitive demands of digital and other alternative forms of communication and how do they impact on work and social connectivity? what factors influence the effectiveness of communication of scientific evidence and national guidance, and how do they influence behaviour? how do restrictions of movement, communication, and social support influence the cognitive, physical, and mental health of older individuals, and what factors lead to improved outcomes? how has the covid- pandemic affected parenting? how has the covid- pandemic affected children's development? how has the covid- pandemic affected family functioning? which factors moderate family members' response to the covid- pandemic? what support is most effective for families during the covid- pandemic? how do we assess biological markers of health and well-being remotely?continued key: cord- -k y t i authors: gómez-salgado, juan; andrés-villas, montserrat; domínguez-salas, sara; díaz-milanés, diego; ruiz-frutos, carlos title: related health factors of psychological distress during the covid- pandemic in spain date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: k y t i measures to prevent and contain the covid- health crisis include population confinement, with the consequent isolation and interruption of their usual activities. the aim of the study is to analyse psychological distress during the covid- pandemic. for this, a cross-sectional observational study with a sample of people over the age of during quarantine was developed. variables considered were sociodemographic variables, physical symptoms, health conditions, covid- contact history and psychological adjustment. the data were collected through a self-developed questionnaire and the general health questionnaire (ghq- ). bivariate analyses were performed, including chi-squared test and student’s t-test. predictive ability was calculated through logistic regression. results obtained showed a high level of psychological distress ( . %), with a higher percentage in women and people of lower middle age. statistically significant differences were found in the variable working situation (χ² = . , p ≤ . , v = . ) and living with children under the age of (χ² = . , p = . , v = . ). the predictive variables with the highest weight were sex (or = . , % ic = ( . , . )), presence of symptoms (or = . , % ci = ( . , . )), and having had close contact with an individual with confirmed covid- (or = . , % ci = ( . , . )). these results could enrich prevention interventions in public health and, in particular, in mental health in similar pandemic situations. coronavirus disease has created a rapidly widening health crisis with dramatic consequences. on december , the wuhan municipal health commission in china notified the world health organization (who) of cases of pneumonia of unknown origin [ ] . on january , who declared an international public health emergency following the covid- outbreak that began in wuhan, china. by that date, cases had been identified across different countries outside china [ , ] . following the increase in the spread to more than , cases in countries and deaths, on march , who reported its pandemic consideration [ ] . as a result of the rapid evolution of in spain, being female, younger, having negative self-perceptions about aging, being more time exposed to news about covid- , having more contact with relatives different to those with whom they co-reside, fewer positive emotions, less perceived self-efficacy, lower quality of sleep, the higher expression of emotion and higher loneliness have been associated with psychological distress during isolation measures as a result of the covid crisis [ ] . this variability in the risk and protective factors of psychological distress against covid- suggests the need for further epidemiological studies to consolidate the results. although there is agreement on the increase of psychological distress in the population during the pandemic, the characteristics of this situation are disparate, and the phenomenon is not yet clearly described [ ] . the objective of the study is to analyse the psychological distress in a spanish population sample during the covid- pandemic, identifying the predictive character and role that sociodemographic variables, the presence of physical symptoms, and other health-related variables may have. as a hypothesis, it is stated that the health crisis caused by covid- does not generate psychological distress in the population. this research employed a cross-sectional observational study design. the initial sample consisted of people, recruited between march ( days after the start of confinement) and april . as inclusion criteria for the participants, the following were established: (i) being years of age or older, (ii) living in spain during the covid- pandemic, and (iii) accepting the informed consent. questionnaires were eliminated for having a percentage of questions answered of less than %, which resulted in a final sample of participants distributed in provinces and the two small spanish autonomous cities located in north africa. based on the sociodemographic characteristics of the sample, . % were women and . % men. the distribution by sex of the spanish general population is . % women and . % men [ ] . the average age of the participants stood at . years (sd = . ). the most common marital status was married or living as a couple ( . %) followed by being single ( . %). most of the participants had university studies or higher educational level ( . %) and the . % had upper secondary education. demographic data of the general spanish population indicate that % of the population has university studies [ ] . in relation to the employment situation, the . % of the subjects were working away from home, . % worked exceptionally from home (teleworking), and . % were not working at the time of their participation in the studio. most participants ( . %) were spending covid- confinement in a flat or apartment and the . % was confined in a house. the . % of the participants stated that they lived with children or youngsters under the age of at the time of their participation in the study. lastly, . % indicated that they cohabited with people with disabilities. this study aims to collect information on varied dimensions to assess the mental health and associated behaviours of the general population so as to assess the impact of this health crisis. therefore, the dependent variable was psychological adjustment and as independent variables sociodemographic data, the presence of physical symptoms of covid- , participants' health status, and history of possible contacts or exposure to covid- were considered. the sociodemographic variables included were sex, age, marital status, education level, employment status, number of people living with, living with a child or adolescent, and living with a disabled person. the participants were asked about the prevalence of the most common symptoms of covid- indicated by who over the past days [ ] : fever equal to or greater than • c, cough, headache, myalgia, dizziness, diarrhoea, sore throat, coryza, chills, and difficulty in breathing. a self-developed questionnaire was designed including the symptoms as items and dichotomous responses ("yes/no"). in relation to the state of health, the level of the participants' current physical and mental health was assessed through dichotomous response questions ("yes/no") to the following items: suffering a chronic illness, having a disability, taking some medication, having been hospitalised in the last days, and having been attended by some health service in the last days. to this end, the process was based on wang et al. approach [ ] . an item with five response options was used to measure perceived health: very bad, bad, not so good, good, and very good. this indicator was initially proposed by ilder and benyamini [ ] and used with small variants, in subsequent pandemic research [ , , , ] . it was assessed whether the person was quarantined due to having had a risk contact or covid- infection, as well as whether they had had a covid test. the contact history was evaluated by three questions with three answer categories (yes, no, i don't know), which evaluate direct/indirect contact with infected people or with people or materials suspected of being infected. a fourth taxonomic item ("yes/no") assessed cohabitating with people at risk of being infected. psychological adjustment was measured through the general health questionnaire (ghq- ), a psychometric instrument widely used as a screening of non-psychotic psychiatric disorders [ ] . it consists of items with four answer options. each item can get a score of (if options or are chosen) or (if options and are selected), getting from its sum a total score ranging from to . this questionnaire developed by goldberg has been translated and validated in many countries, presenting cronbach's alpha values from . to . [ ] and demonstrating, in addition, a good reliability in its version for spanish speakers with . and . in the spanish population [ , ] ; it has also been previously used in other sars-like epidemics [ ] . for this study, the overall score was used as a single factor whose reliability, estimated by cronbach's alpha, was of . . the cut-off point set for the general population was , considering those subjects with scores greater than or equal to more prone to potential psychiatric morbidity cases [ , ] . the independent variables were assessed through a self-elaborated questionnaire. for the design of the questionnaire, a bibliographic review was carried out on the psychological effect that other epidemics, and their prevention measures, had had on the population in the past. with the accumulated evidence, a first version of the instrument was built and evaluated by a panel of experts made up of health professionals: three doctors, four nurses, and three psychologists, two of which were specialists in clinical psychology. after the appropriate modifications were made, piloting was carried out with participants, obtained through a sampling for convenience, all over years of age and with a similar proportion of men and women in the sample ( . % and . %, respectively) and an average age of . (sd = . ). most participants reported being married ( . %) and having completed postgraduate studies, whether a master's or doctoral degree ( . %). they were all asked to complete the survey from different electronic devices. none of the participants expressed comprehension problems or doubts about what they were asked, nor were there any errors regarding the platform or design on the different devices (personal computer, tablet or smartphone) used by the participants. data were collected through the online data collection and survey platform qualtrics ® xm. as a telematics application, the confinement measures decreed by the health alarm state did not affect data collection. the sampling method was through the "snowball" effect, initiated by sending the information through email lists to universities and professional colleges who were asked to facilitate their dissemination. the helsinki declaration [ ] has been taken into consideration. participation in the study was entirely voluntary, and the explicit permission of the participants was obtained through informed consent for the confidential use and processing of data, according to the current laws in force on the protection of personal data. data were stored anonymously, with the assignment of a registration number so that it was not possible to identify the participants' responses. the project was approved by the research ethics committee of huelva, belonging to the andalusian ministry of health (pi / ). the analyses were performed using the spss . version statistical software (ibm, armonk, ny, usa)-an initial descriptive analysis was performed by calculating the means and frequency of the variables. the presence or non-presence of psychological distress was studied in each of the independent variables. subsequently, bivariate analyses were performed, including chi-squared test and student's t-test for independent samples, depending on the type of variable. the size indexes of the crammer's v and cohen's d effect were also calculated with the following cut-off points: to . , negligible; . to . , small; . to . , medium; from . on, high [ ] . then, with the aim of studying the predictive ability for psychological distress of the different sets of variables, logistic regression analyses (controlled by sex and age) were carried out including variables with p value < . . thus, model included sociodemographic variables, and model was related to physical symptoms, model showed health-related variables, and model dealt with contact history. finally, those variables that showed a predictive character in each of the models were included in a global model (model ). odds ratios (ors) were calculated with a % confidence interval. table details the mean scores and standard deviations of the answers provided by the subjects in each of the questions that make up the ghq- . the results show that items "have you been constantly felt overwhelmed and tense?" (m = . ; sd = . ) and "have you been able to enjoy your normal activities every day?" (m = . ; sd = . ) were the ones with the highest score. on the contrary, the items that presented a lower score were the item "have you thought that you are a person who is worthless?" (m = . ; sd = . ) and item "have you lost self-confidence?" (m = . ; sd = . ). the average score obtained in the total of the points scale was . (sd = . ). establishing a cut-off point of or more points, the results showed that a . % of the study participants presented psychological distress. in the light of the sociodemographic variables (table ) , the results showed statistically significant differences between both groups as for sex (χ = . , p ≤ . , v = . ) and age (t = , p ≤ . , cohen's d = . ), though effect sizes were small. a greater presence of psychological distress was observed in women ( . %) and in persons of lower middle age (m = . , sd = . ) with respect to the group that did not present this psychic morbidity (m = . , sd = . ). statistically significant differences were also found regarding the variable working situation (χ = . , p ≤ . , v = . ) and in terms of living with children or youngsters under the age of (χ = . , p = . , v = . ). the highest percentage of psychological distress was observed among people who were working outside home ( . %), and a low percentage of psychological distress was observed among people living with children or youngsters under the age of ( . %). in relation to the presence of symptoms in the days prior to the participation in the study (table ) , more than half of the sample claimed to have had headache ( . %); cough ( . %), myalgia ( . %), sore throat ( . %), and coryza ( . %). to a lesser extent, subjects reported having suffered from diarrhoea ( . %), dizziness ( . %), chills ( . %), breathing difficulty ( . %), and fever higher than • c for at last one day ( . %). on the other hand, according to the number of symptoms, the highest percentage ( . %) stated that they had developed three or more symptoms in the days prior to their participation in the study, followed by . % of participants who had not developed any of these symptoms. similar percentages were among those who reported having had a symptom ( . %) and two symptoms ( . %). statistically significant differences were observed between the presence of physical symptoms and psychological distress (p < . in all cases). statistically significant differences were also found regarding the mean number of symptoms (t = − . , p ≤ . , cohen's d = . ), with an average effect size. the group of subjects with psychological distress had a higher number of symptoms (m = . , sd = . ), as compared to the group that did not present this psychic morbidity (m = . , sd = . ). based on health-related variables (table ) , . % of respondents reported suffering from some form of chronic disease. among these subjects, the most commonly reported diseases were high blood pressure ( . %) and chronic respiratory disease ( . %), and to a lesser extent diabetes ( . %), immunosuppression disease or situation ( . %), metabolic syndrome ( . %), chronic cardiovascular disease ( . %), and active cancer ( . %). referring to the need for medical care, . % of subjects reported having been hospitalised in the last days, and . % reported receiving healthcare at a health centre, clinic, or hospital. . % of participants reported being quarantined for covid- symptoms and . % reported the diagnostic test ( . % negative, . % positive, and . % do not know the result). the variables related to the presence of psychological distress were the need for healthcare in a health centre, clinic, or hospital (χ = . , p < . , v = . ), having been quarantined (χ = . , p < . , v = . ), and having been done the diagnostic test (χ = . , p < . , v = . ). for all of them, the size of the effect was negligible. lastly, and taking into account the subjects' assessment of their perceived health in the last days, the results also showed statistically significant differences between the two groups (t = . , p ≤ . , cohen´s d = . ), with an average effect size. the group of subjects with psychological distress expressed a worse assessment of their health (m = . , sd = . ), as compared to the group without psychological distress (m = . , sd = . ). in relation to contact history in the last days (table ), . % of participants reported having maintained or not knowing if they had maintained close contact with an individual with confirmed infection with covid- . . % of respondents claimed to have had casual contact, and . % said they had maintained or did not know if they had maintained contact with any person or material suspected of being infected with covid- . in relation to the presence of infected people in the participants' immediate circle, . % indicated not having a relative infected with the virus and . % said they did not live with any confirmed infected family members. all contact history variables in the last days showed a statistically significant relationship with the presence of psychological distress (p <. in all cases). however, the effect sizes were negligible. logistic regression analyses have shown an adequate adjustment in general and an explained variance of . % in the overall model, with correct classification percentages of each model around %, which has allowed to identify the predictive variables of psychological distress. logistic regression models, controlled by sex and age, are displayed in table . model (sociodemographic variables) showed a predictive ability of . % (χ = . , p < . ). the result of the hosmer-lemeshow test indicated that this model did not present a good fit (χ = . , p = . ). sex, specifically female (or = . , % ci = ( . , . )), age (or = . , % ci = ( . , . )), and employment situation were predictive, correctly classifying . % of subjects with sensitivity and specificity parameters of . % and . %, respectively. with model , regarding physical symptoms, the variance value explained amounted to . % (χ = . , p < . ). those participants who had a higher number of symptoms in the days prior to their participation in the study (or = . , % ci = ( . , . )) were more likely to present psychological distress. this model correctly classified . % of participants (sensitivity . % and specificity . %). model , which includes health-related variables, had a predictive capacity of . % (χ = . , p < . ), slightly higher than the previous model. this model provided sensitivity and specificity values of . % and . %, correctly classified to . % of the sample. however, it did not present a good fit (hosmer-lemeshow chi-squared value = . , p < . ). participants with a higher score in self-rated health (or = . , % ci = ( . , . )) were less likely to present psychological distress. however, those subjects who had recently been diagnosed with covid- were . times more likely to have psychological distress ( % ci = . , . ) . the contact history variables are included in model , which provided an explained variance rate of . % (χ = . , p < . ). having had a close contact with an individual with confirmed infection with covid- (or = . , % ci = ( . , . ) ), as well as having had any contact with any person or material suspected of being infected (or = . , % ci = ( . , . )) had predictive ability, correctly classifying . % of the participants ( . % sensitivity and . % specificity). finally, model (global model), which included the variables that had a predictive character in the previous models, presented a predictive ability of . %, correctly classifying . % of the participants ( . % sensitivity and . % specificity). the variables that showed the greater weight, with ors greater than , were sex (or = . , % ci = ( . , . )), number of symptoms presented in the last days (or = . , % ci = ( . , . )), having had close contact with an individual with confirmed infection with covid- (or = . , % ci = ( . , . )), and having had contact with any person or material suspected of being infected (or = . , % ci = ( . , . )). other predictive variables with ors less than were age, employment status, and self-rated health. in this study, various sociodemographic variables, variables related to the presence of physical symptoms, and other health-related ones have been identified as predictors of the presence of psychological distress symptoms among the spanish population during a period of health alert due to the covid- epidemic. in spain, during the initial moments of confinement, . % of the study participants showed risk of psychiatric morbidity (or distress). this figure is much higher than the ones found in previous studies carried out on the spanish population, that placed psychiatric morbidity at . % [ ] or . % [ ] , not having subsequent data [ ] . specific studies on the psychological impact during epidemics place the prevalence of psychological distress between . % and . % [ ] [ ] [ ] [ ] [ ] ] . in our study, the highest percentage level of psychological vulnerability during an epidemic can be found. these high results may be due to the fact that the covid- pandemic in our country has affected the spanish population in a more serious way than previous pandemics and the feeling of alarm is greater. as for the role that sex may play in relation to psychological vulnerability in epidemic situations, some studies have found that being male was associated with greater distress during the recovery period of sars [ ] but, in most studies, females were associated with greater vulnerability. women are found to suffer greater distress during the h n influenza outbreak [ ] or during equine influenza [ ] , and a longitudinal study on the impact of the sars outbreak in hong kong [ ] found that women were more likely to suffer anxiety. one of the first studies conducted during the covid- epidemic identified an increased risk of anxiety, depression, and stress among women [ ] . as for the general indicators of mental health in spain, being a woman is associated with greater vulnerability [ ]. our results are in line with those found in most studies, showing that women present significantly higher levels of distress (with low size effect), and this can therefore be understood as an individual risk factor in the face of the impact of the covid- epidemic. the results show that, although weakly, younger people are at higher risk of suffering higher levels of distress. these data are consistent with those from previous studies in epidemic states, and in which being younger was associated with an increased risk of distress [ ] or increased psychiatric morbidity [ ] . however, a study similar to the present one conducted at the beginning of the covid- quarantine identified an increased risk of psychological distress among people over years of age [ ] . mental health indicators in spain show that psychiatric morbidity increases with age [ ] . our data indicate that the youngest part of the study population is the one with the highest psychiatric morbidity. this result can be understood in line with sim [ ] and taylor [ ] , due to the relationship they establish regarding differences in coping styles. thus, youngest adults are less resilient in the face of adversity and also less able to understand that it is an extreme situation that implies radical and sudden changes in the lives of people, and which are not the result of an individual decision. as for the relationships found between the degree of distress and living with children during confinement, the data showed that people with children have a greater psychological vulnerability. however, the effect size was negligible. this result coincides with those by taylor's study [ ] which suggests that people with a child are more likely to have psychological distress, explaining that those who have a child are usually younger adults and hence the association with the greatest risk. on the other hand, as brooks [ ] and naushad [ ] state, there is no link between having children and any psychological impact in their reviews. however, mazza et al., in their recent study, conducted during the covid- crisis in italy, identified an association between having no children and a higher level of depression [ ] . in relation to the employment situation, most previous studies have analysed the role of economic income and its changes as a result of labour measures taken during an epidemic. thus, reduced or low level of economic income was consistently related to an increased risk of psychological impact [ , , ] . general indicators of mental health in spain show that low levels or lack of economic income, as well as lack of employment, are associated with lower mental health [ ] . our data, however, indicated, weakly, that in the pandemic situation by covid- , those who have to work away from home had a higher level of distress. this outcome can be related with a higher risk of contagion and concern for all its consequences, as they can spread the disease to the family and due to the high degree of uncertainty about the disease. in this line, mihashi's study [ ] shows how the perception of risk is associated with psychiatric morbidity during and after recovery of sars. on the other hand, the results obtained by jahanshahi et al. on the effects of covid- quarantine in iran suggest that participants who had to stop working because of the pandemic had more psychological distress than those who worked from home or at their workplace [ ] . quarantine for at least days is associated with increased anxiety and anger [ ] , as well as with increased symptoms of post-traumatic stress disorder [ , , ] . our data showed that quarantine was associated with increased psychiatric morbidity (negligible size effect). in the line posed by hawryluck et al. [ ] , being quarantined can be interpreted by these people like trauma or personal assault. our study coincides with previous ones associating perceived low health with a higher level of stress and psychological impact in general [ , ] . we have also observed, with an average size effect, that a worse perception of health was linked to increased psychiatric vulnerability. the presence of covid- symptoms was also related to the level of distress, so the presence of some symptoms can be considered a factor associated with increased psychological morbidity. the study on the psychological impact of covid- conducted by wang [ ] identified that myalgia, dizziness, chills, sore throat, and having a cold were associated with a greater psychological impact of the outbreak. additionally, the presence of covid- symptoms was associated with higher levels of stress, anxiety, and depression [ ] . similarly, during an outbreak of sars, the presence of symptoms such as fever was linked to the risk of higher distress, which can be understood on the basis that the onset of symptoms can reinforce the sense of vulnerability and threat of infection [ ] . the presence of mers symptoms was related to an increase in anger scores [ ] . also, testing and history of contact with infected people or objects were related, with negligible size effect, to increased psychiatric morbidity. no data from previous studies reveal the role that testing or diagnostic tests may play on the effects of psychological morbidity, but there are studies that indicate that the presence of risk contact may be a predictor of acute stress disorder [ ] or post-traumatic stress disorder [ ] , having found a relationship between anxiety and having had contact with materials suspected of being infected [ ] . our result can answer to what wu [ ] raised by showing that protective measures are often relaxed with close people such as family and friends. however, knowing that contact has been made with a person who has subsequently become ill increases the feeling of danger, similar to the risk of contracting the illness, also increasing psychological vulnerability. among the limitations of the study, as it is cross-sectional observational design which only informs of the perception at the time it was performed, it does not allow to establish cause-and-effect relationships but, on the contrary, it does provide with very valuable and difficult to obtain information about how the problem generated by the pandemic is lived just at the time of further escalation of the contagion curve, this being the largest contribution of the article. the sample collection was not randomised and the ratio by sex was asymmetrical and does not correspond to the distribution of the spanish population. these factors were compensated with a large sample and representation from all provinces and autonomous cities, having taken into account the variable sex in the analysis. comparing these data with those from other epidemics is difficult because the measures established in confinement or isolation are highly variable, even in different geographical areas within the same pandemic, variables that, as seen in this study, have a great influence in the development of psychological distress. it may be interesting to make other cuts of the study at a more advanced stage of the pandemic and at the end of the pandemic in order to assess its evolution. the study, conducted during the health alert decree with confinement measures at home except for essential activities, and initiated at the beginning of growth of the contagion curve, shows that a high percentage ( %) of participants had psychological distress, being this percentage higher among women ( . %). people who work outside home in essential activities are more likely to suffer psychological distress, and those who lived with children or under- youngsters were less likely to show this distress. the most common symptoms in the last days were headache, cough, myalgia, sore throat, and rhinitis; three or more symptoms are more commonly found. although one out of three participants had a chronic disease, only . % had required health care and less than one percent ( . %) required hospital care. a high percentage ( . %) claimed to have had contact or not knowing whether they had had contact with any infected person or material. however, a vast majority claimed not having had any infected family member ( . %) and not living with any infected family member ( . %). an association was found between psychological distress and a poor assessment of health. among the variables that predict psychological distress are, therefore: being female, age, employment situation, number of symptoms, perception of poor health, having been in close contact with an infected person, as well as having been in contact with people or material suspected of being infected. these results should be explored in depth and considered for awareness-raising and information programmes during pandemics or other crisis situations, as they could enrich prevention interventions in public health and, in particular, in mental health. the information provided by the present study can help to design interventions for the psychological and emotional recovery of the population after the pandemic. it can also help in the design of mental health prevention programs aimed to protect the population from psychological distress in case of future pandemics. the authors declare no conflict of interest. world health organization. novel coronavirus ( -ncov) situation report emergency committee regarding the outbreak of novel coronavirus ( -ncov) china coronavirus: who declares international emergency as death toll exceeds world health organization. who director-general's opening remarks at the media briefing on covid- - boletín oficial del estado real decreto-ley / . boletín oficial del estado multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science the size and burden of mental disorders and other disorders of the brain in europe the psychological effects of quarantining a city the psychological impact of quarantine and how to reduce it: rapid review of the evidence mental health strategies to combat the psychological impact of covid- beyond paranoia and panic depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic sars control and psychological effects of quarantine mental health status of people isolated due to middle east respiratory syndrome factors associated with mental health outcomes among health care workers exposed to coronavirus disease immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china posttraumatic stress disorder in parents and youth after health-related disasters is quarantine related to immediate negative psychological consequences during the h n epidemic? gen the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk predictive factors of psychological disorder development during recovery following sars outbreak factors influencing psychological distress during a disease epidemic: data from australia's first outbreak of equine influenza general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h n influenza pandemic severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey demographic and attitudinal determinants of protective behaviours during a pandemic: a review community psychological and behavioral responses through the first wave of the influenza a(h n ) pandemic in hong kong avoidance behaviors and negative psychological responses in the general population in the initial stage of the h n pandemic in hong kong a systematic review of the impact of disaster on the mental health of medical responders understanding, compliance and psychological impact of the sars quarantine experience a longitudinal study on the mental health of general population during the covid- epidemic in china the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations the distress of iranian adults during the covid- pandemic-more distressed than the chinese and with different predictors first study on mental distress in brazil during the covid- crisis a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors affective temperament, attachment style, and the psychological impact of the covid- outbreak: an early report on the italian general population association of self-perceptions of aging, personal and family resources the differential psychological distress of populations affected by the covid- pandemic report of the who-china joint mission on coronavirus disease (covid- ). available online self-rated health and mortality: a review of twenty-seven community studies relations of sars-related stressors and coping to chinese college students' psychological adjustment during the beijing sars epidemic the validity of two versions of the ghq in the who study of mental illness in general health care the -item general health questionnaire (ghq- ): reliability, external validity and factor structure in the spanish population propiedades psicométricas y valores normativos del general health questionnaire (ghq- ) en población general española the general health questionnaire montero-piñar, i. morbilidad psíquica, existencia de diagnóstico y consumo de psicofármacos: diferencias por comunidades autónomas según la encuesta nacional de salud de statistical power analysis for the behavioral science salud mental en españa y diferencias por sexo y por comunidades autónomas psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease longitudinal assessment of community psychobehavioral responses during and after the outbreak of severe acute respiratory syndrome in hong kong key: cord- -e htl authors: petzold, moritz bruno; bendau, antonia; plag, jens; pyrkosch, lena; mascarell maricic, lea; betzler, felix; rogoll, janina; große, julia; ströhle, andreas title: risk, resilience, psychological distress, and anxiety at the beginning of the covid‐ pandemic in germany date: - - journal: brain behav doi: . /brb . sha: doc_id: cord_uid: e htl background: the current covid‐ pandemic comes with multiple psychological stressors due to health‐related, social, economic, and individual consequences and may cause psychological distress. the aim of this study was to screen the population in germany for negative impact on mental health in the current covid‐ pandemic and to analyze possible risk and protective factors. methods: a total of , people took part in an online survey in germany from march to april. the questionnaire included demographic information and ascertained psychological distress, anxiety and depressive symptoms, and risk and protective factors. results: in our sample, over % expressed suffering from anxiety and psychological distress regarding the covid‐ pandemic. participants spent several hours per day thinking about covid‐ (m = . ). psychological and social determinants showed stronger associations with anxiety regarding covid‐ than experiences with the disease. conclusions: the current covid‐ pandemic does cause psychological distress, anxiety, and depression for large proportions of the general population. strategies such as maintaining a healthy lifestyle and social contacts, acceptance of anxiety and negative emotions, fostering self‐efficacy, and information on where to get medical treatment if needed, seem of help, while substance abuse and suppression of anxiety and negative emotions seem to be associated with more psychological burden. the new virus sars-cov- has now rapidly spread to nearly all countries over the world, and the world health organization (who) declared an international pandemic in march (ghebreyesus, ) . the pandemic comes with a large number of potential stressors that might cause psychological distress and mental health burden (inter-agency standing committee, ). potential stressors related to the virus might be the fear of an infection with covid- and the consequences for oneself or loved ones. the taken measures that aim to slow down the spreading of the virus also come with lots of stressors such as social isolation, economic consequences, and uncertainty about the future (inter-agency standing committee, ). therefore, an increase in psychological distress and negative consequences for the mental health of large populations worldwide can be assumed. in a rapid developing situation with a pandemic of a scale that was not known in the last years, substantial research on the psychological consequences of the pandemic is lacking. first studies provide evidence regarding psychological distress in the context of the covid- pandemic. an online survey in the general population in china showed that more than half of the participants rated the psychological impact of the events as moderate-to-severe and . % reported depressive and . % anxiety symptoms of moderate-to-severe intensity during the initial stage of the pandemic. these proportions seemed to be relatively stable-a second survey weeks later showed no significant reduction in those symptoms (wang, pan, wan, tan, xu, mcintyre, et al., ) . another study from china showed a lower prevalence of symptoms of psychological distress in chinese workforce during the covid- outbreak tan, hao, et al., ) , and particularly, individuals with preexisting (mental) health issues seem to suffer from psychological strain in the context of the pandemic . studies that focused on the psychological consequences of previous epidemics or pandemics showed that these were associated with substantial psychological distress and mental health problems, for example, during the ebola epidemic (greenberg, wessely, & wykes, ; mohammed et al., ) or the sars outbreak in (maunder et al., ) . the first case in germany was detected in january (bayrisches staatsministerium für gesundheit und pflege, ), and case numbers have been rising afterward (see figure ). in parallel, stepwise more rules appeared to inhibit a further exponential growth of the infection numbers, for example, the closure of all educational, cultural and gastronomical institutions, and a reduction in retail and service sectors (bundesgesundheitsministerium, ) . since march, throughout germany, more rigorous national rules became effective, including further closures of institutions and restrictions of physical contact and staying outside. to our knowledge, there is no published research on factors of psychological distress in the general population in germany during the current pandemic. hence, the aim of the present study was to assess psychological distress, anxiety, and depression with regard to the covid- pandemic and to analyze possible risk and protective factors. this is a cross-sectional observational study using a convenience sample of the general population in germany via online survey, approved by the ethics committee of charité universitätsmedizin berlin (ea / / ) and registered on clinicaltrials.gov (nct ). to survey the psychological dimension of the covid- pandemic, an online self-report questionnaire via sosci survey was used. data collection started march , when in germany, , cases of infection and deaths attributed to covid- were reported (robert koch institut, ) . the end of the first wave of data collection was days later: april , when in germany , cases and , deaths were reported (robert koch institut, the charité. completing the entire survey required - min. the present paper only examines cross-sectional data of the first wave. further longitudinal measurements will be carried out. all participants gave informed consent prior to participation. figure shows the covid- situation in germany during recruitment period regarding cases of infection, death, and recovery. except the minimum age of years, residence in germany, and the ability to complete the questionnaire in german, there were no other inclusion or exclusion criteria. the online questionnaire contained demographic information and the experiences with the virus (e.g., being in quarantine, tested or diagnosed for the coronavirus). additionally, the subjective risk of being infected within the next month was rated from % to % and the daily average amount of hours spent thinking about covid- was recorded. to screen for general anxiety and depressive symptoms, the ultra-brief screening scale of the patient health questionnaire- (phq- ) (löwe et al., ) was used. the intensity of four items describing major anxiety/depressive symptoms was rated on a -point scale from ("not at all") to ("nearly every day"). the phq- can be examined as a total score or be divided into an anxiety (gad- ) and a depression subscale (phq- ). to assess selected aspects of anxiety regarding covid- , nine items were included (e.g., the fear of being infected and the fear of social or economic consequences). all statements were rated on a -point likert scale, ranging from ("not true at all") to ("totally true"). additionally, a modified version of the validated dsm- severity-measure-for-specific-phobia-adult-scale (beesdo-baum et al., ) was used to ascertain the extent of anxiety symptoms caused by the pandemic. the scale consists of items, rated on a -point likert scale from ("never") to ("all the time"). the questionnaire inquired eight items regarding protective factors in dealing with the pandemic (e.g., self-efficacy in general, social self-efficacy) and five items targeting risk factors (e.g., suppression, substance use). protective and risk factors were adapted from the recommendations on coping with psychological distress in the pandemic of the inter-agency standing committee (iasc) of the united nations (un) (inter-agency standing committee, ). items were rated on a -point likert scale. all questions were administered in german. the questionnaire consisted of eight pages. we included only participants who completed at least page (n = , ). . % of the participants (n = , ) completed all pages. average percentage of missing data on item level was . % (range: . - . ). missing data were handled by casewise deletion. all analyses were carried out using ibm spss statistics version . significance level was set to . (two-tailed). for the analysis, descriptive statistics, pearson's and spearman's correlations, and t tests for independent samples were used. . % of the participants were female (n = , ), . % male (n = , ), and . % identified as diverse (n = ). mean age was . years (sd = . , range - ). . % reported to have children (n = . %). . % had a secondary school degree (n = ), . % had a higher education entrance qualification (n = , ), and . % had a university degree (n = , ). . % of the participants reported to work in a medical context (n = , ). . % of the participants suffered from a severe physical illness (n = ). the participants lived in a household with . persons on average (including themselves). figure shows the experiences of the participants with covid- . about one third of the participants knew someone diagnosed with covid- or already suspected themselves to be infected. about % were currently under quarantine, and < % had been tested for covid- . about % of the sample had been diagnosed with covid- . average rating of the risk of being infected with covid- within the next month was . % (sd = . , range: - ). most participants rated the risk with % ( . %, n = , ). the lowest % of the sample ranked it as . % or lower. median of risk perception was . %. the highest % ranked the risk at least as %. average rating of the risk of being infected with influenza ("flu") was . % on average, the participants thought about covid- for . hr/ day (sd = . , range from to ). % of the participants thought < hr, while % thought hr or more per day about covid- . % reported to think more than hr/day about covid- . women where to get medical treatment showed significant negative correlations ranging from r = −. to r = −. . the overall score of the modified specific-phobia scale was . (sd = . ), with women showing significantly higher scores than men (m = . , sd = . vs. m = . , sd = . ; p > . ). the participants showed an average phq- score of . (sd = . , range - ). % of the participants showed a score of at least , while % of them showed a score of at least . women showed a significantly higher phq- score (indicating more depressive and anxious symptomatology) than men (m = . vs. m = . ). the participants showed an average phq- score of . (sd = . , range - ). % of the sample showed a score of at least and % a score of at least . the average gad- score was . (sd = . , range - ). % of the participants showed a score of at least , while % showed a score of at least . in this study, we wanted to explore how the current covid- pandemic is connected to a psychological burden, especially to upcoming anxiety, among the general population in germany. first, we found that the participants spend a tremendous amount second, we found that the risk perception of getting infected with covid- in the next weeks was very high. these data show that as expected, the fear of becoming infected with covid- is very prevalent in the general population. even in a time where the prevalence of covid- infections seems difficult to estimate, the risk rating of being infected within the next weeks seems to be higher than the expected number of infections in weeks. an infection probability of % within the next weeks (the median) would mean over million of infected people in germany by beginning of may which seems rather unlikely when the current development is taken into account (robert koch institut, ). our (tham, ibrahim, hunt, kapur, & gooding, ). in the current situation, fears regarding the covid- pandemic have to be seen as normal consequences in an exceptional situation rather than as pathologic reactions (petzold, plag, & ströhle, a , b outbreak , where more than half of the participants reported a moderate-to-severe psychological impact of the covid- pandemic on themselves, while about % of reported moderate-to-severe depressive symptoms and nearly % reported moderate-to-severe anxiety symptoms. interestingly, personal experiences with covid- were not strongly connected to covid- anxiety. this could mean that psychological and social determinants may have a larger influence on anxiety in that early phase of the pandemic than immediate experiences with this virus itself. this is undermined by our finding that self-efficacy (meaning a person's believe in his or her own ability to master situations or show a certain behavior) showed essential significant negative correlations with covid- anxiety. low self-efficacy has been shown to be connected with higher anxiety (bandura, ; muris, ) . our results make the assumption reasonable that self-efficacy could be a protective factor also against pandemic-driven anxiety and future longitudinal studies should test this assumption. the result that working in a medical context is associated with more anxiety regarding the covid- pandemic is in line with findings from a recent study from hospitals in singapore and india that showed high proportions of physical and psychological strain in healthcare workers . a further comparison of different professions in the healthcare sector would be interesting-as for example in a study in singapore nonmedical healthcare workers (e.g., pharmacists, technicians) reported more psychological strain than medical personnel tan, hao, et al., ) . these results are of a high practical value as they empirically underpin the recommendations on the reduction of psychological distress in the current pandemic that are given by international or- in our sample, the average phq- score was with a mean of . higher than the phq- score that has been reported by previous research in the general population of . (löwe et al., ) . with all given precautions, this could show that in the current situation there is an increase in depressive and anxiety symptoms in the german general population. due to the nature of the study, this cannot be interpreted as a robust and reliable research result and should be merely seen as an empirical fundament to build hypotheses in this direction. if elevated levels of anxiety and depression turn out reliable and robust in other studies and especially in the longitudinal course, appropriate interventions should be established to reduce psychological strain-for example, cognitive behavioral therapy . in a first longitudinal study from china (wang, pan, wan, tan, xu, mcintyre, et al., ) , a statistically significant but not clinically relevant reduction in ptsd symptoms as a result of the covid- pandemic was found from end of january to end of february . at the same time, there were no significant changes regarding anxiety, depression, and stress. furthermore, the study identified protective factors such as confidence in doctors and satisfaction with health information, risk perception and outcome expectation (perceived survival likelihood), and personal precautionary measures (wang, pan, wan, tan, xu, mcintyre, et al., ) . in our sample, women showed higher scores of covid- anxiety, more time of thinking about covid- per day, as well as more depressive symptoms than men. this is in line with the results of other studies regarding the psychosocial distress caused by the covid- pandemic (qiu et al., ; . up to now, it is not possible to draw conclusions if this is something specific to the covid- pandemic as higher values of anxiety and depression are reported in women in general (salk, hyde, & abramson, ) . our study represents the first study that assesses psychological distress, anxiety, and depression as well as risk and protective factors in the current covid- pandemic in germany. we started recruitment quite early so we assessed our participants still in a situation where case numbers were rising exponentially and media coverage was really large. this allows to study the psychological consequences at an early stage of the pandemic and lays a good basis for further longitudinal follow-ups. with a sample size of over , participants, our sample is large enough to detect even small effects. our sample was fully registered and approved by the local ethics committee. nevertheless, there are some limitations. we recruited our sample as convenience sample mainly through social media. this might have led to a sample bias. people who are familiar with or have easy access to social media might have been more likely to participate in our study, which might have led to a rather young sample. furthermore, people who show higher levels of psychological distress and anxiety might be more likely to take part in a study like ours. this could have led to an overestimation of these factors in our sample. this strategy of recruitment does reduce the generalizability of our results which is shown by several differences between the demographics in our sample and the general population in germany. the sample shows in comparison with the general population a much higher gender imbalance, a lower average age, and a higher percentage of persons working in a medical context (bundesinstitut für bevölkerungsforschung, ). our study is a cross-sectional examination and does not allow any causal interferences. our questionnaire was rather short, using simple scales, not all of them were validated. therefore, all of the study results in general should rather be interpreted as first hints, which might be helpful for further studies as well as to empirically underpin existing recommendations on the reduction in psychological distress in the pandemic. our results suggest that in this early phase of the covid- pandemic with low percentages of diagnosed cases in our study population, we can already observe its fundamental impact on anxiety and in the pandemic such as a healthy lifestyle, social support, acceptance of negative emotions, and avoidance of suppression and substance abuse is supported by our data. the authors declare that there is no conflict of interest. the peer review history for this article is available at https://publo ns.com/publo n/ . /brb . . the data that support the findings of this study are available from the corresponding author upon reasonable request. moritz bruno petzold https://orcid.org/ - - - antonia bendau https://orcid.org/ - - - self-efficacy conception of anxiety bestätigter coronavirus-fall in bayern -infektionsschutzmaßnahmen laufen psychometric properties of the dimensional anxiety scales for dsm-v in an unselected sample of german treatment seeking patients retrieved from www.bunde sgesu ndhei tsmin ister ium.de/coron aviru s/chron ik-coron avirus a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak. brain, behavior, and immunity self-regulation of emotional responses to zika: spiral of fear coping with health problems: the distinctive relationships of hope sub-scales with constructive thinking and resource allocation worry: daily self-report in clinical and non-clinical populations who director-general's opening remarks at the media briefing on covid- - potential mental health consequences for workers in the ebola regions of west africa-a lesson for all challenging environments do psychiatric patients experience more psychiatric symptoms during covid- pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry mental health strategies to combat the psychological impact of covid- beyond paranoia and panic briefing note on addressing mental health and psychosocial aspects of covid- outbreak-version . . retrieved from https://inter agenc ystan dingc ommit tee.org/ syste m/files/ - /mhpss % cov id % bri efing % not e% % mar ch% -engli sh.pdf. international federation of red cross and red crescent societies ( ). mental health and psychosocial support for staff, volunteers and communities in an outbreak of novel coronavirus a -item measure of depression and anxiety: validation and standardization of the patient health questionnaire- (phq- ) in the general population long-term psychological and occupational effects of providing hospital healthcare during sars outbreak an evaluation of psychological distress and social support of survivors and contacts of ebola virus disease infection and their relatives in lagos, nigeria: a cross sectional study- relationships between self-efficacy and symptoms of anxiety disorders and depression in a normal adolescent sample covid- -pandemie: psychische belastungen können reduziert werden dealing with psychological distress by healthcare professionals during the covid- pandemia a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations covid- : fallzahlen in deutschland und weltweit gender differences in depression in representative national samples: meta-analyses of diagnoses and symptoms is returning to work during the covid- pandemic stressful? a study on immediate mental health status and psychoneuroimmunity prevention measures of chinese workforce examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support when worries make you sick: a review of perseverative cognition, the default stress response and somatic health immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china a longitudinal study on the mental health of general population during the covid- epidemic in china reflecting on rumination: consequences, causes, mechanisms and treatment of rumination longitudinal associations between rumination and depressive symptoms in a probability sample of adults mental health considerations during covid- outbreak key: cord- - dr xupy authors: liang, leilei; gao, tingting; ren, hui; cao, ruilin; qin, zeying; hu, yueyang; li, chuanen; mei, songli title: post-traumatic stress disorder and psychological distress in chinese youths following the covid- emergency date: - - journal: j health psychol doi: . / sha: doc_id: cord_uid: dr xupy this study aims to explore the relationship between psychological distress and post-traumatic stress disorder among chinese participants as the result of covid- outbreak. this study was conducted within month after covid- appeared in china, it included participants age from to . the results indicated that . % of all participants with the symptoms of post-traumatic stress disorder and the effects of psychological distress on post-traumatic stress disorder was mediated by negative coping style. gender moderated the direct effect between psychological distress and post-traumatic stress disorder, which is a significant discovery for relevant departments to take further measures. at the end of , a series of cases of an unfamiliar type of pneumonia has been reported in wuhan city, hubei province, china. it has been confirmed that this pneumonia is caused by a new type of coronavirus, which world health organization has officially named it novel coronavirus disease (du et al., ) . on january , the world health organization announced a public health emergency of international concern (pheic) (who, ) . this public health emergency not only damages people's physical health, but also have a significant impact on their mental health (huang et al., ; wang et al., c) . psychological distress as a broader manifestation of mental health-related problems, which is characterized by symptoms of depression anxiety, stressrelated concerns and it is known to continue to show severity (drapeau et al., ) . in previous studies, psychological distress mainly included related psychological problems such as depression, anxiety, and stress (higuchi et al., ; o'brien et al., ) . in a survey with regard to the mental health of general population weeks after the covid- outbreak in china, which the result showed about one-third of participants reported moderate to severe level of anxiety (wang et al., a) , and nearly . % of the youth had a tendency to have psychological problems . simultaneously, medical staff also showed signs of irritability, unwillingness to rest, and difficulties in emotion management and existential stress zaka et al., ) . in addition, the impact of infectious diseases and microbial threats on mental health has become an important public health issue (holloway et al ; norwood et al., ) . however, most of previous studies focused on the impacts of public health emergencies such as infectious diseases on the medical staffs who are diagnosed with post-traumatic stress disorder (ptsd) (brooks et al., ; kang et al., ) , and less on the impacts of ptsd diagnoses among younger people with lower adaptive capacities and less mature cognitive abilities which make them vulnerable against psychological distresses (cénat and derivois, ) . thus, about within month after covid- occurred in china, we conducted this cross-sectional study to assess the mental state of young people who are diagnosed with ptsd due to this outbreak. pstd is a psychological disorder which can occur after people went through a traumatic experience such as earthquakes, hurricanes and sars (ding and xia, ; gonzalez et al., ; mak et al., ) . its basic feature is the characteristic symptoms result from the exposure to a traumatic experience, or a personal tragic life event, or witness events involving death, injury or threat to the physical integrity of others (lin et al., ) . and people with ptsd also will be forced to relive the negative effect caused by traumatic event that gives them the disorder, which can cause dramatic changes in their cognition and mood, make them avoid trauma-related stimuli at all cost, these symptoms has an important impact on daily life and work of people (farooqui et al., ; sekiguchi et al., ) . with the extremely high infection concerns, enough evidences has demonstrated covid- was considered as a life-threatening public health emergency and a disease serious enough to cause ptsd. according to the cognitive model of ptsd, the negative emotions experienced by traumatized patients (such as fear, sadness, and anger) can cause them to adopt negative assessment as a way to deal with traumatic events, which may lead to ptsd. furthermore, previous studies have shown that participants with higher level of psychological distress, such as anxiety, depression, and fear, are more likely to develop ptsd symptoms (wang et al., b; xi et al., ) . this may be because people fear injury and death, especially under unexpected and unprepared situations, which can create panic, fear, and tension (xu et al., ) . since the events are unexpected, people will feel confused about their current situation, and they will be uncertain about their future (yates and stone, ) . furthermore, this uncertainty may cause psychological distress in people, which would result in huge psychological stress aggravating ptsd symptoms. therefore, psychological distress is a predictor of ptsd. however, the mediating and moderating mechanisms underlying psychological distress and ptsd need further investigation. studies have shown that in the absence of other adaptive coping strategies, youths may use material coping as a negative coping style (ncs) to cope with psychological distress (acierno et al., ; pollice et al., ; vlahov et al., ) . in addition, numerous empirical studies also proved that adolescents who use ncs after experienced traumatic events such as earthquakes and hurricanes have a negative impact on their ptsd symptoms (carr et al., ; pina et al., ; ) , which may be a way to alleviate the symptoms of ptsd in youths with psychological distress. it was mainly reflected in the use of methods including denial, blaming, social withdrawal, and disengagement aim to avoid the problematic situations during and after emergencies (zheng et al., ) . thus, this study proposed the hypothesis that ncs would mediate the association between psychological distress and ptsd. in addition, gender is an important biological determinant of vulnerability to psychosocial stress (wang et al., ) . there was no consistent conclusion regarding the relationship between gender and psychological distress and ptsd. research indicates that compare to males, females show more ptsd symptoms (kun et al., ; qi et al., ) . when an emergency occurs, women may be more vulnerable than men, less likely to use effective coping strategies, and tend to interpret ptsd negatively (tolin and foa, ) . on the other hand, women are instinctively more sensitive to loss and stress, and therefore may develop negative emotions and ptsd symptoms (dell'osso et al., ) . however, some studies have found that men have more ptsd diagnoses than women (du et al., ; liang et al., ) , this may be because the men take more responsibility in taking care of the family (guo et al., ) , therefore show more symptoms of ptsd. these different results inspired us to further explore the relationship between gender, psychological distress and ptsd. thus, this study proposes the hypothesis that the gender would moderate the direct association between the psychological distress and ptsd ( figure ). a cross-sectional study was designed in the first month since covid- outbreak hits china. the study took a snowball sampling approach to collect questionnaires remotely, targeting people age from to . the questionnaires will be sent to participants through a wellknown smartphone social network application called wechat. participants can share their questionnaires with their friends, who can then share with their friends, as a way to expand the sample size. finally, approximately questionnaires were collected from participants. after deleting the duplicate ids and random questionnaires, this study collected a total of valid questionnaires, the valid response rate was . %. before collecting the data, the participant was given an informed consent, and researchers received a verbal consent from the participant in return. the ptsd checklist-civilian version. the diagnosis of ptsd was done by using the ptsd checklist-civilian version (pcl-c) (weathers et al., ) , which was designed to assess participants' responses to traumatic experiences encountered in daily lives. the severity of ptsd symptoms was measured using a fivepoint likert scale. the total score range from to , with higher score indicates more serious symptomatological ptsd and participants with a cut-off score of or higher were diagnosed with ptsd symptoms (grubaugh et al., ) . this scale was widely used to evaluate symptomatic ptsd of chinese adolescents, with high reliability and validity (yang et al., ). an early study using this threshold reported cronbach's alpha of the whole scale was . (zhou et al., ) . in this study, the cronbach's alpha of pcl-c was . . the general health questionnaire scale. the psychological distress was measured using the general health questionnaire (ghq- ) (goldberg et al., ) , which contains items assessing participant's mental health. it uses a four-point likert scale, which higher score indicates higher degree of disturbance in the mind. the questionnaire has been proven with great reliability and validity, and it is commonly used by different chinese research (fares et al., ) . previous research has shown that the ghq- coefficients ranged from . to . (arnberg et al., ; yusoff et al., ) . in the present study, the cronbach's alpha of ghq- was . . simplified copying style questionnaire. the simplified coping style questionnaire (scsq) (xie, ) was a -item self-report scale, including two sub-scales: positive coping ( items) and negative coping (eight items). each item options ranged from (never) to (very frequently), and the scores on corresponding sub-scale indicates the level of coping strategy everyone possesses, this study selects the subscale of negative coping style in this questionnaire. previous study has showed that the cronbach's alpha of negative coping was . (lin et al., ) . in the present study, the cronbach's alpha of negative coping was . . in this study, we conducted a descriptive analysis to describe the basic sociodemographic characteristics of participants, and a correlation analysis to verify the relationship between variables. we also used multiple linear regression analysis via spss . (ibm corp) and a process macro to tests the mediating effect of ncs and the moderating effect of gender between psychological distress and ptsd. finally, this study conducted % bootstrap confidence intervals (ci) based on bootstrapped samples, with the effects being significant when the results did not include zero. a significance level of p < . was used for all variables. as the result, the demographic characteristics of participants are shown in table this study used multiple liner regression analysis (baron and kenny, ) to test whether ncs mediate the association between the psychological distress and ptsd. in this study, the direct path coefficient from the psychological distress to ptsd was significant (b = . , β = . , p < . ), and the psychological distress was also significantly associated with ncs (b = . , β = . , p < . ). when we considered both the psychological distress and ncs as predictors of ptsd in the regression model, the path coefficients of the psychological distress on ptsd remained significant (b = . , β = . , p < . ). in addition, we used the process macro (model ) in spss and perform the bootstrap method to test the indirect effect (preacher and hayes, ) . the results indicated that the psychological distress on ptsd through ncs was significant ( % ci = [ . , . ]; excluding ). thus, this study indicated that ncs mediated the association between psychological distress and ptsd. before examining the moderated mediation analysis, all the variables were mean centered to minimize multicollinearity. table showed the detailed results. in model , the psychological distress was positively related to ptsd (β = . , p < . ). gender did not relate to ptsd (β = - . , p > . ), but the interaction term between the psychological distress and gender was positively related to ptsd (β = - . , p < . ), which indicated that gender could moderate the association between psychological distress and ptsd. in model , the main effect of psychological distress on ncs was significant (β = . , p < . ), but this effect could not be moderated by the gender (β = - . , p > . ). in model , the main effect of ncs on ptsd was significant (β = . , p < . ), however, this effect could not be moderated by the gender (β = - . , p > . ). simple slope analyses were used to further analyze the moderate effect of gender on the relationship between psychological distress and ptsd (see figure ). the results indicated that psychological distress can be significantly associated with ptsd in males (β simple = . , t = . , p < . ) and females (β simple = . , t = . , p < . ). the effect of psychological distress on ptsd was higher in males than females. in addition, this study conducted the process macro method (model ) to further analyze the moderation mediation, which was able to verify the above assumptions. the index of moderated mediation was - . (se = . , %ci = [- . , - . ]). analysis of the moderation effect indicated that this path was significantly for males ( % ci = [ . , . ]; excluding ) and females gender was coded so that = male and = female. *p < . ; **p < . . ( % ci = [ . , . ]; excluding ), which tested the above assumption. in this study, we found that within month after the occurrence of covid- outbreak in china, the prevalence of ptsd was . %, which was lower than a cross-sectional study of the prevalence of ptsd ( . %) month after the earthquake in chengdu, sichuan province, china (lau et al., ) and also lower than ptsd ( %) reported by sars patients months after discharge (kwek et al., ) . however, in a -year follow-up study of discharged sars patients, the result shows the reported cases of ptsd was . % among all patients (hong et al., ) . and in a report from italy, the prevalence of ptsd years after the earthquake is only . % (priebe et al., ) . the above differences in ptsd prevalence after a traumatic event may be due to the differences in research methods, culture, type and severity of the disaster, time interval measured after the disaster and diagnostic criteria (liu et al., ) . in addition, a systematic review demonstrated that the ptsd rate declined after disaster , but studies also pointed out that adolescents affected by traumatic events were prone to invasive thoughts such as sleep disorders, nightmares, and separation anxiety (yule, ) . thus, this emphasizes that . . . f . *** . ** . *** *p < . ; **p < . ; ***p < . . relevant government agencies should take measures aimed at the mental health of youths as soon as a public health emergency occurs. in addition, related preventive and clinical measures should also be applied to prevent and treat the damage of covid- to participants' health. a recent study suggested that covid- can cause nervous system damage (wu et al., ) , and also indicated that the negative mental states (such as depression and anxiety) are relate to changes in the immune system (rajkumar, ) . thus, from the perspective of psychoneuroimmunology, the immune system can be improved by eliminating daily psychological distress, maintaining good sleep quality, balancing nutrition intake, keeping a healthy lifestyle and exercising regularly. as the result, if people have strong immune systems, it can reduce the risk of covid- infection (kim and su, ; matias et al., ; ng et al., ) . also, this study provides references that are significant for relevant clinical researches, and they can help psychiatrists to effectively identify the groups with mental health issues due to the covid- outbreak (zhou et al., ) . after picking out people in need, psychological professionals can provide remote services like telephone and internet, which can speed up the development of technologies along the way, such as electronic consent forms and telemedicine (smith et al., ) . as expected, the effect of psychological distress on ptsd was mediated by ncs, which supported the initial hypothesis. in the study, the mediation analysis indicates that psychologically distressed adolescents are more likely to engage in negative coping strategies, which ultimately lead to ptsd (vlahov et al., ) . in addition, traumatic experiences cause people to experience more negative emotions, which in turn results in ptsd (quan et al., ) . people overwhelmed with negative emotions tend to choose negative behaviors like self-blame or avoid problems (xiang et al., ) , this may be because negative emotions have been theorized as an obstacle mechanism to affect ncs (folkman and lazarus, ) . such actions can further weaken people's capability to deal with psychological distresses, which will eventually lead to mental illnesses like ptsd (d'amico et al., ) . moreover, studies have also shown that the symptoms of ptsd and psychological distress have overlapping characteristics (hurlocker et al., ) , sharing common characteristics such as inattention, hypervigilance, and emotional disorders (pacella et al., ) , in which may be because the related symptoms didn't occur in isolation (borsboom and cramer, ) . therefore, these results may help psychiatrists and psychologists to develop or take interventions that target specific symptoms of this relationship. when a public health emergency occurs, the local government should immediately provide relevant psychological interventions to help young people overcome negative emotional experiences, because early psychological interventions can help reduce the prevalence of ptsd (zhou et al., ) . on the other hand, during the covid- outbreak, the government and other relevant agencies should encourage adolescents to take active coping styles, enhance their ability of learning from difficult situations and actively seek help from others who can protect them from ptsd (liu et al., ) . our study indicated that gender played a moderating role in the direct effect between the psychological distress and ptsd, which supported the hypothesis. with the increase of psychological distress, the prevalence of women ptsd increased significantly, but the prevalence of men ptsd increase more. from a biological perspective, gender is an important biological determinant of the vulnerability of psychological distress, and gender differences have been identified in the brains' activation of stress. this may be because by examine the brain activity in response to physiological stresses, significant differences appear between men and women. when people try to cope with psychological distress, the activities of prefrontal lobe in males' brains are asymmetric, meanwhile, the activities are mainly focus on limbic system for females. in brief, the results show men and women will choose different actions and coping strategies in response to when people try to cope with psychological distress (wang et al., ) . the reason may also be caused by the different coping styles during the study time, or it may be because women are more likely to show symptoms during emergencies, which can effectively reduce the chance of get ptsd (du et al., ) . in addition, social expectations related to gender roles may lead to differences (tolin and foa, ) . in china, there may be such a basic rule that men are normally perceived as powerful figures who are dominant in status and rights (chen et al., ) , but this social trend may also bring more psychological distresses to men. during the occurrence of covid- , the chinese government has implemented the strictest prevention and control measures, people need isolation at home to prevent infection, on the other hand, adult males will experience more psychological distress due to increasing financial pressures and loss of job opportunities. such high stress situations can increase chances of getting ptsd in males. therefore, this study suggests that corresponding measures should be taken based on the gender differences in the ptsd. certain limitations of this study should be recognized. we examined only general psychopathology using the ghq- rather than a specific mental health problem (such as depression and fear). our study used a cross-sectional design, which cannot provide strong evidence for causality. thus, further research should use a longitudinal design. in addition, our study is limited by sample size. in order to get more detailed results, larger and more universal sample groups are needed. this study was conducted within month of the covid- emergency in china. in this study, . % of participants were diagnosed with ptsd, which indicates the significance of the public health emergency. government and other relevant agencies must take swift and systematic action to improve the mental health of youth. this study found that general mental health can be affected by ptsd through ncs, highlighting the moderating effect of gender on this association. the prevalence of ptsd in women increased significantly with psychological distress, but the prevalence of men ptsd increased even more. this study provides a reference for formulating psychological intervention measures to improve people's mental health and psychological adaptability during the occurrence of covid- and any similar pandemics in the future. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was funded by international innovation team of jilin university ( gjtd ); research plan of youth development in jilin province-the effect of covid- on adolescent mental health ( jqy- ); research on the problems of covid- of jilin university ( xgzx ). leilei liang https://orcid.org/ - - - violent assault, posttraumatic stress disorder, and depression-risk factors for cigarette use among adult women social support moderates posttraumatic stress and general distress after disaster the moderatormediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations network analysis: an integrative approach to the structure of psychopathology systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak psychosocial sequelae of the newcastle earthquake: i. community disaster experiences and psychological morbidity months post-disaster assessment of prevalence and determinants of posttraumatic stress disorder and depression symptoms in adults survivors of earthquake in haiti after months mental health care for medical staff in china during the covid- outbreak ambivalent sexism and power-related gender-role ideology in marriage the incidence of post-traumatic stress disorder among survivors after earthquakes: a systematic review and meta-analysis perceived self-efficacy and coping styles related to stressful critical life events full and partial ptsd among young adult survivors months after the l'aquila earthquake: gender differences posttraumatic reactions to an earthquake: multidimensional scaling profile analysis of adolescent survivors epidemiology of psychological distress. mental illnesses-understanding the prevalence of posttraumatic stress in adolescents eight years after the wenchuan earthquake risk for transportation coronavirus disease from wuhan to other cities in china coping as a mediator of emotion extracurricular activities associated with stress and burnout in preclinical medical students posttraumatic stress disorder: a serious postearthquake complication the validity of two versions of the ghq in the who study of mental illness in general health care differential effect of hurricane sandy exposure on ptsd symptom severity: comparison of community members and responders frueh screening for ptsd in public-sector mental health settings: the diagnostic utility of the ptsd checklist coping style and posttraumatic growth among adult survivors years after the wenchuan earthquake in china a cross-sectional study of psychological distress, burnout, and the associated risk factors in hospital pharmacists in japan the threat of biological weapons. prophylaxis and mitigation of psychological and social consequences posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a -year follow-up study clinical features of patients infected with novel coronavirus in wuhan, china examining the latent structure mechanisms for comorbid posttraumatic stress disorder and major depressive disorder the mental health of medical workers in wuhan, china dealing with the novel coronavirus using psychoneuroimmunity against covid- . brain, behavior, and immunity. epub ahead of print what are the determinants of post-traumatic stress disorder: age, gender, ethnicity or other? evidence from wenchuan earthquake quality of life and psychological status in survivors of severe acute respiratory syndrome at months postdischarge psychological distress among adolescents in chengdu sichuan earthquake the effect of covid- on youth mental health. psychiatric quarterly. epub ahead of print the psychological effect of severe acute respiratory syndrome on emergency department staff perceived stressfulness mediates the effects of subjective social support and negative coping style on suicide risk in chinese patients with major depressive disorder post-traumatic stress disorder and its predictors among bereaved tibetan adolescents four years after the yushu earthquake: a cross-sectional survey in china post-traumatic stress disorder and it's predictors among tibetan adolescents years after the high-altitude earthquake in china risk factors for chronic post-traumatic stress disorder (ptsd) in sars survivors journal of health psychology. epub ahead of print prevalence and sources of stress among universiti sains malaysia medical students il- β, il- , tnf-α and crp in elderly patients with depression or alzheimer's disease: systematic review and meta-analysis psychological effects of biological warfare the relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress the physical health consequences of ptsd and ptsd symptoms: a meta-analytic review social support, discrimination, and coping as predictors of posttraumatic stress reactions in youth survivors of hurricane katrina marked increase in substance use among young people after l'aquila earthquake asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models mental disorders, psychological symptoms and quality of life years after an earthquake: findings from a community sample in italy prevalence and predictors of posttraumatic stress disorder and depression among adolescents over year after the jiuzhaigou earthquake traumatic exposure and posttraumatic stress disorder among flood victims: testing a multiple mediating model ayurveda and covid- : where psychoneuroimmunology and the meaning response meet. brain, behavior, and immunity. epub ahead of print brain structural changes as vulnerability factors and acquired signs of post-earthquake stress covid- and mental health: a transformational opportunity to apply an evidence-based approach to clinical practice and research sex differences in trauma and posttraumatic stress disorder: a quantitative review of years of research increased use of cigarettes, alcohol, and marijuana among manhattan immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china gender difference in neural response to psychological stress rumination mediates the relationships of fear and guilt to posttraumatic stress disorder and posttraumatic growth among adolescents after the ya'an earthquake psychological assistance during the coronavirus disease outbreak in china the ptsd checklist: reliability, validity, and diagnostic utility emergency committee regarding the outbreak of novel coronavirus ( -ncov) nervous system involvement after infection with covid- and other coronaviruses. brain, behavior, and immunity. epub ahead of print post-traumatic stress disorder and the role of resilience, social support, anxiety and depression after the jiuzhaigou earthquake: a structural equation model relationships among personality, coping style, and negative emotional response in earthquake survivors the initial exploration of reliability and validity of simplified coping styles questionnaire the association between exposure and psychological health in earthquake survivors from the longmen shan fault area: the mediating effect of risk perception the research on the reliability and validity of pcl-c and influence factors risk appraisal when disaster strikes-the need to be "wise before the event": crisis intervention with children and adolescents covid- pandemic as a watershed moment: a call for systematic psychological health care for frontline medical staff life events, coping, and posttraumatic stress symptoms among chinese adolescents exposed to wenchuan earthquake, china prevalence and risk factors of post-traumatic stress disorder among adult survivors six months after the wenchuan earthquake risk factors of severity of post-traumatic stress disorder among survivors with physical disabilities one year after the wenchuan earthquake the author wish to thank his collaborators for their contribution to this study. key: cord- -lrk ty authors: mohammed, abdulaziz; sheikh, taiwo lateef; gidado, saheed; poggensee, gabriele; nguku, patrick; olayinka, adebola; ohuabunwo, chima; waziri, ndadilnasiya; shuaib, faisal; adeyemi, joseph; uzoma, ogbonna; ahmed, abubakar; doherty, funmi; nyanti, sarah beysolow; nzuki, charles kyalo; nasidi, abdulsalami; oyemakinde, akin; oguntimehin, olukayode; abdus-salam, ismail adeshina; obiako, reginald o. title: an evaluation of psychological distress and social support of survivors and contacts of ebola virus disease infection and their relatives in lagos, nigeria: a cross sectional study − date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: lrk ty background: by september , an outbreak of ebola viral disease (evd) in west african countries of guinea, liberia, sierra leone, senegal and nigeria, had recorded over and probable or confirmed cases and deaths respectively. evd, an emerging infectious disease, can create fear and panic among patients, contacts and relatives, which could be a risk factor for psychological distress. psychological distress among this subgroup could have public health implication for control of evd, because of potential effects on patient management and contact tracing. we determined the prevalence, pattern and factors associated with psychological distress among survivors and contacts of evd and their relatives. methods: in a descriptive cross sectional study, we used general health questionnaire to assess psychological distress and oslo social support scale to assess social support among participants who survived evd, listed as evd contacts or their relatives at ebola emergency operation center in lagos, nigeria. factors associated with psychological distress were determined using chi square/odds ratio and adjusted odds ratio. results: the mean age and standard deviation of participants was +/ - . years. of participants, ( . %) were females, ( . %) had a tertiary education and ( . %) were health workers. most frequently occurring psychological distress were inability to concentrate ( . %) and loss of sleep over worry ( . %). losing a relation to evd outbreak (or = . , % ci, . – . ) was significantly associated with feeling unhappy or depressed while being a health worker was protective (or = . , % ci, . – . ). adjusted odds ratio (aor) showed losing a relation (aor = . , % ci, . – . ) was a predictor of “feeling unhappy or depressed”, loss of a relation (aor = . , % ci, . – . ) was a predictor of inability to concentrate. conclusions: survivors and contacts of evd and their relations develop psychological distress. development of psychological distress could be predicted by loss of family member. it is recommended that psychiatrists and other mental health specialists be part of case management teams. the clinical teams managing evd patients should be trained on recognition of common psychological distress among patients. a mental health specialist should review contacts being monitored for evd for psychological distress or disorders. the west african outbreak of ebola virus disease (evd) began in guinea in december [ ] . the outbreak involved sustained transmission in guinea, liberia, and sierra leone [ ] . by september , , the total number of probable and confirmed cases was , with deaths recorded from five countries in west africa namely, guinea, liberia, nigeria, senegal, and sierra leone [ ] . the first known case of evd was reported in nigeria on th july , through a man who travelled to lagos, nigeria, via lomé, togo and accra, ghana [ ] . as of th september , the total number of confirmed evd cases in nigeria was ( in lagos and in port harcourt) of which had survived and seven reported dead. four hundred and seventy contacts had completed days of follow up necessary to rule out evd infection. the news of evd spread into nigeria created widespread media attention, which initially focused mainly on the high infectivity and case fatality, with the potential to create fear and panic. also, the process of infection control and prevention necessary for the control of emerging infectious disease (eid) like evd involves the use of personal protective equipment, quarantine, and isolation [ ] , all of which may be associated with fear and anxiety. public apprehension of newly detected emerging infectious disease with high morbidity and mortality had been previously described. joffe et al. [ ] described pattern of public response to emerging infectious diseases like evd. this general public response pattern includes distancing the disease from self, blame of particular entities for the disease's origin and/or spread, and stigmatization of those who have contracted it and/or who are represented as having intensified its spread. the process may be driven by worry, fear and anxiety, which necessitate a psychosocial intervention as part of all outbreak response to eids like evd. in a study to assess the psychological impact of the outbreak of severe acute respiratory syndrome on hospital employees, about % of the respondents had experienced high levels of post-traumatic stress symptoms [ ] . researches conducted during evd outbreaks tend to focus on clinical manifestations and epidemiology of evd with little or no study on psychosocial impact or distress associated with evd. a study in democratic republic of congo described the feelings and experiences of survivors of ebola epidemic [ ] . they described psychosocial consequences among survivors to include fear of falling seriously ill, denial, fear of being accused by neighbors and shame. others included rejection by society, belief that the infection was a divine punishment, lack of income, and intense grief for colleagues who did not survive the epidemic. the previous study did not include use of a standardized instrument for evaluation of psychological distress and social support available to the respondents. no previous study that employed the use of standardized instruments like ghq or oss to measure psychological distress or social support among survivors and contacts of evd or their relatives was found after a literature review. we set out to determine the prevalence and pattern of psychological distress among the survivors, relatives and contacts of evd. we also assessed the social support available for the survivors, relatives and contacts of evd. finally, we determined factors associated with psychological distress. the study was conducted in lagos state. lagos state is located in the southwestern part of nigeria and has an estimated land area of km ( sq ml). the metropolitan area consists of islands, such as lagos island and extension into the adjacent mainland. the lagos international airport is the busiest of all the international airports in nigeria [ ] . we conducted a descriptive cross sectional study. the study population consisted of persons listed as survivors and contacts by the emergency operations center (eoc) for evd in lagos and a first-degree relation judged to be the primary care giver by the evd patient or contact. inclusion criteria survivors . persons confirmed as a case of evd in the present outbreak response and had been managed in the isolation ward of the response. . persons confirmed cured and discharged from isolation ward by case management team. persons determined by the contact tracing team to have been a contact of a known confirmed case of evd using standard protocol [ ] . . contacts who are being actively followed up or had completed the follow up period. . must be a first-degree relation (father, mother, spouse, child or sibling) who was adjudged to have actively supported the survivor during case management or contacts during contact tracing. . not currently living in lagos. we estimated that by interviewing a third of survivors and contacts in the line list of the contact tracing team as at the time of the evaluation and their relatives, we will be able to achieve the minimum sample size of calculated using the leslie and kish formula [ ] for estimating sample size for cross-sectional study. where: n = minimum sample size zα set at % significant level = . p = estimates of proportion of study population with psychological distress. we used the prevalence of % ( . ) psychological consequences of severe acute respiratory syndrome (similar eid to evd) among hospital workers in china. the calculated sample size was . the calculated sample size was adjusted for small population size (n = ) using the formula for finite population correction. where: n f = the desired sample size when population is less than , n = the desired sample size when the population is more than , n = the estimate of the evd survivors and contact or their relations ( ) as at the time of study for this study we targeted respondents we randomly selected the contacts for the study using the contact tracing team line list of all contacts with over people listed during the duration of the study. of the eight cases listed as survivors during the time of study, four were interviewed during the study period. for every contact or survivor selected for the study, we attempted to interview a first-degree relation (spouse, parent, child or full sibling) identified by the survivor/contact, if available and also meeting the case definition for a relation. we designed a socio-demographic questionnaire to collect information on the respondents' age, gender, marital status, local government area (lga) of residence, and level of education. we also asked if respondents had loss a relation due to the evd outbreak. the general health questionnaire -item version (ghq ) was used to assess psychological distress among the study participants. the general health questionnaire (ghq) is a screening questionnaire, designed for screening individuals with a diagnosable psychiatric disorder [ ] . the ghq does not generate specific psychiatric diagnosis but rather screens for individuals with possible disorders. in its original version, it had items (ghq- ), which were reduced to (ghq- ), and items (ghq- ) [ ] . the -item general health questionnaire (ghq- ) is the most extensively used screening instrument for common mental disorders in addition to being a more general measure of psychological wellbeing. the psychometric properties of ghq have been evaluated in several studies [ , ] . the oslo social support scale (oss) was used to assess patients' social support base during the period. the oslo -item social support scale provides a brief measure of social functioning and has been considered a good predictor of mental health [ ] . it covers different fields of social support, as it measures the number of people the respondent feels close to, the interest and concern shown by others, and ease of obtaining practical help. the oslo social support scale had been validated in nigeria [ ] . respondents who answered "difficult" or "very difficult" to the question "how easy can you get help from neighbors?" were defined as having difficulty getting help from neighbors during need. respondents who answered "none" or " - " to the question "how many people are close to you that you can count on if you have serious problems?" were defined as having less than people who they can count on for help for serious problem. finally those who answered "no", "little", or "uncertain" to the question "how much concern do people show in what you are doing", were defined as having people showing little concern in what they are doing. due to the interest in the pattern of psychological distress and social support among the respondents we analyzed each variable in the ghq and oss separately instead of using aggregate scores we recruited five resident doctors of the nigerian field epidemiology and laboratory training program [ ] as data collectors, who were part of the contact tracing team and had extensive experience with data collection from prior activities. they were trained for a period of days on the use of the study questionnaires and interview techniques prior to the onset of the study. data collection took place over a period of weeks and the average duration of each interview was min. data were entered into epi info . . , cleaned and edited for inconsistencies before analysis. we summarized our findings using frequencies, means (with standard deviation) and proportions. we used odds ratio (or) with % confidence interval ( % ci) to check for statistically significant associations and unconditional logistic regression to check for independent predictors of psychological distress. the evaluation was part of the evd outbreak response and was therefore exempted from ethical clearance by the evd emergency operation center in lagos. the evd emergency operation center however read and cleared the protocol before onset of the study. written informed consent was obtained from each participant after complete description of the study. as part of the response to evd, all the contacts, relatives and survivors who reported or had noticeable distress irrespective of whether they were part of this study or not, had access to counseling and other forms of treatment from the members of the psychosocial subgroup of the clinical management team. those found to have clinically significant psychological morbidity were counseled and all assessed to require specialist care were referred to the neuropsychiatric hospital, lagos. a total of interviews were conducted, of which three were disqualified because the interviews were not completed. the mean age of participants was +/ - . years, age range - years. of the participants, four ( . %) were survivors, ( . %) were contacts, ( . %) were contact relations and one ( . %) was a survivor relation (table ) . two thirds of the participants were females and ( . %) had a tertiary education. forty-five ( . %) were health workers and about half ( . %) resided in eti-osa local government area (lga) of lagos state ( table ) . the most frequently occurring psychological distress among all respondents were "not been able to concentrate on what you are doing" ( . %) and "lost much sleep over worry" ( . %). the least occurring psychological distress was "been thinking of yourself as worthless" ( . %). "not been able to concentrate on what you are doing" and "lost much sleep over worry" were the most frequently occurring psychological distress among survivors ( % and %, respectively) and among contacts ( . and . % respectively). only ( . %) of the participants reported "can count on less than people for help for serious problem" ( table ) . losing a relation to the evd outbreak (or = . , % ci, . - . ) was significantly associated with the psychological distress of "feeling unhappy or depressed" while being a health worker (or = . , % ci, . - . ) was protective. having no tertiary education (or = . , % ci, . - . ) was significantly protective against "not been able to concentrate", while living in eti-osa lga (or = . , % ci, . - . ) was significantly associated with "not feeling reasonable happy". all the four survivors reported they had, "not been able to concentrate" (table ) . losing a relation (aor = . , % ci, . - . ) remained an independent predictor of the psychological distress of "feeling unhappy or depressed". loss of a relation (aor = . , % ci, . - . ) remained an independent predictor of the psychological distress of "not been able to concentrate" while having no tertiary education (aor = . , % ci, . - . ) remained a protective factor against "not been able to concentrate" (table ). the most frequently occurring psychological distress among the respondents: inability to concentrate, losing much sleep over worry and being unhappy or depressed are key clinical features of anxiety, depression and post traumatic stress disorders (ptsd) as described in the diagnostic and statistical manual (dsm) of mental disorders [ ] . though the individual psychological distress does not amount to a neuropsychiatric disorder, it does indicate the presence of some psychological distress among the respondents that may have the potential to progress if not properly managed. evd can be perceived as a life-threatening event that meets a key diagnostic criterion of ptsd in dsm [ ] . the development of ptsd following life-threatening event has been demonstrated among nigerians [ ] and among health workers who had contact with severe acute respiratory syndrome (sars) [ ] . other less severe disorders caused by reaction to extremely stressful situations such as acute stress reaction and adjustment disorders could also present with the above psychological distress. the psychological distress of being unable to concentrate could be mistaken for cognitive impairment by the clinical management team if it occurs in a patient with evd, could be confused for viral encephalopathy or onset of brain damage secondary to evd infection. a case of adjustment disorder, in a survivor of the nigerian evd outbreak, initially diagnosed as having brain damage secondary to viral encephalitis is an example [ ] . losing a relation during this evd outbreak was significantly associated with being unhappy or depressed. this could be dismissed as a usual response to bereavement in people, but the feelings of depression (whether from normal grief or psychopathological) could have implication for the management of patients with evd or for the contact tracing team while monitoring contacts for clinical manifestation of evd. it could affect judgment and thus reduce cooperation with either the clinical management team or contact tracing team. feelings of depression could also cause patients or contacts of evd to tolerate emerging symptoms of evd thereby not reporting them to the management team. this could people show little or no concern in what you are doing ( . ) ( . ) ( . ) ( . ) complicate overall clinical impression of the patient or cause problems with determining the exact time of onset of clinical symptoms. the effect of an evd contact, with feelings of depression, failing to disclose important clinical symptoms may lead to delayed or failed recognition of evd onset with far reaching public health importance. the psychological stress of bereavement can mimic severe depression but also bereavement has long been described as a risk factor for development of depression [ ] . furthermore, it has been suggested that risk factors for common mental health problems arising from the evd outbreak such as witnessing and caring for individuals who are severely ill, perceived life threat, substantial mortality and bereavement, and the deaths of trained health care workers, in conjunction with the lack of well-trained mental health professionals in countries experiencing evd outbreak in west africa could amplify the risks of developing enduring psychological distress and progression to psychopathology by those affected [ ] . although the psychological distress the extensive social support base of the nigerian community, which is not limited to the immediate family members, may have helped the social support respondents had. poor social support was only a problem to less than a quarter of the respondents. this may have been due to the relatives not being aware of what the respondents were going through. overall, only few of the respondents demonstrated poor social support, respondents who had little or no interest shown in their activities were more likely to lack self-confidence. having no tertiary education, which was protective of inability to concentrate, may not be an entirely positive finding because it could reflect the lack of insight into the implication of an infection with evd by those without tertiary education. the study found loss of a relation to be an independent predictor of feelings of unhappiness or depression and inability to concentrate. contacts or survivors who have lost close relations should be considered at high risk of developing psychological distress or even psychological disorders. loss of a relation is a traumatic experience that has been shown to be a predictor of ptsd [ ] and depression [ ] among persons exposed to traumatic experience in nigeria. therefore the psychosocial response team for evd outbreak should prioritize this subgroup of contacts and survivors for special monitoring and evaluation. the contact tracing teams following up this subgroup of contacts should include a member of the psychosocial response team with training in detection of psychological distress/disorders. the findings of this study are subject to the following limitations. we only assessed for psychological distress and not disorders. only few survivors were sampled which limited the ability to independently look at the dynamics of psychological distress among them. the evaluation could not interview the anticipated number of relatives because some of the contacts did not inform their immediate family members about their status as evd contacts and therefore could not be interviewed. despite these limitations, we are confident the findings of this study reflect the possible psychological distress following being a survivor or contact of evd or a relation to any. we concluded that survivors and contacts of evd or their relatives develop psychological distress that could be predicted by loss of a relation and recommended that mental health specialists and social workers be part of the case management team of the response to evd outbreak. the clinical teams managing evd patients should be trained on recognition of psychological distress among the patients and recognition of common psychiatric disorders like depression that could follow evd infection, and special attention should be paid to those who have lost a relation. we also recommended the follow up of all survivors/contacts with increased risk of developing psychological distress or disorders for a minimum period of months by a mental health specialist for early detection of mental health disorders following evd. the findings of this study were shared with the ebola emergency operation center in lagos and the main findings were equally presented to the meeting of the association of psychiatrists and allied professionals in nigeria. nigerian center for disease control, abuja, nigeria. lagos state ministry of health, lagos, nigeria. department of medicine, ahmadu bello university, zaria, nigeria. emergence of zaire ebola virus disease in guinea -preliminary report ebola -underscoring the global disparities in health care resources who ebola response team. ebola virus disease in west africa -the first months of the epidemic and forward projections who. ebola situation in port harcourt, nigeriano title infection prevention and control recommendations for hospitalized patients with known or suspected ebola hemorrhagic fever public apprehension of emerging infectious diseases: are changes afoot? the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk survey among survivors of the ebola epidemic in kikwit, democratic republic of congo: their feelings and experiences muhammed international airport contact tracing during an outbreak of ebola virus disease survey sampling a scaled version of the general health questionnaire using the -item general health questionnaire (ghq- ) to assess the psychological health of malaysian college students the -item general health questionnaire (ghq- ): reliability, external validity and factor structure in the spanish population is the gds- better than the ghq- for screening depression in elderly people in the community? the bambui health aging study (bhas) social support -consequences for individual and society psychometric properties of the -item oslo social support scale among clinical students of bayero university kano nfeltp involvement in ebola response in nigeria american psychiatric association. diagnostic and statistical manual of mental disorders psycho-trauma, psychosocial adjustment, and symptomatic post-traumatic stress disorder among internally displaced persons in kaduna psychiatric treatment of a health care worker after infection with ebola virus in lagos, nigeria a meta-analysis of risk factors for depression in adults and children after natural disasters the ebola outbreak and mental health: current status and recommended response correlates of depression among internally displaced persons after postelection violence in kaduna, north western nigeria submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution submit your manuscript at www the authors declare that they have no competing interests.authors' contributions am conceived the study and developed the initial and subsequent drafts. key: cord- -whn c authors: rooney, l.; mcnicholas, f. title: ‘policing’ a pandemic: garda wellbeing and covid- date: - - journal: irish journal of psychological medicine doi: . /ipm. . sha: doc_id: cord_uid: whn c in response to the global pandemic covid- , the irish government has called upon the garda síochána to implement an unparalleled mode of policing to mitigate and contain the spread of the coronavirus. studies investigating smaller scale epidemics, such as severe acute respiratory syndrome (sars), indicate that staff at the frontlines of an outbreak are exposed to an insuperable amount of stress and experience increased psychological morbidities as a result. furthermore, research not only indicates that heighted levels of psychological distress are an occupational hazard associated with the law enforcement profession, but that members of the garda síochána feel their mental health needs are largely unmet by their organisation. given the pandemic’s propensity to expose officers to indeterminate echelons of physical and psychological threat; there has never been a more appropriate time to explore the potential burdens associated with ‘policing’ a pandemic, question the governments capacity to address the psychological support needs of frontline professionals, and plan future research for best practice. the duties of the garda síochána stretch far beyond 'traditional' modes of policing, such as solving crime and law enforcement. indeed, a considerable amount of their time is spent implementing harm reduction measures which aim to protect vulnerable members of the community, specifically, individuals with mental health and addiction issues, homeless people, children, and the elderly (conway, ; mental health commission & an garda síochána, ). in the wake of the covid- pandemic, the irish government has called upon garda members to impose a unique mode of harm reduction and 'police' for the spread of a fatal pandemic. with an entire population rendered vulnerable by covid- , this occasional piece seeks to explore the extraordinary mission the gardai síochána have been tasked, consider the potential burdens associated with it and make recommendations for future research and practice. the first case of covid- in the republic of ireland was confirmed on february , . almost weeks later, on march , the department of health reported the first coronavirus fatality. in the weeks that followed, the irish government implemented a series of public safety measures which aimed to contain virus spread. namely, on march , all schools, colleges and childcare facilities were closed. three days later, on march , the government requested that all pubs, clubs and entertainment venues close their doors. finally, after a period of steady increases in confirmed cases and fatalities, the country entered full lockdown on march under the advisement of the national public health emergency team. full lockdown required that people remain in their homes at all times, with the exception of the measures outlined in table . the garda síochána has been an integral cog in the government's response to the covid- crisis. the force has had to embrace a series of changes to their professional duties over a very short time frame. initially, system adjustments made by the garda síochána aimed to ensure their availability to assist vulnerable groups in the community. this restructure involved new roster arrangements, postponing retirements, allocating frontline duties to gardaí recruits, commissioning extra vehicles and establishing a specialist covid- unit (department of justice and equality, ; sheehy, ). however, a steady worsening of the problem necessitated a significant increase in public surveillance to keep people safe. specifically, in the lead up to the easter bank holiday weekend, government officials raised concerns that citizens might ignore lockdown measures to flock to popular tourist hotspots, beaches and holiday homes to enjoy a spell of fine weather. accordingly, the decision was made to increase garda powers and implement a graduated policing plan to shift social distancing measures from an informal (moral) practice to a formal (legal) one. on april , it was signed into law that any person in breach of government restrictions on movement would be committing an offence under section a of the health act of and could face a maximum of months in prison or a fine of € (gov.ie, b) . gardaí were given the power to direct people to comply with the new legislation, request the name and address of persons suspected of being in breach of lockdown guidelines, and three different powers of arrest. such legislative changes are quite novel in that gardaí will be operating under public health legislation and not criminal justice legislation as they usually do. as a result, garda visibility has ramped up considerably with garda members manning checkpoints on major roads across the country and patrolling cities, parks and beauty spots to ensure public compliance. as per the taoiseach, leo varadkar's, announcement on april , these measures will remain in place until the lockdown has been lifted, which remains unknown at this time (rte.ie, a). at the beginning of , it was unthinkable that the gardaí could send a person home just for walking outside a -km radius from their house. yet, despite the plethora of rapid changes to the nation's social freedoms, the majority of the public have complied with lockdown measures. this is evidenced by aerial photographs taken by the garda air support unit of empty streets, parks and tourist spots (meneely, ) , and energy consumption data to show that people are in fact staying at home (rte, b). however, media reports suggest that gardaí have been met with varying levels of resistance and threat when enforcing government restrictions on movement. such resistance has ranged from people ignoring lockdown regulations and embarking on non-essential travelto officers being spat and coughed at by members of the public (reynolds, ) . to keep officers safe from spit and cough assaults, frontline personnel have been issued with specialist personal protective equipment (ppe) known as 'spit hoods' along with other items, such as goggles, masks, gloves and antiseptic wipes (ibid). these heinous attacks on gardaí are extremely dangerous in terms of infection control and are likely very upsetting for those who have been targeted. thus, it is imperative that garda officials are mindful of other threats to officer wellbeing that can be equally arduous, but more covert in their manifestation, that of psychological distress. just as it has done with the general public, covid- has exposed the gardaí to a myriad of environmental stressors that have the potential to jeopardise their psychological wellbeing. however, the difference is that garda members not only put their physical health and mortality at risk when they go to work every day, but must do so whilst also having to cope with a new class of anxieties and responsibilities associated with 'policing' a pandemic. research investigating smaller scale epidemics, such as severe acute respiratory syndrome (sars), and emerging scholarship concerning covid- , demonstrates that the unequalled amount of stress experienced by essential staff working at the frontlines of the outbreak is associated with increased psychological morbidities (huang et al. ; tsamakis et al. ) . for instance, in the early stages of the sars outbreak, when virus spread was at its most rapid, healthcare professionals reported feelings of extreme vulnerability and uncertainty, a significant threat to life, and developed symptoms of anxiety (both somatic and cognitive) (huang et al. ; tsamakis et al. ) . current research exploring the experience of healthcare professionals dealing with covid- in china and greece details similar findings. frontline personnel report feeling overwhelmed by the potential to be scrutinised by the press, frustrated by uncooperative patients who resist adherence to safety instructions, and fear of contracting the virus themselves only to expose their loved ones (tsamakis et al. ) . prolonged use of ppe makes it difficult for workers to breathe, access water and use the toilet, causing additional physical and mental fatigue (chen et al. ; tsamakis et al. ) . furthermore, risks to the psychological wellbeing of frontline workers are further exacerbated by reports of ppe shortages and defective equipment (sim, ) . it is also worth noting that most of the scholarship in the area focuses on the experiences of healthcare professionals, whilst the . travel to and from work where the work is considered an essential service. . working in an essential shop, bank or post office. . buying food, medicines and other health products for yourself, your family or someone who is vulnerable or 'cocooning'. . attending medical appointments . vital family reasons including caring for children, elderly or vulnerable people but excluding social family visits. . exercise within km of your house. perspective of the police and other criminal justice professionals (i.e. prison officers, probation officers), heavily involved in the emergency response, has been largely overlooked. the absence of such commentary suggests a collective prioritisation by decision-makers, academics and the public to explore and improve supports for frontline staff with health-focused roles whilst failing to consider the needs of others such as law enforcement. moreover, the lack of a concerted effort to explore, understand and implement supports for criminal justice professionals during covid- means that many essential staff may be experiencing psychological difficulties that could worsen considerably if they remain undetected and untreated. the past couple of months has seen an upsurge in social media and newspaper coverage expressing the nation's justified gratitude to healthcare staff for their incredible courage and sacrifice amidst the covid- crisis. although a great deal of attention has also been given to increasing garda powers and the public response to these directives, there has been very little acknowledgement of the garda síochána's bravery or of the risk their job entails. the absence of such media homage suggests that the gardaí represent a group of frontline professionals whose heroism not only remains unsung, but whose contribution is perhaps taken for granted. media tributes are relevant to this discussion as research indicates that expressions of social support and gratitude help individuals to develop psychological resources that mitigate environmental stressors (eaton et al. ; glasgow et al. ). moreover, the link between gratitude and psychological wellbeing has also been identified amongst groups of first responders following terrorist attacks and natural disasters. for instance, research investigating police officer's ability to successfully adapt to stressors and maintain psychological wellbeing following hurricane katrina revealed that gratitude helped to alleviate symptoms of post-traumatic stress disorder (ptsd) (mccanlies et al. ) . similarly, strong feelings of gratitude were associated with lower levels of psychological distress amongst first responders following the terrorist attacks on september , (fredrickson et al. ) . given the minimal amount of media gratitude expressed to the garda síochána for their role in covid- , this research not only infers that officers are excluded access to certain sociocultural factors that mitigate environmental stressors but highlights an additional level of vulnerability that should be considered when developing support services for the gardaí. even in the absence of a global pandemic, police work is regarded as one of the most stressful occupations. as a result, it is associated with serious challenges to mental and emotional wellbeing (violanti & paton, ; liberman et al., ) . officers are not only exposed to the full gamut of social traumas (i.e. extreme poverty, addiction, violence, death and tragedy), but are forced to contemplate their own mortality when faced with potentially life-threatening situations (miller, ; bartol & bartol, ) . moreover, the death of a colleague in the line of duty is cited as by far the most 'psychologically destabilizing' experience for members of the force (henry, ; miller, : ) . research indicates that exposure to such occupational stressors can negatively impact the professional and personal lives of officers. for instance, when compared to other public servants, the police report elevated rates of alcohol misuse, divorce, anxiety and depression, suicide, and burnout (violanti & paton, ; tanigoshi, et al. ) . in recent years, the garda síochána has enhanced its psychological support services. in , the peer support program was established, which activates the deployment of a trained peer supporter to assist officers following a traumatic event. this was followed by the introduction of a confidential -hour counselling line in (oirachtas.ie ) . however, despite the implementation of these services, research indicates that garda members feel that these programmes are not only ill-equipped to meet their support needs, but that the delivery of these resources are both inconsistent and unreliable (fallon, ) . these sentiments are most acutely felt when it comes to debriefing officers following a traumatic event. for instance, one officer stated, 'i spent years in a busy dublin station and not once was i contacted by a welfare officer following traumatic incidents' (ibid: ). another commented 'far too much box ticking for services without real concern for the affected members welfare' (ibid: ). fallon concludes that 'an garda síochána is a cauldron for adversity in relation to trauma and wellbeing', with one in six officers potentially meeting criteria for ptsd, one in four experiencing significant levels of trauma-induced distress and impairment, and a high rate of completed suicide amongst its members (ibid: ). indeed, the implementation of support service's by the garda síochána is a step in the right direction in terms of promoting occupational mental health. however, the usefulness of these programmes must be called into question when personnel perceive them as tokenistic and are sceptical about their very existence. given the overwhelming body of evidence emphasizing the relationship between police work and impaired psychological health, coupled with domestic research to show that many of the gardaí are 'walking wounded'; it is imperative that garda officials begin to prioritise the psychological wellbeing of their members and provide them with the resources they deserve. 'policing' a pandemic the coronavirus has forced the gardaí síochána to take on an extraordinary mode of policing in the name of public safety and infection control. like many other essential workers, their position at the forefront of the pandemic could expose them to increased levels of death and trauma, not just amongst the general population but within their organisation. it is our position that there has never been a more fitting time to question the government's preparedness and capacity for meeting the psychological support needs of frontline criminal justice professionals whom we continue to rely on so heavily in this time of crisis. at baseline, the gardaí are exposed to an increased level of psychological distress. this is compounded by a perceived lack of support on behalf of the organisation when it comes to addressing matters of mental health and wellbeing (fallon, ) . although it is impossible to know the just how covid- will impact the physical and psychological health of the garda community, what is certain, is that officer wellness has never be more important than it is at this moment and in the weeks that follow. it is extremely unfortunate that very few, if any, interventions addressing the psychological support needs of frontline professionals in the midst of a global pandemic have been evaluated and deemed effective for use. however, a lack of evidence-based practice does not mean that nothing can be done to help and support essential staff. to best determine a way forward, policymakers and senior management can consult literature surrounding the provision of mental health support during natural disasters and national emergencies (see american red cross, ; world health organisation, ), along with broader theory and research regarding first responder occupational mental health and wellbeing. there is no shortage of scientific evidence identifying the significant role that psychological interventions play in helping the police cope with stress and trauma (see, chopko & schwartz, ; andersen et al., ; papazoglou & tuttle, ) . for instance, inquiries into the provision of urgent psychological support in the wake of a traumatic event attests to the benefits of critical incident stress management (cism) systems (flannery, ; everly et al. ; guenthner, ) . cism is defined as a 'formal, highly structured and professionally recognised process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referral for further help if required' (cism network ireland, ) . findings suggest that participants benefit from cism systems by developing a range of strategies that work to mitigate psychological distress and promote mental wellbeing (everly et al. ) . recent research investigating proactive training programmes specifically designed to help first responders cope with future critical incidents have also yielded promising results. for example, mindfulness-based resilience training has been shown to reduce perceived stress, depression, anxiety, disrupted sleep, burnout, selfreported anger and ptsd symptoms in police officers (christopher et al (christopher et al , grupe et al., ) . moving forward, the department of justice should strongly consider piloting and scaling up a cism system or similar programme, not just for garda members, but for all its personnel (i.e. prison officers, probation officers, legal counsel, etc). in the interim, to combat and protect the gardaí from psychological distress during the covid- pandemic, it is recommended that the force is reminded of the supports that are currently available to them (i.e. counselling support line, peer support program). more importantly, it is advised that a concerted effort is made by garda officials to ensure these supports are diligently implemented, fully operational and easily accessible so that they may be of benefit to those who may need them. finally, in the months that follow, it is important that government officials, decision-makers and scholars use covid- as an opportunity to collate experiential knowledge and insights from those working on the frontline (gardaí, healthcare professionals, shopkeepers, bank tellers, etc.). future research exploring the opportunities and challenges associated with maintaining mental health equilibrium and psychological wellbeing will help to identify occupational support needs, inform crucial policy and practice, and contribute to ireland's overall level of preparedness for future national emergencies. this article received no specific grant from any funding agency, commercial or not-for-profit sectors. knowledge and training regarding the link between trauma and health: a national survey of finnish police officers foundations of disaster mental health participant's workbook introduction to forensic psychology mental health care for medical staff in china during the covid- outbreak policing twentieth century ireland: a history of an garda síochána the relation between mindfulness and posttraumatic growth: a study of first responders to trauma-inducing incidents a pilot study evaluating the effectiveness of a mindfulness-based intervention on cortisol awakening response and health outcomes among law enforcement officers mindfulness-based resilience training to reduce health risk, stress reactivity, and aggression among law enforcement officers: a feasibility and preliminary efficacy trial what is critical incident stress management positive predispositions, quality of life and chronic illness critical incident stress management (cism): a review of the literature critical incident stress management (cism): a statistical review of the literature garda representative association wellbeing survey critical incident stress management and the assaulted staff action program what good are positive emotions in crises? a prospective study of resilience and emotions following the terrorist attacks on the united states on with your help : : : we begin to heal": social media expressions of gratitude in the aftermath of disaster public health measures in place until may to prevent spreading covid- minister for health simon harris signs regulations to give an garda síochána the power to enforce covid- restrictions mindfulness training reduces ptsd symptoms and other stress-related health outcomes in police officers emergency and crisis management: critical incident stress management for first responders and business organisations death work: police, trauma, and the psychology of survival psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital routine occupational stress and psychological distress in police positive psychological factors are associated with lower ptsd symptoms among police officers: post hurricane katrina not on covid camera: coronavirus in ireland -aerial snaps show irish beauty spots deserted as gardai say 'excellent lockdown compliance report of joint working group on mental health services and the police tough guys: psychotherapeutic strategies with law enforcement and emergency services personnel line-of-duty death: psychological treatment of traumatic bereavement in law enforcement garda support services: dáil Éireann debate accessed fighting police trauma: practical approaches to addressing psychological needs of officers accessed april, . rte.ie ( a).'taoiseach: 'every sacrifice we make is helping to save someone's life % reduction in energy consumption in holiday homes over easter break', rte news gardaí establish special covid- unit, rte news accessed the covid- pandemic: major risks to healthcare and other workers on the front line the effectiveness of individual wellness counseling on the wellness of law enforcement officers covid- pandemic and its impact on mental health of healthcare professionals police trauma: psychological aftermath of civilian combat the authors have no conflict of interest to disclose. the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the helsinki declaration of , as revised in . the authors assert that ethical approval was not required for publication of this manuscript. key: cord- - dne n authors: um min allah, nasar; arshad, sohaib; mahmood, hina; abbas, hina title: the psychological impact of coronavirus outbreak in pakistan date: - - journal: asia pac psychiatry doi: . /appy. sha: doc_id: cord_uid: dne n nan physical and psychological pressure including high risk of infection, insufficient protective gear from contagion, isolation, exhaustion, and lack of family contact. the intensity causes more mental health issues which not only impair the decision-making capacity of medical workers but may also have a negative impact on their overall wellbeing in the long term. healthcare conditions in pakistan are worsening on daily basis and therefore controlling the disease would require holistic thorough management on both physical and mental healthcare situation. quarantine is one component of communicable disease control and can be a necessary preventive measure (adams et al., ) . recent studies have shown that the psychological effects of quarantine may be huge, leading to a variety of mental health issues ranging from anxiety and frustration to sleep disruptions, depression and post-traumatic stress disorder (brooks et al., ; kang et al., ), yet the repercussions for the emotional well-being of people cannot be ignored. the first thing that gets adversely affected when we are facing a crisis is our emotional health and fear to combat it. as there are a small number of mental health professionals in our hospitals, it is important for all doctors, especially general practitioners and doctors of the emergency department, to constructively screen for psychological problems in patients coming for consultations. psychiatrists and mental health experts will be worth sitting in the covid- task force to advise on social and mental health initiatives and psychological intervention. in conclusion, it is not to say that quarantine or lockdown strategy should not be used; it may be worse for the psychological consequences of not taking timely measures and allowing the disease to spread (hawryluck et al., ) . government should proceed by informing people with the facts that what is happening and why, explaining how long it will last and ensuring essential supplies (such as food, etc.) and reinforcing the sense of altruism that people should, rightly, be feeling. if this extended lockdown or quarantine experience is negative, there could be long-term effects that impact not just the quarantined individuals, but also the health care system, policymakers and the public. bioethics and self-isolation: what about low-resource settings? the psychological impact of quarantine and how to reduce it: rapid review of the evidence sars control and psychological effects of quarantine the mental health of medical workers in wuhan the authors would like to thank zulfiqar ali qureshi for his valuable ideas and suggestions on this topic. the authors declare no conflicts of interest. key: cord- -qn i cdj authors: zheng, lei; miao, miao; gan, yiqun title: perceived control buffers the effects of the covid‐ pandemic on general health and life satisfaction: the mediating role of psychological distance date: - - journal: appl psychol health well being doi: . /aphw. sha: doc_id: cord_uid: qn i cdj background: ways to maintain good health during a pandemic are very important for the general population; however, little is known about the impact of the coronavirus disease (covid‐ ) on individuals’ life satisfaction and perceived general health. this study aimed to examine the effects of covid‐ on life satisfaction and perceived general health and reveal the buffering effect of perceived control on coping with covid‐ . methods: we collected , participants’ data from pandemic‐affected provinces in china and obtained regional epidemic data of the same provinces. we employed a moderated mediation model with both individuals’ self‐report data and regional epidemic data to verify the hypotheses. results: psychological distance mediated the relationships of regional pandemic severity with perceived general health and life satisfaction. perceived control moderated the detrimental effects of regional pandemic severity through the moderating effects of regional pandemic severity on psychological distance, as well as the moderating effects of psychological distance on life satisfaction. conclusions: our findings indicate that perceived control may act as a protective factor buffering the psychological impact of the pandemic on general health and life satisfaction. psychological distance can serve as a mediator that explains how the covid‐ pandemic impacts perceived general health and life satisfaction. the coronavirus disease has been rapidly spreading worldwide after it was first reported in wuhan, china, in december . in march , the world health organization (who) declared the disease a pandemic and that it was in phase , suggesting that the pandemic is a widespread human infection. as covid- spreads easily through ordinary human interactions, the pandemic is not only a serious threat to public health but also causes psychological changes in individuals (qiu et al., ) . thus, social-psychological assistance has been regarded as an important measure in the crisis governance of covid- in china (chen et al., ; duan & zhu, ) . however, compared to mental problems, maintaining positive psychological status, such as in perceiving general health and life satisfaction, is critical for people during the pandemic. surprisingly, it is unclear how the covid- pandemic is impacting people's perception of general health and life satisfaction, as well as how social-psychological protection against the pandemic can be provided. therefore, the present study aimed to address these issues by analysing integrated individual-level self-reported data and regional-level epidemic data in china. the negative psychological outcomes of the covid- pandemic have attracted considerable attention. one prominent aspect which has been widely studied is mental health (chen et al., ; duan & zhu, ; xu et al., ) . in fact, a pandemic often causes feelings of distress and anxiety, according to previous studies (bults et al., ; wong, gao, & tam, ) . in this pandemic, per cent of respondents reported psychological distress in a chinese national study (qiu et al., ) . therefore, researchers highlighted the public's urgent psychological needs during the pandemic (liu, zhang, & wang, ; pfefferbaum & north, ) . in contrast to psychological problems caused by the pandemic, there is scant knowledge regarding the positive psychological outcomes, which contributes to the development of a good life and building a well-functioning society (seligman, steen, park, & peterson, ) . for the general public, maintaining health and life satisfaction during a pandemic is very important. previous studies have revealed that the severe acute respiratory syndrome (sars) outbreak had a considerable impact on individuals' perceived general health and life satisfaction (lai, bond, & hui, ; lau et al., ; main, zhou, ma, luecken, & liu, ) . in fact, considering the importance of psychological intervention in the prevention and control of covid- (chen et al., ; duan & zhu, ; qiu et al., ) , it is extremely important to help people-especially those living in areas where the pandemic has spread-to cope with psychological changes. however, as the existing research has mainly focused on mental health issues resulting from the pandemic, more research exploring the psychological effects of the covid- pandemic on perceived general health and life satisfaction among residents of pandemic-hit regions is necessary. the psychological effects of a pandemic often vary across regions and the negative effects are stronger in regions that are severely affected than in those that are less affected. in particular, people residing in severely affected regions have reported high levels of anxiety and low levels of subjective well-being compared to individuals from more mildly affected regions (kim, ; lau et al., ; wong et al., ) . therefore, given the detrimental effects of the covid- pandemic on psychological outcomes, people may report less perceived general health and life satisfaction in more severe pandemic regions than that in milder pandemic regions. actually, people tend to feel closer to the virus in severely affected regions. this is in line with psychological distance, which refers to the subjective experience that something is close or far away from others, including other persons, events, time periods, and hypotheticality (liberman & trope, ) . as the possibility is also a type of psychological distance (liberman & trope, ) , it affects individuals' subjective perceptions as well as their responses to risks (chandran & menon, ; jones, hine, & marks, ; lermer, streicher, sachs, raue, & frey, ) . as the number of confirmed cases indicates the pandemic's severity (reed et al., ) , an increase in the number in nearby places may be related to the perception of being infected. this will eventually result in decreasing the perceived psychological distance. as subjective distance from a disease has been reported to impact psychological reactions (kim, ) , a recent study found that people who perceived a small distance from death reported low levels of life satisfaction (gerstorf, ram, r€ ocke, lindenberger, & smith, ) . therefore, when people are residing close to infected places, they feel a closer psychological distance from the virus and thereby perceive low levels of positive psychological outcomes, such as life satisfaction and perceived general health. perceived control psychological factors are becoming increasingly important in alleviating the negative effects of pandemics and increasing the government's capacity to deal with disasters (li, yang, dou, & cheung, ; pfefferbaum & north, ) . among these, perceived control was reported to moderate the relationship between the perceived severity of covid- and mental health problems (li, yang, dou, & cheung, ; li, yang, dou, wang, et al., ) . in particular, perceived control has been found to significantly affect both life satisfaction and perceived general health (ferguson & goodwin, ; hofmann, luhmann, fisher, vohs, & baumeister, ) . according to the theory of perceived control, this term refers to an individual's perceived capacity to handle or prevent a certain incident, and the individual differences in sense of control are closely associated with successful coping during stressful situations (lachman, ) . according to prior studies, a sense of control can be a factor enhancing a person's capacity and competence in handling outcomes, thereby leading to effective techniques for coping with stressors and increased life satisfaction and health (alonso-ferres, imami, & slatcher, ; drewelies et al., ; hofmann et al., ; lachman, ; thompson & prottas, ) . additionally, a sense of control alters an individual's perception of their capacity to handle the environment, which changes their perception regarding a threat (witt, proffitt, & epstein, ) . in particular, people with high perceived control feel closer to positive targets and perceive greater distance from negative targets (han, gershoff, kirmani, & dalton, ) . therefore, a sense of control may lead to a further distance from negative objects such as the pandemic, which further results in a high level of perceived general health and life satisfaction. according to previous studies, the covid- pandemic has negatively affected both physical and psychological health in regions where it has spread (pfefferbaum & north, ; qiu et al., ; xu et al., ) . in addition to mental problems, ways to maintain life satisfaction and perceived general health are equally important for the general population living in pandemic-affected regions. however, to the best of our knowledge, few studies have attempted to investigate the effects of the covid- pandemic on life satisfaction and perceived general health. considering the differences in pandemic severity across regions in china, we propose the following hypotheses. hypothesis . regional pandemic severity negatively predicts perceived general health and life satisfaction among citizens in pandemic-affected regions. although some studies have examined the effects of the covid- pandemic on psychological outcomes, little is known regarding the possible mechanisms underlying the above-mentioned process. according to the psychological distance theory, regional pandemic severity may alter the perceived psychological distance, thereby reducing perceived general health, and life satisfaction. therefore, hypothesis . psychological distance mediates the effects of regional pandemic severity on both perceived general health and life satisfaction. psychological factors have become increasingly important for controlling this pandemic (duan & zhu, ; pfefferbaum & north, ) . in particular, perceived control has been demonstrated to have a protective function for mental health during the covid- pandemic (li, yang, dou, & cheung, ) . therefore, we propose the following: hypothesis . perceived control moderates the psychological effects of regional pandemic severity on perceived general health and life satisfaction. specifically, the impact of regional pandemic severity on perceived general health and life satisfaction is stronger for individuals with lower perceived control. lastly, given the protective function of perceived control in disasters (pfefferbaum & north, ), a sense of perceived control not only alters individuals' perception regarding a threat (han et al., ; witt et al., ) , but also helps individuals cope with the threat (infurna & gerstorf, ) . according to the literature, high perceived control increases the psychological distance from a negative target (han et al., ) , which may in turn help individuals in coping with the covid- pandemic and further lead to high levels of perceived general health and life satisfaction. in addition, many studies have reported that a sense of control is a key protective factor during adversity (infurna & gerstorf, ) , suggesting that people with high perceived control tend to successfully cope with the threat, even when they perceive a close psychological distance from the disease. therefore, perceived control may moderate the relationship either between regional pandemic severity and psychological distance or between psychological distance and the outcomes. therefore, we proposed the following hypotheses: hypothesis . perceived control moderates the psychological effects of regional pandemic severity on psychological distance from covid- . in particular, the impact of regional pandemic severity on psychological distance is stronger for individuals with low levels of perceived control, compared to those with high levels of perceived control. hypothesis . perceived control moderates the effects of psychological distance on life satisfaction and perceived general health. in particular, the relationships between psychological distance and outcomes (i.e. life satisfaction and perceived perceived control and covid- general health for individuals) are weaker for individuals with low levels of perceived control, compared to those with high levels of perceived control. hypothesis . perceived control moderates the mediating effects of psychological distance on life satisfaction and perceived general health ( figure ). in particular, the mediating effects of psychological distance are stronger for individuals with high levels of perceived control, compared to those with low levels of perceived control. this study recruited , participants from provinces of china using an online survey platform. their average age was . ae . years. there were men and , women respondents. none of them were confirmed cases, but nine of them reported that they were suspected cases. in addition, participants had completed high school education, had completed junior college education, held bachelor's degrees, and held master's or doctorate degrees. all participants provided informed online consent, and the study design was approved by the ethics committee of the first author's university. only those participants who provided online consent were enrolled in this study; these participants were debriefed using an online page and were compensated with rmb ( . euro) after completing the survey. life satisfaction. this was assessed using a single item, similar to the methodology of a previous study (kobau, sniezek, zack, lucas, & burns, ) . the participants were asked to indicate their levels of life satisfaction on a scale of to , wherein = extremely dissatisfied and = extremely satisfied. the statement was: "overall, how satisfied do you feel with your current life? means extremely dissatisfied and means extremely satisfied." perceived general health. this was also assessed using a single item, which was taken from a previous study (main et al., ) . the participants were asked to indicate their attitudes toward their recent health status on a scale of to . the statement was, "overall, your present health status is_____, where means bad, means normal, means good, means very good, and means extremely good." psychological distance. this was measured using two items, which were adopted from the concept of psychological distance (liberman & trope, ) . individuals were required to report their perceived psychological distance from the pandemic on a scale ranging from (extremely near) to (extremely remote). the statements were: "how much distance do you perceive between yourself and covid- ?" and "how much distance do you perceive between yourself and the people infected with covid- ?" pearson's correlation between the two items was . . regional pandemic severity. this is usually determined using two main factors: clinical severity and transmissibility (reed et al., ) . in this study, the regional number of confirmed covid- cases was used as the regional pandemic severity index, as the number of confirmed cases has been linked to regional pandemic severity. these data were obtained from the website of the national health commission of the people's republic of china. this study used the data from the day on which the survey was conducted ( february ). perceived control. this was measured using the perceived control scale (whitaker, miller, & clark, ) . the scale comprises five inverse items: "i have little control over the things that happen to me", "there is really no way for me to solve some of the problems i have", "sometimes i feel that i'm being pushed around in life", "there is little that i can do to change many of the important things in my life", and "i often feel helpless in dealing with life problems." each item was scored on a -point likert scale ( = "strongly disagree" to = "strongly agree"). the responses were reverse recoded so that higher scores indicated high levels of perceived control. cronbach's alpha was . for this sample. perceived control and covid- as people are residing (nested) in regions with different levels of pandemic severity, those in the same region are more similar in the perception of the pandemic than people residing in other regions. in other words, participants were intraclass correlated within their residing regions in this data. in such cases, the hierarchical linear model (hlm) is commonly used for a nested data structure (stephen & anthony, ) . therefore, we conducted an hlm with the regions of china as clusters; psychological distance, life satisfaction, and perceived general health as individual-level variables; and regional pandemic severity as the region-level variable. first, to estimate the intraclass correlation, we analysed a null model in mplus . . second, in model , we performed hlm with the dependent variables (life satisfaction and perceived general health), and control variables (including age, sex, education level, suspected case, and group size). third, regional pandemic severity and perceived control were entered as predictors with random intercepts in model to test the direct effects of regional pandemic severity. the effects of the random slope of perceived control were included in the latter model (i.e. model ) for testing the cross-level moderation. fourth, in model , we tested the mediation effect of psychological distance on the relationships between regional pandemic severity and outcomes with both random intercepts and random slopes. the random mediation effects were tested with the monte carlo approach in r . . (preacher & selig, ) . fifth, a cross-level moderation model with random slopes was used to estimate the moderating effect of perceived control on the relationship between regional pandemic severity and psychological distance. last, we tested the random moderating effect of perceived control on the relationships between psychological distance and outcomes in model . table shows the participants' demographic statistics and the correlation matrix of the variables in this study. in the null model, the results indicated that the intraclass correlation coefficients were . for psychological distance, . for life satisfaction, and . for perceived general health, respectively. as shown in table , after controlling for . ** (À. **) À. + (À. **) . (. ) À. ** (À. **) . (À. ) note: +p < . ; *p < . ; **p < . . regional pandemic severity was measured by the number of confirmed cases at the province level-the number was transformed by logarithm with base , below the regional pandemic severity was the raw number of confirmed cases; sex: other covariables in model , regional pandemic severity was negatively associated with life satisfaction (b = À . , se = . , p = . ), but was insignificantly related to perceived general health (b = . , se = . , p = . ) in model . therefore, h was partially supported. next, the results of the mediation model showed that regional pandemic severity had a negative effect on the psychological distance from covid- (b = À . , se = . , p < . ), which subsequently led to low levels of perceived general health (b = . , se = . , p < . ) and life satisfaction (b = . , se = . , p < . ). according to h , the mediating effects were both significant (perceived general health: effect size = À . , se = . , p = . , % ci [À . , À . ]; life satisfaction: effect size = À . , se = . , p < . , % ci [À . , À . ]), suggesting that regional pandemic severity affects individuals' life satisfaction and perceived general health through psychological distance. to test the moderating effects of perceived control, the present researchers first tested whether perceived control directly moderates the effect of regional pandemic severity on outcomes. the results of model demonstrated that perceived control insignificantly moderated the effects of regional pandemic severity on perceived general health (b = . , se = . , p = . ) and life satisfaction (b = À . , se = . , p = . ), which does not support h . subsequently, according to h , the results of model indicated that perceived control moderated the effects of regional pandemic severity on psychological distance (b = . , se = . , p = . ; table ). as shown in figure a , the effect of regional pandemic severity on psychological distance was greater among individuals with low levels of perceived control (b = À . , se = . , p < . ) than those with high levels of perceived control (b = À . , se = . , p = . ). next, the results of model indicated that perceived control moderates the effects of psychological distance on life satisfaction (b = À . , se = . , p = . ), but not for the effects of psychological distance on perceived general health (b = À . , se = . , p = . ). therefore, h was partially supported. in particular, regarding the effects of psychological distance on perceived general health, there were no significant differences found across the levels of perceived control ( figure b ). however, the effects of psychological distance on life satisfaction were greater among individuals with low perceived control (b = . , se = . , p < . ) than among those with high perceived control (b = . , se = . , p = . ; figure c ). finally, this study examined whether perceived control moderates mediation effects of psychological distance. the results of the moderated mediation model showed that among people with low perceived control, the psychological distance mediated relationships between regional pandemic severity and perceived general health (effect size = À . , se = . , p = . , % ci [À . , À . ]), and between regional pandemic severity and life satisfaction (effect size = À . , se = . , p < . , % ci [À . , À . ]). however, for people with high perceived control, the effects of psychological distance on both perceived general health (effect size = À . , se = . , p = . , % ci [ . , À . ]) and life satisfaction (effect size = À . , se = . , p = . , % ci [ . , À . ]) were insignificant. according to h , perceived control buffers the psychological effects of regional pandemic severity by moderating the mediating effects of psychological distance in the relationship between regional pandemic severity and outcomes (i.e. perceived general health and life satisfaction). in the covid- pandemic, it is quite important to maintain life satisfaction and the general health of the public. the results indicate that psychological distance can serve as a mediator in the relationship between regional pandemic severity and life satisfaction, and regional pandemic severity and perceived general health. in addition, perceived control can act as a protective factor against regional pandemic severity by moderating the mediating effects of psychological distance. in particular, the regional pandemic severity adversely affects psychological distance when people have low perceived control, which in turn can lead to low levels of both life satisfaction and perceived general health. this is consistent with the results of previous pandemic studies, which reported that pandemics led to considerable negative psychological outcomes (main et al., ; pfefferbaum & north, ) , and perceived control promoted successful coping, which led to life satisfaction and perceived general health (lachman, ; prenda & lachman, ) . it is noteworthy that this study recruited participants from regions in china during the severe phase of the covid- pandemic. the regions that our study sampled reported . per cent of the confirmed cases ( , people) of the total number in china and covered . per cent of the chinese population ( , million people). therefore, our results revealed the relationship between figure . perceived control moderates the effect of regional pandemic severity on psychological distance. note: regional pandemic severity was measured by the number of confirmed cases at the province level, and the number was transformed by logarithm with base ; the moderating effects were significant for figure a and figure c but not for b. environmental threat and psychological outcomes among people who resided mainly in the affected regions in china during the covid- pandemic. the present study provides empirical evidence that covid- pandemic severity at the regional level had a direct impact on individuals' life satisfaction after controlling the covariables. this result is consistent with the psychological effects of sars on subjective life satisfaction (lau et al., ; maunder et al., ) . the present study found that the covid- pandemic can create psychosocial burdens for ordinary citizens, thus resulting in decreased subjective life satisfaction. the present study did not find a direct association between regional pandemic severity and perceived general health. however, we found that the regional pandemic severity could affect individuals' perceived general health by shortening their psychological distance from the virus. in particular, people reported lower levels of perceived general health when they perceived a closer distance to covid- . consequently, the regional pandemic can lead to psychological changes related to perceived general health. our findings suggest that individuals who live in severely affected pandemic regions are more likely to perceive poorer general health, which indicates that more attention to this detrimental effect is needed in the future. our findings revealed the detrimental effects of the pandemic on people's positive psychological outcomes. positive psychology-contrary to mental health problems-focuses more on individuals' health and well-being that not only enhance daily life for individuals but also contribute to well-being (seligman et al., ) . therefore, it is necessary for the crisis management department to direct more attention toward positive psychological intervention programs for ordinary citizens living in pandemic-hit regions. it is noteworthy that this study found the mediating role of psychological distance in the relationship between the severity of the covid- pandemic and psychological outcomes. in particular, people living in areas with a large number of confirmed covid- cases perceived a closer psychological distance from the virus. this is in line with previous studies that the distance between self and sars affected the level of anxiety (lau et al., ; wong et al., ) . additionally, the present study found that people who perceived a close psychological distance from covid- reported low levels of life satisfaction and perceived general health. this is consistent with previous studies wherein people reported less life satisfaction when they perceived the threat at a close psychological distance (gerstorf et al., ) . consequently, the regional threat (i.e. regional pandemic severity) alters the subjective distance from the virus, which can subsequently change people's life satisfaction and perceived general health. our findings that psychological distance mediated the relationship between regional threat and mental outcomes can be further generalised to other highly infectious diseases. previous research has reported that environmental factors affect an individual's reactions through organismic variables (luqman, cao, ali, masood, & yu, ) . in this study, regional pandemic severity was measured from the regional epidemic data, and large numbers of confirmed cases represented higher environmental risks of infection. we believe that regional pandemic severity can be regarded as an environmental factor and can impact individuals' mental health through organismic variables such as psychological distance. according to the present study's findings, perceived control can serve as a protective factor against the psychological effects of covid- . in particular, perceived control was found to enhance the participants' capacity to deal with stressors and alter the subjective experience of environmental stressors (alonso-ferres et al., ; lachman, ; li, yang, dou, & cheung, ) . this study found that perceived control could moderate the mediating effect of psychological distance, in which perceived control not only buffers the detrimental effects of regional pandemic severity on psychological distance, but also alleviates the negative impact of psychological distance from covid- on perceived life satisfaction. our finding that perceived control can moderate the relationship between regional pandemic severity and psychological distance is consistent with previous studies. people with high levels of perceived control feel psychologically further from the disease (han et al., ) , which helps them successfully cope with the pandemic and improve their perceived general health and life satisfaction (alonso-ferres et al., ) . therefore, people with higher levels of perceived control are more likely to feel psychologically further from the current pandemic, which in turn increases their feelings of life satisfaction and general health. previous studies found the moderating role of perceived control in the associations between pandemic severity and mental health problems (li, yang, dou, & cheung, ; li, yang, dou, wang, et al., ) . however, the present study provides the empirical evidence that perceived control can alter the relationship by moderating the relations between regional pandemic severity and positive psychological outcomes (e.g. life satisfaction). given the adaptive function of perceived control in mental health (lachman, ) , the present study demonstrated that perceived control can moderate the psychological impact of the covid- pandemic by moderating the impact of the covid- pandemic on psychological distance and moderating the impact of psychological distance on life satisfaction, thereby improving mental health outcomes. our overall findings not only support the main effects of perceived control on perceived health and life satisfaction but also demonstrate its buffering effect on adjusting psychological outcomes among people living in pandemic-affected regions (alonso-ferres et al., ; lachman, ) . covid- continues to spread globally; ways to maintain good health are becoming important for the general public. our finding revealed that psychological distance explained the relationship between regional pandemic severity and psychological outcomes. programs for increasing psychological distance from the virus may help improve the general public's life satisfaction and health in pandemic-affected regions. for example, social distancing and isolating suspected people may be a way to promote increased psychological distance for the general public. our findings significantly contribute to understanding the adaptive function of perceived control against the psychological impact of the pandemic. enhancing perceived control is a possible approach for helping individuals cope with the psychological effects of the covid- pandemic . prior research has found that perceived control improves as uncertainty decreases (zachariae et al., ) . therefore, in terms of crisis governance, public communication regarding uncertainty related to the pandemic will be important. an objective description of the pandemic transmission and severity will benefit regional stability as well as global pandemic prevention and control. there are some limitations in this study. first, it employed a cross-sectional design, in which causal interpretations among self-report measures are impossible. however, we included an objective index, which is more convincing in determining a causal relationship. in addition, some correlations were low but reached significant levels due to the large sample size. although a large sample size usually leads to more reliable results with greater precision and power, more solid evidence is needed to provide support for the relations among these variables. further research should address these issues through longitudinal studies or experimental designs. second, both perceived general health and life satisfaction were assessed using a single item, which may not have been sufficiently comprehensive. additionally, although the measurement of perceived control has been used in previous studies (whitaker et al., ) , these items involve the components of lack of control. to further clarify the impact of perceived and lack of control during pandemics, we recommend that future studies select a more comprehensive measurement that assesses both perceived control and lack of control. third, covid- has been declared a global pandemic by the who. however, our cohorts were restricted to majorly affected regions, especially eastern and central china. given the cultural differences among regions in china, which may limit the generalisation of the study's findings, future studies should consider the cultural differences among populations when examining the psychological effects of the covid- pandemic. untangling the effects of partner responsiveness on health and well-being: the role of perceived control perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza a (h n ) pandemic in the netherlands: results of three consecutive online surveys when a day means more than a year: effects of temporal framing on judgments of health risk mental health care for medical staff in china during the covid- outbreak the more we are in control, the merrier? partner perceived control and negative affect in the daily lives of older couples psychological interventions for people affected by the covid- epidemic optimism and well-being in older adults: the mediating role of social support and perceived control decline in life satisfaction in old age: longitudinal evidence for links to distance-to-death when good things feel closer and bad things feel farther: the role of perceived control on psychological distance perception yes, but are they happy? effects of trait self-control on affective well-being and life satisfaction perceived control relates to better functional health and lower cardio-metabolic risk: the mediating role of physical activity the future is now: reducing psychological distance to increase public engagement with climate change the effect of psychological distance towards a disease on health communication well-being assessment: an evaluation of well-being scales for public health and population estimates of well-being among us adults perceived control over aging-related declines: adaptive beliefs and behaviors the role of social axioms in predicting life satisfaction: a longitudinal study in hong kong the sars (severe acute respiratory syndrome) pandemic in hong kong: effects on the subjective wellbeing of elderly and younger people thinking concretely increases the perceived likelihood of risks: the effect of construal level on risk estimation self-control moderates the association between perceived severity of the coronavirus disease (covid- ) and mental health problems among the chinese public chinese public's knowledge, perceived severity, and perceived controllability of the covid- and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: a national survey traversing psychological distance individual diversity between interdependent networks promotes the evolution of cooperation by means of mixed coupling empirical investigation of facebook discontinues usage intentions based on sor paradigm relations of sars-related stressors and coping to chinese college students' psychological adjustment during the beijing sars epidemic long-term psychological and occupational effects of providing hospital healthcare during sars outbreak mental health and the covid- pandemic advantages of monte carlo confidence intervals for indirect effects planning for the future: a life management strategy for increasing control and life satisfaction in adulthood a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations positive psychology progress: empirical validation of interventions hierarchical linear models relationships among organizational family support, job autonomy, perceived control, and employee well-being reconceptualizing adolescent sexual behavior: beyond did they or didn't they? family planning perspectives tool use affects perceived distance, but only when you intend to use it anxiety among university students during the sars epidemic in hong kong. stress and health pathological findings of covid- associated with acute respiratory distress syndrome association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease we acknowledge the partial financial support from the scientific research fund from fuzhou university (gxrc ), the fujian social science foundation for education product (jas ), and the ministry of education (moe) of the people's republic of china project of humanities and social sciences ( yjc ). key: cord- -e m g authors: que, jianyu; shi, le; deng, jiahui; liu, jiajia; zhang, li; wu, suying; gong, yimiao; huang, weizhen; yuan, kai; yan, wei; sun, yankun; ran, maosheng; bao, yanping; lu, lin title: psychological impact of the covid- pandemic on healthcare workers: a cross-sectional study in china date: - - journal: gen psychiatr doi: . /gpsych- - sha: doc_id: cord_uid: e m g background: healthcare workers fighting against the coronavirus disease (covid- ) pandemic are under tremendous pressure, which puts them at an increased risk of developing psychological problems. aims: this study aimed to investigate the prevalence of psychological problems in different healthcare workers (ie, physicians, medical residents, nurses, technicians and public health professionals) during the covid- pandemic in china and explore factors that are associated with the onset of psychological problems in this population during this public health crisis. methods: a cross-sectional, web-based survey was conducted in february among healthcare workers during the covid- pandemic. psychological problems were assessed using the generalized anxiety disorder scale, patient health questionnaire and insomnia severity index. logistic regression analyses were used to explore the factors that were associated with psychological problems. results: the prevalence of symptoms of anxiety, depression, insomnia and the overall psychological problems in healthcare workers during the covid- pandemic in china was . %, . %, . % and . %, respectively. the prevalence of the overall psychological problems in physicians, medical residents, nurses, technicians and public health professionals was . %, . %, . %, . % and . %, respectively. compared with healthcare workers who did not participate in front-line work, front-line healthcare workers had a higher risk of anxiety, insomnia and overall psychological problems. in addition, attention to negative or neutral information about the pandemic, receiving negative feedback from families and friends who joined front-line work, and unwillingness to join front-line work if given a free choice were three major factors for these psychological problems. conclusions: psychological problems are pervasive among healthcare workers during the covid- pandemic. receiving negative information and participating in front-line work appear to be important risk factors for psychological problems. the psychological health of different healthcare workers should be protected during the covid- pandemic with timely interventions and proper information feedback. abstract background healthcare workers fighting against the coronavirus disease (covid- ) pandemic are under tremendous pressure, which puts them at an increased risk of developing psychological problems. aims this study aimed to investigate the prevalence of psychological problems in different healthcare workers (ie, physicians, medical residents, nurses, technicians and public health professionals) during the covid- pandemic in china and explore factors that are associated with the onset of psychological problems in this population during this public health crisis. methods a cross-sectional, web-based survey was conducted in february among healthcare workers during the covid- pandemic. psychological problems were assessed using the generalized anxiety disorder scale, patient health questionnaire and insomnia severity index. logistic regression analyses were used to explore the factors that were associated with psychological problems. results the prevalence of symptoms of anxiety, depression, insomnia and the overall psychological problems in healthcare workers during the covid- pandemic in china was . %, . %, . % and . %, respectively. the prevalence of the overall psychological problems in physicians, medical residents, nurses, technicians and public health professionals was . %, . %, . %, . % and . %, respectively. compared with healthcare workers who did not participate in front-line work, front-line healthcare workers had a higher risk of anxiety, insomnia and overall psychological problems. in addition, attention to negative or neutral information about the pandemic, receiving negative feedback from families and friends who joined front-line work, and unwillingness to join front-line work if given a free choice were three major factors for these psychological problems. conclusions psychological problems are pervasive among healthcare workers during the covid- pandemic. receiving negative information and participating in front-line work appear to be important risk factors for psychological problems. the psychological health of different healthcare workers should be protected during the covid- pandemic with timely interventions and proper information feedback. the dramatic spread of coronavirus (covid- ) pandemic worldwide has caused a tremendous public health crisis. across the globe, a greater number of fatalities by covid- have been reported than those by the previous severe acute respiratory syndrome (sars) and middle east respiratory syndrome combined, even though covid- has a relatively low death rate. however, to date, no effective treatment has been developed to cure people with covid- . with increasing number of confirmed cases and death counts due to covid- , this overwhelming global pandemic poses a great challenge to the local healthcare systems. as the number of patients with covid- grows, increasingly more health resources, including personnel, beds and facilities, are at maximum capacity. with limited resources, people will be under greater pressure and experience greater distress, especially healthcare workers. to control the transmission of the offending virus, severe acute respiratory syndrome coronavirus , and treat people with covid- , many medical measures have been implemented in different countries. by april , according to the who, confirmed cases of covid- have been reported among healthcare workers in countries. more than healthcare workers in china, including physicians, nurses, technicians and public health professionals, from other provinces went to hubei province to provide assistance. in addition to supporting hubei, different healthcare workers including physicians, nurses, technicians and public health staff in other provinces were divided into several groups to establish fever clinics, manage individuals with covid- and control the infection among medical staff. to ensure the quality of general psychiatry figure flow chart of subjects' enrollment. medical services, several researchers have appealed to the authorities to take the necessary steps for strengthening mental health and wellness for healthcare workers. compared with the general population, healthcare workers are facing tremendous pressure from covid- , especially those who might be in contact with suspected or confirmed cases, due to the high risk of infection, inadequate protection, loss of control, lack of experience in managing the disease, overwork, negative feedback from patients, perceived stigma, significant lifestyle changes, quarantine and less family support. [ ] [ ] [ ] these factors increase the incidence of psychological problems among healthcare workers, such as fear, anxiety, depression and insomnia, which can negatively affect work efficiency and long-term well-being. during the sars epidemic, %- % of hospital workers suffered from a high degree of emotional distress. even several years later, % of healthcare workers still reported symptoms of post-traumatic stress. individuals who experienced quarantine or worked in wards for patients with infection were two to three times more likely to have post-traumatic stress symptoms. although a few studies have investigated the prevalence of psychological problems among healthcare workers during the covid- pandemic, no study has investigated the distribution of psychological problems among different groups of healthcare workers. a more comprehensive understanding of psychological burden among different groups of healthcare workers during this period is crucial for providing psychological support, improving mental health support services and strengthening mental healthcare worldwide. this crosssectional study investigated the prevalence of psychological problems in different healthcare workers during the covid- pandemic in china and explored the demographics and covid- -related and work-related factors that are associated with various psychological problems. an anonymous cross-sectional study was performed using the social media platform-based (wechat) survey program questionnaire star in february in china. healthcare professionals, including physicians, medical residents, nurses, technicians and public health professionals, were invited to voluntarily participate in the selfadministered online survey. the detailed flowchart of this study is shown in figure . at the beginning of the questionnaire, we informed participants that they would be signing the consent by default if they completed the survey. healthcare workers from different regions throughout china were recruited based on social networks of investigators and research teams, in order to reach a large number of subjects. the participants were contacted via a designated link, which was disseminated through the primary means of communication and social networks of each participant. those who are not medical professionals, are non-users of wechat or did not complete the assessment were not involved in this survey. medical students were excluded in this analysis because most of them do not enter the stage of clinical practice. we analysed the data collected from february to february , at the early stage of the covid- pandemic, until a projected sample size was reached based on estimates of the prevalence of psychological problems during the sars outbreak. we developed a questionnaire to collect data on demographic characteristics and psychological status of subjects and information about the covid- pandemic. the duration of the questionnaire was approximately min. demographic data, including age, gender, race, years of education, annual household income, geographical region and occupation, were obtained. we assessed regular exercise and hazardous drinking and smoking by asking the respondents the following questions: 'did you engage in physical exercise for min or more per week?' 'did you drink regularly more than units of alcohol (equivalent to six pints of beer or six glasses of wine) per week?' and 'did you smoke or more cigarettes per day for one or more years?' the respondents responded 'yes' or 'no'. the chinese version of the seven-item generalized anxiety disorder scale (gad- ) was used to measure symptoms of anxiety during the past weeks. cutoff points of , and were classified as mild, moderate and severe anxiety, respectively. the diagnostic threshold of the gad- was previously reported to be . we identified depressive symptoms during the past weeks using the chinese version of the nine-item patient health questionnaire (phq- ), which has shown high consistency with a diagnosis of major depression based on structured interviews. cut-off general psychiatry points of , and were classified as mild, moderate and severe depression, respectively. a phq- score ≥ was previously reported to have a sensitivity of % and specificity of % for major depression. symptoms of insomnia were measured using the chinese version of the insomnia severity index (isi). cut-off points of , and were classified as subthreshold, moderate and severe insomnia, respectively. an isi score ≥ was defined as insomnia, based on a diagnostic utility study. in this study, we also assessed the overall psychological problems. the overall mild psychological problems were defined as any symptom of mild anxiety, depressive or insomnia, and the overall moderate/ severe psychological problems were defined as any symptom of moderate/severe anxiety, depressive or insomnia. we also collected a series of information about exposure to covid- . we assessed the influence of the covid- pandemic by asking four questions. first, we asked 'do you pay attention to information about the covid- pandemic?' responses were dichotomised as 'never/seldom' and 'often/always'. second, we asked 'what kind of information about the pandemic are you concerned about?' the response options were 'positive', 'neutral' and 'negative'. third, we asked 'did you receive feedback from your families or friends who joined front-line work?' the response options were 'no', 'yes, he/she is satisfied with front-line work' and 'yes, he/she is unsatisfied with front-line work'. fourth, we asked 'is anyone close to you suspected of being infected or confirmed to be infected?' the response options were 'yes' or 'no'. front-line work was defined as jobs in which one may be in contact with suspected or confirmed cases. the questions 'did you participate in front-line work?' and 'were you suspected of being infected or confirmed to be infected during front-line work?' were used to assess the effects of participation in front-line work on psychological problems. we also explored the association between psychological problems and the willingness to join front-line work by asking 'if given a free choice, did you want to join frontline work?' the response options were 'willing', 'uncertain' and 'unwilling'. we used descriptive statistical analysis to characterise the samples of healthcare workers. the prevalence of symptoms of anxiety, depression, insomnia and the overall psychological problems was reported. according to previous studies, a gad- score ≥ indicates anxiety. a phq- score ≥ indicates depression. an isi score ≥ indicates clinical insomnia. gad- , phq- and isi scores were treated as dichotomous variables in the univariate analysis. we performed unadjusted logistic regression analyses to investigate factors that are associated with anxiety, depression, insomnia and the overall psychological problems. variables were included in the multiple backward logistic regression analysis if they had p values < . in the unadjusted analysis. the results are reported as adjusted ors with % cis. all of the tests were two-sided. p< . was considered statistically significant. spss v. software was used for statistical analyses. table presents the prevalence of anxiety, depression, insomnia and the overall psychological problems in healthcare workers. for anxiety, . % of the healthcare workers had gad- scores ≥ , including . % with mild anxiety and . % with moderate/severe anxiety. the highest prevalence of anxiety symptoms was observed in nurses ( . %). the lowest prevalence of anxiety symptoms was observed in medical residents ( . %). for depression, . % of the healthcare workers had phq- scores ≥ , including . % with mild depression and . % with moderate/severe depression. the highest prevalence of depressive symptoms was observed in public health professionals ( . %). the lowest prevalence of depressive symptoms was observed in medical residents ( . %). for insomnia, . % of the healthcare workers had isi scores ≥ , including . % with subthreshold insomnia and . % with moderate/severe insomnia. the highest prevalence of insomnia symptoms was observed in nurses ( . %). the lowest prevalence of insomnia symptoms was observed in medical residents ( . %). for the overall psychological problems, . % of the healthcare workers had symptoms of anxiety, depression or insomnia, including . % with mild symptoms and . % with moderate/severe symptoms. the highest prevalence of psychological problems was observed in public health professionals ( . %). the lowest prevalence of insomnia symptoms was observed in medical residents ( . %). we performed binary logistic regression analyses to identify demographic and relevant contextual factors that are associated with psychological problems (table ). in the unadjusted logistic regression analysis, several factors *gad- score of - indicates mild anxiety symptoms. †gad- score ≥ indicates moderate to severe anxiety symptoms. ‡phq- score of - indicates mild depressive symptoms. §phq- score ≥ indicates moderate to severe depressive symptoms. ¶isi score of - indicates subthreshold insomnia. **isi score ≥ indicates moderate to severe insomnia. † †met the criteria in * or ‡ or ¶, but not in † or § or **. ‡ ‡met the criteria in † or § or **. gad- , seven-item generalized anxiety disorder scale; isi, insomnia severity index; phq- , nine-item patient health questionnaire. were independently associated with anxiety (gad- score ≥ ), depression (phq- score ≥ ), insomnia (isi score ≥ ) and the overall moderate/severe psychological problems. in the multiple logistic analyses, factors that were independently associated with a higher risk of anxiety included attention to neutral information about the pandemic (or= . , % ci . to . ), receiving negative feedback from families or friends who joined front-line work (or= . , % ci . to . ), joining front-line work (or= . , % ci . to . ) and unwilling to join front-line work if given a free choice (or= . , % ci . to . ). high annual household income (¥ -¥ vs <¥ , or= . , % ci . to . ; >¥ vs <¥ , or= . , % ci . to . ) and regular exercise (or= . , % ci . to . ) were independently associated with a lower risk of depression. factors that were independently associated with a higher risk of depression included attention to negative information about the pandemic (or= . , % ci . to . ), attention to neutral information about the pandemic (or= . , % ci . to . ), receiving negative feedback from families or friends who joined front-line work (or= . , % ci . to . ), unwilling to join frontline work if given a free choice (or= . , % ci . to . ) and uncertain about joining front-line work if given a free choice (or= . , % ci . to . ). factors that were independently associated with a higher risk of insomnia included drinking (or= . , % ci . to . ), attention to negative information about the pandemic (or= . , % ci . to . ), receiving negative feedback from families or friends who joined front-line work (or= . , % ci . to . ), joining front-line work (or= . , % ci . to . ) and unwilling to join front-line work if given a free choice (or= . , % ci . to . ). regular exercise (or= . , % ci . to . ) was a protective factor against the overall psychological problems. however, drinking (or= . , % ci . to . ), attention to neutral pandemic information (or= . , % ci . to . ), attention to negative pandemic information (or= . , % ci . to . ), receiving negative feedback from families or friends who joined front-line work (or= . , % ci . to . ), joining front-line work (or= . , % ci . to . ), unwilling to join front-line work if given a free choice (or= . , % ci . to . ) and uncertain about joining frontline work if given a free choice (or= . , % ci . to . ) were independently associated with increased risk of overall psychological problems (table ) . the present results show that self-reported psychological problems are prevalent in healthcare workers during the covid- pandemic. moreover, different kinds of healthcare workers exhibited a distinct prevalence of anxiety, depression, insomnia and overall psychological problems. we further identified the possible risk factors associated with psychological problems, including participation in front-line work, attention to neutral or negative information about the pandemic, receiving negative feedback from people who worked on the front-line, and uncertainty or unwillingness to join front-line work and so on. the findings help provide information for psychological interventions among healthcare workers in other countries and religions. the high prevalence of psychological problems that was found in this study is consistent with recent findings from two other chinese research studies with relatively small samples. the prevalence of self-reported symptoms of anxiety, depression and insomnia in these two previous surveys was . %, . % and . % and . %, . % and . %, respectively. another study confirmed the severe mental health conditions in healthcare workers and indicated that medical health workers reported more symptoms compared with non-medical health workers. in addition, compared with the general population (eg, . % of the general population experienced psychological distress), healthcare workers have a much higher risk of psychological problems (eg, anxiety, depression and insomnia) during the epidemic. this may be related to the higher risk of infection on account of being exposed to patients with covid- and tedious work involved in caring for them and reminds us of the importance of providing psychological support to healthcare workers during a pandemic. moreover, this study analysed the prevalence of psychological problems in different healthcare workers, including nurses, physicians, medical residents, technicians and public health professionals. approximately one-third to half of the nurses reported symptoms of anxiety, depression and insomnia. nurses, mostly women who are more susceptible to mental problems, may have a higher workload and greater risk of direct exposure to patients with covid- . moreover, owing to the contagious nature of covid- , as a preventive measure, nurses may be separated from their family members to reduce the risk of transmission, and research has shown that worrying about family members may be one of the main sources of stress in nurses, indicating the critical role of community support for nurses' mental health. similar to nurses, physicians are also under great stress, and nearly half of the physicians reported anxiety and depression. however, majority of the physicians are male and may have a higher acceptance of risk than nurses and have better coping skills. in this study, we also found a high prevalence of psychological problems in public health professionals and technicians. however, few studies have investigated their mental health during a pandemic, and further research is warranted to provide more evidence. during the covid- pandemic, many medical residents do not directly participate in the care general psychiatry of patients with covid- (eg, many medical residents may only be on stand-by at home during the covid- pandemic), and thus, they reported less anxiety, depression, insomnia and overall psychological problems. these findings indicate that based on the sociodemographic, occupational and institutional disparities, different psychological interventions should be delivered to healthcare workers. one interesting finding of this study was that paying attention to negative or neutral information (rather than positive information) about the covid- pandemic and receiving negative feedback from families and friends who joined front-line work were associated with a higher risk of psychological problems. exposure to a preponderance of negative information about a disaster and misinformation from the media and surrounding people can potentially damage mental health. however, although individuals with psychological disorders might tend to focus on negative information about the covid- pandemic, such information can also have a negative impact on their mental health, which may lead to a vicious circle. in addition, engaging in regular exercise might serve as a protective factor against depression and overall psychological problems, and a higher household income was also found to be protective against depression, which is consistent with previous studies. we also found that hazardous drinking was independently associated with insomnia and overall psychological problems. these results demonstrated the importance of information control and a healthy lifestyle (eg, regular exercise and no hazardous drinking) in reducing psychological problems in healthcare workers. another intriguing finding in this study was that healthcare workers' unwillingness to join front-line work if given a free choice was independently associated with psychological problems, which is consistent with findings that were reported during the sars epidemic. the major reason for unwillingness to work on the front-line is lack of confidence in infection control knowledge and skills. individuals who perceive that they have a limited capacity in such knowledge and skills are more likely to experience psychological problems. healthcare workers' knowledge and skills need to be improved so that they are well equipped to cope with infectious disease, and steps should be taken to provide necessary support to reduce the risk of infection and improve the work environment. limitations this study has several limitations. this was a crosssectional online survey and the sample is not necessarily a well representation. the causal relationships should be interpreted with caution. although a relatively large number of healthcare workers participated in this study, the limited number of participants in the northeast areas of china might have caused the findings to be underpowered. more studies are needed to explore the longitudinal trajectories of anxiety, depression and insomnia symptoms in healthcare workers during the covid- pandemic in china. moreover, the number of nurses, technicians and public health professionals who participated in this survey was limited, which may limit the generalisability of findings. the results were based on self-reported questionnaires that investigated psychological problems, which might be different from clinical diagnostic interviews. the results of this study show the burden of psychological problems among different healthcare workers during the covid- pandemic. the findings suggest that a greater risk of psychological problems may be associated with receiving negative information about the pandemic. participation in front-line work appears to be an important risk factor for anxiety, insomnia and overall psychological problems. moreover, depression and symptoms of post-traumatic stress might persist even after such a crisis is over and might exceed the consequences of the pandemic itself. these findings will help improve our understanding of the influence of pandemics on psychological health among healthcare workers and suggest implementation of steps that go beyond saving the lives of patients with covid- -psychosocial interventions and support should be integrated into public health responses to the covid- pandemic, particularly for healthcare workers. evidence-based psychosocial interventions and support for short-term psychological problems, such as anxiety, depression and insomnia, at the early stage of the pandemic are necessary. moreover, self-relaxation training, regular exercise and healthy lifestyle should be emphasised. additional studies should be conducted to explore the long-term impact of the covid- pandemic (eg, depression and post-traumatic stress disorder) and psychosocial interventions to improve mental health. world health organization a novel coronavirus outbreak of global health concern coronavirus: covid- has killed more people than sars and mers combined, despite lower case fatality rate covid- -the search for effective therapy covid- : protecting health-care workers global challenges in health and health care for nurses and midwives everywhere national health commission of the people's republic of china covid- infection epidemic: the medical management strategies in heilongjiang province managing mental health challenges faced by healthcare workers during covid- pandemic mental health care for medical staff in china during the covid- outbreak the mental health of medical workers in wuhan, china dealing with the novel coronavirus psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital the experience of the sars outbreak as a traumatic stress among frontline healthcare workers in toronto: lessons learned longterm psychological and occupational effects of providing hospital healthcare during sars outbreak immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk factors associated with mental health outcomes among health care workers exposed to coronavirus disease mental health and psychosocial problems of medical health workers during the covid- epidemic in china -ncov epidemic: address mental health care to empower society world health organization. global recommendations on physical activity for health alcohol guidelines review: report from the guidelines development group to the uk chief medical officers an investigation on the mental health status of tobacco dependent soldiers reliability and validity of a generalized anxiety disorder scale in general hospital outpatients a brief measure for assessing generalized anxiety disorder: the gad- validation and standardization of the generalized anxiety disorder screener (gad- ) in the general population reliability and validity of depression scales of chinese version: a systematic review validation and utility of a selfreport version of prime-md: the phq primary care study. primary care evaluation of mental disorders. patient health questionnaire the phq- : validity of a brief depression severity measure psychometric property of the insomnia severity index in students of a commercial school validation of the insomnia severity index as an outcome measure for insomnia research the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response online mental health services in china during the covid- outbreak a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations the occupational and psychosocial impact of sars on academic physicians in three affected hospitals psychosocial effects of sars on hospital staff: survey of a large tertiary care institution factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto work stress among chinese nurses to support wuhan in fighting against covid- epidemic sars risk perceptions in healthcare workers coping responses of emergency physicians and nurses to the severe acute respiratory syndrome outbreak a systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak disaster media coverage and psychological outcomes: descriptive findings in the extant research the association between disaster exposure and media use on post-traumatic stress disorder following typhoon hato in macao, china exercise and the prevention of depression: results of the hunt cohort study the epidemiology of depression across cultures he obtained a bachelor's degree from qiqihar medical college in and got a master's degree from peking university in alcohol dependence and its relationship with insomnia and other sleep disorders sleep problems, comorbid mental disorders, and role functioning in the national comorbidity survey replication severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers psychological effects of the sars outbreak in hong kong on high-risk health care workers how to provide an effective primary health care in fighting against severe acute respiratory syndrome: the experiences of two cities acknowledgements we thank all the participants for their willingness to participate in the study and the time that they devoted to the study. funding this study was supported by grants from the beijing natural science foundation (no. ), special research fund of pkuhsc for prevention and control of covid- (no. bmu hkyzx ) and the national natural science foundation of china (no. , and ). patient consent for publication not required.ethics approval this study was approved by the ethical review committee of the peking university sixth hospital.provenance and peer review commissioned; externally peer reviewed. key: cord- -erlmyzwn authors: cabarkapa, sonja; nadjidai, sarah e.; murgier, jerome; ng, chee h. title: the psychological impact of covid- and other viral epidemics on frontline healthcare workers and ways to address it: a rapid systematic review date: - - journal: brain behav immun health doi: . /j.bbih. . sha: doc_id: cord_uid: erlmyzwn background: as the world is battling the covid- pandemic, frontline health care workers (hcws) are among the most vulnerable groups at risk of mental health problems. the many risks to the wellbeing of hcws are not well understood. of the literature, there is a paucity of information around how to best prevent psychological distress, and what steps are needed to mitigate harm to hcws’ wellbeing. methods: a systematic review using prisma methodology was used to investigate the psychological impact on hcws facing epidemics or pandemics, using three electronic databases (pubmed, medline and cinahl), dating back to until the st of august . the search strategy included terms for hcws (e.g., nurse and doctor), mental health (e.g., wellbeing and psychological), and viral outbreaks (e.g., epidemic and pandemic). only studies with greater than frontline hcws (i.e. doctors or nurses in close proximity to infected patients) were included. results: a total of studies were included, with using quantitative methodology and were qualitative. of the quantitative studies used validated measurement tools while used novel questionnaires. the studies were conducted across various countries and included people with sars ( studies), ebola ( ), mers ( ) and covid- ( ). findings suggest that the psychological implications to hcws are variable with several studies demonstrating an increased risk of acquiring a trauma or stress-related disorders, depression and anxiety. fear of the unknown or becoming infected were at the forefront of the mental challenges faced. being a nurse and being female appeared to confer greater risk. in past epidemics, the perceived stigma from family members and society heightened negative implications; predominantly stress and isolation. coping strategies varied amongst the contrasting sociocultural settings and appeared to differ amongst doctors, nurses and other hcws. implemented changes, and suggestions for prevention in the future consistently highlighted the need for greater psychosocial support and clearer dissemination of disease-related information. conclusion: this review can inform current and future research priorities in the maintenance of wellbeing amongst frontline hcws. change needs to start at the level of policy-makers to offer an enhanced variety of supports to hcws who play a critical role during largescale disease outbreaks. psychological implications are largely negative and require greater attention to be mitigated, potentially through the involvement of psychologists, raised awareness and better education. the current knowledge of therapeutic interventions suggests they could be beneficial but more long-term follow-up is needed. large-scale disease epidemics pose various challenges to individuals of all ages and cultures but the emotional stress experienced by frontline health care workers (hcws) is severe, and can be enduring. - the novel coronavirus (covid- ) which emerged in wuhan, china, led to a pandemic unlike any other in the last century. the subsequent demand placed on hcws is difficult to encompass in its entirety. even less is known about the implications for their mental health and well-being. evidence from studies during covid- and similar past epidemics can help inform this, and how best to address it. a pandemic is the worldwide spread of a new disease, otherwise known as an epidemic that has spread over several countries or continents. high global death toll, with thousands of hcws becoming infected. the fast changing response to this novel virus was likely to have had a profound effect on the wellbeing of hospital employees working on the front-line. furthermore, the rapid transmission rate of covid- led to unparalleled tasks that hcws may not have been adequately equipped to deal with, from both a professional and psychological viewpoint. dealing with a severe global health disaster is an uncharted journey into the unknown at various levels. government bodies make plans using other countries' data to project infection rates. the high degree of uncertainty associated to novel pathogens further j o u r n a l p r e -p r o o f contributes to the communal anxiety held, and makes for an overall negative experience for most. however, the challenge encountered can also result in positive changes, as individuals harness their coping skills, work together in teams, and the change instrumented by leaders can strengthen nations' preparedness against future disasters. in terms of mental health impact of epidemics, hcws represent a particularly vulnerable group due to the high risk of infection, increased work stress and fear of spreading to their families. during the recent ebola outbreak, an unprecedented number of hcws were infected , and survivors of infectious diseases have higher rates of post-traumatic stress disorder (ptsd). recommendations around the use of psychological first aid (pfa) have been made by global authorities. however, the efficacy of this strategy is not well studied and barriers to its application exist. , the many risks to the wellbeing of hcws are not well understood. post-sars, there has been some research into this area but little is known about the psychological impact during infectious disease outbreaks. detrimental outcomes such as burnout, traumatic stress, anxiety, and depressive symptoms have been reported even after an outbreak, suggesting long-term implications. given the likely increased rate of psychological problems amongst hcws, these factors must be addressed. in the context of the covid- pandemic, this timely review is both relevant and urgent. it is imperative that those working at the frontline with infected patients or in afflicted j o u r n a l p r e -p r o o f regions have the necessary strategies and resources to endure various challenges. there is a lack of systematic reviews published specifically on the mental health implications experienced by frontline hcws during an epidemic. of the literature, there is also a paucity of information around how to best prevent psychological distress, and what steps are needed to mitigate harm to hcws' wellbeing. the purpose of this review is to explore the main findings from the literature examining the psychological impact on hcws in times of severe epidemics, and to identify strategies to address this. we performed a systematic literature review to identify all international research related to epidemics and pandemics. specifically, we aimed to identify original research pertaining to severe viral outbreaks, from to the st of august . to obtain relevant articles, we systematically searched pubmed, medline and cinahl. the following search terms were used: 'health worker', 'health care worker', 'medical', 'doctor', 'nursing', 'nurse', 'allied health', 'pandemic', 'outbreak', 'mental health', 'mental illness', 'psychiatric', 'psychological', 'coping', 'psychosocial', 'covid- ', 'coronavirus', 'sars', 'mers' and 'ebola'. the references of identified articles were also manually searched for additional studies meeting study criteria. the studies included in this review had to be original research (i.e. commentaries, editorials and reviews were excluded), be published in peer-reviewed journals, be written in english, include frontline hcws as study participants, and include factors associated with their mental health or psychological wellbeing. as the clear majority of papers used self-reported measures, to ensure inclusion of high quality and adequately powered research, studies needed to include at least frontline hcws. hcws j o u r n a l p r e -p r o o f needed to be working in close proximity with infected patients. the initial search yielded , papers, of which included relevant data and were included in this review. the screening process is depicted in figure . one reviewer (sn) examined the titles and abstracts initially to yield the preliminary publications for inclusion ( ). two reviewers (sc and sn) examined the full text studies independently with identical study selection criteria and removed the articles ( ) that did not fulfil inclusion criteria. a third reviewer (cn) examined studies that required further consideration. the studies were conducted across various countries and included people with sars ( studies), ebola ( ), mers ( ) and covid- ( ) . of the articles, were quantitative and were qualitative. details of the characteristics are listed in table . of the quantitative studies, fifty studies - , - incorporated validated questionnaires or measurement tools, while five - used novel questionnaires. all the studies included in this review assessed the psychological impact of severe epidemics on hcws. the most common psychiatric disorders diagnosed were posttrauma stress syndrome (ptss), depression and anxiety, as assessed in studies. , , , - , - , - , , in the covid- pandemic, somatisation was reported frequently , , with . % ( , of , ) of frontline nurses identifying somatic symptoms , particularly headache, throat pain and lethargy, which were significantly associated with psychological outcomes. sleep disorders including insomnia were also frequently identified. , , , , , female nurses with close contact to covid- patients appeared to have the highest mental health risks , , however, it is important to note that most studies included predominantly female participants, especially nurses, with only one study suggesting higher stress levels amongst males. specifically, being female conferred greater risks for depression, anxiety and higher levels of stress , , [ ] [ ] [ ] suicidal ideation was identified amongst . % ( of , ) of hcws with lower self-perceived health status listed as an additional risk factor. , at the early stages of the covid- pandemic, a wuhan study found that . % ( of ) of medical and nursing staff had mild mental health disturbances while . % ( ) had severe disturbances, while in another study of , chinese hcws . % had psychological abnormalities. in the hubei province, . % ( of ) of medical staff had anxiety, being more severe in those with direct contact with infected patients. two-weeks after wuhan went into lockdown, the proportion of female hcws with depression, anxiety and acute stress symptoms were respectively . % ( of , ), . % ( ) and . % ( ). one study j o u r n a l p r e -p r o o f found a moderate degree of burnout amongst , hcws across two hospitals in wuhan, with high levels of fear reported. approximately % ( of ) of hcws had ptsd two months after the sars outbreak in singapore. while % ( of ) of staff members at a hospital in east taiwan met criteria for an acute stress disorder (asd) during the sars pandemic. similarly, hcws and other staff with direct contact or exposure to ebola patients, had a range of psychological symptoms, such as obsession-compulsion, interpersonal sensitivity, depression and paranoid ideation. during the -year period following their exposure to the sars outbreak, around % ( of ) of beijing hospital employees had a high degree of post-traumatic stress symptoms which were strongly associated with exposure to sars, quarantine and a relative or friend acquiring sars. a study of , hcws assessed the psychological impact in the initial stages of the mers outbreak and one month later. those who performed mers-related tasks reported greater distress and more intrusive phenomena. they also had the greatest risk for ptsd symptoms one-month later, and interestingly, this risk was increased even after home quarantine. home quarantined hcws had poorer sleep and a heightened degree of numbness than those who were not quarantined. in terms of impact on different health professionals, a recent study comparing medical hcws ( ) to non-medical hcws ( , ) demonstrated significantly higher levels of insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms in medical hcws. a spanish study also found that hcws ( ) had higher symptoms of acute stress than compared with non-hcws ( ). similarly, anxiety and insomnia were j o u r n a l p r e -p r o o f significantly higher in frontline hcws compared to non-frontline hcws. , , eight studies compared doctors and nurses , , , , , , , . four of these studies focused on sars and found that nurses experienced greater levels of stress. of these, one study reported higher distress for nurses and those with direct contact with infected patients. in two quantitative studies , from hong kong, overall distress level for nurses was significantly higher than for other hcws with the exception of doctors, and nurses also experienced higher levels of stress and psychological morbidity compared with other professionals. interestingly, one study of , nurses, showed that nurses in moderate-risk areas appeared to have more stress symptoms than those working in high-risk areas, but the reasons for this remain unclear. alternate findings were depicted in two studies , where doctors and single nurses were found to be at higher risk compared to nurses and those who were married, and doctors had more stress and anxiety compared to nurses. further, % of participants ( of ) had psychiatric symptoms, with the doctors being . times more likely to experience psychiatric symptoms than nurses, and % ( of ) had ptsd. in contrast, a study comparing hcws impacted by sars, found no significant difference in feelings of stress between the physicians, nurses and other hcws. an italian study hcws during the covid- pandemic, showed that general practitioners were more likely to have ptss than other hcws, while nurses and health care assistants were more likely to exhibit severe insomnia. similarly, another chinese study found that nurses ( ) working in the frontline against covid- experienced significantly greater levels of vicarious traumatisation when compared to non-frontline nurses ( ). this theme was replicated with findings to suggest that frontline hcws in close contact with j o u r n a l p r e -p r o o f infected patients were . times more likely to feel fear and twice more likely to suffer anxiety and depression when compared to non-clinical staff. in a study of , hcw's during the covid- outbreak, high rates of depression, anxiety and insomnia were reported with over % reporting psychological distress. a survey of chinese hcws during the covid- outbreak found that . % ( of , ) had symptoms of insomnia. a comparison of hcws in wuhan, the epicentre of the covid- outbreak, compared to those in a different province found that staff in wuhan had higher rates of insomnia and stress responses. one study compared hcws with healthy controls and found that hcws were not more stressed than controls the publications included in this review were predominantly focused on the stressors arising during an outbreak, however, six articles , , , , , focused either entirely on j o u r n a l p r e -p r o o f the period following the outbreak, or in part, had follow-up. two , articles examined predictors and one study considered the stressors before care was given. predictors of the incidence of new-onset episodes of psychiatric disorders after the sars outbreak included; a past history of psychiatric illness, years of health care experience (inversely associated) and the perception of adequate training and support. new episodes of psychiatric disorders occurred among % ( of ) of hcws. a greater degree of psychiatric morbidity was identified amongst nurses and younger hcws. taiwanese nurses found that the pre-care stage contributed to fear, as all ( ) reported having difficulties keeping up with daily changing knowledge and skills and being anxious about their safety and of their families, clients, and colleagues. participants across seventeen studies , , , , , , , , , - , , reported fear as the prominent stressor. particularly, fear of the unknown, becoming infected and threats to their own mortality. the vulnerability of colleagues and family member were also a major cause of concern as reported in an italian study , being exposed to contagion was associated with symptoms of depression, while having a colleague hospitalised or placed in quarantine was associated with ptss, whereas, a colleague dying was associated to depression and insomnia. a major theme was anxiety, especially across most of the covid- studies , - , , , , - , - . in a chinese study the most important factor in hcws with high anxiety was being suspected of having covid- infection when compared to those who were not suspected of infection. of , hcws in singapore, % perceived an increased j o u r n a l p r e -p r o o f risk of becoming infected, % reported work stress and % had increased workloads. doctors, nurses and staff in daily contact with sars patients, and staff from sarsaffected institutions expressed significantly higher levels of anxiety than other hcws. in questionnaires experienced psychological distress. similarly, a survey of hcws after the mers outbreak found that safety fears for themselves and others were a major concern, with worries that they would transmit the disease to their families and friends. all nurses ( ) responding to a qualitative study expressed that a lack of defensive protection against the disease, and difficulties keeping up with daily changing knowledge/skills contributed to fear. the media was also noted to play a role in amplifying uncertainty. ten studies , , , , , , , , , highlighted the importance of social support, with emphasis on the need for increased social support mechanisms and regular contact with families . a lack of family support and social isolation had a negative psychological impact on nurses who chose to isolate away from their families while treating sars patients. correspondingly, the lack of social support during the sars outbreak brought out discrimination from the community as well as distancing behavior from hcws' own families. a study of , nurses identified three attitudinal factors j o u r n a l p r e -p r o o f (health fear, social isolation and job stress) mediated the association between contact with sars patients and psychological stress. the levels of anxiety, stress, and selfefficacy exhibited amongst chinese hcws in wuhan during the covid- pandemic appeared dependent on their degree of social support and quality of sleep. stigma was a major factor identified across five studies , , , , , and during the covid- pandemic, it was associated to a higher risk of depressive symptoms . in a large-scale study of , hcws, % experienced social stigmatization and % ostracism by family members. analogous findings, amongst nurses ( ) during a mers outbreak in korea found that stigma contributed negatively to the mental health of nurses through a direct effect but also indirectly via stress. amongst hcws findings showed that % ( of ) felt stigmatized and rejected in their neighborhood because of their hospital work, and % ( of ) reported reluctance to work or had considered resignation. hcws often found themselves working under high levels of physical and psychological stress , sometimes attributed to work conditions. during the covid- pandemic, long work hours were found to increase stress levels amongst nurses. similarly, the burden of adhering to strict protective measures seemed to increase distress levels. the heavy protective gear was found to add to the physical difficulties of carrying out procedures. spanish hcws who perceived protection as insufficient rated higher levels of depression, anxiety and acute stress than those who perceived it to be adequate. contrastingly, findings from , hcws during the sars outbreak demonstrated that % reported that the personal protective measures implemented j o u r n a l p r e -p r o o f were effective, % felt that institutional policies and protocols were clear and % felt they were timely. similar findings were depicted by hcws who generally declared confidence in infection-control measures. measures to address the psychological risks to hcws during epidemics thirteen studies , , , , , , , , , , , , considered coping strategies, such as acceptance, resilience, active coping and positive framing. of hcws, doctors were significantly more likely than nurses and health care assistants (hcas) to use planning as a coping strategy, while nurses were more likely than doctors to use behavioural disengagement, and hcas were more likely than doctors to use selfdistraction. amongst american hcws, exercise was the most commonly used coping strategy ( %), and access to an individual therapist with online self-guided counselling ( %) generated the most interest. support from supervisors and colleagues was found to be a significant negative predictor for psychiatric symptoms and ptsd. further mental health predictors amongst a group of chinese emergency hcws included the tenacity, strength and the availability of support. in a study of hcws, psychological support and practical support with insurance and compensation matters had a protective effect against stress. in parallel with this, positive feedback emerged when counsellors asked the medical staff to share how they coped with this difficult situation. several studies , , , , identified a need for greater support through collaboration, training and education. this appeared to strengthen teams and have protective effects in reducing hcw stress as simple protective measures were reassuring for hcws . additionally, clear communication was seen to reduce psychiatric symptoms. the duration of follow-up was not specified in most studies and there was a lack of studies on the long term supports for hcws post-epidemic. while others emphasised the need for prompt and continuous psychiatric interventions in high mortality infectious disease outbreaks. , , , imminent utilisation of interventions promoting wellbeing for hcws facing covid- was suggested for frontline workers, females and nurses. furthermore, it is important that nurses are not stigmatised and policymakers should make efforts to ensure this stress is minimised and also allow them to focus on patient care. stigma could also be minimised through an integrated administrative and j o u r n a l p r e -p r o o f psychosocial response to challenges that are caused by outbreaks. there is a need for the development of prevention programs for stress related psychiatric disorders. in addition, health authorities should provide proactive psychological support for staff by offering support and training, counselling hotlines and offer reimbursements to staff. workplace awareness and measures many recommendations focused on enhanced awareness amongst authorities or hospital administrators of their employees' mental health. only two qualitative studies met inclusion criteria and the rest were quantitative studies. the majority of studies used online survey methodology and self-report measures which have inherent limitations. there was a lack of longitudinal studies and therefore little evidence on the long term psychological sequelae and treatment needs. further, indepth research considering the pre-and post-outbreak psychological risk factors, the effects of stigma and discrimination or impact on families is lacking. of note, it was difficult to compare studies due to heterogeneity of design and outcome measures. geographic factors may have influenced results due to unique social and cultural contexts amongst the study locations where research was conducted. from this review of hcws, fear of uncertainty or becoming infected in the course of their work were at the forefront of the psychological challenges faced. providing medical care during a global epidemic generates fear and heightens stress levels, with one large-scale study reporting over % identified that becoming infected was most distressing. during the covid- pandemic, hcws have been exposed to high infection risk, death and dying, moral dilemma in deciding who qualifies for intensive care, and excessive workloads. the entire experience can be traumatising and heighten the risk of mental health conditions in a group that are already at increased risk, for instance hcws are at higher risk of suicide than the general population. it is likely that the psychological effects of epidemics on hcws are variable across different contexts with several studies demonstrating an increased risk of acquiring a trauma or stress-j o u r n a l p r e -p r o o f related disorder. the risk to the mental well-being of hcws are likely to be multi-faceted and more research is needed to elucidate the underlying mechanisms that can potentially be mitigated with appropriate measures. collection of high quality data is urgently needed, especially for vulnerable groups exposed to a pandemic. interventions to reduce morbidity and severity of psychological problems in hcws in the early stage may prevent adverse short-term and long-term implications. it is important to note that professional recognition and ethics can positively reinforce hard work but the value of these are diminished when they are applied in a punitive way that stereotypes hcws. the emphasis on their self-sacrifice while providing essential and life-saving services becomes magnified in the midst of an epidemic and often hcws are portrayed as heroes. this in turn can impose certain expectations on them, to demonstrate personal strength and resilience, both emotionally and professionally. however, this can also impede their ability to recognise vulnerabilities or share traumatic experiences, similar in some aspects to military personnel. this may inadvertently increase their mental health risks and stigmatising beliefs, thus prevent them from seeking psychological help. as such, hcws must feel free to express their emotions and share experiences, both positive and negative, even when society portrays them as faceless masked agents, and hails them as heroes. severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers. psychological medicine factors associated with the psychological impact of severe prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak. psychiatric services emergencies preparedness, response website: world health organization real estimates of mortality following covid- infection. the lancet infectious diseases timely mental health care for the novel coronavirus outbreak is urgently needed. the lancet psychiatry protecting health care workers from ebola: personal protective equipment is critical but is not enough unprecedented number of medical staff infected with ebola [online] geneva: world health organization posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a -year follow-up study. general hospital psychiatry psychological first aid during ebola virus disease outbreaks workforce development at the local level: the naccho perspective sustainability of psychological first aid training for the disaster response workforce long-term psychiatric morbidities among sars survivors. general hospital psychiatry mental health of nurses working at a government-designated hospital during a mers-cov outbreak: a cross-sectional study mental symptoms in different health professionals during the sars attack: a follow-up study. the psychiatric quarterly prevalence of psychological symptoms among ebola survivors and healthcare workers during the - ebola outbreak in sierra leone: a crosssectional study the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk psychological impact of the mers outbreak on hospital workers and quarantined hemodialysis patients psychological effects of the sars outbreak in hong kong on high-risk health care workers psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore risk perception and impact of severe acute respiratory syndrome (sars) on work and personal lives of healthcare workers in singapore what can we learn? medical care factors associated with mental health outcomes among health care workers exposed to coronavirus disease survey of insomnia and related social psychological factors among medical staff involved in the a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease mental health outcomes among frontline and second-line health care workers during the coronavirus disease (covid- ) pandemic in italy mental health impact of covid- pandemic on spanish healthcare workers the prevalence and influencing factors in anxiety in medical workers fighting covid- in china: a cross-sectional survey impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study. brain, behavior, and immunity mental health and psychosocial problems of medical health workers during the covid- epidemic in china work stress among chinese nurses to support wuhan in fighting against covid- epidemic prevalence, risk factors, and clinical correlates of insomnia in volunteer and at home medical staff during the covid- . brain, behavior, and immunity psychological status of medical workforce during the covid- pandemic: a cross-sectional study the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china psychological impact on women health workers involved in covid- outbreak in wuhan: a cross-sectional study tackling the mental health burden of frontline healthcare staff in the covid- pandemic: china's experiences. psychological medicine the psychological status of hospital workers during covid- : a cross-sectional study in chongqing prevalence and predictors of stress, anxiety, and depression among healthcare workers managing covid- pandemic in india: a nationwide observational study effect of covid- pandemic on mental wellbeing of healthcare workers in tertiary care hospital assessment of mental health factors among health professionals depending on their contact with covid- patients epidemic on medical staff in different posts in china: a multicenter study mental health burden of frontline health professionals treating imported patients with covid- in china during the pandemic psychological distress, coping behaviors, and preferences for support among new york healthcare workers during the covid- pandemic. general hospital psychiatry impact of covid- on the mental health of healthcare professionals in pakistan covid- psychological impact in healthcare workers in spain: the psimcov group anxiety and depression and the related factors in nurses of guilan university of medical sciences hospitals during covid- : a web-based cross-sectional study mental health status of paediatric medical workers in china during the covid- outbreak the mental health effects of covid- on health care providers in china the anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in covid- services psychological distress surveillance and related impact analysis of hospital staff during the covid- epidemic in chongqing, china frontline nurses&#x ; burnout, anxiety, depression, and fear statuses and their associated factors during the covid- outbreak in wuhan, china: a large-scale cross-sectional study immediate psychological impact on nurses government-designated hospital during covid- outbreak in china: a crosssectional study depression, anxiety, stress levels of physicians and associated factors in covid- pandemics psychological symptoms among frontline healthcare workers during covid- outbreak in wuhan. general hospital psychiatry mental health of healthcare workers during the covid- a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak the mental health of frontline and non-frontline medical workers during the coronavirus disease (covid- ) outbreak in china: a case-control study psychological effects of the covid- pandemic: perceived stress and coping strategies among healthcare professionals prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the covid- outbreak survey of stress reactions among health care workers involved with the sars outbreak the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak the impact of work-related risk on nurses during the sars outbreak in hong kong vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid- control the psychological impact of sars on health care providers dying and caring on the edge: taiwan's surviving nurses' reflections on taking care of patients with severe acute respiratory syndrome suicide among physicians and health-care workers: a systematic review and meta-analysis multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science. the lancet psychiatry uk military doctors; stigma, mental health and help-seeking: a comparative cohort study first responders and psychological first aid resilience scale- . dsm-iv=diagnostic and statistical manual of mental disorders ghq- = general health questionnaire mers=middle east respiratory syndrome mspss=multidimensional scale of perceived social support primary care ptsd screen for dsm- . phq- = patient health questionnaire- . phq- =patient health questionnaire- . phq- =patient health questionnaire. phq- = patient health questionnaire- scid=structured clinical interview for dsm-iv. scl- -r=symptom checklist- -revised. scl- = symptom checklist- . sds=zung self-rating depression scale sf- = medical outcomes study short form survey ☐ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒the authors declare the following financial interests/personal relationships which may be considered as potential competing interests:the corresponding author is not a recipient of a scholarship. there is no funding associated to this study. sonja cabarkapa, sarah nadjidai and jerome murgier have no conflicts of interest. chee ng declares receiving the following over the last months; travel support and honorarium for delivery of talk from both lundbeck and pfizer. he has also received travel support and honorarium for consulting service for janssen. key: cord- -dueab authors: imran, nazish; masood, hafiz muhammad umar; ayub, maryam; gondal, khalid masood title: psychological impact of covid- pandemic on postgraduate trainees: a cross-sectional survey date: - - journal: postgrad med j doi: . /postgradmedj- - sha: doc_id: cord_uid: dueab background: the present study aimed to evaluate psychological impact of covid- outbreak on postgraduate trainees in pakistan by quantifying the symptoms of depression, anxiety and acute stress disorder and by analysing potential risk factors associated with these symptoms. methods: following institutional review board approval, a cross-sectional study was conducted among , postgraduate trainees following covid- outbreak through e-log system of college of physicians and surgeons of pakistan. the nine-item patient health questionnaire, seven-item generalised anxiety disorder scale and stanford acute stress reaction questionnaire were used to collect data. statistical analyses were conducted using spss. . descriptive statistics, mann-whitney u test, the χ( ) test and logistic regression analysis were performed. the significance level was set at α= . . results: the prevalence of depressive symptoms, generalised anxiety disorder and acute stress disorder were . %, . % and . %, respectively. female postgraduate trainees, senior trainees and front-line workers reported experiencing more anxiety, depression and acute stress symptoms (p value< . ). logistic regression showed that being a front-line and senior staff member and female was associated with higher risk of experiencing symptoms of depression, anxiety and acute stress. conclusions: our study findings raise concerns about the psychological well-being of postgraduate trainees during the acute covid- outbreak in pakistan. it is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during crisis situation such as covid- pandemic. the world health organization (who) identifies viral disease outbreaks like covid- pandemic as a serious threat to public health. similar to previous outbreaks like severe acute respiratory syndrome-corona virus (sars-cov) and middle east respiratory syndrome, covid- outbreak has also raised various difficulties for healthcare workers (hcws) around the globe including increase workload, limited availability of personal protective equipment, scarcity of life-saving resource, frustration, isolation and 'fear of possible infection in themselves and their families'. all these factors are likely to increase psychological distress among hcws. recent literature also suggests that hcws are very vulnerable to emotional distress during covid- . [ ] [ ] [ ] insufficient data are currently available from lowand middle-income countries (lmics) regarding changes in prevalence of depression during the pandemic. however, a recent study conducted in india found . % of hcws having depression during covid- pandemic, which is much higher than the % prevalence for common mental disorders reported in its general population. postgraduate trainees are among the most vulnerable hcws even in usual times with high prevalence of burnout and psychological morbidity. previous studies report that junior doctors feel pressured and resentful that the primary care in acute situations is often left to them. during covid- pandemic, postgraduate trainees are likely to be the main workforce to deal with the impending influx of patients with covid- . mobilisation of postgraduate trainees to high demand departments, high likelihood of contacting suspected or confirmed cases with covid- , making difficult ethical decisions, cancellation of teaching programmes, and study leaves, uncertainty regarding jobs and rotations are some of the concerns identified by junior doctors during covid- pandemic and are likely to adversely impact their mental and physical well-being. similar views have been reported from pakistan. a recent rapid review shows that presence on front lines, being younger and being more junior is associated with increased risk of psychological distress in hcws during viral outbreaks. the psychological distress is associated with medical errors and lapses in professionalism as well as high risk of serious psychiatric problems including suicidal ideation. although psychological distress is to be expected during covid- in lmics like pakistan, where postgraduate trainees in particular are under pressure to look after a large number of potentially infectious patients, institutions, supervisors and employers can help to mitigate this by implementation of several effective interventions. however, their psychological well-being has not been formally evaluated so far. to address this gap, the present study aimed to evaluate psychological impact of covid- outbreak on postgraduate trainees in pakistan by quantifying the symptoms of depression, anxiety and acute stress, and by analysing potential risk factors associated with these symptoms. this was a cross-sectional study conducted following covid- outbreak, through e-log system of college of physicians and surgeons (cpsp) from april to may . cpsp is the largest internationally recognised postgraduate medical institute in pakistan established in and is responsible for postgraduate medical training and research. it awards fellowships in specialities/subspecialities and membership in disciplines. all postgraduate trainees inducted from onwards in cpsp residency programmes have to make entries of all academic activities and work performed in mandatory e-logbook using their registration numbers and passwords. trainees are unable to enter activities that are more than months old. supervisors verify the entries on a regular basis helping in monitoring the progress of trainees. currently, there are , postgraduate trainees enrolled with cpsp. our study target population was postgraduate trainees who would access their e-logbook during the study duration from april to may . all trainees accessing e-portal were able to see the survey and answer the questionnaire by clicking on the relevant link. among the , trainees, who accessed e-log portal during the study period, , participated with a response rate of . %. institutional review board approved the study. participation was voluntary; all study participants provided informed consent, and confidentiality of information was assured. demographic data collected from the participants included age, gender, marital status, speciality, year of residency, and medical and psychiatric history. residents who were directly involved in diagnosing, treating or providing care to patients with diagnosed or suspected patients with covid- on self-report were classified as frontline workers, while others were considered as second-line workers. furthermore, postgraduate trainees in the first years of residency were classified as junior trainees and those in year and year were considered as senior residents. the questionnaire included three validated questionnaires in english language focusing on depression, anxiety and acute stress disorder. the nine-item patient health questionnaire (phq- ) was used to screen and measure the severity of symptoms of depression. it has nine items, score of each item ranges from to with total score range being - . the scores are interpreted as normal ( - ), mild ( - ), moderate ( ) ( ) ( ) ( ) ( ) and severe ( - ) depression. as recommended, phq- -total score of points or greater was defined as the presence of depressive symptoms for the current study. the seven-item generalised anxiety disorder (gad- ; range - ) was used to assess the severity of symptoms of anxiety. the scores are interpreted as normal ( - ), mild ( - ), moderate ( ) ( ) ( ) ( ) ( ) and severe ( ) ( ) ( ) ( ) ( ) ( ) ( ) anxiety. stanford acute stress reaction questionnaire (sasrq; range - ) questionnaire was used to measure residents acute stress in accordance with diagnostic and statistical manual of mental disorders, fourth edition, criteria for acute stress disorder. the sasrq is a six-point likert scale consisting of items assessing dissociation, re-experiencing, avoidance, anxiety and hyperarousal. each item has a score of between and , with a combined score ranging from to , and a higher score indicating higher levels of self-reported stress. to meet acute stress disorder criteria, respondent had to indicate having at least three of five possible dissociation symptoms, and at least one symptom each of hyperarousal, anxiety, avoidance and reexperiencing of stressful event. information to access confidential psychological support was also provided during the study. data were analysed using spss version . (ibm corp., ny, usa). a descriptive analysis was conducted using numbers and percentages for categorical data and mean±sd for continuous data. medians with iqrs were reported for the skewed data values, mann-whitney u test was performed for comparison between the groups. data for each level for symptoms of depression, anxiety, and stress were presented as numbers and percentages. the significance level was set at α= . . qualitative variables were compared using χ test. logistic regression analysis was performed to observe the potential risk factors for symptoms of depression, anxiety and acute stress in participants. factors with significant association (p< . ) with the outcome variables at univariate analysis level were further included in the final multivariate analysis model. the associations between risk factors and outcomes are presented as ors and % cis, after adjustment for confounder variables. a total of , postgraduate residents completed the survey with majority ( %) being female and belonging to surgery and allied speciality ( %). a total of ( %) were directly involved in diagnosing, treating or providing care to patients with diagnosed or suspected patients with covid- (frontline workers). table gives further demographic details of the study participants (table ) . the prevalence of depressive symptoms, gad and acute stress disorder was . %, . % and . %, respectively (table ) . the values for women were higher than those for man in all scales (p value< . ). the median (iqr) scores on the phq- for depression, the gad- for anxiety and the sasrq for acute stress disorder for all respondents were . ( . - . ), . ( . - . ) and . ( . - . ), respectively. female residents, front-line workers and senior residents had higher scores in depression, anxiety and acute stress subscales compared with those men, second-line workers and junior staff (table , online supplemental table s ). all these three groups also reported experiencing more severe symptom levels on psychiatric outcome variables (table ) . the associations of potential risk factors with depressive symptoms, gad and acute stress disorder during covid- outbreak are presented in table . in the logistic regression models, being female (or= . , % ci . to . ) and front-line worker during covid- (or= . , % ci . to . ) and senior resident (or= . , % ci . to . ) were significantly associated with depression in residents. similarly, being female, senior resident and front-line worker during covid- also appeared to be an independent risk factor for anxiety and acute stress symptoms after adjustment (table ) . discussion covid- pandemic had a considerable impact on healthcare systems worldwide, and threaten not only the physical health but also psychological and social health of hcws including junior doctors. to our knowledge, this study is the first largescale national survey in pakistan to investigate the psychological impact of covid- pandemic on postgraduate trainees. this cross-sectional survey enrolled , respondents, and overall, our findings raise concerns about the psychological well-being of postgraduate trainees involved in the acute covid- outbreak. even prior to pandemic, lmics have reported higher prevalence of depressive disorders and anxiety than the aggregate prevalence for very high human development index countries in the world. people in lmics, including pakistan, are exposed to more stressors, which alongside greater stigma and social inequalities leads to less likelihood of accessing timely treatment. in the absence of any large population-based studies from pakistan looking at the relative change or increase in anxiety and depression during the covid- pandemic, we are unable to comment that symptoms observed in postgraduate trainees in our study differ from those of the general population. our study contributes to literature on prevalence of psychological symptoms in postgraduate trainees. prevalence of gad and depression as . % and . %, respectively, in our sample are in line with few recent studies of hcws during covid- . zhu et al reported prevalence of anxiety symptoms as . %, while in another web-based survey of hcws in china, . % of hcws appeared to have depressive symptoms. however, these results are in contrast with extremely high prevalence ( %- %) of psychological morbidity in some reports from china, particularly in wuhan province and in neighbouring india. similarly, prevalence of acute stress disorder as . % in our sample, although closer to % observed in a study following sars outbreak in taiwan in , is very low compared to . % reported by zhu et al during current covid- outbreak. this comparatively low psychological morbidity in our sample may partially be explained due to relatively lower ( . %) covid- case fatality of pakistan as compared to usa ( . %), italy ( . %), uk ( . %), iran ( . %) and china ( . %). another reason may be the timings of the study, as it was conducted prior to the peak of the cov outbreak in pakistan, when healthcare system was coping well comparatively. the differences in the results between various studies in the literature can also be contributed to variability in study settings, methodologies, instruments used to assess the psychological morbidity and participants' backgrounds such as age and culture. previous small-scale studies done to assess psychological morbidity among postgraduate trainees in pakistan found that % had depression symptoms and % had moderate anxiety. thus, although many other factors may have contributed, our results indicate that covid- outbreak perhaps led to increase in prevalence of depression and anxiety among postgraduate trainees in pakistan. increase workload, sleep deprivation, being junior resident and pay disparity were observed to be associated with depression in junior doctors in pakistan in literature. these stressors are likely to be compounded by high risk of infection, inadequate safety equipment, social isolation-especially from family-and physical exhaustion leading to high psychological morbidity during these challenging times. female postgraduate trainees in our sample had higher prevalence of psychological morbidity as well as more severe symptoms on all psychological measures. previous studies have also demonstrated that female gender is associated with increased vulnerability to psychological distress. similar to recent literature, front-line workers and those directly exposed to patients with covid- in our sample had high risk of developing psychological symptoms. this is understandable given that not only front-line postgraduate trainees are more exposed to the risk of covid- infection themselves but also have to deal with the sickest patients. our results of senior postgraduate trainees having significantly high psychological morbidity than year and year trainees are different from existing literature, in which less clinical experience has been linked with high adverse psychological outcome. this could be explained by observed practice in hospitals in pakistan of senior postgraduate trainees being given more responsibility of looking after covid- units, intensive care units and high dependency units, thus perhaps being more exposed to patients at greatest risk of dying from the covid- illness. however, this finding warrants further research. although all the health resources of the country are currently deployed towards service provision for increasing number of patients with covid- , the policy makers in teaching and training institutions need to make special efforts to promote the psychological well-being of post-graduate trainees. selfcare, need to maintain healthy balance lifestyle during residency training and in future careers and building skills in resilience should be emphasised in the training curriculum. adequate training around infectious diseases and provision of adequate personal protective equipment should be recommended to all institutions. the postgraduate trainees should have appropriate work shifts, regular breaks and guaranteed supplies. encouragement among peers, adequate supervision and access to psychological interventions should be guaranteed in order to deal with the psychological problems. psychological first aid for front-line workers has also been recommended by who and includes the assessment of needs and concerns; practical care and support; basic needs provision; empathic listening; and access to information, services and social supports. these steps can allow postgraduate trainees to function at their best during this global health emergency. the study has some limitations. although all scales showed very good reliability (cronbach's alpha > . ) in our sample, only phq- and gad- has been previously validated in pakistani population. as the study was cross sectional, we cannot evaluate the temporality and causality of the observed factors. psychological assessment in our study was based on self-report tools. the use of clinical interviews may help in a more comprehensive assessment. we also cannot exclude the possibility of a response bias. almost % of total enrolled residents in e-log portal ( / ) accessed it during the study period. it may be possible that many medical residents, who were directly participating in the care of patients with covid- and thus having increase likelihood of psychological morbidity, were too busy to log in during the study duration. also, residents who saw but did not responded to survey may have been too stressed out and overwhelmed to respond, thus skewing the results. alternatively, those who received the survey but did not reply may have had no distress and therefore were not interested in responding. furthermore, our study was conducted during a critical period of the covid- pandemic in pakistan when cases were still rising but prior to mid-june (the days that pakistan saw the peak of covid- cases and most likely high stressful time for hcws). longitudinal approach might help verifying whether long-term overload and distress develops as cases with covid- reach their peak in the country and whether psychiatric disorders, especially posttraumatic stress disorder, might occur with the covid- progression. despite the limitations, this study has significant strengths. to the best of our knowledge, this is the first national study to report the psychological symptoms among postgraduate trainees during the covid- pandemic. the data represented all four provinces and included trainees from multiple specialities. thus, the results of the study can be considered representative of postgraduate trainee doctors' psychological well-being during this outbreak. to conclude, the present study provides insight into the potential immediate psychological sequelae of covid- pandemic on postgraduate trainees in the resource-constrained setting of a lmic. our results show high levels of depression and anxiety experienced by trainees caring for patients with covid- in pakistan. female residents, those in the third and fourth year of residency and front-line workers experience more psychological distress. it is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during a crisis situation such as covid- . further research is needed to assess the long-term impact of this outbreak on trainee mental health as well as effectiveness of interventions to improve their psychological well-being. contributors ni and kmg conceived the idea of this study. ni, hmum and ma did literature review. ni, hmum and kmg collected and analysed data. ni and ma prepared tables and wrote the first draft of manuscript. hmum and kmg helped with writing-reviewing and editing. kmg was responsible for the supervision of this project. all authors approved the final version of this article. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. ethics approval approved by institutional review board and permission obtained from cpsp. provenance and peer review not commissioned; externally peer reviewed. data availability statement all data relevant to the study are included in the article or uploaded as supplementary information. supplemental material this content has been supplied by the author(s). it has not been vetted by bmj publishing group limited (bmj) and may not have been peerreviewed. any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by bmj. bmj disclaims all liability and responsibility arising from any reliance placed on the content. where the content includes any translated material, bmj does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/ or omissions arising from translation and adaptation or otherwise. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, noncommercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. ► high psychological distress among postgraduate trainees during covid- pandemic is reported in pakistan. ► female postgraduate trainees and those working as front-line healthcare workers reported experiencing more anxiety, depression and acute stress symptoms. ► senior postgraduate trainees reported more anxiety and depression symptoms. ► provision of adequate psychosocial support for postgraduate trainees during a crisis situation such as covid- outbreak is essential. ► studies outside pakistan, with larger sample size and similar/ uniform scales and cut-off points are needed for comparison. ► further research is needed to explore the reasons for senior residents having high prevalence of anxiety and depression. ► longitudinal studies with larger sample sizes are needed to understand the long-term mental health consequences of this devastating global pandemic on postgraduate trainees. ► qualitative research will also be helpful to gain insight into the impact of covid- pandemic on postgraduate trainees' psychological well-being. what is already known on the subject ► the unprecedented nature of the covid- pandemic challenges is likely to cause extreme psychological stress among the healthcare workers. orcid id nazish imran http://orcid.org/ - - - world health organization. current novel coronavirus ( -ncov) outbreak. b occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors associated with mental health outcomes among health care workers exposed to coronavirus disease generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey psychological status of medical workforce during the covid- pandemic: a cross-sectional study psychological impact of covid- on ophthalmologists-in-training and practicing ophthalmologists in india burnout in medical residents: a review the impact of severe acute respiratory syndrome on medical house staff: a qualitative study lostis e covid- : junior doctors are worried about their physical and mental health mental health of medical workers in pakistan during the pandemic covid- outbreak association of resident fatigue and distress with perceived medical errors suicidal thoughts among medical residents with burnout the phq- : validity of a brief depression severity measure optimal cut-off score for diagnosing depression with the patient health questionnaire (phq- ): a meta-analysis a brief measure for assessing generalized anxiety disorder: the gad- psychometric properties of the stanford acute stress reaction questionnaire (sasrq): a valid and reliable measure of acute stress prevalence of depression in the community from countries between risk factors, prevalence, and treatment of anxiety and depressive disorders in pakistan: systematic review covid- in wuhan: immediate psychological impact on health workers survey of stress reactions among health care workers involved with the sars outbreak mortality analyses johns hopkins coronavirus resource center frequency of anxiety and depression among doctors at postgraduate resident level anxiety and depression in doctors undergoing postgraduate training courses at armed forces postgraduate medical institute rawalpindi mental health and psychosocial problems of medical health workers during the covid- epidemic in china facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital key: cord- -bp q plt authors: zhang, yuan; wang, shu; ding, wei; meng, yao; hu, huiting; liu, zhenhua; zeng, xianwei; guan, yuguang; wang, minzhong title: status and influential factors of anxiety depression and insomnia symptoms in the work resumption period of covid- epidemic: a multicenter cross-sectional study date: - - journal: j psychosom res doi: . /j.jpsychores. . sha: doc_id: cord_uid: bp q plt objective: in this study, the authors analyzed the status of anxiety depression and insomnia symptoms and influential factors in the work resumption period of coronavirus disease (covid- ). methods: a multicenter cross-sectional survey was conducted from march , to march , in shandong province, china, using quota sampling combined with snowball sampling. the generalized anxiety disorder- (gad- ), the patient health questionnaire- (phq- ), and the insomnia severity index (isi) were used to assess the anxiety, depression, and insomnia symptoms. the multivariate logistic regression analysis was used to explore the influential factors. results: a total of invitations were sent from three centers, valid questionnaires were received. based on gad- , phq- , and isi scales, . %– . % of the participants had anxiety, depression, or insomnia symptoms; . %– . % had severe symptoms. besides, . %, . %, and . % of the participants had anxiety-depression, anxiety-insomnia, or depression-insomnia combined symptoms. the scores of anxiety and insomnia symptoms, along with scores of depression and insomnia symptoms were positively correlated in these samples. aged – years and outside activities once in ≥ days were risk factors of anxiety, depression, and insomnia symptoms in common. during the epidemic, . % of the participants had received psychological interventions, and only . % had received individual interventions. conclusions: the incidence of psychological distress increased during the outbreak of covid- in the work resumption period than the normal period. current psychological interventions were insufficient; target psychological interventions should be conducted in time. the outbreak of coronavirus disease (covid- ) became a global health threat in early [ , ] . the covid- was highly infectious and fatal to some patients [ ] . so far, there was no specific remedy [ ] . to control the spread of covid- , the chinese government implemented a strict restriction on outdoor activities from the spring festival [ ] . by the late february , the epidemic was effectively controlled in mainland china [ ] . on february , , the state council of the p.r.c. published a guideline for the prevention and control of covid- during the work resumption period, which announced the permission of work resumption [ ] . as the epidemic has not been completely resolved [ ] , the work resumption procedure was gradually conducted and cross-regional activities were still restricted. the panic caused by the epidemic, the communication reduction caused by interpersonal isolation, and the economic impact caused by production suspension can trigger the stress response, which may induce psychological distress even mental illness [ ] [ ] [ ] [ ] [ ] . previous studies suggested that the severe acute respiratory syndrome (sars), the middle east respiratory syndrome (mers), and the ebola virus disease (ebola) epidemics had serious psychological influences to a wide range of people [ ] [ ] [ ] . it is necessary to conduct target psychological intervention timely and effectively to prevent psychological distress from worsening. although previous studies conducted some investigations of the psychological status during the outbreak of covid- , there was limited analysis of the psychological status and influential factors in the work resumption period [ , , ] , and this is a global research gap for covid- research [ ] . in the work resumption period, the present study consisted of a pre-investigation and a formal investigation. the pre-investigation was launched from february , (next week after the permission of work resumption [ ] ) to february , . the objectives of the pre-investigation were to foster multicenter collaboration, to assess sampling procedure, to examine the accessibility of the questionnaire, and to determine the sample size of the formal investigation. the three collaboration centers sent a total of invitations ( for each center) and received ( . %) valid questionnaires. the proportion of participants with anxiety, depression, or insomnia symptoms was . - . %. based on the pre-investigation, the permissible error was set as . and the drop-out rate was set as . %. the clopper-pearson formula for two-sided confidence intervals for one proportion was used to determine the sample size. after calculation in pass software (ncss llc., kaysville, utah, usa; version ), the desired dropout-inflated enrollment sample size was . the number of invitations sent in the formal investigation was set as . the official investigation was performed from march , , to march , . as cross-regional outside activities were still restricted, it was impossible to conduct a random sampling procedure by investigating from house to house. a population-based representative quota sampling method combined with a snowball sampling method was designed. first, the proportion of the population in each region was determined according to the census of shandong province (published in , data as of the end of ) [ ] . the quotas for invitations sent was based on the proportion of population in these three regions (western region (western center): n = ; middle region (middle center): n = ; eastern region (eastern center): n = ). second, a cross-control quota sampling procedure for characteristics of the population (subregion, age, gender, occupation) in each region was conducted. third, based on online unified questionnaire or a telephone survey (for people who cannot answer online, such as elderly; the content is consistent with the online questionnaires). all participants were required to answer only once through one review method. a detailed description of the similar sampling method has been published elsewhere [ ] . figure shows the sampling process. the questionnaire consisted of three parts. the first part collected characteristics, (public, individual). the third part was standardized scales, including gad- , phq- , and isi, to assess anxiety, depression, and insomnia symptoms. participants were required to respond based on the experiences of the past two weeks. the suitable classification standards of these three scales were determined by the chinese consensus reviewed by psychologists. the gad- , phq- , and isi score ≥ , , indicate anxiety, depression, and insomnia symptoms; scores ≥ , , indicate severe anxiety, severe depression, and severe insomnia symptoms. for participants aged under , total scores ≥ points in phq- is consider to have depression symptoms [ ] . at the end of the questionnaire, a trust question was set as "did you answer truthfully". questionnaires with "no" response in the trust question, the all statistical analyses were performed using the spss software package (ibm, armonk, new york, usa; version ). the influential factors of anxiety, depression and insomnia symptoms were analyzed by logistic regression. the division of ages was consistent with the chinese epidemiology study of mental disorders by huang et al. [ ] in the normal period and the cross-sectional study of psychological status by wang et al. [ ] in the outbreak of covid- to set as contracts. variables showing a p-value of < . in the univariate analysis (pearson x or fisher exact test) were then entered into a multivariate logistic regression analysis with a backward method. the or value and its % confidence interval ( %ci) were given for independent factors, and the or value > indicated risk factors. besides, after the gad- , phq- , and isi scores of the participants were tested for normality (kolmogorov-smirnov test), pearson's correlation analysis was performed to explorer the correlation of scores. a p value of < . was considered statistically significant. table shows the participants' characteristics and experiences related to the covid- epidemic. according to the gad- , phq- , and isi scales, . % ( ) table . ). the wildly spread covid- epidemic and strict interpersonal isolation can trigger stress response [ ] . the occurrence of stressful life events is a risk factor for psychopathology, and environmental stressors also induce stable changes in gene expression within the brain that may lead to mental illnesses [ , ] . coming into the work resumption period, many factors can become stressors of a wide range of people in a comprehensive effect, including epidemical panic, interpersonal isolation, economic volatility, and resumption status. the present study revealed that resumption period than the normal period. an online survey [ ] and another study on chinese web users [ ] suggested that one-third of people had anxiety symptoms during the outbreak of covid- and the negative emotion increased. but they only focused on web users, which might limit their overall representation. a previous nationwide cross-sectional study of the research team was conducted from february , to february , (during the outbreak of covid- ) in china with a similar design of the present study. they proposed . %, . %, and . % of the participants had anxiety, depression, or insomnia symptoms. the proportion of anxiety, depression, and insomnia symptoms got increased the present study [ ] . wang et al. besides, the present study also showed that . %, . %, and . % of participants had anxiety-depression, anxiety-insomnia, or depression-insomnia combined symptoms. the scores of anxiety and insomnia symptoms (r = . ), along with scores of depression and insomnia symptoms (r = . ) were positively correlated in these samples. previous studies suggested that environmental stressors or physiological disease might cause the comorbidity of anxiety, depression, or insomnia, which could provide a great challenge in the diagnosis and intervention [ , ] . the comorbidity of anxiety and depression could make psychological distress worse and reduce treatment response, which should be considered [ ] . sleep disturbance is a common manifestation of anxiety and depression. insomnia has been identified as a predictor of multiple mental disorders and could increase the risk for psychopathology [ ] . efforts should be made to strengthen interventions for sleep problems such as cognitive behavior therapy and mindfulness-based therapy [ ] . this study also analyzed the risk factors for anxiety, depression, and insomnia according to an epidemiological study of mental disorders, chinese aged - years had a higher incidence of mental illness than the other age groups [ ] , which may explain the higher prevalence of anxiety, depression, and insomnia symptoms in participants aged - years in the present study. furthermore, in china, many middle-aged and elderly people are in leadership positions in companies and families. the economic stress caused by the epidemic and work resumption could influence their mental health [ ] . therefore, middle-aged and elderly people, especially aged - years, are easier to have psychological distress that needs interventions. in addition, the previous study of wang et al. suggested participants aged - years had more severe anxiety, depression, and insomnia symptoms during the outbreak of covid- [ ] . this change in the high-risk age groups might be the combined influence of economic and epidemic pressure changes with time, which needs further exploration. affected by the covid- epidemic, a wide range of people reduced unnecessary outside activities and interpersonal communication, some of them even stayed home alone for a long time. in the present study, . % of the participants had outside activities once in ≥ days. previous studies suggested that the interpersonal isolation of patients had a significant impact on mental health [ ] . with further control of covid- , more and more people can restore interpersonal contacts and resume normal work in the future. the psychological distress may get released in some people. however, interpersonal isolation has a long-term influence on mental health, some people with psychological distress cannot relieve by himself, even after resuming interpersonal contacts [ ] . target psychological interventions should be performed in time to people under long-term interpersonal isolation before and after work resumption. in addition, several previous studies concerned the healthcare workers had a higher risk of psychological symptoms [ , , ] . the present study did not find being frontline medical staff was a risk factor of psychological distress, which might relate to the effectively control of the epidemic, lower proportion of confirmed patients, higher proportion of accepting psychological interventions for these group, and higher proportion of recovering patients. however, more attention in the present study, only . % of current participants had received psychological interventions, . % had received individual psychological interventions during the outbreak of covid- . compared with a previous study ( . % received counseling during the outbreak) [ ] , the proportion of people received psychological interventions got a great increase. but it was still insufficient for the potential proportion of people with psychological distress. the outbreak of covid- limited face-to-face counseling and individualized psychological interventions, which was a serious challenge to the mental health service. besides, there were still many people who did not pay enough attention to mental health [ ] . irvine et al. suggested that there was no significant difference between online or telephone psychological therapy and face-to-face psychological intervention in efficacy and detrimental effects [ ] . besides, community interventions by internet or telephone and app-supported smartphone interventions also showed advantages in promoting mental health [ , ] such as internet-based cognitive behavior therapy [ ] . however, some studies concerned that non-face-to-face psychological interventions might have defects in reliability and individualized treatment [ , ] . we suggest that under the current circumstances, individualized psychological interventions are still important for high-risk groups, and the others should adopt public psychological education. as the outbreak of covid- has not been completely resolved, online or telephone interventions can be chosen as preferred. when the epidemic is under control, individualized face-to-face psychological interventions should be resumed in time to adjusted for all other variables. phq- : the patient health questionnaire- ; * p < . (multivariate logistic regression); ** p < . (multivariate logistic regression). adjusted for all other variables. isi: the insomnia severity index; * p < . (multivariate logistic regression); ** p < . (multivariate logistic regression). epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study characteristics of covid- infection in beijing the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges national-health-commission-of-the-p.r.c., notice on strengthening community prevention and control of coronavirus disease the effect of human mobility and control measures on the covid- epidemic in china guidelines for the prevention and control of coronavirus disease during in the work resumption period covid- and italy: what next? do psychiatric patients experience more psychiatric symptoms during covid- pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak psychological impact of the covid- pandemic on health care workers in singapore neurological, cognitive, and psychological findings among survivors of ebola virus disease from the ebola outbreak in kikwit, democratic republic of congo: a cross-sectional study immediate psychological responses and associated factors during the initial stage of the covid- ) epidemic among the general population in china the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users pandemic: a global analysis of literature psychological distress and sleep problems when people are under interpersonal isolation during an epidemic: a nationwide multicenter cross-sectional study shandong statistical yearbook health-commission-of-the-shandong-province, epidemic status of coronavirus reliability and validity of a generalized anxiety scale in general hospital outpatients reliability and validity of the chinese version of the patient health questionnaire (phq- ) in the general population assessing insomnia in adolescents: comparison of insomnia severity index, athens insomnia scale and sleep quality index evaluation of the patient health questionnaire- item for detecting major depression among adolescents prevalence of mental disorders in china: a cross-sectional epidemiological study progression of mental health services during the covid- outbreak in china stressful life events and depressive symptomatology among basque adolescents: the mediating role of attachment representations depression and anxiety among pregnant women living with hiv in kilimanjaro region temperament clusters associate with anxiety disorder comorbidity in depression insomnia as a predictor of mental disorders: a systematic review and meta-analysis mental health strategies to combat the psychological impact of covid- beyond paranoia and panic depression and sleep duration: findings from middle-aged and elderly people in china impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis psychological interventions during covid- : challenges for low and middle income countries are there interactional differences between telephone and face-to-face psychological therapy? a systematic review of comparative studies community interventions to promote mental health and social equity the efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials moodle: the cost effective solution for internet cognitive behavioral therapy (i-cbt) interventions making multiple 'online counsellings' through policy and practice: an evidence-making intervention approach coverage of health information by different sources in communities: implication for covid- epidemic response demand for health information on covid- among vietnamese characterize health and economic vulnerabilities of workers to control the emergence of covid- in an industrial zone in vietnam reaching further by village health collaborators: the informal health taskforce of vietnam for covid- responses key: cord- -ktck y authors: lian, shuai-lei; sun, xiao-jun; niu, geng-feng; yang, xiu-juan; zhou, zong-kui; yang, chen title: mobile phone addiction and psychological distress among chinese adolescents: the mediating role of rumination and moderating role of the capacity to be alone date: - - journal: j affect disord doi: . /j.jad. . . sha: doc_id: cord_uid: ktck y background: with the increasing incidence of mobile phone addiction, mobile phone addiction has been considered to be related to adolescents’ psychological distress. however, the underlying mechanisms of this relation were still unclear. the present study tested the mediating role of rumination and the moderating role of the capacity to be alone in the relation between mobile phone addiction and psychological distress. methods: middle school students were recruited to complete measures of mobile phone addiction, rumination, the capacity to be alone, psychological distress and demographic variables. results: mobile phone addiction was significantly and positively associated with psychological distress, and this link could be mediated by rumination. moreover, the direct effect of mobile phone addiction on psychological distress and the indirect effect of rumination in this link were moderated by the capacity to be alone. both these two effects were stronger for adolescents with lower capacity to be alone. limitations: the present study is limited in terms of its sample selection, cross-sectional design, and self-reported instruments. conclusions: the present study advances our understanding of how and when or for whom mobile phone addiction is related to serious psychological distress. education professionals and parents should pay special attention to the psychological distress of adolescents suffering from mobile phone addiction, particularly for those with lower capacity to be alone. with the popularity of mobile internet devices, mobile internet has profoundly changed human thinking habits, and also influenced individuals' behavioral and psychosocial adaptation (barr, pennycook, stolz, & fugelsang, ; yang, zhou, liu, & fan, ) . as the most popular mobile internet terminal, mobile phone has become an essential medium to reshape the way of human existence and live. globally, % of people own mobile phones, of which % are smartphones (pew research center, ) . in china, the number of mobile phone users has reached million, and the population of mobile phone users is still increasing (cnnic, ). mobile phones not only change the ways of social interaction, leisure and entertainment, and information acquisition for adolescents, but also shape their behavioral modes, such as mobile payment, online finance, and online shopping. the multiple functions of mobile phones bring various conveniences and benefits to adolescents' everyday life. under this background, more and more individuals spend most of their spare time on mobile phones to satisfy their multiple needs (han, kim, & kim, ; weller, shackleford, dieckmann, & slovic, ) , which greatly enhances the user stickiness of mobile phones. namely, people form a habit of carrying or using mobile phones anytime and anywhere (kwon et al., ) , which further increases the risk for mobile phone addiction. recent research also revealed that more and more adolescents cannot live without mobile phones (han, kim, & kim, ; volkmer & lermer, ) , and even become addicted to mobile phones (chen et al., ) . these adolescents showed the similar symptoms of non-material addiction in their use of mobile phones (al-barashdi & jabur, ; kwon et al., ; min, dai-jin, hyun, soo, & doo-sup, ; leung, ) . data from multiple countries also showed that the incidence of mobile phone addiction among adolescents was % (he et al., ) . therefore, mobile phone addiction, as a significant risk factor of adolescents' mental health, has aroused the common concern of researchers and the public liu et al., ) . mobile phone addiction has been considered as an important inducement for a variety of psychological and behavioral adaptation problems seo et al., ; soni et al., ; yang, zhou, liu, & fan, ) . for instance, lepp et al. ( ) showed that mobile phone users may experience great anxiety and poor academic performance. soni et al. ( ) demonstrated that adolescents were not only addicted to smartphone usage but were also developing significant sleep and behavior problems owing to excessive smartphone usage. among these unfavorable outcomes, psychological distress, as the most direct psychological problem induced by excessive or uncontrolled use of mobile phones, has attracted more and more researchers' attention (chen et al., ; yang, zhou, liu, & fan, ) . prior studies have shown that mobile phone addicts not only experience more sleep disorders, but also have more procrastination liu et al., ) . poor sleep quality and procrastination have been proved to be associated with depression, anxiety and stress (steel, ; woods & scott, ) . therefore, adolescents addicted to mobile phones may have more psychological distress owing to their poor sleep quality and high levels of procrastination induced by excessive or uncontrolled use of mobile phones. besides, addictive mobile phone users may have more interpersonal problems, which are associated with psychological distress (chen et al., ) . in addition, bandura's concept of reciprocal determinism in social cognitive theory (bandura, ) demonstrated that individual' behavioral problems can affect their emotions. the cognitive-behavioral model (davis, ) also pointed that individuals' cognitions and emotions could be affected by their behavioral problems. empirical studies also showed that adolescents suffering from mobile phone addiction have more psychological distress, especially depressive symptoms and anxiety symptoms (yang, zhou, liu, & fan, ) . therefore, mobile phone addiction may be positively associated with psychological distress. although the positive association between mobile phone addiction and psychological distress has been proved, few studies have focused on the underlying mediating and moderating mechanisms in this relation. in other words, the questions about how (or why), and when (i.e., under what conditions) mobile phone addiction is related to psychological distress remain unclear. addressing these questions can provide efficient practical guidance for adolescents as well as for educators to develop intervention strategies. therefore, the present study begins to open the black boxes of how (or why) and when mobile phone addiction can be related to psychological distress. specifically, this study proposed a moderated mediation model to reveal the underlying mechanisms between mobile phone addiction and psychological distress. given that rumination has been considered as an effective role linking risk factors to individuals' psychological problems (feinstein, bhatia, & davila, ; liu et al., ; michl, mclaughlin, shepherd, & nolen-hoeksema, ) , this study will analyze rumination as a mediator to clarify the mechanisms of mobile phone addiction resulting in psychological distress. moreover, the capacity to be alone has been proved to be a powerful buffer, which could mitigate the adverse effects of risk factors on individuals' psychological adoption (larson & lee, ; wu & chen, ) . this study will shed light on the moderating role of the capacity to be alone to reveal the conditional direct and indirect effect of mobile phone addiction on psychological distress. in summary, this study could improve our understanding of how mobile phone addiction causes psychological distress, and under what condition or for whom the direct and indirect effects would be more significant. as a style of coping with negative mood and other negative life events, rumination is characterized by repetitive and passive focus on the causes and consequences of one's symptoms of distress without engagement in active coping or problem solving to alleviate dysphoric mood (nolen-hoeksema, ; treynor, gonzalez, & nolen-hoeksema, ) . according to the response style theory, rumination may prolong and exacerbate the negative effects of negative mood and other negative experiences by increasing negative thinking, deteriorating coping behaviors, and interacting with pessimistic cognitive process (nolen-hoeksema, ) . numerous studies suggest that rumination is prospectively associated with depressive symptoms, anxiety, perceived stress, and suicidal ideation (feinstein, bhatia, & davila, ; michl, mclaughlin, shepherd, & nolen-hoeksema, ; tucker et al., ) . given that depression, anxiety and stress are significant indicators of psychological distress (alfonsson, wallin, & maathz, ) , rumination may induce and exacerbate psychological distress. studies on the direct link between rumination and psychological distress also verified that rumination was an important predictor of psychological distress (geiger & kwon, ; morrison & rory, ) . for instance, a longitudinal study conducted by morrison and rory ( ) showed that rumination could positively predict psychological distress over time. given that rumination is among the most robust risk factors for psychological distress (o'connor, o'connor, & marshall, ) , various factors that may predict rumination have been concerned about. a large number of studies have revealed the predictive effects of stressful life events (michl, mclaughlin, shepherd, & nolen-hoeksema, ) , low self-esteem (kuster, orth, & meier, ) , cyber-victimization (feinstein, bhatia, & davila, ) , and negative social comparison on facebook (feinstein et al., ) on rumination. although few studies pay attention to the direct relationship between mobile phone addiction and rumination, it is reasonable to demonstrate the influence of mobile phone addiction on rumination. first, adolescents suffering from mobile phone addiction are more likely to be engaged into academic and interpersonal problems, which in turn causes rumination. previous studies showed that mobile phone addicts may experience more stressful life events, such as high levels of academic procrastination (jung & han, ) , poor interpersonal competence (kwon & paek, ) , and more interpersonal problems (chen et al., ) . these stressful life events were associated with lower self-esteem (samaha & hawi, ; sirois, ) . according to stress reactive model and related empirical research, rumination could be induced by low self-esteem and stressful life events (kuster, orth, & meier, ; michl, mclaughlin, shepherd, & nolen-hoeksema, ; robinson & alloy, ) . thus, rumination may be induced by negative events or experience resulting from mobile phone addiction. second, adolescents suffering from mobile phone addiction usually spend lots of time on social networking sites (cha & seo, ; salehan & negahban, ) . excessive engagement in social networking sites may lead to rumination. for instance, social networking sites use has been proved to trigger rumination (feinstein et al., ; shaw, timpano, tran, & joormann, ) . therefore, mobile phone addicts may experience more rumination owing to the negative social comparison on facebook they are involved in. besides, the stress reactive model of rumination also illustrated that negative life event was an important inducing factor of rumination (robinson & alloy, ) . therefore, mobile phone addicts experiencing more negative life events may ruminate more about their unsatisfactory state of life. in addition, a recent study further explored the direct relation between mobile phone addiction and rumination, and confirmed that adolescents suffering from mobile phone addiction may have more rumination after using cell phones over time . besides, previous studies also found that rumination could mediate both the relation between perfectionism cognitions and psychological distress (flett, madorsky, hewitt, & heisel, ) and the relation between negative social comparison on social networking sites and depression (feinstein et al., ) . a prior study also demonstrated that rumination could play a mediating role in the link between mobile phone addiction and sleep quality . as far as this study is concerned, mobile phone addicts may ruminate more about their negative mobile phone experience, which, in turn, makes them have more psychological distress. therefore, the present study hypothesized that rumination may act as a mediator in linking mobile phone addiction to psychological distress (hypothesis ). the capacity to be alone is not only one of the most important indicators of emotional maturity, but also nearly synonymous with emotional maturity (winnicott, ) . it was characterized by freedom from distraction and the possibility of focused attention, which may provide a unique opportunity to examine and clarify one's current stress and life situation (fiske, ) . the concept of the capacity to be alone was putted forward by larson and lee ( ) based on deliberately structured solitude. larson and colleagues argued that solitude refers to the absence of all of aspects of being with others, and divided solitude into involuntary solitude and constructive solitude (larson & lee, ) . involuntary solitude refers to the situation in which individuals yearned for company were forced to be alone; whereas constructive solitude refers to the state of solitude with high autonomy accompanied by more positive experience. they also considered that structured solitude, as the core connotation of the capacity to be alone, consists of two parts: solitary comfort (the degree to which an individual feels comfortable when he or she is alone) and solitary coping (the ability to cope with stress by using one's time being alone). the latest research suggested that solitude and alone were two different states (nguyen, weinstei, ryan, & deci, in press) . alone refers to the state of a person without any other person around physically. whereas solitude is a specific type of alone, one having the features of being both physically alone and free of specific activities. in other words, solitude means the absence of immediate social demands, constraints, and scrutiny, as well as the absence of the opportunity for relating, social engagement, and mutual enjoyment. according these views, larson and colleagues seemed to have ignored the connotation difference of alone and solitude, when they used the phrase "the capacity to be alone" to describe the two states of solitude coping and solitude. but this does not affect our understanding of the meaning of the capacity to be alone. it refers to the capacity of individuals handling stress and feeling emotional comfort using the time been alone in daily life (larson & lee, ) . individuals with high capacity to be alone may benefit more from their time being alone and have good psychological adaptation (detrixhe, ) . numerous studies have demonstrated that time being alone may serve as both cognitive function and emotional function, providing an opportunity for individuals to evaluate the adverse situation they faced and reestablish emotional homeostasis (cohen & hoberman, ; winnicott, ) . considering that high capacity to be alone means more time being alone, it is reasonable for us to infer that the capacity to be alone can have a positive effect on individual's psychological adaptation through both the cognitive and emotional processes. empirical research has also proved that the capacity to be alone was positively associated with adolescents' mental health (larson & lee, ; wu & chen, ) . besides, a study conducted by wu and chen ( ) also showed that the capacity to be alone could moderate the adverse effect of subjective life pressure on mental health, with this effect being stronger for individuals with low capacity to be alone. therefore, the capacity to be alone may also exert a moderating effect on both the link between mobile phone addiction and psychological distress and the link between mobile phone addiction and rumination. first, the capacity to be alone may buffer the adverse effect of mobile phone addiction on psychological distress. individuals with a high level of capacity to be alone may feel a higher sense of control, happiness, relaxation, freedom, and optimism. also, they use their time to cope with stress more effectively when they are alone (larson & lee, ) . instead, individuals with a low level of capacity to be alone may involve in other activities to distract their attention when being alone, and fail in releasing their negative emotions and deal with the problems they faced (larson & lee, ) . thus, when suffering from mobile phone addiction, individuals with a high level of capacity to be alone could benefit more from being alone. they are good at using the time being alone to renew their emotion in a short time and take measures to cope with the adverse consequences of mobile phone addiction quickly. whereas, individuals with low capacity to be alone may be trapped in the adverse consequences of mobile phone addiction and experience more depression, anxiety, and stress since they could not use the time being alone to adjust their negative emotional state. besides, according to displacement theory (kraut et al., ) , adolescents with a compulsive need to use mobile phones may experience more social isolation and social exclusion owing to the decline of both their face-to-face social communication and their social circle size. chen et al. ( ) also showed that interpersonal problems (such as social isolation) could be a psychological mechanism underlying the strong link between mobile phone addiction and negative emotions, such as depression and social anxiety. suffering from the social isolation and other interpersonal problems resulting from excessive or uncontrolled use of mobile phones, individuals with a high level of capacity to be alone will be more able to accept the state of social isolation and enjoy their time to be alone, resulting in less psychological distress than those with a low level of capacity to be alone. in addition, larson and lee ( ) also considered that the capacity to be alone may play as a buffer, alleviating the adverse effect of stress on individuals' mental health. therefore, the capacity to be alone may serve as a buffer in the relation between mobile phone addiction and psychological distress. second, the capacity to be alone may also alleviate the influence of mobile phone addiction on rumination. larson and lee ( ) considered that some people prefer to spend their time alone in a more constructive and autonomous way, and thus have more positive experiences. whereas, when the other people yearned for company are forced to be alone, they tend to have more negative experiences. individuals with a low level of the capacity to be alone may involve in more experience of being forced to be alone and have more negative emotions. by contrast, individuals with a high level of the capacity to be alone may spend their time alone more constructively and autonomously and have more positive experiences (e.g., deepening self-knowledge and improving self-recovery). given that negative experience is an effective booster for rumination (michl, mclaughlin, shepherd, & nolen-hoeksema, ), individuals with a low level of capacity to be alone may ruminate more after perceiving adverse consequences of mobile phone addiction. besides, according to stress reactive model of rumination, individuals suffering more negative experience may ruminate more about their life status and emotional states (robinson & alloy, ) . therefore, the capacity to be alone may act as an alleviator in the link between mobile phone addiction and rumination. above all, the present study supposed that the capacity to be alone may play a moderating role in the mediation model of mobile phone addition, rumination and psychological distress (hypothesis ). considering the prevalence of mobile phone addiction and the severe consequences of psychological distress, it is imperative to examine the mechanisms underlying the link between mobile phone addiction and psychological distress. previous studies mainly focused on the effects of mobile phone addiction on adolescents' negative emotions and sleep quality (chen et al., ; liu et al., ; yang, zhou, liu, & fan, ) , however, limited attempts have been paid to how and when mobile phone addiction can affect adolescents' psychological distress. given that rumination plays a bridge role in the relation between problematic mobile devices use and individuals' psychological adaptation (feinstein et al., ; liu et al., ) , the current study would attempt to examine the mediating effect of rumination on the association between mobile phone addiction and adolescents' psychological distress. besides, the capacity to be alone has been considered as an effective buffer to weaken stress and other risk factors on individuals' mental health (larson & lee, ; wu & chen, ) . therefore, the capacity to be alone was tested as a moderator to reveal when the direct and indirect relations between mobile phone addiction and adolescents' psychological distress are stronger or weaker. the proposed model was illustrated in fig. . convenience sampling was adopted to recruit middle school students ( . % female), who have experiences of using mobile phone, to participate in this study. all the participants were recruited from two junior middles schools, which located in two cities (shangqiu and wuhan) in china. the mean age of the participants was . years old (sd = . ), with an age range of - years old. three hundred and forty-nine ( . %) of them were grade students; two hundred and seventy-six ( . %) of them were grade students; one hundred and twenty-nine ( . %) of them were grade students. participants were informed of the requirements of this survey by using standard instructions, emphasizing the authenticity, independence, and integrity of all answers. all of the questionnaires were conducted in the form of paper-and-pencil in different classrooms taking a class as a unit in minutes. a signed consent form was collected after the ethical committee for scientific research of correspondence author approved this study. mobile phone addiction mobile phone addiction was assessed using mobile phone addiction index (mpai; leung, ) , which has been used in chinese adolescents and young adults with good reliability and validity (chen et al., ; liu et al., ) . this scale includes seventeen items that assess four factors related to mobile phone addiction including inability to control cravings, anxiety and feeling lost, withdrawal and escape, as well as productivity loss (e.g., "you have attempted to spend less time on your mobile phone but are unable to"). participants responded on a likert-type scale ranging from (never) to (always). responses were averaged to form a measure of students' mobile phone addiction, with higher scores indicating greater mobile phone addiction. the items also demonstrated high reliability in the present study (cronbach's α = . ). psychological distress psychological distress was assessed by the chinese version of depression anxiety stress scale- (dass- ; wang, shi, geng, zou, & chan, ) , which has been widely used to measure individuals' psychological distress (alfonsson, wallin, & maathz, ) . twenty-one items measured the symptoms of depression, anxiety and stress (e.g., "i found it hard to wind down") on a scale from (did not apply to me at all) to (applied to me very much or most of the time). higher scores represent more serious psychological distress. cronbach's α for the dass- was . . the chinese short version of ruminative response scale (lei et al., ) was used in this study. participants responded to the items on a likert-type scale ranging from (never) to (always) (e.g., "go someplace alone to think about your feelings''). higher scores reflect higher tendency to respond to negative factors with a ruminative response style. this scale has been used in a sample of chinese middle students with good reliability and validity (lian, sun, niu, & zhou, ). in the current study, the items demonstrated acceptable reliability (cronbach's α = . ). the capacity to be alone scale the capacity to be alone was measured by the chinese version of the capacity to be alone scale (wu & chen, ) , which was revised from the original version developed by larson ( ) . the chinese version of the capacity to be alone scale has been used in chinese students with good reliability and validity (jiang & zhao, ) . this scale consists of two intercorrelated l -item subscales, named as solitary coping scale and solitary comfort scale. participants responded on a likert-type scale ranging from (never) to (always). the solitary coping scale concerns the specific use of solitude to handle stress (e.g., "being alone is not healing for me"). the solitary comfort scale concerns a person's emotional comfort or discomfort in being alone (e.g., "i can't have fun unless i'm with someone"). cronbach's α for the whole scale was . . the reliability coefficients were . for solitary coping and . for solitary comfort. given that there was a significant and positive high correlation between solitary coping and solitary comfort (r = . , p < . ), we averaged the scores of all items from these two subscales to measure adolescents' general capacity to be alone. gender, age and time spending on mobile phone per day were included as control variables in the present study, as previous studies found that they were closely related to the main variables in this study (bayram & bilgel, ; george, russell, firstly, we conducted descriptive statistics and pearson correlations to examine the means, standard deviations and bivariate associations for all research variables. secondly, we used the spss macro process (model ) suggested by hayes to test the proposed moderated mediation model (hayes, ) . this spss macro has been used to test mediating and moderating models in several studies, in which this spss macro showed higher statistical testability liu et al., ; zhou, liu, niu, sun, & fan, ) . in addition, all the potential significant interaction effects were decomposed by simple slopes analyses (toothaker & larry, ) . table presented the means, standard deviations, and correlations for all of the observed variables. as hypothesized, mobile phone addiction was positively correlated with rumination and psychological distress and has no significant correlation with the capacity to be alone. rumination was positively correlated with psychological distress and the capacity to be alone. the capacity to be alone was positively correlated with psychological distress. gender was positively correlated with the capacity to be alone. time spending on mobile phone per day was positively correlated with mobile phone addiction and psychological distress. whereas, age showed no significant correlation with all of the core observed variables. testing for the proposed moderated mediation model hayes's ( ) spss macro process was adopted to examine the proposed moderated mediation model. table presented the main results. as expected, the total effect model (f( , ) = . , r = . , p < . ), the mediator variable model (f( , ) = . , r = . , p < . ) and dependent variable model (f( , ) = . , r = . , p < . ) were all significant after controlling students' gender, age and time spending on mobile phone per day. in specific, mobile phone addiction positively predicted rumination (β = . , p < . ) and psychological distress (β = . , p < . ). rumination positively predicted psychological distress (β = . , p < . ). furthermore, sobel test was employed to examine the significance of the indirect effect of mobile phone addiction on psychological distress via rumination. the results indicated that rumination significantly mediated the relationship between mobile phone addiction and psychological distress (z = . , p < . ). these results provided compelling evidence that mobile phone addiction was associated with increasing in psychological distress and that this relation was mediated by rumination. thus, hypothesis was supported. in order to examine hypothesis , two interaction effects were analyzed with process macro (model ) by hayes ( ) . there was a significant mobile phone addiction × the capacity to be alone interaction effect on rumination (b = - . , p < . ) in mediator variable model. a significant mobile phone addiction × the capacity to be alone interaction effect on psychological distress (b = - . , p < . ) in the dependent variable model. these findings indicated that both the association between mobile phone addiction and psychological distress and the association between mobile phone addiction and rumination were moderated by the capacity to be alone. additionally, simple slope analyses were conducted to illustrate these significant interactions and explore whether slopes for the high-capacity to be alone group ( sd above the mean) were different from slopes for the low-capacity to be alone group ( sd below the mean) in the two models. the results were plotted in fig. and fig. . fig , the effect of mobile phone addiction on rumination was stronger for students with lower capacity to be alone (b = . , t = . , p < . ) than for those with higher capacity to be alone (b = . , t = . , p < . ). as shown in fig , the effect of mobile phone addiction on psychological distress was stronger for students with lower capacity to be alone (b = . , t = . , p < . ) than for those with higher capacity to be alone (b = . , t = . , p < . ). in other words, mobile phone addiction interacted with the capacity to be alone, such that students with higher levels of capacity to be alone had fairly similar rumination and psychological distress across low and high levels of mobile phone addiction. students who had lower levels of capacity to be alone, however, reported higher levels of rumination and psychological distress when they suffering from mobile phone addiction. likewise, students with higher levels of capacity to be alone reported lower psychological distress regardless of their levels of rumination, while students with lower levels of capacity to be alone reported strong psychological distress because of strong rumination. furthermore, the results of two conditional analyses showed that no matter what levels of capacity to be alone are, all of the direct and indirect effects were positively and significantly different from zero. namely, both the direct effect of mobile phone addiction on psychological distress and the indirect effect of rumination in this link were stronger for students with lower capacity to be alone. [ table in current mobile internet era, mobile phones have even been regarded as an organic part of the everyday lives of adolescents (oksman & rautiainen, ) , and more and more adolescents are walking on the edge of mobile phone addiction yang, zhou, liu, & fan, ) . therefore, the antecedents and potential adverse consequences of mobile phone addiction have been explored in a large number of domains. however, limited attention has been paid to the relation between mobile phone addiction and adolescents' psychological distress and its underlying mechanisms. this study was designed to examine how (mediating mechanisms) and when or for whom (moderating mechanisms) mobile phone addiction influences psychological distress (anxiety, depression, and stress). the moderated mediation analyses revealed that rumination mediated the association between mobile phone addiction and psychological distress. hypothesis was supported. the direct and indirect effects of mobile phone addiction on psychological distress would be exacerbated when adolescents cannot bear being alone or fail to use their time being alone to handle negative experience induced by mobile phone addiction. in other words, adolescents with higher levels of capacity to be alone could successfully alleviate the adverse effects of mobile phone addiction on mental health. hypothesis was supported. findings enlightened us that we could attenuate the potential adverse effects resulting from mobile phone addiction on our mental health by enhancing our capacity to be alone. first, consistent with a previous study conducted by yang, zhou, liu and fan ( ) , the present study indicated that mobile phone addiction could positively and significantly predict psychological distress among adolescents. this finding illustrated that although mobile phone use could satisfy various psychological needs of adolescents and promote their psychological adaptation, excessive use of mobile phones may lead to adverse outcomes. previous studies considered that the symptoms of withdrawal and daily life disturbance experienced by mobile phone addicts could induce psychological distress (coyne, stockdale, & summers, ; yang, zhou, liu, & fan, ) . besides, the uncontrolled use of mobile phones accompanied by mobile phone addiction would take up the time of face-to-face interpersonal interaction, resulting in poor interpersonal and emotional adaptation (coyne, stockdale, & summers, ; david & roberts, ; roberts & david, ) . moreover, mobile phone addiction has been proved to predict poor sleep quality, which was a significant predictor of emotional problems, such as depressive symptoms, anxiety symptoms and stress symptoms (demirci, akgönül, & akpinar, ; liu et al., ; sarchiapone et al., ) . therefore, adolescents suffering from mobile phone addiction may have more psychological distress. second, rumination has been considered as an important factor leading to individual psychological distress (morrison & rory, ; treynor, gonzalez, & nolen-hoeksema, ) . our findings, consistent with and expanding previous studies, showed that rumination acted as a mediating role that linked mobile phone addiction to adolescents' psychological distress. this finding indicated that symptoms and maladaptive behaviors associated with mobile phone addiction lead to changes in adolescents' responses to adverse life experience, further resulting in plenty of negative mood and affects, such as depression, anxiety and stress. at the same time, as a negative response style, rumination has also been proved to be an important mediating mechanism to link mobile phone addiction to psychological problems . symptoms of mobile phone addiction, including craving, withdrawal, tolerance and preference for cyberspace-oriented relationship, may lead to loads of daily-life disturbance (pavia, cavani, di blasi, & giordano, ) . according to the response style theory (nolen-hoeksema, ) , mobile phone addicts may engage in self-focused rumination as an attempt to reduce the daily-life disturbance caused by uncontrolled use of mobile phones. unfortunately, rumination on daily-life disturbance following excessive use of mobile phones may persist if their rumination focuses on the causes and/or consequences of excessive use of mobile phones rather than on measures aimed to reduce their dependence on mobile phones. therefore, rumination induced by mobile phone addiction often leads to psychological problems, especially psychological distress. besides, surfing on social networking sites was one of the most important motivations for mobile phone addicts to keep in touch with mobile phones (elhai et al., ) . motivated by fear of missing out, mobile phones were used to refresh social networking profiles in an automatic and impulsive fashion. this may increase the possibility for mobile phone addicts to experience upward social comparison, which was an important trigger of rumination (feinstein et al., ) . feinstein et al ( ) demonstrated that in the context of social networking, negatively comparing oneself with others may place individuals at risk for rumination and, in turn, lead to depressive symptoms. liu et al ( ) has also proved that rumination could be predicted by mobile phone addiction, and eventually lead to adolescents' poor sleep quality. in addition, according to the cognitive-behavioral model (davis, ) , rumination was not only the antecedent of mobile phone addiction, but also the consequence of mobile phone addiction. after excessive or uncontrolled use of mobile phones, mobile phone addicts may ruminate about problems associated with their mobile phone use and regret for wasting time on mobile phones, which may lead to increasing in depression, anxiety and stress. overall, rumination was an underlying mechanism for us to understand how mobile phone addiction influences psychological distress. in addition, one most important finding in the present study was the individual difference in the predictive effects of mobile phone addiction on rumination and psychological distress. specifically, both the direct effect that mobile phone addiction itself exerted on psychological distress and the indirect effect via rumination were moderated and buffered by the capacity to be alone, with these effects being stronger for adolescents with lower level of capacity to be alone. these results indicated that the capacity to be alone, as one of the signs of mental health and emotional maturity, could help us alleviate the potential adverse effects of mobile phone addiction on our response style and psychological distress. previous studies considered that we could turn the focus of attention from the outside to the inside, and have the opportunity to listen to our own hearts and make a deeper understanding and evaluation of ourselves when we are alone (larson, ) . thus, adolescents and adults will be more excited and alert when they enter the crowd after being alone. they could also choose to stay away from others actively to release their negative emotions, which was helpful for them to renew their emotion as soon as possible. therefore, adolescents with the higher capacity to be alone could actively choose to be alone to adjust their response style to deal with the adverse effects of excessive use of mobile phones. at the same time, they could also get rid of the psychological distress caused by mobile phone addiction through breaking away from external stimulation and focusing on their current physiological, emotional and cognitive changes (roberts, ; wu & chen, ) . besides, according to mindfulness meditation (brown, ryan, & creswell, ) , the capacity to be alone is a necessary condition for mindfulness meditation, and it can promote individuals to enter the realm of mindfulness meditation. previous studies have found that mindfulness meditation could help us to enhance our attention control and avoid getting involved in rumination, regulate our negative emotions and promote our positive emotions (deyo, wilson, ong, & koopman, ; marchand, ; ramel, goldin, carmona, & mcquaid, ) . therefore, the capacity to be alone could buffer the priming effect of mobile phone addiction on rumination and psychological distress. unfortunately, adolescents with lower capacity to be alone cannot benefit from being alone. they often spend more time on the distracting activities when they are alone and describe the feeling of being alone as sadness, loneliness and depression (long, seburn, averill, & more, ) . therefore, adolescents with lower capacity to be alone are more likely to be involved in rumination and psychological distress when they suffer from mobile phone addiction. although this study provides valuable findings for us to understand how and when mobile phone addiction influence adolescents' rumination and psychological distress, this study is not without limitations. first, it was noteworthy that the capacity to be alone was positively associated with rumination and psychological distress. given that the capacity to be alone is endowed with different values and purposes by different cultures (long, seburn, averill, & more, ) , our findings cannot be generalized to adolescents in other cultural backgrounds. compared with individualism, collectivism emphasizes the interdependent relationship between individuals and regards the state of being alone as a violation of collective interests, or even as a manifestation of selfishness or problematic behavior. therefore, the capacity to be alone showed a positive association with rumination and psychological distress among chinese adolescents. besides, different from the previous study (larson & lee, ) , which took adults as subjects, this study took adolescents as subjects. this may also be the reason why the correlation between the capacity to be alone and psychological distress in our study was significant positive. adolescence is a transition period for an individual to mature from infancy. adolescents have not yet learned effective emotional regulation strategies and could not deal with the various growth crises and stressful life events independently (compas, orosan, & grant, ) . it is difficult for them to renew their emotions and reestablish their emotional harmony by using the time being alone. therefore, as an expected stress buffer, the effect of the capacity to be alone may backfire. however, this conjecture still needs further cross-culture empirical research support. it is necessary to carry out cross-cultural research to validate the buffering effect of the capacity to be alone in the process of mobile phone addiction leading to rumination and psychological distress among adolescents from different cultural backgrounds. second, limited by cross-sectional design, the present study could not permit a strict causal relationship. future studies could adopt longitudinal design to examine the causal direction among mobile phone addiction, rumination and psychological distress. it is also necessary to conduct intervention research to examine the role of the capacity to be alone in the pathway of mobile phone addiction influencing rumination and psychological distress by enhancing the capacity to be alone of mobile phone addicts. moreover, data were collected from junior middle school students using only self-reported questionnaires, which might have caused social desirability bias and common method bias. future studies should employ multidimensional scaling to collect more objective data from multiple informants including their parents and peers. in spite of these limitations, the present study deepens previous studies by revealing the mediating and moderating mechanisms underlying the link between mobile phone addiction and psychological distress. specifically, the present study is the first attempt to reveal the mediating role of rumination and the protective effect of the capacity to be alone to explain how, when, and when of how mobile phone addiction leads to psychological distress. besides, practical implications could also be drawn from this study. adolescents isolated at home during the covid- pandemic have more time to be alone. unfortunately, more and more adolescents spend most of their time alone on their mobile phones and even are addicted to mobile phones, which makes them fall into a variety of psychological crises, such as conflicts in parent-child relationship, academic problems, and all kinds of psychological distress (sun et al., ) . to prevent the deterioration of adolescents' psychological problems, parents and educators should guide adolescents to avoid excessive dependence on mobile phones and enjoy the time to be alone. adolescents should also be acknowledged that the sense of bondage and social and technology overload accompanying the freedom and benefits brought by mobile phone (choi & lim, ; david & roberts, ; lee, son, & kim, ) . at the same time, it is necessary for people, especially adolescents, to enhance their capacity to be alone and extricate themselves from the predicament caused by excessive use of mobile phones. considering that the capacity to be alone is the first step to enter mindfulness meditation, measures to improve mindfulness may be effective for individuals improving their capacity to be alone. meditation training, including body scan and yoga exercises, has been proved to be effective intervention methods to promote mindfulness (burke, ) . therefore, adolescents with lower capacity to be alone could improve their capacity to be alone by participating in mindfulness training, which ultimately mitigates the negative impact of mobile phone addiction. specifically, when being alone, adolescents with lower capacity to be alone need to try to do the following to improve their ability to be alone. first, be aware of but not judge their emotions, thoughts, body feelings, etc. second, they should learn to coexist with their physical and mental states patiently and peacefully. third, keeping a beginner's mind on their own state. fourth, believing in the arrangement of nature and let it be. fifth, just be aware of all the physical and mental phenomena that happen at the moment. sixth, accepting the current situation and taking care of their body and mind. seventh, letting go of all kinds of differences between likes and dislikes, and just being aware of every physical and mental phenomenon that happens every second. in addition, given that rumination plays a bridge role in the relation between mobile phone addiction and psychological distress, parents and educators could help adolescents suffering from mobile phone addiction avoid engaging in psychological distress by decreasing their tendency to be ruminative. prior studies showed that individuals could reduce their rumination level by changing their non-adaptive cognitive and emotional response style (cohen, mor, & henik, ) . cohen, mor, and henik ( ) found that training individuals to exert executive control when processing negative stimuli can alleviate ruminative thinking and rumination-related sad mood. therefore, changing adolescents' non-adaptive cognitive and emotional response style may also be an effective way to decrease the negative impacts of mobile phone addiction. specifically, adolescents can reduce the possibility of excessive use of mobile phones leading to rumination. first, controlling the time they spend on their mobile phone every day consciously. second, trying to use the mobile phone as a tool for work and entertainment instead of being kidnapped by the mobile phone. third, turning their attention away from the negative experience resulting from excessive or uncontrolled use of mobile phones. fourth, avoid regret for excessive or uncontrolled use of mobile phones, do what should to do. all co-authors have expressed agreement with the order of authorship and contents of the manuscript. the authors have no conflicts of interests that might be interpreted as influencing the research. note. n = . unstandardized regression coefficients are reported. bootstrap sample size = . ll = low limit, ci = confidence interval, ul = upper limit. * p< . . ** p< . . *** p< . . smartphone addiction among university undergraduates: a literature review factor structure and validity of the depression, anxiety and stress scale- in swedish translation social foundations of thought and action: a social cognitive theory the brain in your pocket: evidence that smartphones are used to supplant thinking the prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students mindfulness: theoretical foundations and evidence for its salutary effects mindfulness-based approaches with children and adolescents: a preliminary review of current research in an emergent field smartphone use and smartphone addiction in middle school students in korea: prevalence, social networking service, and game use mobile phone addiction levels and negative emotions among chinese young adults: the mediating role of interpersonal problems the nd statistical report on internet development in china. retrieved on effects of social and technology overload on psychological well-being in young south korean adults: the mediatory role of social network service addiction linking executive control and emotional response: a training procedure to reduce rumination positive events and social supports as buffers of life change stress adolescent stress and coping: implications for psychopathology during adolescence problematic cell phone use, depression, anxiety, and self-regulation: evidence from a three year longitudinal study from adolescence to emerging adulthood phubbed and alone: phone snubbing, social exclusion, and attachment to social media a cognitive-behavioral model of pathological internet use relationship of smartphone use severity with sleep quality, depression, and anxiety in university students solitude's paradox: the role of object relations and attachment in the capacity to be alone mindfulness and rumination: does mindfulness training lead to reductions in the ruminative thinking associated with depression? fear of missing out: testing relationships with negative affectivity, online social engagement, and problematic smartphone use rumination mediates the association between cyber-victimization and depressive symptoms negative social comparison on facebook and depressive symptoms: rumination as a mechanism changing hierarchies of commitment in adulthood. themes of work and love in adulthood perfectionism cognitions, rumination, and psychological distress rumination and depressive symptoms: evidence for the moderating role of hope concurrent and subsequent associations between daily digital technology use and high-risk adolescents' mental health symptoms understanding nomophobia: structural equation modeling and semantic network analysis of smartphone separation anxiety introduction to mediation, moderation, and conditional process analysis. a regression-based approach a probe into mobile phone dependence in adolescents: measurement, harmfulness and genesis mechanism relations between preference for solitude and positive affection: moderating effect of the ability to be alone the effect of adolescents' time perspective and self-control on academic procrastination: the mediating effect of cellular phone addiction rumination mediates the prospective effect of low self-esteem on depression: a five-wave longitudinal study the influence of smartphone addiction on depression and communication competence among college students development and validation of a smartphone addiction scale (sas) the solitary side of life: an examination of the time people spend alone from childhood to old age the emergence of solitude as a constructive domain of experience in early adolescence the capacity to be alone as a stress buffer daily companionship in late childhood and early adolescence: changing developmental contexts information and communication technology overload and social networking service fatigue: a stress perspective effects of parental psychological control on child's school life: mobile phone dependency as mediator psychometric properties of the -item ruminative response scale in chinese university students the relationship between cell phone use, academic performance, anxiety, and satisfaction with life in college students linking psychological attributes to addiction and improper use of the mobile phone among adolescents in hong kong mobile phone addiction and college students' procrastination:analysis of a moderated mediation model upward social comparison on sns and depression: a moderated mediation model and gender difference social networking site addiction and undergraduate students' irrational procrastination: the mediating role of social networking site fatigue and the moderating role of effortful control mobile phone addiction and sleep quality among chinese adolescents: a moderated mediation model solitude experiences: varieties, settings, and individual differences mindfulness-based stress reduction, mindfulness-based cognitive therapy, and zen meditation for depression, anxiety, pain, and psychological distress rumination as a mechanism linking stressful life events to symptoms of depression and anxiety: longitudinal evidence in early adolescents and adults the smartphone addiction scale: development and validation of a short version for adolescents predicting psychological distress in college students: the role of rumination and stress the possibilities of aloneness and solitude: developing an understanding framed through the lens of human motivation and needs sex differences in unipolar depression: evidence and theory responses to depression and their effects on the duration of depressive episodes perfectionism and psychological distress: evidence of the mediating effects of rumination perhaps it is a body part": how the mobile phone became an organic part of the everyday lives of finnish children and teenagers. machines that become us: the social context of personal communication technology smartphone addiction inventory (spai): psychometric properties and confirmatory factor analysis social media use continues to rise in developing countries but plateaus across developed ones the effects of mindfulness meditation on cognitive processes and affect in patients with past depression my life has become a major distraction from my cell phone: partner phubbing and relationship satisfaction among romantic partners winnicott's "capacity to be alone" in normative and non-normative adolescent development negative cognitive styles and stress-reactive rumination interact to predict depression: a prospective study social networking on smartphones: when mobile phones become addictive relationships among smartphone addiction, stress, academic performance, and satisfaction with life hours of sleep in adolescents and its association with anxiety, emotional concerns, and suicidal ideation mobile phone dependency and its impacts on adolescents' social and academic behaviors correlates of facebook usage patterns: the relationship between passive facebook use, social anxiety symptoms, and brooding procrastination and stress: exploring the role of self-compassion prevalence of smart phone addiction, sleep quality and associated behavior problems in adolescents the nature of procrastination: a meta-analytic and theoretical review of quintessential self-regulatory failure challenges to hiv care and psychological health during the covid- pandemic among people living with hiv in china multiple regression: testing and interpreting interactions rumination reconsidered: a psychometric analysis rumination and suicidal ideation: the moderating roles of hope and optimism unhappy and addicted to your phone? -higher mobile phone use is associated with lower well-being cross-cultural validation of the depression anxiety stress scale- in china possession attachment predicts cell phone use while driving the capacity to be alone sleepyteens: social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem relationships among the ability to be alone, subjective life stress and mental health in junior iigh school students mobile phone addiction and adolescents' anxiety and depression: the moderating role of mindfulness bullying victimization and depression in chinese children: a moderated mediation model of resilience and mindfulness the authors gratefully acknowledge all the participants and schools cooperated in this survey. hereby thank all the postgraduates who cooperated with us in conducting this study. key: cord- -oa i ss authors: luo, li-sha; jin, ying-hui; cai, lin; pan, zhen-yu; zeng, xian-tao; wang, xing-huan title: covid- : presumed infection routes and psychological impact on staff in administrative and logistics departments in a designated hospital in wuhan, china date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: oa i ss objective: our aim was to explore the presumed infection routes and psychological impact of covid- on staff in administrative and logistics departments (alds). methods: we gathered data from all staff members with covid- in alds in zhongnan hospital of wuhan university, china. the baseline, job before diagnosis, presumed infection environment, use of protective equipment, and psychological status before and after diagnosis were collected and analyzed. a total of uninfected staff members working alongside them in the same environment and random matched infected doctors and nurses formed two control groups; the psychological impact of these three groups was then compared. results: of the members of staff, . % were infected due to the working environment (hospital), and nine had face-to-face conversations with doctors and nurses in their daily work. many staff members did not take any protective measures in their routine work. before they were diagnosed, staff members were aware of the seriousness of the epidemic, and most of the staff maintained a neutral attitude to the covid- outbreak. a total of . % of the staff experienced psychological stress or emotional changes after diagnosis, which were mainly caused by family health and disease related issues. most of them managed their emotions by self-control and video calls with their families. there was no significant difference in psychological impact among the three groups, but uninfected staff members were fully aware of the seriousness of the epidemic. conclusions: effective protective measures should be taken for staff members in alds. psychological interventions are very important to help infected staff members in alds cope with psychological distress. the novel coronavirus disease , caused by severe acute respiratory syndrome coronavirus (sars-cov- ), has been spreading rapidly worldwide, creating a tremendous public health burden . as of february , , there were a total of , infected healthcare staff members ( % in wuhan) (wu and mcgoogan, ) . staff in administrative and logistics departments (alds) are also front-line workers, alongside doctors and nurses, who provide strong support for the orderly conduct of medical work. compared with doctors and nurses, these staff members receive less attention from society. through their work in hospitals, this group is likely to be directly or indirectly exposed to the sars-cov- with a high risk of infection. additionally, they suffered high psychological pressures from an increased workload, fears of possible infection of their families and colleagues, and a lack of knowledge about protection from infectious diseases (lai et al., ) . public health emergencies can easily cause anxiety and panic among healthcare workers, and previous studies have shown that the severe acute respiratory syndrome (sars) outbreak has had adverse psychological effects on healthcare workers (bai et al., ) . the incidence of stress disorder among doctors and nurses has reached . % during the covid- epidemic . unlike doctors and nurses, staff in alds lack knowledge of protection, diagnosis, and treatment; the psychological effects of the epidemic may thus be more serious, especially for those contracting the disease. therefore, identifying their presumed routes of infection and psychological changes is also crucial to the success of fighting . several studies about psychological effects on healthcare workers during the covid- outbreak have been published, but none of them have focused on infected ald personnel kisely et al., ) . the current study thus aimed to explore the potential infection routes and psychological changes among hospital staff in alds and to provide scientific suggestions on preventing adverse effects among this population's during large-scale infectious diseases outbreaks. this retrospective study was conducted in the zhongnan hospital of wuhan university, one of the key hospitals at the epicenter of covid- outbreak. the participants were confirmed as covid- based on the diagnostic criteria of the national health committee of the people's republic of china (jin et al., b; ma et al., ) . this study is part of a larger cross-sectional study and was reviewed and approved by the committee for ethical affairs of zhongnan hospital (approval number: ). the study period was from february to , ; and data about doctors and nurses have been published elsewhere . data were collected using a validated electronic questionnaire, including informed consent, which was jointly developed by experts from multidisciplinary fields, such as epidemiology, evidence-based medicine, and front-line clinicians during the covid- epidemic. the readability and content validity of the questionnaire were tested by experts from several fields from different medical institutions, and the test-retest reliability was . (wang et al., a,b) . the questionnaire items included basic information, exposure history, protective measures, clinical symptoms, treatment measures, and psychological changes. in terms of psychological items, we collected staffs' awareness and feelings about the epidemic before diagnosis, as well as their psychological changes and coping mechanisms after diagnosis, to get a preliminary understanding of the impact of the epidemic on ald staffs. all infected staff members in the alds of this hospital were contacted through the division of medical affairs. to ensure the accuracy of results, we confirmed the exposure status through phone calls to all participates and their department directors. additionally, we compared the psychological impact between infected staff in alds with two control groups: one was infected doctors and nurses, randomly selected from the infected staff members , and the other group was uninfected alds staff members, nominated by their infected colleagues who worked in the same environment. they were also investigated used the validated electronic questionnaire (wang et al., b) . categorical variables were described as counts and percentages; wilcoxon signed rank sum tests and fisher exact tests were conducted to compare the psychological impact between staff in alds and the two control groups. the data analysis was performed by the sas software, version . ts m (sas institute inc., cary, nc) and visualized by microsoft powerpoint , where p < . was considered statistically significant. all staff members with covid- in alds were included in this study (table ) , and all have now recovered. five were males and were females, and their ages ranged from to years. a total of . % thought they were infected by the working environment in hospitals, and one case did not know the source of infection. nine staff members regularly had face-toface conversations with doctors and nurses in the course of their work. more than half of staff thought that the way they got the infection was droplets and contact transmission. table presents detailed information of these staff; four who worked as hospital environmental cleaners and often wore masks and gloves during work, while another one, responsible for operating the elevator, never wore masks or gloves. three staff members in the security department who distributed medical materials to each department sometimes wore gloves. two staff working in the sterilized supply center transporting patients and cleaning surgical instruments always wore masks and gloves. one person in convalescent department who was responsible for accompanying doctors to patients' homes never wore masks and gloves at work. one person working in the division of operation management to calculate the hospital's performance never took any protective measures. one person in the division of medical insurance never wore gloves when handling insurance problems for patients. one person in the division of personnel services occasionally wore gloves when receiving documents from staff. one person working in the scientific research center as laboratory manager occasionally wore masks. the psychological status before and after diagnosis of these infected staff were shown in figure . before they were diagnosed, staff said they were aware of the seriousness of the epidemic. most staff 's attitude remained neutral to covid- outbreak, and none of them were pessimistic. during the treatment, . % of staff experienced psychological stress or emotional changes, which were mainly caused by family health, disease related issues and negative news via the internet. they managed their emotions and stress by self-control, video calls with family members or colleagues, and communicating with others on wechat. most staff received comfort and care from leaders and colleagues, partners, and children. additionally, there was no significant difference for psychological impact between infected staff in alds and doctors and nurses before and after their diagnosis (tables , ) . in terms of the mental attitude toward the covid- outbreak, no significant difference was also observed between uninfected and infected staff before diagnosis in alds. however, uninfected staff was fully aware of the seriousness of the epidemic compared with infected staff ( table ) . it has been reported that the infection rates among healthcare workers during sars and middle east respiratory syndrome (mers) were and %, respectively (al-tawfiq and memish, ). unfortunately, the sars-cov- also infected a large number of healthcare workers. during previous infectious diseases outbreaks, studies on the healthcare staff 's infection have focused on the front-line doctors and nurses, while the staffs in figure | psychological status before and after diagnosis of the covid- staffs in administrative and logistics departments (a: awareness of the epidemic before diagnosis; b: mental attitude before diagnosis; c: psychological stress or emotional changes after diagnosis; d: the possible causes of emotional change after diagnosis; e: the methods used to control stress or mood changes after diagnosis; and f: the sources of comfort and care after diagnosis). alds were often ignored. these staff are crucial to the normal operation of the hospital, so protecting this population from infection is also crucial to success in fighting covid- . our study included all infected staffs in alds in zhongnan hospital of wuhan university: . % were in the logistics support department and therefore regularly come into contact with medical wastes when cleaning the hospital. there is no air circulation in the overcrowded elevator, and the infection of the elevator operator will thus expose all occupants to the virus. a recent study indicated that both air and surfaces may be contaminated by sars-cov- ; we therefore suggest that these staff must wear gloves and masks correctly in their routine work (ong et al., ) . for departments that have contact with doctors and nurses, such as personnel, finance and operation management departments, one infected staff member may transmit the virus to other staff and cause explosive infection both in the same department and also in clinical departments, and this potentially causes nosocomial infection. hence, special frontiers in psychology | www.frontiersin.org windows should be set up, and gloves and masks should be worn when documents are submitted and collected, especially in the autumn and winter when infectious diseases are prone to occur. additionally, hospitals can adopt the paperless offices in alds, thereby reducing direct and indirect contact with potentially contaminated materials. staff in the sterile supply department should wear more advanced protective equipment when cleaning surgical instruments and transporting patients (suen et al., ) . staff in convalescent department should take the same protective measures as healthcare workers when visiting patient's home, as they may constitute an infection source to spread the virus to other alds and clinical departments. at the same time, we should pay attention to the disinfection of offices, and careful use of central air conditioning in alds. the emerging virus outbreaks have had a significant psychological impact on healthcare workers. several viral outbreaks have occurred in the past years, such as sars, mers, and ebola disease (kisely et al., ) , and previous studies have reported that doctors and nurses at the frontline involving diagnosis and treatment commonly reported psychological problems during sars epidemic in (bai et al., ; lee et al., ) and the mers outbreak of (lee et al., ) . currently, several published studies highlighting psychological effects on healthcare workers during the covid- outbreak indicate that healthcare workers are at increased risk of psychological distress kisely et al., ) . most studies about the psychological impact focused on doctors and nurses who performed the tasks of diagnosis and treatment, while few studies have been conducted on the psychological effects of the covid- epidemic on staff in alds who were not infected (chen et al., ; huang et al., a,b; lai et al., ; xing et al., ) . however, no studies have focused on the psychological state of staff in hospitals who have been infected. thus, it can be argued that our study is of great significance for further understanding the psychological effects on staff in alds during virus epidemics. our study indicated most of staff in alds experienced psychological stress or emotional changes. a total of % of them were anxious about their conditions due to a lack of professional knowledge. almost everyone was concerned about health of his/her family members' health, and eight staff members were influenced by negative news via the internet. additionally, most logistics staffs are not regular employees of the hospital, and they may thus suffer from the risk of unemployment due to the impact of the epidemic, which further increases their psychological burden. consequently, psychological intervention treatment is very urgent to cope with the psychological stresses and emotional changes among this group of staff. in our study, we found no significant difference in psychological impact between infected doctors and nurses and staff in alds-neither in the awareness and mental attitude to the epidemic before diagnosis or the psychological changes after diagnosis. the results indicated that working in hospital and having clinical professional knowledge does not affect the psychological impact of covid- epidemic on hospital staff. in alds, the mental attitude to the epidemic was not different between infected and uninfected staff, while uninfected staff members' awareness of the epidemic was higher than that of infected staff, which may have reduced the risk of infection by influencing their behavior. the main limitation of this study is that it was a single-center study with a small sample size. although all infected staff in alds in this hospital were included, more studies are needed to verify the results. additionally, some memory bias maybe exist among participates. in conclusion, reasonable effective protective measures should be taken for staff in alds, such as setting up specialized windows for departments that have prolonged contact time with healthcare workers, adopting paperless offices to reduce contact with potentially contaminated materials, choosing appropriate protective equipment, disinfecting offices properly, and using central air conditioning carefully. most staff experienced psychological stress during their isolation period after diagnosis, and psychological interventions are thus very urgent when it comes to coping with psychological distress among this group of people. verification is needed using multi-center studies with a larger sample size in the future. all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by committee for ethical affairs of zhongnan hospital of wuhan university. the patients/participants provided their written informed consent to participate in this study. x-tz, x-hw, and lc: the conception and design of the study. lc, l-sl, y-hj, z-yp, and x-tz: collection and assembly of data. l-sl, y-hj, and x-tz: analysis and interpretation of the data and drafting the article. y-hj, lc, z-yp, x-tz, and x-hw: revising it critically for important intellectual content. all authors contributed to the article and approved the submitted version. this work was supported by the fundamental research funds for the central universities ( kf ) and the special project for emergency of hubei province ( fca ). middle east respiratory syndrome coronavirus in the last two years: health care workers still at risk survey of stress reactions among health care workers involved with the sars outbreak mental health care for medical staff in china during the covid- outbreak mental health survey of medical staff in a tertiary infectious disease hospital for covid- emotional responses and coping strategies of nurses and nursing college students during covid- outbreak. medrxiv a rapid advice guideline for the diagnosis and treatment of novel coronavirus ( -ncov) infected pneumonia (standard version) perceived infection transmission routes, infection control practices, psychosocial changes, and management of covid- infected healthcare workers in a tertiary acute care hospital in wuhan: a cross-sectional survey occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and metaanalysis factors associated with mental health outcomes among health care workers exposed to coronavirus disease stress and psychological distress among sars survivors year after the outbreak psychological impact of the mers outbreak on hospital workers and quarantined hemodialysis patients the legal class b infectious disease -the novel coronavirus ( -ncov) infected pneumonia in wuhan, china: a review developments, evolution, and implications of national diagnostic criteria for covid- in china air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus (sars-cov- ) from a symptomatic patient comparing mask fit and usability of traditional and nanofibre n filtering facepiece respirators before and after nursing procedures development and preliminary validation of questionnaire for novel coronavirus related nosocomial infection development and preliminary validation of questionnaire for infection process and prevention of novel coronavirus infection in medical staffs characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention study of the mental health status of medical personnel dealing with new coronavirus pneumonia we express our gratitude to jean glover from tianjin golden framework consulting company for english editing. we also express our gratitude for the contribution of consultant experts and healthcare practitioners from all hospitals for their participation. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © luo, jin, cai, pan, zeng and wang. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -znuqdzdp authors: sun, niuniu; shi, suling; jiao, dandan; song, runluo; ma, lili; wang, hongwei; wang, chao; wang, zhaoguo; you, yanli; liu, shuhua; wang, hongyun title: a qualitative study on the psychological experience of caregivers of covid- patients date: - - journal: am j infect control doi: . /j.ajic. . . sha: doc_id: cord_uid: znuqdzdp background: the coronavirus disease (covid- ) is spreading rapidly, bringing pressure and challenges to nursing staff. objective: to explore the psychology of nurses caring for covid- patients. method: using a phenomenological approach, we enrolled nurses who provided care for covid- patients in the first affiliated hospital of henan university of science and technology from january to february . the interviews were conducted face-to-face or by telephone and were analysed by colaizzi's -step method. results: the psychological experience of nurses caring for covid- patients can be summarized into four themes. firstly, negative emotions present in early stage consisting of fatigue, discomfort, and helplessness was caused by high-intensity work, fear and anxiety, and concern for patients and family members. secondly, self-coping styles included psychological and life adjustment, altruistic acts, team support, and rational cognition. thirdly, we found growth under pressure, which included increased affection and gratefulness, development of professional responsibility, and self-reflection. finally, we showed that positive emotions occurred simultaneously with negative emotions. conclusions: during an epidemic outbreak, positive and negative emotions of the front-line nurses interweaved and coexisted. in the early stage, negative emotions were dominant and positive emotions appeared gradually. self-coping styles and psychological growth played an important role in maintaining mental health of nurses. the severe acute respiratory syndrome coronavirus (sars-cov- ) is a newly discovered ribonucleic acid coronavirus isolated and identified from patients with unexplained pneumonia in wuhan, china in december [ ] . before it was named by the international committee of viral classification on february, , it was called -ncov. sars-cov- mainly causes respiratory and digestive tract symptoms [ ] , with symptoms ranging from mild self-limited disease to severe pneumonia, acute respiratory distress syndrome, septic shock, and even systemic multiple organ failure syndrome. the infection source of coronavirus disease is mainly patients with sars-cov- infection. asymptomatic infected patients may also become the source of infection, mainly via aerosols from the respiratory tract, but also through direct contact [ ] . elderly people with underlying diseases are more likely to be infected with the virus and develop severe disease and children and infants are also at risk. at present, there are no specific drugs for this disease. the treatment and nursing mainly include antiviral and traditional chinese medicine treatment, isolation, symptomatic support, and close monitoring of disease progression [ ] . since the first case of unexplained pneumonia in wuhan, countries in the world have confirmed cases by february according to who data, of which about % are in china [ ] . on that day in china, there were , active confirmed cases (including , severe cases) in provinces, , recovered and discharged cases, , deaths, amounting to , confirmed cases as well as , suspected cases. [ ] a total of , close-proximity interactions were tracked, including , close-proximity interactions under medical observation. although china experienced sars in and h n in , the outbreak of covid- as a new infectious disease severely tested the country's public health system. in this context, medical workers, as the main force in the battle against the epidemic, bear the monumental task. unfortunately, many front-line personnel have sacrificed their own well-being and have been infected or died, which causes increasing psychological pressure. according to the chinese center for disease control and prevention, by february, over health care personnel in china were suspected to be infected with sars-cov- . among them, were confirmed cases and had died [ ] . previous studies have shown that during sudden natural disasters and infectious diseases, nurses will sacrifice their own needs to actively participate in the anti-epidemic work and make selfless contributions out of moral and professional responsibility [ ] . at the same time, nurses would be in a state of physical and mental stress and feel isolated and helpless in the face of health threats and pressure from the high-intensity work caused by such public health emergencies [ ] . previous studies have shown that when nurses are in close contact with patients with emerging infectious diseases such as sars [ ] , mers-cov [ , ] , ebola [ ] , h n [ ] , they will suffer from loneliness, anxiety, fear, fatigue, sleep disorders, and other physical and mental health problems. studies have shown that the incidence of depression, insomnia, and post-traumatic stress among nurses involved in the treatment of sars patients was . %, %, and %, respectively [ ] . in a study on the psychological status of ebola patients' caregivers, % of respondents felt lonely and % received psychological counselling [ ] . on the contrary, some studies also demonstrate the positive experience and growth brought by the collective anti-epidemic efforts [ , ] . due to the sudden outbreak of the epidemic, nurses from the department of infectious diseases had to enter the negative pressure ward to care for the patients after only undergoing a brief training on covid- . nurses from other departments were required to go through three training stages before starting nursing duties for patients with covid- : pre-job training, adaptive training by nursing other patients in the infection department, and negative pressure ward training. this process occupied about one week. nurses who entered the negative pressure ward would work for . - months before being transferred to other non-anti-epidemic positions. because covid- is a new disease and the medical system and culture of different countries varies, further research is needed on the psychological experience of frontline nurses fighting against covid- . currently, published studies have highlighted the disease prevalence [ ] , clinical characteristics, diagnosis, and treatment [ ] . some reports have paid attention to the severity of psychological problems in medical personnel [ ] and the urgency of providing psychological care [ ] . however, no qualitative studies have been published on the psychological experience of nurses. therefore, our study aims to understand the subjective experience of nurses participating in nursing covid- patients through semi-structured interviews and to analyse the data using phenomenological methods [ ] , providing fundamental data for the psychological experience of nurses. our research used the colaizzi's phenomenological method to qualitatively analyse the psychological experience of nurses caring for patients with covid- . colaizzi's phenomenological method focuses on the experience and feelings of participants and finds shared patterns rather than individual characteristics in the research subjects. this scientific approach guarantees the authenticity of the collected experience of participants to adhere to scientific standards. by using a purposeful sampling method, we selected nurses caring for patients with covid- in the first affiliated hospital of henan university of science and technology from january to february . the inclusion criteria included ( ) nurses who entered the negative pressure ward and provided nursing care for confirmed covid- patients and ( ) volunteers who participated in the study. the exclusion criteria were inability to conduct two or more interviews during the study period. we determined the number of required respondents by interviewing nurses who met the inclusion criteria until the data was saturated and no new topics were generated. we determined the interview outline by consulting relevant literature, seeking we communicated the purpose and significance of the study with the participant in advance and scheduled the interview time at their convenience. the interviewer possessed a master of science in nursing with experience in qualitative interview and had worked as a head nurse in the sars isolation ward and was experienced in epidemic prevention and control. with years of clinical nursing, teaching, and scientific research experience and years of psychological consultation experience, the researcher obtained a second level psychological consultant certificate (the highest level in china) issued by the ministry of human resources and social security of china. therefore, the researcher was able to carry out this research independently. the one-to-one interviews were conducted in a separate room in a quiet manner without interruptions. the interviews were recorded, which were kept strictly confidential. the interviews took - minutes per person. if the participant exhibited emotional problems during the interview, adequate psychological intervention was provided to prevent secondary psychological harm. the study subjects were allowed to withdraw consent at any time. the researchers remained neutral in collecting the data and established good relationships with the participants. we used techniques such as unconditional acceptance, active listening, and clarification to promote the authenticity of the data and to avoid bias. for each participant, at least - face-to-face interviews and - telephone interviews were arranged as needed to ensure data collection at multiple time points. within hours of each interview, the recording was transcribed and analysed by colaizzi's phenomenological analysis method. two researchers independently reviewed the interview materials, summarized and extracted meaningful statements, and formulated the themes present. conflicting opinions on the contents of a theme were discussed and resolved by a research group composed of a master of nursing, a doctor of nursing, and two chief nurses. this study was reviewed and approved by the ethics committee of the first affiliated hospital of henan university of science and technology (ethics code: - -b ). all participants signed informed consent. the authors promise that there will be no academic misconduct such as plagiarism, data fabrication, falsification, and repeated publication. in our study, we enrolled three males and females between to with an average age of . ± . . the working experience ranged from to years with an average of . ± . . all nurses possessed a bachelor's degree. seven nurses were married with children, five were married without children, and eight were unmarried without children. there were general nurses and head nurses. table outlines the baseline characteristics of the participants. we explored the psychological experience of caregivers of patients with covid- using phenomenological methods. we found four themes that are summarized below. exemplar quotes for each theme are displayed in table . iv. bidirectional concerns with their own family members "i am worried that i will infect my children" "my partner is very worried that i will be infected." "i am the only child and my mother cries every day and fears that i will be infected, and i worry more about them... "i feel good using mindfulness-based stress reduction." ii. life adjustment "i feel sleep is the best stress relief, i just want to sleep." "i think eating and drinking will increase my resistance. i don't lose weight now; i eat a lot." "i am exercising less than before because the heavy workload is also exercise and the right amount is the best." iii. taking the initiative to be altruistic and seeking team support by "huddling together for warmth" "everyone is very welcoming and friendly. experienced colleagues will take the initiative to teach me. i also take the initiative to teach new colleagues." "everyone is willing to do more work so colleagues can rest more. colleagues are particularly united." "if someone is uncomfortable, everyone will take care of him and work for him." all study subjects experienced a significant amount of negative emotions in the first week, especially in the period from the first pre-job training to the first time they entered the negative pressure ward. as the number of patients continued to rise, the workload of all nurses (n = ) increased proportionally with . - times normal work hours and workloads. nurses were required to conserve protective clothing by reducing the number of times they wear it since protective equipment was in short supply, resulting in fatigue and discomfort. failing to meet physical and psychological needs brought a sense of helplessness. all participants (n = ) expressed their fears, which peaked when they entered the negative pressure ward for the first time, which then gradually declined. similarly, outsourced support nurses (n = ) also experienced a strong sense of fear when they first entered the department of infectious diseases, but gradually eased as their work adjusted. most nurses (n = ) expressed concerns about patients in an isolated environment with relatively few caregivers and many patients. they were mainly concerned about the unknown conditions of the patients, severe emergencies, and the patients' psychological state. as with any emerging infectious disease, work processes and nursing routines need to be explored while working. most of the participants (n = ) felt different levels of anxiety. under the challenges of changes in working environment and team members, % of nurses said they felt anxious. most nurses in this study were between and years old. some came from a single-child family and have elderly and children in their family. all nurses expressed concern about the impact of the outbreak on the health of their families. they also said that their families were also worried about their health. those who did not live with their parents (n = ) chose to hide the fact that they work in isolation ward from their parents. after separation from their families, they felt helpless and guilty. the nurses (n = ) with the elderly and children at home were particularly worried of their families. all nurses (n = ) activated psychological defence mechanisms, such as speculation, isolation, depression, distraction, self-consciousness, humour, rationalization, etc. nurses used existing knowledge and new knowledge of psychological decompression communicated by colleagues or the internet to adjust themselves and actively or passively used psychological techniques, such as writing diary and letters, breathing relaxation, mindfulness, music meditation, and emotional expression and venting. most nurses (n = ) chose to adjust their sleep when stressed by work. some nurses will increase their food intake and some will exercise regularly and maintain physical strength to ensure normal work ability. during times of stress, nurses (n = ) cared and helped each other and showed support for stress relief. most nurses said that they felt the collective power and the team cohesion was stronger. some nurses (n = ) took the initiative to process information and use medical knowledge for analysis. their attitudes were calm and rational. nurses also took the initiative to compare situations, find favourable information, and encourage themselves. all participants (n = ) mentioned their gratitude for the support from colleagues, relatives, friends, and all sectors of society. they also realised the importance of health and family. most nurses (n = ) said that they would work and live with a state of appreciation and gratitude in the future. more than % of the participants mentioned that professional responsibility prompted them to participate in the mission to contain the epidemic. most nurses (n = ) reviewed the value of the nursing profession and identified more with their chosen profession. half of the nurses (n = ) conveyed that although the epidemic prevention work was hard, they started to self-reflect. for example, they strengthened their will, discovered their potential, and increased their courage to face life. although most nurses had negative emotions such as fear, anxiety, and worry, positive emotions appear synchronously or progressively. after a week, positive emotions prevailed in % of the nurses. while fear and anxiety were brought on by the epidemic, nurses also evaluated the epidemic prevention and control progress and felt confidence in the medical capability of the government and its subunits. at the same time, they felt confidence in self-prevention and control ability after training and practice. all nurses actively accepted anti-epidemic tasks and most (n = ) volunteered. most nurses (n = ) showed calmness when receiving these tasks. although, as mentioned earlier, there were negative emotions such as fear and anxiety in the early stages, these subsided after the pre-job training and environmental adaptation. most nurses (n = ) said that after entering the negative pressure ward to care for patients, they felt calm and relaxed. despite difficult conditions and challenges in the fight against the disease, % of the nurses reported feeling happy. firstly, the nurses felt the patient's goodwill, respect, active cooperation, and gratitude. secondly, family and team support brought happiness. contact with family was a key factor in our study. in addition, the hospital has a reward and welfare system in place to support and motivate nurses. the encouragement of colleagues also brought happiness to nurses. other forms of social support were important to the nurses' feeling of appreciation. this study explored the psychological experience of caregivers of patients with covid- using phenomenological methods and we summarised our findings into four themes: significant amounts of negative emotions at an early stage, self-coping styles, growth under stress, and positive emotions that occur simultaneously or progressively with negative emotions. the nurses caring for covid- patients felt extreme physical fatigue and discomfort caused by the outbreak, intense work, large number of patients, and lack of protective materials, which was consistent with the studies on the outbreak of mers-cov [ , ] and ebola [ ] . in this study, nurses' concerns about family members were consistent with the study of lee et al. [ ] , especially those with elderly and children in the family. the physical exhaustion, psychological helplessness, health threat, lack of knowledge, and interpersonal unfamiliarity under the threat of epidemic disease led to a large number of negative emotions such as fear, anxiety, and helplessness, which have been reported by several studies [ , , ] . we showed that nurses' negative emotions are more pronounced in the first week when entering pre-job training and negative pressure ward for the first time. therefore, early psychological intervention is particularly important to nurses in an epidemic. it is best to conduct stress assessment and screening of nurses immediately after receiving the epidemic prevention tasks and to provide professional, flexible, and continuous psychological intervention [ , ] to promote emotional release and improve nurses' mental health [ ] . at the same time, it is important to establish early support systems [ ] , such as adequate supplies of protective materials, reasonable allocation of human resources, elderly and infant care services for nurses' families, pre-job training, and interpersonal interaction among nurses to facilitate nurses' adaptation to the anti-epidemic tasks. it is known that coping style, cognitive evaluation, and social support are all mediators of stress. studies have shown that psychological adaptation and social support play an intermediary role in psychological rehabilitation under outbreak stress [ ] . pressure of the epidemic may prompt nurses to use their medical and psychological knowledge to actively or passively make psychological adjustments. in our study, nurses adopted avoidance, isolation, speculation, humour, self-consciousness, and other psychological defences to psychologically adjust to the situation. it has been demonstrated that all coping measures under the epidemic disaster can alleviate stress and promote mental health [ ] . participants adopted breathing relaxation, music, meditation, mindfulness, and other ways to reduce stress, which was consistent with the study of nurses in the sars wards that adopted multiple ways to deal with stress [ , ] . in addition, our results showed active altruism and greater team solidarity, reflecting the study of kim et al. [ ] and shih et al. [ ] . generally, nurses can adjust their cognitive rationality to adapt to the epidemic, which may also be related to health care professionals' rich medical knowledge and more rational and positive attitude [ ] . according to american psychologist richard lazarus' stress and coping model, whether the stressors are effective or not depends mainly on the process of cognitive evaluation and coping. when stressed, nurses constantly adjust cognitive evaluation through professional knowledge to promote self-psychological balance, take the initiative to be altruistic, seek team support [ ] , take the initiative to reduce stress, adjust sleep, diet and exercise to adapt to internal and external environment changes, and prevent injuries caused by stress, which has positive significance for mental health [ ] . many studies have shown that epidemic outbreaks can cause psychological trauma for caregivers [ , , ] . in contrast, the results of our study demonstrate that most nurses grew psychologically under pressure. nurses partook in self-reflection of their own values and found positive forces such as expressing more appreciation for health and family and gratitude for social support, which was consistent with study of shih et al. [ ] . the sense of responsibility brought by professional ethics in an epidemic [ , ] encouraged nurses to actively participate in anti-epidemic tasks and boosted their professional identity and pride, in line with previous reports [ ] . therefore, actively guiding and inspiring nurses to realise their own psychological growth during an epidemic may play a positive role in psychological adjustment. our finding of the existence of positive emotions in our nurses such as confidence, calmness, relaxation, and happiness, which simultaneously or gradually appeared with negative emotions, was in contrast to the results several studies that describe only the presence of a large amount of negative emotions during outbreak stress [ , ] . however, other studies report similar findings [ , , ] . in the case of an outbreak, confidence in safety, early training, and confidence in professional skills are all factors that promote medical staff's willingness to actively participate in anti-epidemic work [ ] . physical and mental rewards to nurses from work units are also important supporting factors [ ] . our participants generally believed that positive emotions were related to the multi-dimensional support of patients, family members, team members, government, social groups etc. therefore, social support is critical for nurses in the fight against epidemics [ , , ] . the calmness and ease of most nurses in this study after starting the anti-epidemic tasks is rarely mentioned in other studies and may be related to nurses' gradual adaptation, acceptance, positive response, and personal growth [ , ] . studies have shown that positive emotions play an important role in the recovery and adjustment of psychological trauma [ ] . optimism has a protective effect on psychological trauma under disasters and can promote the psychological rehabilitation of post-traumatic stress disorder [ ] . therefore, in the process of psychological intervention of nurses in an epidemic, strengthening multi-dimensional social support, adjusting cognitive evaluation, guiding positive coping styles, and stimulating positive emotions are crucial to promote the psychological health of nurses. most existing qualitative studies are retrospective studies. in contrast, this study established a good relationship of consultation and visit with the participants in an early stage when the participants just accepted the anti-epidemic tasks. we collected the psychological experience data of the participants over time through multiple interviews. this led to a deep understanding of their work experience, resulting in comprehensive and authentic data. diverging from the results of many studies on the experience of negative emotions during outbreak stress, we found that positive emotions coexist with negative emotions, as well as psychological adjustment and growth under pressure, and preliminarily discussed its impact on nurses' mental health. due to the characteristics of qualitative research, the sample size of this study was limited. firstly, most of the participants were nurses, including three nursing managers. the experiences of other health care workers and administrators besides nurses need to be further explored. secondly, due to the nature of outbreak prevention and control, we were unable to conduct focus group interviews and did not collect data from multiple centres in order to avoid potential cross-infection. in addition, this study was a short-term study. long-term experience of the research subjects would be a valuable avenue to explore in the future. this study provided a comprehensive and in-depth understanding of the psychological experience of caregivers of patients with covid- through a phenomenological approach. we found that during the epidemic, positive and negative emotions of frontline nurses against the epidemic interweave and coexist. in the early days, negative emotions were dominant and positive emotions appeared simultaneously or gradually. self-coping style and psychological growth are important for nurses to maintain mental health. this study provided fundamental data for further psychological intervention. a novel coronavirus from pat ients with pneumonia in china clinical features of patients infected with novel coronavirus in wuhan interpretation of pneumonia diagnosis and treatment scheme for novel coronavirus infect ion (trial version ) who novel coronavirus( -ncov) situation report - update on pneumonia of new coronavirus infect ion as of : on china disease control report: more than , medical staff infected with new crown virus ethical and legal challenges associated wit h disaster nursing nurses' beliefs about public healt h emergencies: fear of abandonment sars: caring for patients in hong kong nurses' experiences of care for patients wit h middle east respiratory syndrome-coronavirus in south korea healt hcare worker semotions, perceived stressors and coping strategies during mers-cov outbreak sources and symptoms of stress among nurses in the first chinese ant i-ebola medical team during the sierra leone aid mission: a qualitat ive study new zealand nurses percept ions of caringfor patients with influenza a (h n ) prevalence of psychiatric morbidit y and psychological adaptat ion of the nurses in a structured sars caring unit during outbreak: a prospect ive and periodic assessment study in taiwan the psychosocial challenges of caring for pat ients with ebola virus disease instructive messages from chinese nurses'stories of caring for sars patients the cont inuing -ncov epidemic threat of novel coronaviruses to global healt h-the latest novel coronavirus outbreak in wuhan the mental healt h of medical workers in wuhan, china dealing wit h the novel coronaviru s timely mental healt h care for the novel coronavirus outbreak is urgently needed colaizzi pf， ) colaizzi pf. psychological research as the phenomenologist views it working experiences of nurses during the middle east respiratory syndrome outbreak facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital nat ional healt h commission of the people's republic o f china. the guideline of psychological crisis intervent ion for -ncov pneumonia b b b be c b .sht ml social support and psychological adjust ment to sars: the mediat ing role of self -care self-efficacy relat ions of sars -related stressors and coping to chinese college students' psychological adjust ment during the beijing sars epidemic the psychological impact of severe acute respiratory syndrome outbreak on healt hcare workers in emergency depart ments and how they cope the impact of the - earthquake experiences of taiwanese nurses as rescuers knowledge, attitude and anxiet y towards pandemic flu a potent ial bio weapon among healt h professionals in indore cit healt hcare workers'willingness to work during an influenza pandemic: a systemat ic review and meta-analysis the regulatory power of posit ive emot ions in stress: a temporal funct ional approach effects of optimism on recovery and mental healt h after a tornado outbreak key: cord- -pw odm authors: moccia, lorenzo; janiri, delfina; pepe, maria; dattoli, luigi; molinaro, marzia; de martin, valentina; chieffo, daniela; janiri, luigi; fiorillo, andrea; sani, gabriele; di nicola, marco title: affective temperament, attachment style, and the psychological impact of the covid- outbreak: an early report on the italian general population date: - - journal: brain behav immun doi: . /j.bbi. . . sha: doc_id: cord_uid: pw odm the outbreak of covid- is severely affecting mental health worldwide, although individual response may vary. this study aims to investigate the psychological distress perceived by the italian general population during the early phase of the covid- pandemic, and to analyze affective temperament and adult attachment styles as potential mediators. through an online survey, we collected sociodemographic and lockdown-related information and evaluated distress, temperament, and attachment using the kessler psychological distress scale (k ), the temperament evaluation of memphis, pisa, paris and san diego-autoquestionnaire short version (temps-a) and the attachment style questionnaire (asq). in our sample (n= ), % of the individuals reported no likelihood of psychological distress, whereas . % and . % displayed mild and moderate-to-severe likelihood. cyclothymic (or: . ; p< . ), depressive (or: . ; p< . ) and anxious (or: . ; p= . ) temperaments, and the asq “need for approval” (or: . ; p= . ) were risk factors for moderate-to-severe psychological distress compared to no distress, while the asq “confidence” (or: . ; p= . ) and “discomfort with closeness” were protective (or: . ; p= . ). cyclothymic (or: . ; p= . ) and depressive (or: . ; p= . ) temperaments resulted as risk factors in subjects with moderate-to-severe psychological distress compared to mild distress, while the asq “confidence” (or: . ; p= . ) and “discomfort with closeness” (or: . ; p= . ) were protective. our data indicated that a relevant rate of individuals may have experienced psychological distress following the covid- outbreak. specific affective temperament and attachment features predict the extent of mental health burden. to the best of our knowledge, these are the first data available on the psychological impact of the early phase of the covid- pandemic on a sizeable sample of the italian population. moreover, our study is the first to investigate temperament and attachment characteristics in the psychological response to the ongoing pandemic. our results provide further insight into developing targeted intervention strategies. the coronavirus disease pandemic has been spreading across italy for over a month. on march th, , the italian government implemented several emergency containment measures, including strict limitations on movement on the whole national territory, except for proven work and health reasons. these measures are unprecedented and aim to contain the epidemic after an increase in total deaths of nearly % in the hours before the decree (lazzerini and putoto, ) . the covid- outbreak is currently leading to severe mental health burden in worst-hit countries (fiorillo et al., ; kang et al., ) . containment measures, including self-isolation and social distancing, have a strong impact on the population's daily life and may negatively affect psychological well-being (brooks et al., ) . however, mixed evidence is available about the role of interindividual characteristics and demographics in determining the psychological response of a population facing large-scale stressful events. hence, it is crucial to detect possible predictors of the psychological impact during the covid- outbreak, in order to implement prompt intervention strategies (sani et al., ) . temperament refers to early-appearing individual differences in emotional reactivity, is stable across the lifespan, and has strong biological underpinnings. certain affective temperament traits and related personality constructs might, to some extent, mediate adaptive functioning, e.g., by subserving better coping mechanisms to environmental stressors (akiskal and akiskal, ; balestri et al., ) . the attachment theory postulates that the intimate bonds built with caregivers very early during infancy are crucial for social and emotional development and provide a template model for enduring patterns of emotional, cognitive and behavioral strategies in adulthood, i.e., adult attachment style (aas) (bartholomew and horowitz, ) . stressful situations are thought to activate the attachment system, and evidence supports the existence of a relationship between attachment patterns and stress responsivity during adulthood (kidd et al., ) . to the best of our knowledge, no study has investigated the determinants of psychological response to the ongoing covid- outbreak so far. we hypothesized that temperament and attachment may affect the degree of perceived psychological distress during the covid- pandemic. therefore, we aimed to evaluate the psychological impact of the covid- outbreak on the italian general population and to analyze the affective temperament and aas as potential predictive factors influencing the extent of psychological burden. the study was conducted through an online survey between april th and april th, . this timeframe was chosen to assess participants' response during an early phase of the covid- outbreak, following the italian government declaration of lockdown (decree of march th, ) and the world health organization (who) announcement of the covid- as a pandemic (march th, ) . the snowball sampling method was used to recruit participants (goodman, ) . we selected an initial set of five participants, ensuring a broad range of age, gender, occupation, education, and geographical area. each participant was asked to choose five people they consider suitable for the survey and to send them the questionnaire. further participants were reached out in the same way until data saturation. efforts were made to recruit subjects from all italian regions, which had been affected by the pandemic to different extents, so to have a representative sample of the italian population. the survey was anonymous, and data confidentiality was assured. eligible participants were aged - , had lived in italy for at least four weeks from february , were fluent in both written and spoken italian, and had at least five years of education. exclusion criteria were: non-italian language speakers; current hospitalization; a history of mental disorder. the study followed the european survey research association (esra) guidelines. all participants completed the questionnaire online via eusurvey. the study was approved by the ethics committee of the fondazione policlinico universitario agostino gemelli irccs, università cattolica del sacro cuore of rome. a dedicated, self-report questionnaire was set up to collect demographic and epidemiological variables of interest (age, gender, educational level, occupation, marital status, geographical area), medical status (lifetime history of chronic diseases, family history of psychiatric disorders), and information on lockdown conditions (living alone, changes in working activities, working on the frontline, and having direct contact with confirmed cases of covid- infection). the kessler psychological distress scale (k ; kessler et al., ) was used to assess the psychological impact of the covid- outbreak. k is a -item questionnaire intended to yield a global measure of distress experienced in the most recent -week period. we adopted the cutoff scores of > and > to detect the likelihood of mild and moderate-to-severe psychological distress, respectively (andrews and slade, ) . affective temperaments (cyclothymic, depressive, irritable, hyperthymic, and anxious) were assessed through the short version of the validated italian temperament evaluation of memphis, pisa, paris and san diego-autoquestionnaire (temps-a; preti et al., ) . aas was evaluated through the italian validated version of the attachment style questionnaire (asq; fossati et al., ) , a self-report instrument containing items. the asq comprises five subscales: ( ) "confidence", describing secure attachment; ( ) "discomfort with closeness" and ( ) "relationships as secondary", both measuring attachment avoidance; ( ) "need for approval", and ( ) "preoccupation with relationships", both assessing attachment anxiety. previous sensitivity analysis suggested that with n= the power was= . to detect a minimally interesting effect size of δ= . (α= . ; two-tailed). to fit our aims, we subdivided our sample into three groups according to k cutoffs: ) subjects without likelihood of psychological distress, ) subjects with likelihood of mild psychological distress, and ) subjects with likelihood of moderateto-severe psychological distress. analyses used standard univariate/bivariate comparisons of continuous measures (anova) and categorical measures (contingency table/χ ) to compare factors of interest (including sociodemographic, aas, and temperament characteristics) in the three groups. we used a statistical model corrected for multiple comparisons according to the bonferroni procedure (p< . /number of comparisons) to minimize the likelihood of type i statistical errors. factors significantly associated with mild or moderate-to-severe psychological distress in bivariate analyses subsequently underwent a multiple multivariate logistic regression to generate odds ratios (ors) and their % confidence intervals (cis), with no psychological distress risk/ mild psychological distress/ and moderate-to-severe psychological distress as dependent outcome measures. we examined possible multicollinearity between variables of interest by ensuring that the variance inflation factor (vif) indicator obtained from linear regression analysis was < . we used the statistical routines of spss statistics . for windows (ibm co., armonk, new york, usa). in our sample (n= ), subjects ( %) reported no likelihood of psychological distress, whereas distress, respectively. sociodemographic and epidemiological characteristics, as well as results of the univariate/bivariate analysis of temperament and aas features of the sample, are summarized in table . the three groups differed only in gender (χ = . ; p= . ) and age (χ = . ; p= . ). anovas revealed significant differences among the three groups regarding cyclothymic (f= . ; p< . ), depressive (f= . ; p< . ), irritable (f= . ; p< . ), and anxious temperaments (f= . ; p< . ). the three groups also differed in several asq dimensions, including "confidence" (f= . ; p< . ), "discomfort with closeness" (f= . ; p< . ), "need for approval" (f= . ; p< . ), and "preoccupation with relationships" (f= . ; p< . ). multinomial logistic regression identified anxious temperament (or: . ; p= . ) as a risk factor for mild psychological distress compared to no psychological distress, whereas male gender (or: . ; p= . ) was protective. cyclothymic (or: . ; p< . ), depressive (or: . ; p< . ) and anxious (or: . ; p= . ) temperaments, and the asq "need for approval" (or: . ; p= . ) were risk factors for moderate-to-severe psychological distress as compared to no distress, while the asq "confidence" (or: . ; p= . ) and "discomfort with closeness" subscales were protective (or: . ; p= . ). lastly, cyclothymic (or: . ; p= . ) and depressive temperaments (or: . ; p= . ) were identified as risk factors when comparing subjects with moderate-to-severe psychological distress to individuals with only mild distress, whereas both the asq "confidence" (or: . ; p= . ) and "discomfort with closeness" (or: . ; p= . ) subscales were protective ( the documented connection between viral epidemics and psychological distress dates back more than years ago, when menniger linked the spanish flu pandemic with psychiatric complications (menninger, ) . people's emotional responses during massive infectious disease outbreaks are likely to include feelings of extreme fear and uncertainty that, along with the separation from loved ones and the limitations of freedom, may eventually lead to dramatic mental health burden (brooks et al., ) . hence, we conducted a survey to investigate the italian population's psychological response during an early phase of the epidemic. our findings indicate that % of the general population is currently perceiving a form of psychological distress. similar results were observed both in online surveys conducted on the chinese population during the covid- pandemic (li et al., ) and among the italian general population following previous natural disasters (dell'osso et al., ) . however, the majority of subjects in our sample displayed no relevant distress. this might be due to the still relatively short exposure to the pandemic, as well as to individual features promoting resilience (mukhtar, ) . anxious temperament and male gender represented, respectively, a predictive and protective factor for mild psychological distress. on the one hand, anxious temperament, as a trait-like phenotype, is characterized by increased behavioral and physiological reactivity to mildly stressful stimuli and is more prevalent in women (akiskal and akiskal, ) . on the other hand, gender is an important biological determinant of vulnerability to psychosocial stress, in addition to genetic, socio-cultural, hormonal, and developmental factors (wang et al., ) . our results indicate that males are, to a certain degree, less likely to develop psychological symptoms in the face of a stressful event. similarly, a recent survey conducted in china one month after the covid- outbreak reported higher post-traumatic stress symptoms in women (liu et al., ) . when comparing subjects with likelihood of moderate-to-severe psychological distress to individuals with no risk, depressive, anxious, and cyclothymic temperaments, as well as the insecure-anxious attachment dimension "need for approval", appeared to be risk factors. conversely, the asq "confidence", as well as the asq "discomfort with closeness", dimensions of secure and avoidant patterns of attachment respectively, were protective. the same asq subscales were protective also for mild psychological distress, compared to moderate-to-severe distress, whereas cyclothymic and depressive temperaments proved to be predictors. depressive temperament is characterized by being pessimistic, highly self-critical, gloomy, prone to excessive worrying and striving to please others, whereas cyclothymic temperament is outlined by shifts in mood, energy, behavior, and thinking. both cyclothymic and depressive temperaments display increased stress reactivity in daily life, as well as enhanced desire for social contact (walsh et al., ) . our results suggest that cyclothymic/depressive individuals may be more likely to perceive the covid- outbreak and related containment measures as distressful and to experience increased negative affect in response to social isolation. in our sample, features of both secure and avoidant aas appeared to be protective for the risk of higher psychological burden during the covid- outbreak, compared to anxious style. a function of attachment is to regulate distress (bartholomew and horowitz, ) and evidence suggests that quality of early caregiving experiences and aas may affect stress responsivity, both at a physiological and psychological level (kid et al., ) . anxiously/avoidantly attached individuals are less able to regulate their emotions, as opposed to securely attached subjects, so that several strategies have developed internally to reduce or manage any distress experienced. bartholomew and horowitz ( ) described anxiously-attached individuals as overly dependent on others and in constant need of attention, in contrast to those high in avoidance who may feel uncomfortable in social interactions. a possible explanation to our results is that while subjects with anxious style overreport distress to ensure care will be provided, individuals with an avoidant attachment may appear as if they are very calm in a distressing situation while their internal experience may be quite the opposite. alternatively, individuals with prominent avoidant attachment features, who tend to be self-directed, and often do not exhibit distress upon social separation, might perceive self-isolation, as well as social distancing preventive measures, as less stressful compared to anxiously-attached individuals. some issues might limit the generalizability of our results. the study was carried out throughout four days and lacks longitudinal follow-up. the impact of the covid- outbreak on the italian population's mental health could worsen over time and long-term implications warrant further investigation. the survey design involved an online invitation, thus leaving unexplored the population who does not use network devices. further, we cannot determine the participation rate since it is unclear how many subjects received the survey. finally, the reliability of self-administered questionnaires may be partially biased. to the best of our knowledge, our survey results are the first showing that a relevant percentage of the italian population might have experienced from mild to moderate-to-severe psychological distress symptoms during the early phase of the covid- outbreak, and that both temperament and aas features may predict the extent of mental health burden. interventions promoting mental health among the general population should be rapidly implemented, bearing in mind individual background and characteristics. none. the theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolar disorder and human nature interpreting scores on the kessler psychological distress scale (k ) temperament and character influence on depression treatment outcome attachment styles among young adults. a test of a four-category model the psychological impact of quarantine and how to reduce it: rapid review of the evidence gender differences in the relationship between maladaptive behaviors and post-traumatic stress disorder. a study on l'aquila the consequences of the covid- pandemic on mental health and implications for clinical practice on the dimensionality of the attachment style questionnaire in italian clinical and nonclinical participants snowball sampling impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a crosssectional study short screening scales to monitor population prevalences and trends in non-specific psychological distress examining the association between adult attachment style and cortisol responses to acute stress covid- in italy: momentous decisions and many uncertainties. lancet glob health vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control prevalence and predictors of ptss during covid- outbreak in china hardest-hit areas: gender differences matter psychoses associated with influenza, i: general data: statistical analysis mental health and emotional impact of covid- : applying health belief model for medical staff to general public of pakistan the italian version of the validated short temps-a: the temperament evaluation of memphis, pisa, paris and san diego mental health during and after the covid- emergency in italy the expression of affective temperaments in daily life gender difference in neural response to psychological stress key: cord- -ghmqd yv authors: wang, peng-wei; ko, nai-ying; chang, yu-ping; wu, chia-fen; lu, wei-hsin; yen, cheng-fang title: subjective deterioration of physical and psychological health during the covid- pandemic in taiwan: their association with the adoption of protective behaviors and mental health problems date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ghmqd yv this study aimed to determine the proportion of individuals who reported the deterioration of physical and psychological health during the coronavirus disease (covid- ) pandemic in taiwan. moreover, the related factors of deterioration of physical and psychological health and the association between deterioration of health and adoption of protective behavior against covid- and mental health problems were also examined. we recruited participants via a facebook advertisement. we determined the subjective physical and psychological health states, cognitive and affective construct of health belief, perceived social support, mental health problems, adoption of protective behavior and demographic characteristics among respondents ( women and men; mean age: . years with standard deviation . years). in total, . % and . % of respondents reported deteriorated physical and psychological health during the covid- pandemic, respectively. participants with higher perceived harm from covid- compared with severe acute respiratory syndrome (sars) were more likely to report the subjective deterioration of physical and psychological health, whereas respondents who were older and perceived a higher level of social support were less likely to report a deterioration of physical and psychological health. the subjective deterioration of psychological health was significantly associated with avoiding crowded places and wearing a mask. both subjective deteriorations of physical and psychological health positively related to general anxiety. the coronavirus disease (covid- ) pandemic has been raging globally. as a novel respiratory infectious disease that is highly contagious, the covid- pandemic has impacted int. j. environ. res. public health , , of physical [ ] and mental health [ , ] , the economy [ ] , education [ ] , quality of life [ ] , occupations [ ] , and the interpersonal relationships [ ] of humans. the first covid- case in taiwan was confirmed on january [ ] . due to proactive containment and comprehensive contact tracing, the number of covid- cases in taiwan has remained lower than in other countries [ ] . by august , taiwan had tested , individuals. a total of confirmed cases were identified, of which were domestic and had died [ ] . therefore, taiwan did not impose a social lockdown. however, the pandemic has impacted the economy and unemployment rate profoundly [ ] . in - , taiwan experienced a major outbreak of severe acute respiratory syndrome (sars). the covid- outbreak rekindled memories of sars and caused fear among the people of taiwan. covid- is a threat to the physical health of both infected individuals and the general public. a study in canada found that % of the population was very or extremely concerned about the impact of covid- to their health [ ] . an online-based study on the general public in china found that % of the participants experienced physical pain or discomfort on the euroqol- d evaluating health-related quality of life [ ] . the psychological health of the public has also been deeply affected by the covid- pandemic. a review study found that both specific populations such as children, elderly, and medical personnel and the general population were harmed psychologically by imposition of strict isolation during the covid- pandemic [ ] . the covid- pandemic might also threaten individual bodily integrity and autonomy and subsequently result in psychiatric comorbidity representing as atypical pictures, such as functional movement disorders [ ] . these studies examined the cross-sectional status of physical and psychological health among people during the covid- pandemic. given that covid- has impacted human lives rapidly and unprecedentedly, examining the deterioration of physical and psychological health since the pandemic began may provide insights into changes in health status during the covid- pandemic. several individual and environmental factors may correlate with the physical and psychological health problems evident during the covid- pandemic, such as pre-existing physical and mental health conditions [ , , [ ] [ ] [ ] , low income [ , ] , and experiencing the profound influence of the pandemic on daily activities [ , , ] . determining the modifiable factors predicting the deterioration of physical and psychological health during the covid- pandemic may provide evidence to develop prevention and intervention programs for the public affected by the covid- pandemic. the health belief model (hbm) can serve as a theoretical basis for determining the predictors of deteriorating physical and psychological health during the covid- pandemic. the hbm proposes cognitive and affective constructs that predict whether an individual will adopt health-promoting behaviors. these include perceived susceptibility to and severity of a health problem, perceived benefits of and barriers to engaging in recommended action, and the belief in one's ability to successfully perform a behavior [ , ] . several studies have examined the association of cognitive and affective constructs of health beliefs with physical and psychological health during the covid- pandemic. for example, perceived high vulnerability for contracting covid- [ , ] , perceived low survival likelihood [ ] , anxiety regarding contracting covid- [ ] , and the distress caused by the uncertainty of the endpoint of the covid- pandemic [ ] predict physical and psychological health during the covid- pandemic. however, hbm-based assessment is inadequate. liao et al. [ ] proposed cognitive and affective constructs of health beliefs concerning the risk of contracting ( ) influenza a/h n in and ( ) respiratory infectious diseases in future epidemics or pandemics. these can be used to examine the cognitive and affective constructs of health beliefs predicting physical and psychological health during the covid- pandemic. studies have found that levels of social support were significantly associated with self-efficacy and sleep quality and negatively associated with the degree of anxiety and stress among medical staff in china who were treating patients with covid- [ ] . however, the association between perceived social support and deteriorating physical health has not been well examined. studies on the association between demographic characteristics and physical and psychological health during the covid- pandemic have revealed mixed results. one study found that aging individuals had a higher risk of physical pain or discomfort and depression or anxiety [ ] , whereas other studies have found that young people were more likely to report mental health problems during the covid- pandemic [ , , ] . moreover, several studies have confirmed that women are more likely to report poor mental health during the covid- pandemic than men are [ , , , ] ; however, gender difference in determining physical health during the covid- pandemic has not been examined. further study is needed to examine whether demographic factors relate to the deterioration of physical and psychological health during the covid- pandemic. adopting protective behaviors, such as avoiding crowded places, washing hands frequently, and wearing a mask, are essential to prevent contracting covid- and staying healthy. a two-wave study in china indicated that precautionary measures, such as maintaining hand hygiene and wearing a mask, were associated with a lower psychological impact from the outbreak and lower levels of stress, anxiety, and depression in both the initial stage of the covid- outbreak [ ] and four weeks later [ ] . however, studies on people during the sars epidemic have reported that respondents with a moderate level of anxiety were most likely to take comprehensive precautionary measures against the infection [ ] . moreover, the use of personal protective equipment increases the discomfort level and causes difficulties in communication [ ] . there is a need of further research into the roles played by deteriorating physical and psychological health in the adoption of protective behaviors against covid- . physical symptoms and poor self-rated health status were significantly associated with a higher incidence of post-traumatic stress disorder and symptoms of stress, anxiety, and depression [ ] . both sleep problems [ ] and suicidal ideation [ ] are serious mental health problems in the era of covid- . it is reasonable to hypothesize that the deterioration of psychological health is significantly associated with sleep problems and suicidal ideation that have become more prevalent during the covid- pandemic, whether the deterioration of physical health is significantly associated with sleep problems and suicidal ideation bears further exploration. this study had three aims: ( ) to determine the proportion of individuals who reported the deterioration of physical and psychological health during the covid- pandemic in taiwan, ( ) to examine the association between cognitive and affective constructs of health beliefs and demographic characteristics and the subjective deterioration of physical and psychological health, and ( ) to examine the association between subjective deterioration of physical and psychological health and adoption of protective behavior against covid- and mental health problems. the current investigation was based on the dataset of the survey of health behaviors during the covid- pandemic in taiwan, which was comprehensively described elsewhere [ ] . briefly, a facebook advertisement was deployed between april and april . we targeted the advertisement to facebook users by location (taiwan) and language (chinese), where facebook's advertising algorithm determined which users to show our advertisement to. facebook users who were years or older and resided in taiwan were eligible for this study. participants reached the research questionnaire website through the facebook advertisement, which was composed of a headline, main text, pop-up banner, and weblink. a total of respondents completed the research questionnaire; of them, respondents were excluded due to missing data on any variable or being younger than . data from respondents were analyzed. figure demonstrates the flowchart of study design. the institutional review board (irb) of kaohsiung medical university hospital that is responsible for ethical review approved this study (kmuhirb-exempt(i) ). as participation was voluntary and survey responses were anonymous, written informed consent was waived based on the approval of irb. the participants were given no incentive for participation. we provided links to taiwan centers for disease control, kaohsiung medical university hospital, and medical college of national cheng kung university for participants to learn more about covid- at the end of the online questionnaire. the analyses of information sources [ ] , sexual behaviors [ ] , and sleep and suicidality [ ] using the dataset have been published elsewhere. facebook advertisement was deployed between april and april . we targeted the advertisement to facebook users by location (taiwan) and language (chinese), where facebook's advertising algorithm determined which users to show our advertisement to. facebook users who were years or older and resided in taiwan were eligible for this study. participants reached the research questionnaire website through the facebook advertisement, which was composed of a headline, main text, pop-up banner, and weblink. a total of respondents completed the research questionnaire; of them, respondents were excluded due to missing data on any variable or being younger than . data from respondents were analyzed. figure demonstrates the flowchart of study design. the institutional review board (irb) of kaohsiung medical university hospital that is responsible for ethical review approved this study (kmuhirb-exempt(i) ). as participation was voluntary and survey responses were anonymous, written informed consent was waived based on the approval of irb. the participants were given no incentive for participation. we provided links to taiwan centers for disease control, kaohsiung medical university hospital, and medical college of national cheng kung university for participants to learn more about covid- at the end of the online questionnaire. the analyses of information sources [ ] , sexual behaviors [ ] , and sleep and suicidality [ ] using the dataset have been published elsewhere. the four-item self-perceived health questionnaire was developed by ko et al. [ ] to evaluate the physical and psychological health of the public during the sars epidemic. for this study, the four questions were modified to evaluate the self-rated physical and psychological health of the respondent compared with those of other people before the covid- outbreak and during the week before filling out the questionnaire ("how is the state of your physical/psychological health compared with other people before the covid- pandemic/in the recent week?"). the questions are listed in table s . the rating for each question ranged from (much worse), (mildly worse), (the same), (mildly better), and (much better). then, the self-reported physical and psychological health states were compared between before and during the covid- pandemic. respondents whose self-rated physical health score in the preceding week was lower than that before the covid- outbreak were classified as having a deterioration of physical health during the covid- pandemic. the respondents whose self-rated physical health score in the preceding week was the same as or higher than that before the covid- outbreak were classified as having no deterioration respondents completed the research questionnaire respondents who were years or older and resided in taiwan completed the questionnaire without missing data data from respondents were analyzed respondents were excluded due to missing data or being younger than the four-item self-perceived health questionnaire was developed by ko et al. [ ] to evaluate the physical and psychological health of the public during the sars epidemic. for this study, the four questions were modified to evaluate the self-rated physical and psychological health of the respondent compared with those of other people before the covid- outbreak and during the week before filling out the questionnaire ("how is the state of your physical/psychological health compared with other people before the covid- pandemic/in the recent week?"). the questions are listed in table s . the rating for each question ranged from (much worse), (mildly worse), (the same), (mildly better), and (much better). then, the self-reported physical and psychological health states were compared between before and during the covid- pandemic. respondents whose self-rated physical health score in the preceding week was lower than that before the covid- outbreak were classified as having a deterioration of physical health during the covid- pandemic. the respondents whose self-rated physical health score in the preceding week was the same as or higher than that before the covid- outbreak were classified as having no deterioration in physical health. the respondents with or without a deterioration of psychological health during the covid- pandemic were classified according to the same rules. we examined the cognitive and affective constructs of health beliefs in the context of covid- , according to the particularization of the hbm to respiratory infectious disease pandemics [ ] . the four cognitive constructs included perceived relative susceptibility to covid- ("what do you think are your chances of contracting covid- over the next month compared with others outside your family?"), perceived severity of covid- relative to sars ("how serious is covid- relative to sars?"), sufficiency of knowledge and information about covid- ("do you think you have sufficient knowledge and information on covid- ?"), and perceived self-confidence in coping with covid- ("how confident are you that you can cope well with covid- ?"). the affective construct included worry about covid- ("please rate how worried you are toward covid- "). the questions, response scales, and dichotomous scales for statistical analysis are listed in table s . three questions developed in the study of tardy [ ] were used to assess the levels of perceived social support from families, friends, and colleagues during the preceding week ("in the past days, were you satisfied with the support from your ( ) family, ( ) friends, and ( ) colleagues or classmates?). the questions and response scales are listed in table s . the total score for the three questions indicates the level of perceived social support. higher scores represent higher perceived social support. the internal reliability (cronbach's α) of the measure was . in this study. as the scores of perceived social support were not normally distributed (skewness = − . , kurtosis = − . , p of kolmogorov-smirnoff test < . ), we used the median score of as the cutoff, and respondents whose score of perceived social support was lower than and whose score was or higher were classified as the groups of low and high perceived social support, respectively. we assessed whether the participants avoided crowded places, washed their hands more often, or wore a mask more often in the preceding week to protect themselves from contracting covid- ("in the past week, did you ( ) avoid going to crowded places, ( ) wash your hands more often, and ( ) wear a mask more often?") [ ] . the questions, response scales, and dichotomous scales for statistical analysis are listed in table s . respondents' level of general anxiety was assessed with the previously validated state-anxiety scale of the chinese version of state-trait anxiety inventory (c-stai), wherein respondents rate their feelings in response to general statements (for example, "i feel rested") [ , , ] . a previous study found that the state-anxiety scale of c-stai had a high internal consistency (cronbach's alpha = . , split-half reliability = . ) and high item-total correlations (r = . - . ) [ ] . two questions adopted from the revised -item brief symptom rating scale were used to assess sleep problems ("in the past week, did you have sleep problems?") and suicidal ideation ("in the past week, did you ever have suicidal thoughts?") in the preceding week [ , ] . previous studies confirmed that both questions had acceptable test-retest reliability (paired sample correlation coefficients = . - . ) and significant correlations with suicidal risk in general population (p < . ) [ , ] . the questions, response scales, and dichotomous scales for statistical analysis are listed in table s . data on gender (women vs. men), age, and education level (university qualifications or above vs. high school qualifications or below) were collected. as age was not normally distributed (skewness = . , kurtosis = − . , p of kolmogorov-smirnoff test < . ), we used the median age int. j. environ. res. public health , , of ( years old) as the cutoff, and respondents who were younger than and who were or older were classified as the younger and older groups, respectively. data analysis was performed using spss . statistical software (spss inc., chicago, il, usa). demographic characteristics, cognitive and affective constructs of health beliefs related to covid- , and perceived social support were compared between respondents who did or did not exhibit a subjective deterioration in physical and psychological health during the covid- pandemic using univariate logistic regression with the crude odds ratio (cor). furthermore, all potential predictive variables identified from the first step were eligible for inclusion in the multivariate logistic regression models with an adjusted odds ratio (aor) to determine the independent predictors of the subjective deterioration of physical and psychological health. the association between the deterioration of physical and psychological health and adoption of protective behaviors against covid- (avoiding crowded places, washing hands, and wearing a mask) and mental health problems (general anxiety, sleep problems, and suicidal ideation) was examined using multivariate logistic regression after controlling for the effects of gender, age, and educational level. moreover, p values, odds ratios (ors), and % confidence intervals (cis) of or were used to indicate significance. a two-tailed p value of < . indicated statistical significance. we also used the standard criteria proposed by baron and kenny [ ] to examine whether the associations of the deteriorated physical and psychological health and related factors (cognitive and affective constructs of health beliefs, perceived social support, adoption of protective behaviors, and mental health problems) were moderated by demographic characteristics that were significantly associated with the deterioration of physical and psychological health. the interactions (demographic characteristics × related factors) were selected into the logistic regression analysis to examine the moderating effects. data from respondents ( women and men) were analyzed. the mean age was . years (standard deviation [sd] = . years; range: - ), ( . %) participants were classified as the older group, and ( . %) participants had university qualifications or above. the mean scores for worry and self-confidence were . (sd = . ; range: - ) and . (sd = . ; range: - ), respectively. regarding the cognitive and affective constructs of health beliefs related to covid- , ( . %) respondents reported high perceived susceptibility to covid- ; moreover, ( . %) perceived that covid- was more harmful than sars, ( . %) reported having sufficient knowledge and information about covid- , ( . %) reported having high confidence in coping with covid- , and ( . %) reported having a high degree of worry about covid- . the mean level of perceived social support was . (sd = . ; range: - ), and ( . %) participants were classified as the group of high perceived social support. table shows the proportions of the respondents with various levels of subjective physical and psychological health and changes in health from before to during the covid- pandemic. most of the respondents reported their health the same as other people before (physical: . %; psychological: . %) and during the covid- pandemic (physical: . %; psychological: . %). regarding the changes in health from before to during the covid- pandemic, . % and . % of the respondents reported no change in physical and psychological health, respectively. of those who had changes in physical and psychological health, most reported mild deterioration (physical: . %; psychological: . %) or improvement (physical: . %; psychological: . %). in total, ( . %) and ( . %) respondents reported that their physical and psychological health deteriorated during the covid- pandemic, respectively. table presents the results of the univariate logistic regression model examining the associations between demographic characteristics, cognitive and affective constructs of health beliefs related to covid- , perceived social support, and the subjective deterioration of physical and psychological health. participants who reported higher perceived harm with respect to covid- than to sars all variables that were significantly associated with the subjective deterioration of physical and psychological health during the covid- pandemic in the univariate logistic regression model were included in the multivariate logistic regression models ( table ). the results indicate that participants with higher perceived harm from covid- compared with sars (b = . , aor = . , % ci: . - . , p = . ) and sufficient knowledge and information about covid- (b = . , aor = . , % ci: . - . , p = . ) were more likely to report the subjective deterioration of physical health during the covid- pandemic because both b values were larger than zero. the moderating effects of age on the associations between perceived harm of covid- relative to sars, sufficiency of knowledge and information about covid- , confidence in coping with covid- , and perceived social support with the deterioration of physical health were further examined based on the criteria proposed by baron and kenny ( ) . the results demonstrate that the interaction between age and sufficiency of knowledge and information about covid- was significantly associated with the deterioration of physical health (b = − . , aor = . , % ci: . - . , p = . ), indicating that age moderated the association between the deterioration of physical health and sufficiency of knowledge and information about covid- . further analysis found that the significant association between the deterioration of physical health and sufficient knowledge and information about covid- existed only in younger respondents (b = . , aor = . , % ci: . - . , p = . ) but not in older ones (b = . , aor = . , % ci: . - . , p = . ). the moderating effects of gender and age on the associations between perceived harm of covid- relative to sars, worry about covid- , and perceived social support with the deterioration of psychological health were also examined. the results demonstrate that the interactions between age and other factors were not significantly associated with the deterioration of psychological health, indicating that age did not moderate the associations between the deterioration of psychological health and other factors. regarding the adoption of protective behaviors against covid- , respondents ( . %) reported avoiding crowded places, ( . %) washed hands more often, and ( . %) wore a mask more often. table demonstrates the results from examining the association between the deterioration of physical and psychological health and the adoption of protective behaviors against covid- . the results indicate that after controlling for the effects of demographic characteristics, the subjective deterioration of psychological health was associated with more adoption of two protective behaviors, including avoiding crowded places (b = . , aor = . , % ci: . - . , p = . ) and wearing a mask (b = . , aor = . , % ci: . - . , p = . ). the interactions between demographic characteristics and the deterioration of psychological health were not significantly associated with avoiding crowded places, indicating that demographic characteristics did not moderate the associations between the deterioration of psychological health and avoiding crowded places. no significant association was found between the deterioration of physical health and adoption of protective behaviors against covid- . regarding mental health problems, respondents ( . %) had a high level of general anxiety, ( . %) had sleep problems, and ( . %) had suicidal ideation. the results from examining the association between the deterioration of physical and psychological health and mental health problems are shown in table . the results show that after controlling for the effects of demographic characteristics, the deterioration of both physical and psychological health was associated with more general anxiety (physical: b = . , aor = . , % ci: . - . , p < . ; psychological: b = . , aor = . , % ci: . - . , p < . ). the deterioration of psychological health and not physical health was associated with more sleep problems (b = . , aor = . , % ci: . - . , p = . ). the interactions between gender and the deterioration of physical and psychological health were not significantly associated with general anxiety. the interaction between age and the deterioration of psychological health was not significantly associated with sleep problems. the results indicate that neither gender nor age moderated the association between the deterioration of health and general anxiety and sleep problems. the deterioration of physical or psychological health was not significantly associated with suicidal ideation. before discussing the results, some issues related to the method of recruiting participants using the facebook advertisement warrants discussion first. recruiting participants through facebook can deliver large numbers of participants quickly, cheaply, and with minimal effort as compared with mail and phone recruitment [ ] . facebook is a platform that provides the opportunity to assess the general public during fast-moving infectious disease outbreaks. however, facebook users may not be representative of the population. a review of a study that recruited respondents through facebook reported a bias in favor of women, young adults, and people with higher education and incomes [ ] . the gender disproportion of the respondents also existed in the present study. to control the effect of gender, gender was used as the covariate when we examined the associations between the deterioration of health and the adoption of protective behaviors and mental health problems. moreover, the present study examined the moderating effects of gender. however, the nonrepresentation of the population in the study should be cautiously considered, and is a consequence of using social media to recruit the participants. this study found that . % and . % of respondents reported experiencing a deterioration of physical and psychological health during the covid- pandemic, respectively. according to the statistics of the national health insurance administration, taiwan, the numbers of patients visiting health care facilities during the period of april to june in reduced . % when compared with the same period in [ ] . people with chronic illnesses may worry about contracting covid- in hospitals and doctor's offices and therefore not seek medical assistance and delay treatment. people with anxiety may interpret changes in perceived bodily sensations as symptoms of being ill, related or unrelated to covid- , and complain of deteriorating physical and psychological health [ ] . although taiwan was not placed under lockdown, people may have reduced outdoor activities or stopped routine exercise due to the worry of contracting covid- and the burden of physical and psychological health problems may have therefore increased [ ] . the results of this study indicate that in addition to monitoring health states of people who are quarantined or have contracted covid- , it is necessary for the governments and health professionals to early detect health problems of and timely deliver medical assistance to the public in the pandemic. introducing novel methods of clinical interaction, such as telemedicine and the use of electronic devices for covid- education, self-assessment, and maintenance of a symptom diary may assist in overcoming the mounting challenges of the covid- pandemic [ , ] . health promotion strategies directed at adopting or maintaining positive health-related behaviors should be utilized to address the increase in psychological distress during the pandemic [ ] . moreover, promoting community-supported interventions for stress and anxiety due to covid- is recommended [ ] . this study found that the perceived harm from covid- , more than that from sars, was significantly associated with the subjective deterioration of physical and psychological health during the covid- pandemic. the perceived risk of contracting covid- may cause stress, which may compromise physical and psychological health [ ] . the public evaluates the risk of covid- relative to sars based on the information they receive from the media and social networks. this study also found that self-rated knowledge and information about covid- were positively associated with the deterioration of physical health. the provision of timely and accurate information on covid- is fundamental to mitigating the disease [ ] and for rationally understanding covid- . moreover, high confidence in coping with covid- was negatively associated with deterioration of physical health. helping build confidence to successfully cope with the pandemic by delivering information through traditional and social media should be a priority for governments and health professionals. however, controlling misinformation on covid- remains a challenge. this study found that perceived social support was negatively associated with the deterioration of physical and psychological health. good social interactions not only provide emotional support but also daily necessities, which may contribute to the maintenance of physical and psychological health. for example, social support can increase individual capacity to maintain health behaviors [ ] . a study on women's sport practice in spain found that brothers/sisters, best friends and workmates encourage women to practice exercise; in particular, the presence of supportive friends increases with age [ ] . social support may be attenuated due to social distancing according to the health policy requirement and the fear of contracting covid- . social support can be offered through telecommunication instead of physical contact to those who have been quarantined to prevent mental health problems. the governments should take an initiative to provide support for those who were socially isolated before the pandemic. this study found that the respondents who reported deteriorated psychological health were more likely to avoid crowded places and wear masks. the results of previous studies were mixed. a study in cyprus found that higher anxiety was positively associated with the adoption of measures related to personal hygiene, whereas higher depression was negatively associated with higher compliance with precautionary measures [ ] . a study in china during the initial outbreak of covid- demonstrated that the adoption of precautionary measures was associated with a lower psychological impact from the outbreak of covid- and lower levels of stress, anxiety, and depression [ , ] . another study in china found that people's perceptions that the outbreak can be controlled by protective behaviors were associated with lower prevalence of depression and anxiety [ ] . the results of the present and previous studies indicate that there might be factors such as the timing of survey, severity of the pandemic and definition of psychological health influencing the association between psychological health and adoption of protective behaviors. this study found that the deterioration of both physical and psychological health was significantly associated with general anxiety and that of psychological health with sleep problems. general anxiety is closely connected to dysfunction of interoception, which can disturb the process by which the nervous system senses, interprets, and integrates signals originating from within the body, providing a moment-by-moment mapping of the body's internal landscape across conscious and unconscious levels [ ] . somatic discomfort, such as increased muscle ache and heart rate, and psychological discomfort, such as excessive worry and irritability were also the core symptoms of generalized anxiety disorder [ ] . therefore, general anxiety and the perception of deteriorating health may occur together. moreover, the present study found that deteriorated psychological health was significantly associated with sleep problems. sleep disturbance is the core symptom of several mental disorders; for example, depression and anxiety disorders [ ] . sleep problems may be used as an indicator of psychological health and may warrant psychological intervention during the covid- pandemic. the present study has some limitations in addition to the gender nonrepresentation of the participants recruited by the facebook advisement. first, there might be recall bias for the health state before the covid- outbreak. second, the cross-sectional design of this study limited causal inference between changes in health state and related factors. third, some factors such as chronic diseases that might influence deteriorated health in the covid- pandemic were not examined in the present study. fourth, the psychometric measures used in the present study for evaluating perceived social support warrants further examination. this facebook-based online study on the general public in taiwan found that . % and . % of respondents reported deteriorated physical and psychological health during the covid- pandemic, respectively. both subjective deteriorations of physical and psychological health positively related to general anxiety. the results indicate that the physical and psychological health of the public, but not only those who were contracted with covid- , should be focus of health professionals' concern. the present study identified several health belief constructs, social support and demographic characteristics that were significantly associated with deteriorated physical and psychological health. these factors can be used to screen for the individuals who need intervention for physical and psychological health problems. the subjective deterioration of psychological health was significantly associated with avoiding crowded places and wearing a mask. further study is needed to examine the mechanism accounting for the association and provide reference for developing strategies to promote adoption of protective behaviors against respiratory infectious diseases. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors. the authors declare no conflict of interest. the outbreak of covid- coronavirus and its impact on global mental health preventing suicide in the context of the covid- pandemic the socio-economic implications of the coronavirus pandemic (covid- ): a review covid- -related school closings and risk of weight gain among children impact of the covid- pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study the traumatic impact of job loss and job search in the aftermath of covid- regulation and trust: -month follow-up study on covid- mortality in european countries a new reportable disease is born: taiwan centers for disease control's response to emerging zika virus infection initial rapid and proactive response for the covid- outbreak-taiwan's experience accounting and statistics, executive yuan health-related concerns and precautions during the covid- pandemic: a comparison of canadians with and without underlying health conditions evaluation of health-related quality of life using eq- d in china during the covid- pandemic mental health effects of covid- pandemia: a review of clinical and psychological traits functional movement disorders in a patient with covid- the psychological impact of preexisting mental and physical health conditions during the covid- pandemic understanding the perceived mental health of canadians during the covid- pandemic depression, anxiety and stress during covid- : associations with changes in physical activity, sleep, tobacco and alcohol use in australian adults the impact of physical activity on psychological health during covid- pandemic in italy covid- pandemic and its impact on mental health of healthcare professionals social learning theory and the health belief model fear and the -ncov outbreak immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the psychological impact of quarantine and how to reduce it: rapid review of the evidence anxiety, worry and cognitive risk estimate in relation to protective behaviors during the influenza a/h n pandemic in hong kong: ten cross-sectional surveys the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey factors associated with mental health outcomes among health care workers exposed to coronavirus disease a longitudinal study on the mental health of general population during the covid- epidemic in china the impact of community psychological responses on outbreak control for severe acute respiratory syndrome in hong kong human factors considerations in using personal protective equipment in the covid- pandemic context: a bi-national survey study aggregated covid- suicide incidences in india: fear of covid- infection is the prominent causative factor covid- -related information sources and their relationships with confidence of people in coping with covid- : a facebook survey study in taiwan (preprint) changes in sex life among people in taiwan during the covid- pandemic: the roles of risk perception, general anxiety, and demographic characteristics covid- -related factors associated with sleep disturbance and suicidal thoughts among the taiwanese public: a facebook survey psychosocial impact among the public of the severe acute respiratory syndrome epidemic in taiwan social support measurement reliability and factorial structure of the chinese version of the state-trait anxiety inventory state trait anxiety inventory: a test manual/test form predictive validity of a five-item symptom checklist to screen psychiatric morbidity and suicide ideation in general population and psychiatric settings development and verification of validity and reliability of a short screening instrument to identify psychiatric morbidity the moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations social media divide: characteristics of emerging adults who do not use social network websites the use of facebook in recruiting participants for health research purposes: a systematic review social isolation during the covid- pandemic can increase physical inactivity and the global burden of cardiovascular disease using ehealth to support covid- education, self-assessment, and symptom monitoring in the netherlands: observational study covid- related stress exacerbates common physical and mental pathologies and affects treatment (review) infodemic" and emerging issues through a data lens: the case of china theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories estudio de la relación del entorno psicosocial en la práctica deportiva de la mujer prevalence and predictors of anxiety and depression symptoms during the covid- pandemic and compliance with precautionary measures: age and sex matter public behavior change, perceptions, depression, and anxiety in relation to the covid- outbreak © by the authors key: cord- -glm qcuz authors: tam, cheuk chi; sun, shufang; yang, xueying; li, xiaoming; zhou, yuejiao; shen, zhiyong title: psychological distress among hiv healthcare providers during the covid- pandemic in china: mediating roles of institutional support and resilience date: - - journal: aids behav doi: . /s - - -w sha: doc_id: cord_uid: glm qcuz psychological distress among healthcare providers is concerning during covid- pandemic due to extreme stress at healthcare facilities, including hiv clinics in china. the socioecological model suggests that psychological distress could be influenced by multi-level factors. however, limited covid- research examined the mechanisms of psychological distress among hiv healthcare providers. this study examined organizational and intrapersonal factors contributing to psychological health during covid- pandemic. data were collected via online anonymous surveys from hiv healthcare providers in guangxi, china during april–may . path analysis was utilized to test a mediation model among covid- stressors, institutional support, resilience, and psychological distress (phq- ). thirty-eight percent of the providers experienced psychological distress (phq- score > ). institutional support and resilience mediated the relationship between covid- stressors and psychological distress. psychological distress was common among chinese hiv healthcare providers during covid- pandemic. psychological health intervention should attend to institutional support and resilience. since the first case emerged in december in china, the novel coronavirus disease (covid- ) has spread rapidly across the world and become a worldwide public health emergency [ ] . the covid- pandemic has led to numerous detrimental consequences, including fatalities and significant socio-economic impacts (e.g., significant medical costs, increased unemployment and financial stress) [ , ] . in addition to medical and economic consequences, growing literature suggests prevalent psychological distress (e.g., depression and anxiety) during the covid- pandemic [ ] [ ] [ ] . healthcare providers may be particularly vulnerable to psychological distress due to a variety of factors. relative to non-medical workers, healthcare providers encounter greater covid- threats (e.g., the high risk of infectious exposure, shortage of personal protection equipment, and increasing workloads) detrimental to their psychological health [ , ] . a recent meta-analysis on covid- studies has identified a high prevalence of psychological distress among healthcare providers ( . % depression, . % anxiety) [ ] . psychological distress in healthcare providers during covid- have been associated with physical problems, including insomnia and somatic symptoms [ , ] . however, existing covid- studies regarding psychological distress among healthcare providers mostly focused on nurses or surgical staffs [ , ] , and limited research have focused on other providers. psychological distress among hiv healthcare providers in china could be particularly concerning due to several covid- related stressors at hiv clinics. first, as the first country to experience this novel infectious disease, the chinese medical system lacked initial preparedness for the immediate transitions necessary at hiv healthcare services (e.g., in-person to internet-based medical care) [ ] . second, medical management system in china is relatively centralized, and hiv patients usually receive hiv care at designated clinics. thus, city lockdowns and quarantine enforcement during the pandemic could lead to massive hiv care disruptions [ , ] , which may adversely affect providers' psychological health. third, due to hiv providers' background in infectious disease and a shortage of providers on the frontline, many hiv healthcare providers were assigned to provide covid- care and control [ ] , leading to increased workload. however, despite multiple stressful burdens at hiv clinics during the covid- pandemic, no studies have yet attended to the influences of these stressors on psychological distress in chinese hiv healthcare providers. from an ecological perspective, the psychological impact of covid- stress among hiv healthcare providers may be shaped by factors from different levels. the ecological systems theory posits that individuals' health outcomes are determined by factors of multi-level systems, such as microsystem (e.g., intrapersonal), exosystem (e.g., organizational), and macrosystem (e.g., contextual) [ ] . in addition to highlighting systematic structure of factors, this theory illustrates the underlying mechanism of multi-level factors on individual's psychological outcomes, suggesting that factors from distal levels (e.g., contextual factors) can indirectly impact psychological outcomes through affecting factors from proximal levels (e.g., organizational and intrapersonal) [ ] . in other words, distal factors would first affect proximal factors, and, in turn result in psychological consequences for the individual. thus, covid- stressors as a contextual factor may indirectly affect psychological distress through organizational and intrapersonal factors among chinese hiv healthcare providers. to better understand the stress-psychological-distress mechanism among chinese hiv healthcare providers, it is worth identifying organizational and intrapersonal factors contributing to psychological health in the covid- context. institutional support has been consistently identified as an organizational factor that influences psychological distress in healthcare providers. institutional support can be understood as supportive responses offered by institutes for addressing physical, emotional, and psychosocial needs of the workforce [ , ] . systematic reviews of literature among healthcare providers documented that institutional support (e.g., organizational climates and infrastructure of health facilitates) was associated with psychological health [ , ] . in addition to the direct effect, as suggested in the ecological systems theory, previous studies identified an indirect effect of institutional support, such that individuals with a lower occupational stress perceived more institutional support, and, in turn, individuals reported a lower psychological distress [ , ] . it is particularly worth noting that institutes play a critical role in providing support for healthcare providers during other similar public health crisis (e.g., influenza pandemic) [ ] . in the context of covid- , a focus group among frontline healthcare providers during the outbreak highlighted the lack of institutional supportive responses to covid- as a direct source of distress (e.g., 'uncertainty if their organization would take care of their personal and family needs if they become infected by covid- '), suggesting an importance of institutional support in this unprecedented public health emergency [ ] . taken all together, institutional support (i.e., institutional supportive responses to covid- ) could be an important organizational-level factor to directly and indirectly affect psychological distress among hiv healthcare providers in face of covid- stressors. as an intrapersonal factor, psychological resilience (or resilience) refers to personal abilities and resources (e.g., optimism, tenacity, tolerance to stress, and self-efficacy) and is a protective factor for coping with or overcoming stressful circumstances [ , ] . for instance, a meta-analysis on studies found resilience to be a protective factor for psychological distress across diverse samples [ ] . similar to institutional support, resilience could have an indirect effect in the association between pandemic stressors and psychological distress [ ] [ ] [ ] . specific to the pandemic context, a recent study found a negative association of resilience with psychological distress among chinese healthcare providers during the covid- outbreak [ ] . further, as a higher-level factor (exosystem), institutional support could affect resilience (at microsystem), and, in turn, influence psychological outcomes. indeed, a previous study have shown an indirect effect of resilience in the relationship between institutional support and depression among individuals with high occupational stress (e.g., frontline correctional officers) [ ] . in line with the institutional support influences on resilience, covid- stressors may exert influences on psychological distress by the intermediating effects of institutional support and resilience. that is, the stress-psychological distress mechanism among hiv healthcare providers would occur through a serial association, including a link between covid- stressors and institutional support and a link between institutional support and resilience, followed by a link between resilience and psychological distress. understanding this mechanism among hiv healthcare providers in china is important, as it can potentially guide timely and needed interventions and contribute to scientific knowledge on the utility of an ecological perspective in psychological health during extreme stress. the aim of the present study was to investigate the underlying mechanisms among covid- stressors, institutional support, resilience, and psychological distress among hiv healthcare providers in china. figure depicts our research hypotheses in the form of a serial indirect model, guided by the ecological systems theory [ ] , specifically, we hypothesized that ( ) covid- stressors would be positively associated with psychological distress; ( ) institutional support would mediate the association between covid- stressors and psychological distress; ( ) resilience would mediate the association between covid- stressors and psychological distress; ( ) the association between covid- stressors and psychological distress would be serially mediated by institutional support and resilience. the present cross-sectional study used data collected by a online survey from a convenience sample of healthcare providers who engaged in hiv care services in guangxi, one of the chinese regions with the fastest growth of the hiv epidemic. since , guangxi reported the third highest number of hiv cases among china's provinces [ , ] . data were collected from april through may , a time when the confirmed covid- cases exceed , in china according to chinese center of disease control and prevention (cdc) [ ] . the so jump system technology, a popular chinese online survey platform [ ] , was used for data collection. eligibility criteria for participants included: ( ) currently providing hiv-related care and services in guangxi; and ( ) being years of age or older. personnel in guangxi cdc contacted hiv healthcare providers across the region by an email invitation to the -min online survey. a total of hiv healthcare providers from counties (see table ) in guangxi responded the invitations and participated in the survey. participants were provided with an electronic consent prior to the survey started. the consent showed information regarding study purpose, voluntary nature, and confidentiality. after obtaining consent, the so jump system navigated participants to the online survey. data were saved at the so jump system with the password protection. participants were encouraged to share the survey invitation with their colleagues. the research protocol was approved by the institutional review boards at both university of south carolina in the united states and guangxi cdc in china. participants provided their demographic (i.e., age, gender, residence, educational level, and marital status) and occupational information including professional position (i.e., nurse, lab personnel, cdc staff, physician, and other), professional ranking (i.e., no ranking, entry level, middle level, senior level, and advanced level), administrative ranking (i.e., no ranking, department leader, hospital/cdc director, and other), and level of affiliated institution (i.e., province, city, country, and rural). psychological distress was measured through the patient health questionnaire- (phq- ; chinese version) [ , ] . the phq- had four items asking mood disorder symptoms (two items for depression and other two items for anxiety) in the past two weeks. all items were rated on a four-point scale ranging from (not at all) to (nearly every day). given that the depressive and anxiety symptoms were highly correlated (r = . ), a sum score of all four items was used to represent psychological distress, with higher scores indicating higher levels of psychological distress. in addition, we divided responses into four psychological distress levels (i.e., normal [ - ], mild [ ] [ ] [ ] , moderate [ ] [ ] [ ] , and serve [ ] [ ] [ ] [ ] ) according to the diagnosis guideline suggested by kroneke et al. [ ] . the cronbach's alpha of the phq- was . in the current study. a self-developed and -item checklist was used to evaluate the covid- stressors. participants were asked to answer ( = 'no'; = 'yes') whether potential stressful events occurred at the hospital or hiv clinics during the covid- outbreak, such as care of covid- patients (e.g., "treated/ provided care for patients infected by covid- "), occupational overload (e.g., "hospital was overloaded due to the covid- outbreak"), difficulties in the delivery of healthcare (e.g., "inadequate personal equipment for covid- prevention"), and daily life disturbance (e.g., "guilt because i was unable to take care of my family during the outbreak"). a sum score was calculated, with a higher score representing the exposure to more covid- stressors. cronbach's alpha was . in the current sample. institutional support was measured through a self-developed scale with five items describing supportive responses (i.e., financial, emotional, medical, and technical) from participants' institutes to cope with difficulties at clinics due to covid- (e.g., "my institute offers trainings about the provision of hiv care during the covid- outbreak" and "my institutes provide sufficient personal preventive equipment"). participants rated items on a four-option scale ( = strongly disagree to = strongly agree). a sum score was generated, with higher scores presenting higher levels of institutional support. cronbach's alpha of this scale was . . psychological resilience among hiv healthcare providers was assessed using a measure adapted from the connor-davidson resilience scale (cd-risd) [ ] . a total of nine items assessed personal capacities in response to stress such as tenacity, tolerance of negative affect, positive acceptance of change, self-efficacy to deal with stress, and positive view of adversities (e.g., "able to adapt to change" and "can deal with whatever comes"). participants were asked to rate items from (not at all) to (nearly all the time). a higher sum score indicated a greater level of resilience. internal reliability for the current study sample was excellent (α = . ). first, data were screened for proper coding and random or careless responses. mahalanobis distance (d ) [ ] was utilized to identify multivariate outliers. considering that path analysis model can be strongly jeopardized by multivariate outliers [ ] , we followed the suggested best practice and removed surveys with multivariate outliers and random responses, resulting in an analytical sample of participants. kurtosis and skewness tests were used to detect normality of data. descriptive statistics were performed on demographic variables and psychological distress. bivariate analyses, pearson's correlation coefficients, were used to assess correlations among study variables (covid- stressors, institute support, resilience, and psychological distress). pearson's (for continuous variables) and point-biserial correlation tests (for categorical variables) were used to examine the bivariate relationship of demographic variables and psychological distress. descriptive statistics and bivariate analyses were employed using spss software version . path analysis was employed to examine the hypothesized model (fig. ) . this model adjusted for significant demographic variables in bivariate analyses. all study variables were entered as manifest factors and the standardized regression weights for all paths between study variables were calculated. given that endogenous variables (psychological distress, institutional social support, and resilience) were continuous and normally distributed (kurtosis and skewness estimates closed to ) [ ] , the path analysis model was tested using maximum likelihood (ml) estimation as suggested by meyers et al. [ ] . model's goodness of fit was determined by several indices, including the root mean square of approximation (rmsea), the comparative fit of index (cfi), the tucker-lewis index (tli), and the standardized root mean squared residual (smsr) [ ] . according to hu an bentler [ ] , the suggested cutoff values were . for cfi, . for tli, . for rmsea, and . for smsr, with higher cfi and tli and lower rmsea and smsr indicating a greater fit. the indirect effects of institute support and resilience in the relationship between covid- stressors and psychological distress were examined using the delta z score [ ] . the indirect effect analysis examined whether institutional support and resilience partially or completely mediated the relationship between covid- stressors and psychological distress. as suggested by baron and kenny [ ] , complete mediation is identified when a mediation factor reduces the regression coefficients between independent variable (covid- stressors) and criterion variable (psychological distress) to zero (non-significant). partial mediation occurs when a mediation factor reduces the regression coefficient between independent and criterion variables, but the regression coefficient remains significant. path analysis was performed in mplus version [ ] . as shown in table as presented in table , pearson's correlation tests suggested that covid- stressors was positively correlated table correlations among covid- stressors, resilience, institute support, and psychological distress (n = ) *p < . ; **p < . ; ***p < . with psychological distress (r = . , p < . ) and negatively correlated with resilience (r = − . , p < . ) and institutional support (r = − . , p < . ). psychological distress was negatively correlated with resilience (r = − . , p < . ) and institutional support (r = − . , p < . ). resilience was positively correlated with institutional support (r = . , p < . ). pearson's and point-biserial correlation tests suggested that psychological distress was significantly correlated with age (r = − . , p = . ), gender (r = . , p = . ), marital status (r = − . , p < . ), and affiliated institute level (r = . , p < . ). professional position was not significantly correlated with psychological distress (r = . , p = . ). the final path analysis model with standardized regression coefficients is shown in fig. . according to bivariate results, this model controlled for age, gender, marital status, and affiliated institute level. the chi-square test of the model (chi-square = . , df = , p = . ) and the model-fit indices (cfi = . ; tli = . , rmsea = . , and srmr = . ) suggested an excellent fit to data. covid- stressors were positively associated with psychological distress (β = . , p < . ). the paths from covid- stressors to institutional support and resilience were negative (β = − . , p = . ; β = − . , p = . ; respectively). institutional support and resilience were negatively associated with psychological distress (β = − . , p = . ; β = − . , p < . ; respectively). institutional support was positively associated with resilience (β = . , p < . ). the model explained . % of variance in psychological distress, . % of variance in resilience, and . % of variance in institutional support. the indirect effects in the hypothesized model were presented in table . as hypothesized, covid- stressors had a direct effect on psychological distress (β = . , delta z = . , p < . , % confidence interval [ci] . , . ). results suggested significant indirect effects (β = . , p < . , % ci . , . ) in the association between covid- stressors and psychological distress by resilience and institutional support were significant (β = . , delta z = . , p < . , % ci . , . ; β = . , delta z = . , p = . , % ci . , . ; respectively). in addition, the total indirect effect of institutional support together with resilience was statistically significant (β = . , delta z = . , p = . , % ci . , . ). these results suggested partial mediations of institutional support and resilience (solely or jointly) in the association between covid- stressors and psychological distress. in the relationship between institutional support and psychological distress, results suggested a direct effect of institutional support (β = − . , delta z = − . , p = . , % ci − . , − . ) and an indirect effect of resilience (β = − . , delta z = − . , p < . , % ci − . , − . ), indicating that resilience partially mediated the association between institutional support and psychological distress. guided by an ecological perspective, the current study explored psychological distress among chinese hiv healthcare providers and examined the roles of covid- stressors, institutional support, and resilience in psychological distress. to the best of our knowledge, this is the first attempt to document psychological distress and apply an ecological framework for examining the effects of protective factors on our study found . % ( . % mild, . % moderate, . % severe) chinese hiv healthcare providers exhibited psychological distress during the covid- pandemic, which was similar to yet higher than the findings in a previous meta-analysis study (pooled prevalence of . % for anxiety and . % for depression) in chinese healthcare providers [ ] . our findings indicated that during the covid- pandemic, hiv healthcare providers, similar to nurses and surgical staffs, were highly vulnerable to psychological distress. their psychological health should not be neglected and merits more attention. our serial indirect model plotted a stress influences on psychological distress among chinese hiv healthcare providers in response to the emergent pandemic. results suggested that such stress influences occurred through two intermediating factors, namely institutional support (at organizational level) and resilience (at intrapersonal level). this finding provided a novel insight regarding covid- stress management at hiv clinics, particularly on the importance of institutional support. previous studies showed that healthcare providers in supportive working environments were inclined to exhibit greater resilience-related abilities, including emotional regulation [ ] , self-efficacy [ ] , and adaptive coping strategies [ ] . in facing a public health emergency, sufficient institutional support might enable hiv healthcare providers to use their internal coping recourses (i.e., resilience) and facilitate providers' adaptive coping instead of being overwhelmed to deal with covid- stressors, resulting in reduced levels of distress. this implied that psychological health among hiv healthcare providers could benefit from effective institute responses to covid- , such as covid- training and guidelines, sufficient supplies of personal protection equipment, and cares of workers' personal and family needs [ , ] . in addition to institutional support, the protective and mediating role of resilience also highlighted the effects of personal coping abilities on psychological health in chinese hiv healthcare providers during the covid- pandemic. in face of the extreme pandemic stress, the availability of cognitive resources (e.g., self-efficacy) might allow hiv healthcare providers to reappraise stressors as controllable or manageable instead of threatening, resulting in reduced levels of perceived stress and a lower likelihood of emotional exhaustion [ ] . the role of resilience supports the value of providing resilience-enhancing interventions for hiv healthcare providers during the covid- pandemic. for example, group-based resilience-enhancing intervention programs have shown psychological benefits to healthcare providers [ ] . after resilience-based cognitive trainings (e.g., selfawareness and meditation practice) at workplaces, healthcare providers demonstrated significant improvements in resilience, perceived stress, and interpersonal abilities (e.g., empathy and understanding of peers) comparing to those in control group [ , ] . it may be worthwhile to adapt the group-based resilience-enhancing intervention and tailor it to the covid- context for hiv healthcare providers in china. there are several limitations in the current study. first, the participants were recruited online using a convenience sampling approach. although the current study has covered counties in guangxi, our findings may not be generalized to other regions in china and may be limited by only reaching participants who are familiar with web-based devices. future research would benefit from using a random sampling approach and recruiting participants from multiple chinese regions. second, given cross-sectional data, the indirect model from covid- stressors to psychological distress cannot draw conclusion about causality. future longitudinal research is needed to ascertain the directionality of relationships identified in this study. third, self-report data were subject to bias (e.g., social desirability). fourth, some measures were self-developed (covid- stressors and institutional support) and future research is needed to validate these measures. fifth, data were collected in a certain period of the covid- outbreak. our results may not be replicated as the pandemic evolves and hiv healthcare providers' experience changes. future research would benefit from collecting data across different phases of the pandemic. despite these limitations, as the first attempt to examine psychological distress and its related factors among chinese hiv healthcare providers during the covid- pandemic, our study offered some important insights. first, the current study expanded the knowledge of healthcare providers' psychological health during the covid- pandemic by attending to hiv healthcare providers. psychological distress was prevalent ( . %) among hiv healthcare providers during the covid- pandemic in china. second, by using an ecological perspective, we identified that institutional support (as interpersonal factor) and resilience (as intrapersonal factor) mitigated the influences of covid- stress on psychological distress among hiv healthcare providers in china. our findings implied that multi-level intervention approaches, such as the establishment of supportive environment at hiv clinics and the resilience-enhancing intervention, should be utilized for promoting psychological health among hiv healthcare providers in china. world health organization. novel coronavirus ( -ncov) situation report b the potential health care costs and resource use associated with covid- in the united states: a simulation estimate of the direct medical costs and health care resource use associated with covid- infections in the united states labor markets during the covid- crisis: a preliminary view covid- , unemployment, and suicide suicide risk and prevention during the covid- pandemic mental health and the covid- pandemic burnout among healthcare providers during covid- pandemic: challenges and evidence-based interventions grief during the covid- pandemic: considerations for palliative care providers prevalence of depression, anxiety, and insomnia among healthcare workers during the covid- pandemic: a systematic review and meta-analysis a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey psychological status of surgical staff during the covid- outbreak vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control covid- , telemedicine, and patient empowerment in hiv care and research challenges to hiv care and psychological health during the covid- pandemic among people living with hiv in china provider burnout and fatigue during the covid- pandemic: lessons learned from a high-volume intensive care unit ecological models of human development still misused after all these years? a reevaluation of the uses of bronfenbrenner's bioecological theory of human development understanding and addressing sources of anxiety among health care professionals during the covid- pandemic developing and testing a measure of covid- organizational support of healthcare workers-results from peru, ecuador, and bolivia prevalence and factors associated with burnout among frontline primary health care providers in low-and middle-income countries: a systematic review organizational climate and employee mental health outcomes: a systematic review of studies in health care organizations the relationship between work-stress, psychological stress and staff health and work outcomes in office workers work-family conflict, perceived organizational support and professional commitment: a mediation mechanism for chinese project professionals local public health workers' perceptions toward responding to an influenza pandemic development of a new resilience scale: the connor-davidson resilience scale (cd-risc). depress anxiety vulnerability and competence: a review of research on resilience in childhood a meta-analysis of the trait resilience and mental health. pers individ diff risk and resilience in family wellbeing during the covid- pandemic association between perceived hiv stigma, social support, resilience, self-esteem, and depressive symptoms among hiv-positive men who have sex with men (msm) in nanjing social capital and ptsd among plwha in china: the mediating role of resilience and internalized stigma a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease positive resources for combating depressive symptoms among chinese male correctional officers: perceived organizational support and psychological capital declining trend in hiv new infections in guangxi, china: insights from linking reported hiv/ aids cases with cd -at-diagnosis data public mental health crisis during covid- pandemic up-to-day estimates of the covid- outbreak in china investigation on the status of influencing factors for depression symptom of children and adolescents with home quarantine during the prevalence of novel coronavirus pneumonia an ultra-brief screening scale for anxiety and depression: the phq- . psychosomatics reliability and validity of the chinese version of the patient health questionnaire (phq- ) in the general population psychometric analysis and refinement of the connor-davidson resilience scale (cd-risc): validation of a -item measure of resilience applied multivariate research: design and interpretation. thousand oaks: sage publications principles and practice of structural equation modeling statistical notes for clinical researchers: assessing normal distribution ( ) using skewness and kurtosis. restor dent endod cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives mplus user's guide. th ed. los angeles: muthén & muthén the moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations sexual minority status and psychological risk for suicide attempt: a serial multiple mediation model of social support and emotion regulation. front psychiatry cultivating secondary traumatic growth among healthcare workers: the role of social support and self-efficacy aggression and violence against health care workers in germany-a cross sectional retrospective survey factors contributing to healthcare professional burnout during the covid- pandemic: a rapid turnaround global survey handbook health, health care, health professional the impact of mindfulness-based interventions on doctors' well-being and performance: a systematic review mindfulness-based stress reduction for residents: a randomized controlled trial stress management and resilience training among department of medicine faculty: a pilot randomized clinical trial acknowledgements we appreciated ms. shuaifeng liu for her assistance in irb application and project coordination. we also greatly thank all the hiv care providers who finished the online survey. research reported in this publication was supported by the national institute of allergy and infectious diseases of the national institutes of health under award number r ai - s and the university of south carolina office of vice president for research covid- grant (uscip ). the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. work by shufang sun was also supported by national institute of health (t mh and k at ). conflict of interest the authors have no conflicts of interest to report. key: cord- - kcoodyv authors: dobson, hanna; malpas, charles b; burrell, aidan jc; gurvich, caroline; chen, leo; kulkarni, jayashri; winton-brown, tobias title: burnout and psychological distress amongst australian healthcare workers during the covid- pandemic date: - - journal: australas psychiatry doi: . / sha: doc_id: cord_uid: kcoodyv objective: to examine psychological distress in healthcare workers (hcws) during the covid- pandemic in april–may . methods: a cross-sectional survey examining demographic, employment and mental health characteristics of hcws in a large metropolitan hospital in australia. results: hcws showed significant symptoms of moderate-severe level depression ( %), anxiety ( %) and posttraumatic stress disorder (ptsd; %), associated with burnout, prior psychiatric history, profession and resilience. conclusion: despite low levels of covid contact, moderate to high levels of psychological distress were reported. continued monitoring and support for hcws’ mental well-being is warranted as the covid- pandemic develops. exposure, profession, past psychiatric history and measures of burnout. a cross-sectional survey was conducted between april and may amongst staff at a major tertiary hospital in melbourne, australia. in anticipation of the covid- pandemic, major hospital preparations including ward repurposing and staff redeployment occurred alongside mandated restriction of social contact outside hospital. the survey closed at a time that initial social distancing practices were being relaxed in australia. the hospital ethics committee approved the study (project id / ). participants were recruited via wellbeing workshops in front-line departments, followed by targeted emails, posters and word of mouth. written information was provided to participants and electronic consent obtained. the survey was anonymous; however, participants had the opportunity to engage with a psychiatric clinician following the survey. demographic data were reported, including occupation (senior medial staff, junior medical staff, nursing, allied health, other), gender (male, female, non-binary), age, past psychiatric history and years of experience. participants who reported direct contact with covid- patients were defined as 'front-line'. 'high-exposure environments' were classified as the emergency department (ed), intensive care unit (icu), respiratory medicine and infectious diseases departments. the primary outcome was self-reported levels of psychological distress (symptoms of depression, anxiety and ptsd) experienced during the weeks prior to the survey. the nine-item patient health questionnaire (phq- ; range - ), seven-item generalised anxiety disorder scale (gad- ; range - ), -item impact of event scale-revised (ies-r; range - ), -item connor-davidson resilience scale (cd-risc , range - ), and stanford professional fulfilment index (pfi; burnout range - ) were used to assess the severity of symptoms of depression, anxiety, ptsd, resilience and burnout, respectively. the total scores of these instruments were interpreted as per previously validated cut-offs. [ ] [ ] [ ] [ ] [ ] we calculated descriptive statistics, including means and percentages. contingency table analyses, using χ tests of independence, were used to investigate the relationship between nominal variables, and t-tests were used for continuous variables. general linear models (glms) were used to investigate the predictors of psychological outcome variables. continuous variables were centred prior to analysis and categorical variables were dummycoded after choosing a sensible reference class. omnibus f tests were used for null hypothesis significance testing of overall model effects, with effect sizes reported as partial eta squared (η p ). unstandardised model coefficients with % confidence intervals were computed for key models. care was taken to assess for statistical assumptions, including the distribution of model residuals where necessary. all statistical analyses were performed using jamovi (version . ) and r (version . . ). during the study period, responses were recorded; were excluded as no psychometric scales were completed. the final sample included participants. this included medical practitioners ( %, senior medical staff, junior medical staff), nurses ( %), allied health practitioners ( %) and non-clinical or other ( %). the majority of participants were female ( %). two hundred and forty-one participants ( %) had at least years of clinical experience and participants ( %) were front-line workers. medical and nursing staff were more likely to be in direct contact with covid- patients than other professions (χ ( ) = . , p < . , table ). ninety-eight participants ( %) reported a previous psychiatric diagnosis. senior medical staff were less likely to report a prior psychiatric diagnosis compared with other professions (χ ( ) = . , p = . , table ). a subset of participants screened positively for moderate-to-severe symptoms of depression ( %), anxiety ( %), and ptsd ( %; table ). twenty-three participants ( . %) reported suicidal ideation during the -week reporting period; participants ( . %) requested follow-up by a psychiatric clinician. eighty-three participants ( . %) screened positively for symptoms of burnout. rates of burnout, depression, anxiety and ptsd differed across the professions sampled; senior medical staff reported the lowest levels of psychological distress. front-line workers reported high levels of resilience when compared with other hcws and no greater severity of psychological distress (table ) table ). note. gad- = seven-item generalised anxiety disorder; ies-r = impact of event scale-revised; phq- = nine-item patient health questionnaire. we report the first study, to our knowledge, of mental health outcomes amongst australian hcws during the covid- pandemic. a substantial proportion of hcws self-reported moderate-to-severe symptoms of depression, anxiety and ptsd ( %, % and %, respectively). this was comparable to published rates reported by countries severely affected by the covid- pandemic, , and to those reported in the australian public around the same time. similar to these reports, this study doesn't allow comparison to pre-pandemic baseline data. however, previous research suggests hcws experience higher rates of anxiety and depression when compared with the general population. , psychological distress in hcw may develop in response to a range of stressors: risk of personal infection, fear of spreading the illness to family and friends, inadequate access to personal protective equipment and moral distress. our survey found working in front-line settings was not associated with increased risk of psychological distress. this could be because distress related to covid- extended beyond one's occupational exposure risk, which at the time of the survey was low, to a general preoccupation with the pandemic, its uncertain future course, socio-economic and lifestyle impacts, exposure to media and the limitation of social supports. this highlights the importance of making supports flexible and available to all hcws, not just front-line workers. data from previous epidemics and abroad during covid- have identified disparate mental health impacts amongst different professionals. , in our study, senior medical staff reported lower rates of psychological distress than other staff. this is consistent with beyondblue survey data, showing senior doctors report less psychological distress than their less senior colleagues. there is limited research examining the relationship between mental health outcomes and a pre-existing mental illness during the covid- pandemic. cardozo et al. reported that a history of mental illness increased the risk of psychological distress following deployment in humanitarian workers. our study supported this finding, identifying past psychiatric history as predictive for reporting symptoms of anxiety, depression, ptsd and burnout. this study also investigated the relationship between resilience, burnout and symptoms of psychological distress. the relationship between burnout and mental illness remains unclear; however, recent research suggests burnout increases the risk of developing depression and ptsd. in our study, . % of participants screened positively for burnout, and symptoms of burnout were predictive of psychological distress. psychological resilience mediates the stress response to trauma. high levels of psychological resilience are protective against the development of mental illness, and this was reflected in this study. recent research has considered introducing resilience training as a preventative treatment for reducing mental health outcomes amongst first responders. similar strategies could be developed for hcws in anticipation of future public health emergencies. our study had some limitations. cross-sectional studies don't allow tracking of changes in psychological distress following the onset and escalation of the pandemic. our dissemination strategy precluded a formal response rate calculation. a large number of responses were excluded due to incomplete data. selection bias and response bias may have resulted in an overestimation or underestimation of psychological distress and rates of pre-existing psychiatric history. unstandardised model coefficients [ % confidence intervals] from separate general linear models (glms) gad- = seven-item generalised anxiety disorder phq- = nine-item patient health questionnaire coronavirus disease (covid- ) situation reports. world health orgnsation beyondblue doctors' mental health program. national mental health survey of doctors and medical students depression in hospital-employed nurses understanding the burnout experience focus on mental health during the coronavirus (covid- ) pandemic burnout and joy in the profession of critical care medicine factors associated with mental health outcomes among health care workers exposed to coronavirus disease mental health outcomes among frontline and second-line health care workers during the coronavirus disease (covid- ) pandemic in italy prevalence of depression, anxiety, and insomnia among healthcare workers during the covid- pandemic validation and utility of a self-report version of prime-md a brief measure for assessing generalized anxiety disorder assessing psychological trauma and ptsd psychometric analysis and refinement of the connor-davidson resilience scale (cd-risc) a brief instrument to assess both burnout and professional fulfillment in physicians r: a language and environment for statistical computing mental health of people in australia in the first month of covid- restrictions mental health and the covid- pandemic psychological distress, depression, anxiety, and burnout among international humanitarian aid workers role of resilience in mindfulness training for first responders the study highlights the importance of mental health support during and following the covid- pandemic. future research should consider long-term mental health outcomes and burnout in front-and second-line workers, and in junior and senior clinicians. it should examine the factors underlying these with the aim of developing effective interventions. the authors report no conflict of interest. the authors alone are responsible for the content and writing of the paper. the authors received no financial support for the research, authorship, and/or publication of this article. dobson h https://orcid.org/ - - - kulkarni j https://orcid.org/ - - - key: cord- -z x wax authors: yao, yang; tian, yao; zhou, jing; diao, xin; cao, bogan; pan, shuang; di, ligai; liu, yan; chen, hui; xie, chunxia; yang, yuanli; li, feiyu; guo, yuqi; wang, shengyu title: psychological status and influencing factors of hospital medical staff during the covid- outbreak date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: z x wax background: the aim of this study was to analyze the psychological status of and its influencing factors in health care workers (hcws) during the coronavirus disease (covid- ) outbreak so as to provide sufficient theory and scientific basis for the formulation and implementation of relevant policies and measures in improving the psychological status of hcws. method: during february to february , , , members of the hcws from xi’an and wuhan completed a -item questionnaire regarding pressure about the covid- influenza pandemic, along with the -item general health questionnaire (ghq- ). the ghq- scale was divided by three points. the positive group was scored more than . all data were analyzed by spss. results: more than half of the participants ( . %) reported psychological distress. the hcws have sufficient information about the covid- symptoms, prognosis, treatment, infection route, and preventive measures (medians ranged from / to / ). female, engaged in clinic work less than years, married person, and working in wuhan were risk factors affecting the psychological status of hcws (p < . ). conclusion: psychological distress is common in hcws during the covid- outbreak. hospitals and relevant departments should provide psychological support to hcws, and strict infection control measures should be developed. last december , the epidemic of coronavirus disease (covid- ) has a breakout in wuhan, china (paraskevis et al., ; wang et al., ) , and spread rapidly around the world. on february , , who named the novel coronavirus pneumonia as "covid- , " and the new crown pneumonia is ncp. early studies mainly focused on clinical characteristics, treatment measures, and epidemiological features (chen n. et al., ; chen z.m. et al., ; guan and xian, ) . in addition, this research paid more attention to patients but ignoring the health of health care workers (hcws), especially psychological status. as of february , more than , hcws from medical teams across china have come to hubei for support. however, the understanding of covid- -related knowledge and prevention measures is still in its infancy, coupled with the increase of workload and the risk of infection, resulting in a serious impact on the psychological health of hcws. moreover, the psychological state of hcws is closely related to the therapeutic effect and prognosis of patients. previous studies on the impact of disease outbreaks on the psychological health of hcws have shown that many hcws show a high degree of psychological distress, the pressure over severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) outbreak have been related to work pressure, social isolation, and health concerns (lee et al., ; wu et al., ) . however, there are few studies have been conducted to investigate the psychological distress of hcws at the height of the epidemic of covid- . this study aims to evaluate the psychological status of and influencing factors in hcws during the outbreak of covid- and to provide a scientific basis for improving the psychological status of the hcws and making relevant policies. the study was carried out by online survey from february to february , . a total of , respondents from the first affiliated hospital of xi'an medical university, xi'an chest hospital, xi'an eighth hospital, wuhan union hospital (hcws supported by shaanxi), and wuhan ninth hospital (hcws supported by shaanxi). the questionnaire consists of three parts: basic characteristics, online survey, and the -item general health questionnaire (ghq- ). the ghq- has been widely used to assess mental health status (montazeri et al., ) . ( ) basic characteristics: age, years of clinical work, marital status, education level, profession, and whether working in wuhan were included in the basic characteristics. ( ) online surveys: in order to reduce face-to-face communication and avoid infection, the existing research invites potential interviewees electronically. they completed the questionnaire in chinese through the online survey platform (surveystar, changsha ranxing science and technology, shanghai, china). previous surveys on the psychological impacts of sars and influenza outbreaks were reviewed (nickell et al., ; goulia et al., ) . authors included additional questions related to the covid- outbreak. finally, this section contains items which are all scored on a -point likert scale, a higher score indicated a strongly degree. ( ) twelve-item general health questionnaire: the questionnaire consists of items, of which six are positive items and six are negative, which are scored at four levels. ( ) never, ( ) rarely, ( ) sometimes, and ( ) often. the most common scoring methods bimodal ( - - - ) are used according to who scoring method. if the answer is "often" or "sometimes, " it is point. if the answer is "never" or "little, " it is point. results the higher the score, the lower the level of mental health. therefore, this gives scores ranging from to . the total score ≥ was poor mental health. the data were analyzed using spss software . (spss inc., chicago, il, united states). chi-square test or fisher's exact test was used for analysis of categorical variables. the anova test or student's t test was utilized to compare measurement variables. f test was used if related to non-normal distribution parameters. categorical variables were expressed as number (%) and mean (sd); logistic regression analysis was used to analyze the correlation before multiple factors. p < . was considered statistically significant. the basic characteristics of the participants were shown in as shown in figure , under stress (item ), able to concentrate (item ), and lose much sleep (item ) have the most participants with a score of . the numbers of participants were , , and , respectively. the major demographic, professional characteristics, and psychological distress scores were shown in table . six hundred twelve out of , participants ( . %) presented scores on ghq ≥ (positive), indicative of severe psychological distress. three hundred ninety ( . %) presented scores on ghq < (negative), indicative of mild to moderate psychological distress. in the positive group, there were ( . %) females and ( . %) males. the difference of positive psychological stress between different genders was statistically significant (p = . ). three hundred eight ( . %) of the positive participants have engaged in clinical work for less than years, and ( . %) participants had more than years of work (p = . ). for marital status, out of positive participants ( . %) were married, ( . %) were single, and ( . %) were divorced (p = . ). for educational level, . % were junior college, . % were undergraduate, . % were master, and . % were doctor (p = . ). for profession, . % of positive participants were nurses, . % were medical, . % were technicians, and . % were others (p < . ). five hundred eighty-nine of positive participants were working in wuhan, and were not (p = . ). there was no significant difference in age among the positive participants. as shown in table , we analyzed the source of psychological pressure according to occupations. the hcws have sufficient information about the covid- symptoms, prognosis, treatment, infection route, and preventive measures (medians ranged from / to / ). medical staff scored the highest in terms of symptoms, prognosis, and treatment compared to the other groups. the difference is statistically significant (p < . ). nurses have the highest score in infection route and preventive measures (p < . ). most hcws believe that their department provides clear information about covid- (median / ). the score of nurse group was . ± . , with the highest score compared with the other groups. medical staff and technicians have confidence in the cure after infection. the scores were . ± . and . ± . , respectively. while nurses and others were . ± . vs. . ± . (p < . ). the appeal for psychological support for medical staff is very high (median / ). but the differences between groups were not statistically significant. most of the participants will not stop working during the outbreak of covid- (median / ). with the psychological distress of health care workers as shown in table , female, engaged in clinic work less than years, married person, and working in wuhan were risk factors hospital medical staff show an absolutely important position in the outbreak of infectious diseases, but people often pay more attention to the cure rate, diagnosis, and treatment effect and prognosis of patients and ignore the psychological distress of hcws. studies that investigated the psychological status during sars and a/h n influenza pandemic indicated that a high level of distress is common (caputo et al., ; goulia et al., ) . in addition, we are dealing with an epidemic the likes of which we have never seen in this century. as of february , , , confirmed and , death cases have been reported in china and spread rapidly in chinese provinces or municipalities. therefore, it is urgent to investigate the psychological state of and related factors in medical staff and provide a certain scientific basis for improving the psychological status of hcws. our results showed that during the period of the covid- epidemic, more than half of hcw participants have suffered from psychological distress. the proportion of married female is relatively large. it may be related to women's physiological reasons. compared with men, their ability to bear pressure is slightly weaker. the main reason for married people's stress is that their work increases the risk of infection among family members. the score of physiological distress of nurses was higher than that of other staff. although both doctors and nurses are in contact with patients, medical staff expressed a lower degree of psychological distress. the possible reason may be that medical staff mostly regarded themselves as sufficiently informed, and it is generally true that medical staff are highly educated and have sufficient knowledge reserve, so they have a better understanding of the information they have acquired. in addition, nurses are the largest occupational group in the hospital. they have a direct and close relationship with patients and have a higher risk of infection. therefore, it is easy to understand that nurses think themselves have a full understanding of the infection pathway and prevention measures of covid- and have the highest voice for psychological support. the study also found that long-term clinical work can reduce psychological stress. this may be due to that the rich experience can be accumulated through long-term work, which can better cope with emergencies and complex situations. finally, the psychological distress of medical staff working in wuhan is higher than that out of wuhan. the covid- outbreak is in wuhan, and until now, wuhan is still the worsthit region of covid- infection. the number of confirmed cases and mortality rate in there have been ranked first in the country, accounting for % of total mortality rate. in addition, the disease has been confirmed to be human-human transmission (du et al., ; xu and kraemer, ) . according to reports, more than , medical staff have been infected with covid- . in addition, most of the medical staff are non-native. unfamiliarity with the local environment and language increases their psychological pressure. these results are consistent with the results of previous studies in sars. angelina om chan performed a study focused on psychological impact of the sars outbreak on hcws in singapore and found that % participants had psychological distress (chan and huak, ) . bai et al. ( ) also investigated stress reactions among staff members in a hospital in east taiwan and came to the conclusion that % suffered from an acute stress disorder during the sars outbreak. as the covid- epidemic continues to spread, our findings will provide important guidance for the development of psychological support strategies for china and other affected areas. our findings also have clinical and policy implications. the results show that female medical staff are suffering from greater psychological impact and higher levels of pressure in this epidemic. this will help health authorities to identify high-risk groups for early psychological intervention. moreover, as concerns about protective measures are a major source of stress, strict and detailed infection control measures should be developed. furthermore, to minimize face-to-face interaction, health authorities may consider providing online or smartphone-based psychological education and intervention. this study also has several limitations. firstly, there is gender bias in this study. comparison of the characteristics of the research samples in this epidemic suggested that the study sample is gender-specific. despite this, however, we cannot refute the criticism that an underlying response style might have led to our results. secondly, there is no classified analysis on the psychological status of medical staff in the intensive care unit (icu) and non-icu, which may also be a potential factor. finally, social discrimination is ignored in this study. there is a general psychological pressure among medical staff during the covid- pandemic. pressure was significantly associated with preventive measures and infection route. the perceived sufficiency of information and psychological intervention measures about covid- was associated with a reduced degree of pressure. all datasets presented in this study are included in the article/ supplementary material. ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. participation was anonymous via an online survey questionnaire. yuy and yt designed the study and drafted the work. jz and xd conducted the analysis. bc made substantial contribution to the design of the work. sp and ld contributed to the interpretation of the work and revising the draft for important intellectual content. yl, cx, and hc helped with access to the data and provided information and consulting. sw and fl made substantial contributions to the conception of the work. yg and sw revised the draft for important intellectual content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. all authors reviewed and approved the final manuscript. survey of stress reactions among health care workers involved with the sars outbreak intubation of sars patients: infection and perspectives of healthcare workers psychological impact of the severe acuterespiratory syndrome outbreak on health care workers in a medium sizeregional general hospital in singapore diagnosis and treatment recommendations for pediatric respiratory infection caused by the novel coronavirus epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study risk for transportation of novel coronavirus disease from wuhan to other cities in china general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h n influenza pandemic the progress of novel coronavirus ( -ncov) event in china psychological impact of the mers outbreak on hospital workers and quarantined hemodialysis patients the -item general health questionnaire (ghq- ): translation and validation study of the iranian version psychosocial effects of sars on hospital staff: survey of a large tertiary care institution full-genome evolutionary analysis of the novel corona virus ( -ncov) rejects the hypothesis of emergence as a result of a recent recombination event a novel coronavirus outbreak of global health concern the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk open covid- data curation group.open access epidemiological data from the covid- outbreak we thank all the frontline health care staff fighting against covid- in china. key: cord- -klystgj authors: huang, naizhu; qiu, shaoping; alizadeh, amin; wu, hongchao title: how incivility and academic stress influence psychological health among college students: the moderating role of gratitude date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: klystgj many students suffer from academic stress and uncivil behaviors at colleges and there is a need to identify to what extent these negative phenomena might impact students’ mental health. the main purpose of this study is to examine the relationships between incivility, academic stress, and psychological health, as well as investigate the moderating role of gratitude. the study design of this research is cross-sectional. the final sample consisted of university students in china; the statistical package for the social sciences (spss) version was utilized to conduct statistical analysis. sample t-tests were used to examine whether there were gender differences in terms of four continuous variables: incivility, stress, gratitude, and psychological wellbeing. we also used multiple hierarchical linear regression analysis to test the relationships between the aforementioned four variables and the moderating effect of gratitude. the results of our study indicate that academic stress and incivility are positively associated with psychological distress, and gratitude moderates the relationship between incivility and psychological distress. however, no significant moderating effect of gratitude was found in the relationship between academic stress and psychological distress. the problems of psychological distress are prevalent across the globe and have been the major causes of disproportionately higher rates of disability and mortality [ ] . as a set of painful mental and physical symptoms, psychological distress includes anxiety, confused emotions, hallucinations, and depression [ ] . statistics on psychological distress are alarming; mental illness accounts for % of non-fatal disease burdens worldwide and % of overall disease burdens, including death and disability [ ] . the proportion of the global population with depression in was estimated to be . % [ ] . the problems of psychological distress are especially prominent among college students, as they are particularly more vulnerable to psychological disorders [ ] . for example, in china alone, about % of college students suffer from various forms of mental problems, such as depression, anxiety, and stress [ ] . therefore, psychological distress of college students has become an issue of utmost concern worldwide [ ] . in parallel, the topic of psychological distress has drawn much attention among researchers and practitioners worldwide. research has demonstrated that stress perceived as a personal threat and loss the study design of this research was cross-sectional. data were obtained from students in november at a large university in south china. since the survey was administered in chinese, and we used instruments originally developed in western countries, we conducted a back-translation to guarantee that the meaning of the instrument items was accurate and culturally appropriate. prior to conducting the survey, a pilot study was carried out using students to assess clarity, length, comprehensiveness, and completion time of the measures. the survey instrument was distributed via the internal email listserv of the university to , students who came from all provinces of china. a total of students participated in this study and returned their responses. after excluding incomplete questionnaires, we obtained valid, usable data cases with a response rate of . %. therefore, the final sample consisted of university students. among participants, ( . %) were female students. the average age was . years old. in total, students ( . %) were freshman while ( . %) were sophomores. in addition, participants ( . %) reported that their monthly family income was between to rmb yuan, while only respondents reported their family earned , or above rmb yuan per month. most students reported that their father ( . %) and mother ( . %) only graduated from middle school. a vast majority of students ( , . %) originally came from the province where the university is located. however, the remaining participants were roughly evenly distributed among other provinces of china except for three autonomous regions. all measures employed were developed and validated and used in previous studies. in addition to ensuring participating students' anonymity and confidentiality, we used a few negatively worded items in the survey to reduce common method variance [ ] . incivility was assessed using a sevenitem scale developed by cortina et al. [ ] . students were asked to rate the frequency they have been in a situation where any of their classmates exhibited uncivil behavior to them. the rating scale of (never) to (very frequent) was used. an example item was: "how often did my classmates make demeaning or derogatory remarks about me in the last year?". the reliability of this scale was acceptable with an alpha of . . stress was measured using a -item scale developed by lepine et al. [ ] . students were required to rate the extent to which they experienced academic stress on a scale of (no stress) to the study design of this research was cross-sectional. data were obtained from students in november at a large university in south china. since the survey was administered in chinese, and we used instruments originally developed in western countries, we conducted a back-translation to guarantee that the meaning of the instrument items was accurate and culturally appropriate. prior to conducting the survey, a pilot study was carried out using students to assess clarity, length, comprehensiveness, and completion time of the measures. the survey instrument was distributed via the internal email listserv of the university to , students who came from all provinces of china. a total of students participated in this study and returned their responses. after excluding incomplete questionnaires, we obtained valid, usable data cases with a response rate of . %. therefore, the final sample consisted of university students. among participants, ( . %) were female students. the average age was . years old. in total, students ( . %) were freshman while ( . %) were sophomores. in addition, participants ( . %) reported that their monthly family income was between to rmb yuan, while only respondents reported their family earned , or above rmb yuan per month. most students reported that their father ( . %) and mother ( . %) only graduated from middle school. a vast majority of students ( , . %) originally came from the province where the university is located. however, the remaining participants were roughly evenly distributed among other provinces of china except for three autonomous regions. all measures employed were developed and validated and used in previous studies. in addition to ensuring participating students' anonymity and confidentiality, we used a few negatively worded items in the survey to reduce common method variance [ ] . incivility was assessed using a seven-item scale developed by cortina et al. [ ] . students were asked to rate the frequency they have been in a situation where any of their classmates exhibited uncivil behavior to them. the rating scale of (never) to (very frequent) was used. an example item was: "how often did my classmates make demeaning or derogatory remarks about me in the last year?". the reliability of this scale was acceptable with an alpha of . . stress was measured using a -item scale developed by lepine et al. [ ] . students were required to rate the extent to which they experienced academic stress on a scale of (no stress) to (a great deal of stress). two example items were: "the amount of hassles i need to go through to get projects or assignments done" and "the difficulty of the work required in my classes" cronbach's alpha was acceptable at . . gratitude was evaluated using the gratitude questionnaire-six item form (gq- ) developed by mccullough, emmons, and tsang [ ] . participants rated the extent to which they agreed with statements on a scale ranging from (strongly disagree) to (strongly agree). one example item was: "i have so much in life to be thankful for" the measure had an adequate internal consistency (α = . ). psychological distress was measured using k screening scale developed by kessler et al. [ ] . students rated on a scale of (never) to (very often) how often they felt psychologically distressed, such as hopeless. the reliability of this scale was . . control variables included age, gender, and family income. these variables were found to predict psychological distress in previous research [ ] [ ] [ ] . for gender, we coded male as " " and female as " ". in terms of age, we coded age as " ", age as " ", age as " ", age as " ", age as " ", and age or above as " ". with respect to family income, we coded family monthly income below rmb yuan as " ", - as " ", - as " ", - as " ", and above as " ". spss version was utilized to conduct statistical analysis. mplus was used to test convergent and discriminant validities of the main variables. independent sample t-tests were used to examine whether there were gender differences in terms of the four continuous variables: incivility, stress, gratitude, and psychological wellbeing. we also used multiple hierarchical linear regression analysis to test relationships between the aforementioned four variables and the moderating effect of gratitude, controlling for age, gender, grade, and household income. the p-values ≤ . were considered throughout as statistically significant. we used harman's single factor test to check whether there was common method variance in the data. results revealed that one single factor only explained . % of the variance, much lower than %, indicating no major issues with common method variance. means, standard deviations, reliability, and intercorrelations between study variables are shown in table . as can be seen from table , gender is associated with gratitude (r = . , p < . ). however, it has no significant relationship with incivility, stress, and psychological wellbeing. psychological distress is significantly related to incivility (r = . , p < . ), stress (r = . , p < . ), and gratitude (r = − . , p < . ), whereas correlation between stress and gratitude is not statistically significant. confirmatory factor analysis (cfa) was performed to test convergent and discriminant validities of main variables (i.e., incivility, academic stress, gratitude, and psychological distress). for this purpose, we compared four measurement models. in the three-factor model, we combined incivility and academic stress because they were two independent variables. in the two-factor model, incivility, academic stress, and gratitude were put together as one variable. the fit indices of all four models are shown in table . as can be seen from this table, the four-factor model provided a good fit with the data and was much better than any other models (χ = . , df = , rmsea = . , cfi = . , tli = . , srmr = . ). thus, the discriminant validity was established. in addition, the factor loadings in the four-factor model were all greater than . and all values of average variance extracted (ave) for the four variables were also greater than . . therefore, convergent validities were achieved for all four variables. note: n = incivility; st = academic stress; gr = gratitude; ps = psychological distress. ** p < . . ∆ χ is χ difference between respective and four-factor models. results from independent sample t-tests revealed that there were no statistically significant differences between male and female students in terms of incivility, stress, and psychological wellbeing. however, discrepancies between male and female students were significant, with female participants reporting more gratitude towards others (t = − . , p < . ). hierarchical multiple regression analysis was performed to examine the relationships between incivility, stress, gratitude, and psychological wellbeing, as well as the moderating effect of gratitude. we mean-centered the values of incivility, stress, and gratitude [ ] . results are presented in table . as seen from this table, there was a significant main effect of incivility in both model (β = . , p < . ) and model (β = . , p < . ), indicating that students feel more psychologically unhealthy under high-level incivility from their classmates. we also found that a significant effect of stress in both model (β = . , p < . ) and model (β = . , p < . ) revealed that students experience more psychological distress issues under high academic stress. in addition, the effect of gratitude on psychological distress was also negatively significant in both model (β = − . , p < . ) and model (β = − . , p < . ), indicating that college students who express more appreciation to others suffer less from psychological distress problems. most importantly, the interaction term between incivility and gratitude was significant in model (β = . , p < . ). however, there was no significant moderating effect of gratitude on the relationship between incivility and psychological wellbeing. following the guidelines of aiken and west [ ] , we plotted the regression of psychological distress on incivility to assess the moderation effect at two values of gratitude (mean + standard deviation and mean − standard deviation) ( figure ). as illustrated in this figure, the higher the level of gratitude, the stronger the relationship between incivility and psychological wellbeing. when incivility is low, students with a low level of gratitude experience more severe psychological distress problems. however, as the level of incivility becomes higher, psychological distress issues become less different across these two gratitude groups. following the guidelines of aiken and west [ ] , we plotted the regression of psychological distress on incivility to assess the moderation effect at two values of gratitude (mean + standard deviation and mean - standard deviation) ( figure ). as illustrated in this figure, the higher the level of gratitude, the stronger the relationship between incivility and psychological wellbeing. when incivility is low, students with a low level of gratitude experience more severe psychological distress problems. however, as the level of incivility becomes higher, psychological distress issues become less different across these two gratitude groups. using a sample of students recruited from a university in south china, we investigated the relationships between incivility, academic stress, gratitude, and psychological distress. in addition, using a sample of students recruited from a university in south china, we investigated the relationships between incivility, academic stress, gratitude, and psychological distress. in addition, we examined underlying mechanisms through which incivility and academic stress affect students' psychological distress. that is, we tested how incivility and academic stress interact with gratitude to predict students' psychological distress. moreover, we compared differences between male and female students with respect to incivility, academic stress, gratitude, and psychological distress. results of this study illustrate that incivility is positively associated with psychological distress. our findings are consistent with prior studies [ , , ] . academic stress was also confirmed as related to psychological distress. this conclusion is also in line with previous research that examined the aforementioned relationship [ , ] . it was also identified that gratitude moderates the relationship between incivility and psychological distress. however, no significant moderating effect of gratitude was found in the relationship between academic stress and psychological distress, which is contrary to our expectations. in low incivility environments, grateful students are less likely to suffer from psychological distress than those with low levels of gratitude. it is sensible because under normal conditions, grateful individuals tend to hold a positive attitude towards life, take more pleasure from benefits in life, and feel happier [ ] . as uncivil behaviors or comments become relatively more frequent, grateful students can still keep psychologically healthier. however, as incivility frequency increases, the psychological distress college students experience increases more rapidly for grateful students. a possible reason would be that grateful individuals take uncivil communications more seriously and attempt to resolve conflicts to maintain high-quality interpersonal relationships with others [ ] . most probably they attribute sources of these uncivil behaviors and comments to themselves and ruminate on how they could change their thoughts, thus aggravating their psychological problems [ ] . in this study, we did not find any gender differences on perceived incivility, perceived level of stress, and reported psychological health. the finding of no gender disparity on perceived stress and psychological distress contradicts the study results of moksnes and lazarewicz [ ] . in their research on norwegian adolescents from to years old, they found that boys scored lower than girls on stress and symptoms of depression and anxiety. these inconsistencies may be attributed to the difference of age range. another plausible reason could be the emphasis chinese universities place equally on both male and female students. in our study, the sample participants were chinese college students who were developing or built their own resilience and coping strategies. in chinese universities, there are counselors at both university and department levels dedicated to helping students with personal, emotional, and psychological concerns. when facing stress and adversity, both male and female students are likely to be equipped with the same skills to handle negative situations encountered and to perceive the stress as less severe. however, female college students, compared to male students, were found to be more likely to express gratitude towards others. this finding corresponds with previous studies showing that women tend to report higher levels of gratitude than men [ ] [ ] [ ] . as reasoned by watkins et al. [ ] , men generally associate gratitude with weakness in personality. therefore, men tend to avoid expressions of gratitude to protect their masculinity and maintain their social status. this study makes both theoretical and practical contributions. first, research examining the association between incivility, academic stress, and psychological distress in the chinese context is scarce. using chinese college students as a study sample is even more scant. this study adds to the current literature by enhancing our understanding of whether incivility and academic stress influence students' psychological distress in a chinese university setting. additionally, given that little is known about how incivility and stress affect psychological health, testing the moderating effects of gratitude helps us gain an understanding of boundary conditions under which such an association might occur. therefore, this study might fill a theoretical gap in the literature. third, findings of this study could provide insight and timely advice to chinese university students on how to keep psychologically healthy. especially during this difficult time of novel coronavirus outbreak, students are learning online from home. the study of gratitude and stress might offer some useful guidelines to develop positive psychology-based student counseling interventions to help chinese students cope with adversity and hardship. although we used a relatively large sample size and well-validated instrument scales, this study has some limitations. first, the data used in this study were obtained from a single source (i.e., university students). we reduced common method variance by using some negatively-worded items, ensuring anonymity and confidentiality. however, there is still a potential for common method variance to bias our study results. future studies could adopt as many measures as possible, as recommended by podsakoff et al. [ ] , to further minimize this issue. second, this study was cross-sectional in nature, which precludes us from making a causal conclusion about the main and moderation effects. if possible, a longitudinal study or experimental design is recommended to interpret the relationships between incivility, academic stress, and psychological distress in a causal way. third, despite the large sample size in this study, most participants came from the province where the university is located and no students from the three autonomous regions participated in this study. this sample distribution, together with a low response rate ( . %), might bias the study results. future studies could collect more data from other provinces in order to be more representative of the whole chinese student population. next, we only solicited data from one university in china. although students were from all parts of china, the sample may not represent the whole college student population in china. finally, we only used gratitude as a moderator to examine how incivility and academic stress impact students' psychological health, ignoring other possible mediators and moderators. if more variables were examined in the study, such as rumination, personality traits, and students' attribution, we could gain a higher understanding of the underlying mechanisms and boundary conditions about how, whether, and when such effects might be most likely to occur. this study showed that both incivility and academic stress positively affect university students' psychological health. it also demonstrated that gratitude moderates the relationship between incivility and psychological distress after controlling for age, gender, and family income. however, the interaction of gratitude and academic stress does not significantly impact university students' psychological health. for highly grateful students, the relationship between incivility and psychological distress is stronger than those with low levels of gratitude. in addition, female students scored higher on gratitude than male students, whereas there were no differences between these two groups on perceived incivility, perceived academic pressure, and psychological distress. this study contributed insight into the moderating role of gratitude in the incivility-psychological distress relationship. to advance our understanding, future researchers could use more measures to combat common method bias, employ a longitudinal study or experimental design to create causal interpretation, and recruit more representative samples for the study results to be generalized. incivility is a rude or impolite attitude or behavior towards others. considering the vagueness and prevalence of incivility, maintaining civility on campus still remains a great concern for most college administers [ ] . incivility interferes with a harmonious and cooperative learning atmosphere, contributing to increased psychological distress among college students. given its widespread effect on both students and college culture, colleges and universities should take measures to tackle this disturbing issue. at the college or university level, administers should create a culture in which each and every student is treated with respect, fairness, and equality. at the department level, college counseling staff and department faculty should make it clear what behaviors students need to follow and what should be avoided. in addition, they should provide counseling to help change students' behaviors. furthermore, students as individuals also need to understand their own roles and assume corresponding responsibilities. they must stand up against any uncivilized behaviors occurring on campus in order to stop such behaviors. in this way, we can facilitate civility and enhance learning effectiveness among college students. psychometric study of depression, anxiety and stress among university students psychological distress: concept analysis making mental health a global priority depression and other common mental disorders: global health estimates; world health organization the prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students changes in undergraduate students' psychological well-being as they experience university life impacts of socio-cultural environment and lifestyle factors on the psychological health of university students in bangladesh: a longitudinal study qualitative and quantitative analyses of psycho-logical distress: methodological complementarity and ontological incommensurability conservation of resources: a new attempt at conceptualizing stress correlations among work stressors, work stress responses, and subjective well-being of civil servants: empirical evidence from china a meta-analytic test of the challenge stressor-hindrance stressor framework: an explanation for inconsistent relationships among stress and performance the relationship between challenge and hindrance stressors and emotional exhaustion: the moderating role of perceived servant leadership stress at college: effects on health habits, health status and self-esteem college students: mental health problems and treatment considerations how rude! emotional labor as a mediator between customer incivility and employee outcomes uncivil communication in everyday life: a response to benson's "the rhetoric of civility customer incivility and employee well-being: testing the moderating effects of meaning, perspective taking and transformational leadership daily cyber incivility and distress: the moderating roles of resources at work and home an integrative review examining student-to-student incivility and effective strategies to address incivility in nursing education gratitude as a psychotherapeutic intervention is gratitude always beneficial to interpersonal relationships? the interplay of grateful disposition, grateful mood, and grateful expression among married couples an attributional theory of achievement motivation and emotion gratitude works: a twenty-one-day program for creating emotional prosperity religious/spiritual struggles and life satisfaction among young roman catholics: the mediating role of gratitude gratitude moderates the mediating effect of deliberate rumination on the relationship between intrusive rumination and posttraumatic growth perceived psychological well-being among university students: a comparative study by gender the association between stress, resilience, and emotional symptoms in norwegian adolescents from to years old sources of method bias in social science research and recommendations on how to control it incivility in the workplace: incidence and impact challenge and hindrance stress: relationships with exhaustion, motivation to learn, and learning performance the grateful disposition: a conceptual and empirical topography screening for serious mental illness in the general population with the k screening scale: results from the who world mental health (wmh) survey initiative perceived health locus of control, self-esteem, and its relations to psychological well-being status in iranian students psychological well-being (pwb) of school adolescents aged - yr, its correlation with general levels of physical activity (pa) and socio-demographic factors in multiple regression: testing and interpreting interactions linking work-family interference, workplace incivility, gender and psychological distress gratitude and happiness: development of a measure of gratitude, and relationships with subjective well-being gratitude and well-being: a review and theoretical integration ruminative coping with depressed mood following loss gratitude and subjective well-being in early adolescence: examining gender differences what are children thankful for? an archival analysis of gratitude before and after the attacks of general feelings of gratitude, gratitude to god, and hemoglobin a c: exploring variations by gender the debt of gratitude: dissociating gratitude and indebtedness the level of student incivility: the need of a policy to regulate college student civility this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank the students at a chinese university for their participation in this study. the study received no funding from any institutions. the authors declare no conflict of interest. key: cord- -c dgf mx authors: shahrour, ghada; dardas, latefa ali title: acute stress disorder, coping self‐efficacy, and subsequent psychological distress among nurses amid covid‐ date: - - journal: j nurs manag doi: . /jonm. sha: doc_id: cord_uid: c dgf mx purpose: healthcare professionals, particularly nurses, are considered a vulnerable group to experience acute stress disorder (asd) and subsequent psychological distress amid covid‐ pandemic. this study aims to establish the prevalence of acute stress disorder and predictors of psychological distress among jordanian nurses. methods: a quantitative, cross‐sectional, descriptive and comparative design was used. data was collected using a web‐based survey. a total of jordanian nurses ( % females) completed and returned the study questionnaire. results: the majority of nurses ( %) are experiencing asd due to the covid‐ pandemic and thus are at risk for ptsd predisposition. more than one third of nurses ( %) are also suffering significant psychological distress. among our sample, age, asd, and coping self‐efficacy significantly predicted psychological distress. more specifically, younger nurses are more prone to experience psychological distress than older ones. while higher scores on asd showed more resultant psychological distress, coping self‐efficacy was a protective factor. conclusion: given that individuals who suffer from asd are predisposed to ptsd, follow‐up with nurses to screen for ptsd and referral to appropriate psychological services is pivotal. coping self‐efficacy is found to ameliorate the effect of psychological distress on nurses' traumatic experience. such findings warrant intensive efforts from healthcare institutions to provide psychosocial support services for nurses and ongoing efforts to screen them for traumatic and psychological distress symptoms. implications for nursing management: nursing leaders and managers are in the forefront of responding to the unique needs of their workforces during the covid‐ crisis. they need to implement stress‐reduction strategies for nurses through providing consecutive rest days, rotating allocations of complex patients, arranging support services, and being accessible to staff. they also need to ensure nurses’ personal safety through securing and providing personal safety measures and undertake briefings to ensure their staff's physical and mental well‐being, as well as providing referrals to appropriate psychological services. this article is protected by copyright. all rights reserved healthcare workers are limited. one study investigated asd symptoms among emergency medical technicians (emts) and paramedics during combat and found that paramedics had higher asd symptoms than emts, with a prevalence of . % and . %, respectively (lubin et al., ) . asd has been found to result in subsequent psychological distress exemplified in depression, anxiety, and somatization among individuals who are exposed to a traumatic event (e.g., benight & harper, ) . it has been manifested in various trauma-exposed individuals including orthopedic patients (vincent et al., ) ; immigrants (li & anderson, ) ; and war survivors (qouta; punamäki; & sarraj, ) . it has been estimated that approximately one-third of individuals with major trauma suffer persisting significant psychological impact (shih, schell, hambarsoomian, belzberg, &marshall, ) . another factor that was found to play a significant role in psychological distress is the individual's coping self-efficacy (cse) (benight & harper, ) . cse refers to the individual's capability or confidence to cope effectively with stressful or traumatic event (chesney et al., ) . according to bandura's ( ) theory of self-efficacy, self-efficacy is considered a prerequisite for effective coping. it is a self-evaluative process in which individuals appraise their own capability to manage a threatening situation (bandura, ) . cse was found to play an important role in psychological recovery after trauma (bosmans & van der velden, ) . in a meta-analysis conducted on cross-sectional and longitudinal studies, higher levels of cse were associated with lower levels of distress and ptsd symptoms (luszczynska, benight, & cieslak, ) . it was also found that cse reduces immediate and long-term distress levels in various types of trauma including disasters (e.g., benight, cieslak, molton, & johnson, ; bosmans, benight, van der knaap, winkel, & van der velden, ) .coping self-efficacy reduces the individual's stress reaction through positive appraisal of one's capability in coping with the traumatic event and its aftermath (bosmans & van der velden, ) . psychological distress is also affected by the individual's sociodemographic and clinical background; gender, age, income, and the existence of a mental disorder. extensive research in trauma and non-trauma related psychological distress has shown that women report higher psychological distress than men (e.g., hansen & ghafoori, ; jayawardene, agha, lajoie, & torabi, ; matud, bethencourt, & ibanez, ) . both types of research explain that women tend to use ineffective coping strategies and have less social support than men, lending to their experiencing higher psychological distress (matud et al., ; watson & sinha, ) . furthermore, higher stress in women has been linked to women's tendency this article is protected by copyright. all rights reserved to carry out more household responsibilities (e.g., harryson, strandh, & hammarstrom, ) . however, in a study of childhood victimization among college men and women, elliott et al ( ) , did not find statistical gender differences in psychological distress as evaluated by the symptom checklist- -revised (scl- -r). research supports that, compared to younger populations, older individuals employ more adaptive and directive approaches to managing distress, thus contributing to younger people experiencing higher stress (hansen & ghafoori, ; krause, shaw, & cairney, ) . while existing mental disorders intensify psychological distress among traumaexposed individuals (e.g., lewis et al., ) , income has been shown to be a potential variant. although the majority of studied found that high income has a protective effect against psychological distress (e.g., fullerton et al., ; lewis et al., ), sun et al ( reported that perceived income inadequacy, rather than actual income level, significantly predicted psychological distress. healthcare professionals, particularly nurses, are considered a vulnerable group to experience (asd) amid the covid- pandemic. they are on the frontline of dealing with this aggressive and rapid-spreading virus; detecting and treating infected patients and thereby making themselves vulnerable to contracting the infection at any time, and possibly making them unable to care for future cases. concerns have been raised regarding the possible insufficiency of hospital beds and medical equipment to care for future patients given the exponential increase in covid- infections (world health organization [who], ), which also serves to add more pressure on healthcare professionals. recent studies on the psychological impact and trauma-related responses of covid- among healthcare workers are scarce and focused on symptoms of ptsd rather than asd. in a multinational, multicenter study on the association of psychological outcomes and physical symptoms among healthcare workers in which nurses constituted . % of the sample, . % of the study cohort screened positive for ptsd and . % reported moderate to severe levels of psychological distress (chewa et al., ) . in another study investigating mental health status among medical staff of which . % were nurses, . % of the study sample reported covid- related symptoms of ptsd (xing, sun, xu, geng, & li, ) .the importance of asd diagnosis is based on its capacity to predict individuals who will develop ptsd. bryant and harvey ( ) found that % of patients who had been diagnosed with asd developed ptsd symptoms six months later. edmondson, mills, and park ( ) reported that asd has a % predictive validity for ptsd. research indicates that early treatment of acute stress disorder can effectively prevent development of ptsd (bryant, harvey, dang, this article is protected by copyright. all rights reserved sackville, & bbasten, ) , particularly given that ptsd may develop months or years after the traumatic event takes place (bryant & harvey, ) . therefore, this study represents the first to focus on asd prevalence and predictors of trauma-related psychological distress among nurses. more specifically, this study aims to establish the prevalence of asd and predictors of psychological distress among jordanian nurses. a quantitative, cross-sectional, descriptive and comparative design was used in this study to (a) explore the prevalence of asd and (b) investigate the predictors of psychological distress among jordanian nurses amid covid- . a convenient sample of jordanian nurses working in jordanian hospitals was recruited electronically. we used qualtrics, which is an electronic survey, or more specifically a web-based survey to distribute the study questionnaire. according to stanton ( ), a web-based survey is a survey instrument that physically resides on a network server and which can be accessed only through a web browser. we used daniel's ( ) formula to calculate the sample size needed for the prevalence estimate using the following parameters: (a) a precision rate of % (appropriate if the prevalence is going to be between % and %, (b) an average prevalence of % based on (lubin et al., ) study of asd among healthcare workers, and (c) a % confidence interval (ci). the yielded sample size was participants. a total of jordanian nurses returned the online survey. of them, responses were incomplete with more than % of the data missing. therefore, these responses were not included in the analysis. the final sample included nurses. among this sample, the frequencies of missing values across all items were less than %. a multivariate diagnostic test (little, ) was used to explore the degree of randomness in the identified missing data. the analysis revealed that the missing pattern was completely at random (p > . ). the mean/median of the non-missing items was imputed for the missing scores and all analyses were run with and without imputed data yielding no significant differences. this article is protected by copyright. all rights reserved the survey link was distributed to nurses through hospitals' websites along with an online invitation letter explaining all aspects of the study including: its purpose, voluntary participation, confidentiality, length of survey and potential benefits and risks. furthermore, an online consent form was developed and participants were instructed to read the informed consent carefully, and click on the agreement button at the end of the consent form if they were willing to take part in the study. the anonymity option of the participants was guaranteed by not including the participants' identifying information in the study questionnaire. nor were they identified by the e-survey software once the survey was completed. since the study instruments may include some items that have the potential of eliciting negative feelings, participants were informed that they could refrain from answering any particular questions that may elicit distress. completed questionnaires were automatically saved on qualtrics software which is password protected and can only be accessed by the study authors. the study was approved by the institutional review board (irb) of xxxx. . sociodemographic data sheet. participants were asked to complete a sociodemographic data sheet containing participant' age, gender, income, years of work experience, hospital ward where they are working, and past or current diagnosis of mental disorder. et al., ) . this instrument consists of -item relevant to the diagnosis of asd. it presents items representing three subscales including: dissociation ( items in total), reexperiencing of trauma ( items), avoidance ( items), anxiety and hyperarousal ( items). it also has two additional items regarding impairment in functioning. sasrq is scored on a -point likert scale ranging from (not experienced) to (very often experienced). the scale has been shown to present adequate psychometric properties (e.g., cardena et al., ; benight & harper, ) . . trauma coping self-efficacy scale. this measure is an adaptation of the hurricane coping self-efficacy scale (benight, ironson, & durham, l ) which assesses an individual's confidence in his/her ability to cope effectively with a trauma. the words "caused by the hurricane" at the end of each item of the original measure were changed to "caused by covid- ". the measure consists of items scored on a -point likert scale ranging from "not at all capable" to "totally capable". the items measure the individual's capability to maintain personal, financial, housing, and food security, in addition to their this article is protected by copyright. all rights reserved capability to deal with the emotions and personal losses they have experienced from the trauma. examples of scale items were: ' maintaining personal security-protecting yourself and your property' , and 'maintaining housing and food-negotiating and dealing with contractors, landlords, obtaining and keeping food fresh ' (benight et al., l ) . the psychometric properties of the scale were found adequate (e.g., benight et al., ) . the statistical package for social sciences version was used for data entry and analyses. descriptive statistics of frequencies, means, range, and standard deviations were calculated to describe participants' demographics and the prevalence of asd and psychological distress. simultaneous multiple regression was used to estimate predictors of this article is protected by copyright. all rights reserved nurses' psychological distress. the psychological distress total score was entered as an outcome variable, whereas nurses' gender, age, income, history of mental disorders, asd total score, and cse total score were entered as potential predictors. a total of jordanian nurses ( % females) completed and returned the online survey. the mean age was . years (sd= ) across a field ranging from - . the majority were married ( %, n= ), full time workers ( %, n= ), and had a bsn degree ( %, n= ). the mean monthly income was jd (usd ). on average, participants had years (sd= ) of work experience as nurses, with the total ranging from to years. thirteen nurses ( %) reported they either previously had or currently have a mental disorder (primarily, anxiety and depression) (see table ). the mean asd score among the nurses was (sd= ), with scores ranging from - . according to cardena et al ( ), a cutoff score of or greater signifies clinical asd and predicts ptsd predisposition. in this study, % of nurses had scores at or above the cutoff point of on the sasrq. results for sasrq eight subscales are described in table ii . on the trauma coping self-efficacy scale, the mean score was (sd= ), with scores ranging from - . on the brief symptom inventory, the mean psychological distress scale was (sd= ), with scores ranging from - . approximately % of nurses had a gsi tscore of and greater, indicating significant psychological distress. results related to psychological distress subscales of somatization, depression and anxiety are described in table ii . the results revealed that overall, the model was able to predict a significant proportion of nurses' psychological distress (f ( , ) = . , p < . , r = . ). almost % of the variability in nurses' psychological distress was accounted for by their gender, age, income, history of mental disorders, acute stress, and coping self-efficacy. however, it should be noted that only age, asd, and coping self-efficacy were significant predictors of psychological distress. more specifically, younger nurses ( = -. , t ( ) = - . , p = . ), and those this article is protected by copyright. all rights reserved with higher asd ( = . , t ( ) = . , p < . ), and lower coping self-efficacy ( = -. , t ( ) = - . , p = . ) reported higher psychological distress than their counterparts. table iii shows the model fit. our findings show that the majority of nurses are experiencing asd due to the covid- pandemic, and thus are at risk for ptsd predisposition. more than one-third of nurses are also suffering significant psychological distress. among our sample, age, asd, and coping self-efficacy significantly predicted psychological distress. more specifically, younger nurses are more prone to experience psychological distress than older ones. while higher scores on asd resulted in more psychological distress, coping self-efficacy was a protective factor. although available literature shows that asd predicts ptsd among trauma-exposed individuals (e.g., bremner et al., ; weiss, marmar, metzler, & ronfeldt, ) , the majority of available studies focused on the latter one. the very few studies that investigated asd among healthcare workers reported lower rates compared to our sample of nurses. the prevalence of asd among disaster workers including healthcare professionals ranged between . % (biggs et al., ) to . % (fullerton et al., ) . in the study of lubin et al ( ), rates of asd among physicians and paramedics during combat were . % and . %, respectively. prevalence of asd during infectious diseases pandemic was reported in the study of bai et al ( ) . this study found that only % of healthcare professionals met criteria for asd during the sars outbreak (bai et al., ) . some researchers argued that the prevalence of ptsd is not stable and that it depends on the population that has been investigated ( sadock & sadock, ) . a higher prevalence is found among women and those who are at high risk (e.g., sadock & sadock, ) . the majority of our sample was female nurses ( %) who are at high risk for contracting covid- infection due to their being on the frontline for screening and treating patients at risk. the aggressiveness and rapid spread of covid- may also explain the high rate of asd observed within our sample. another reason can be related to the rising number of covid- cases, both suspected and infected, in jordan at the time of the study, and the inadequate preparedness of hospitals to provide the necessary care. the first case of covid- in jordan was identified on march nd (alarabiya, ) , and two weeks after, the country was in a strict lockdown as the this article is protected by copyright. all rights reserved number of infected was rising rapidly. as of april th , the starting date of our study, officials announced that the number of infected cases had reached (world meters, ) significant psychological distress among trauma-exposed individuals is widely reported in the literature. clinically significant psychological symptoms were reported among urban trauma-exposed adults (hansen & ghafoori, ) ; college students with childhood victimization (elliott et al., ) ; and physically injured adults (munter et al., ) among others. nurses in the present study however, had a higher rate of psychological distress ( %) than those reported in the literature. for example, rates of psychological distress exemplified in depression and anxiety among patients with traumatic facial injury ranged from . % to % (islam, ahmed, walton, dinan, & hoffman, ) and from % to % among physically injured adults (munter et al., ) . a recent study of the impact of covid- outbreak on healthcare professionals' psychological health reported that among healthcare workers in singapore, % suffered from anxiety and % from depression. a study by suleiman et al ( ) that was conducted between march and march , which was around the time of our data collection, reported that only . % of frontline physicians in jordan had all protective measures (ppes) available at hand and the most shortage was for facemasks ( . %). doctors without full ppes reported significantly higher fear and anxiety than those with full ppes. we would expect that nurses were also experiencing similar shortages in ppes equipment for personal safety, which may explain the high rate of reported psychological distress. this warrants nurse mangers in other countries where ppes resources are inadequate to proactively test their healthcare workers for psychological distress. munter et al ( ) found that rates of psychological distress due to anxiety and depression were higher one week after trauma and decreased thereafter. therefore, this necessitates the provision of early psychological interventions for nurses with continued screening and referral for such services. o'donnell et al ( ) explains that early interventions in trauma high-risk individuals are associated with better outcomes. our findings on the inverse relationship between age and psychological distress are consistent with available literature. in a study of a community sample during sars outbreak; younger individuals were found to suffer greater psychological comorbidity (sim, chan, chong , chua , & soon, ) . younger people were more likely to utilize ineffective coping strategies during the outbreak (sim et al., ) . other studies reported that psychological distress, especially depression and anxiety, decline with increasing age (e.g., christensen et this article is protected by copyright. all rights reserved al. ; jorm et al., ) . one possibility is that the aging of the brain affects emotional responsiveness. older adults are found to be less likely to attend to and remember negative emotional experiences than positive ones (mather et al. ) . future research needs to investigate the role of aging on psychological distress and the specific risk factors interplay between both variables. the findings on the association between psychological distress and sociodemographic and clinical variables of gender, income, and existing mental disorders are inconsistent with the majority of literature. a plethora of trauma-related articles on psychological distress have reported women having higher psychological distress than men (e.g., hansen & ghafoori, ; jayawardene et al., ) . however, our finding of the non-existent relationship between gender and psychological distress is consistent with the study of elliott et al ( ) , in which no significant gender differences were found. some researchers (e.g., emslie et al., ) explain that context and socio-cultural factors should be taken into account in explaining psychological distress. our sample of nurses is mainly female ( %) and the higher female representation in the current study may relate to nursing being a female- regarding the non-existent relationship between income and psychological distress in our data, one possibility is offered by sun et al. ( ) who reported that it is the perception of income inadequacy, rather than actual income, which affects psychological distress. a more reasonable explanation is that all of the nurses in our study are employed and thus their income is secured, rendering income as a non-significant predictor of psychological distress compared to fear for one's own safety or dealing with the emotions associated with the traumatic event of covid- . nevertheless, more research is needed to further explore the nature of the relationship between income and psychological distress. since only % of the sample reported existing mental illness, mainly depression and anxiety, this may also explain the insignificant predictability of this variable on psychological distress. coping self-efficacy (cse) as a protective factor against psychological distress is congruent with studies on natural disasters. for example, in the study of benight et al. (l ) on hiv positive men following hurricane andrew, cse accounted for % for ptsd this article is protected by copyright. all rights reserved symptoms (benight et al., ) . cse was also a significant predictor of psychological distress among flood and fire survivors (benight & harper, ) . cse had a direct negative pathway to acute psychological distress among survivors of hurricane andrew (benight, ironson, klebe, et al., l ) . similarly, pritchard and gow ( ) found that greater coping self-efficacy was associated with lower trauma-related psychological distress among survivors of the queensland flood in australia. although this study is considered the first to investigate the prevalence of asd among nurses during covid- , and to explore predictors of psychological distress, it has some limitations. this study is cross-sectional in nature and relied on measuring asd, coping self-efficacy and psychological distress using an online self-administered survey. longitudinal research is needed to explore the magnitude of the study variables over time. another limitation is the descriptive nature of the study, which limits having detailed and rich understanding of nurses' psychological well-being during covid- outbreak. further research is needed to examine this phenomenon employing different research methodologies (i.e., qualitative or mixed-methods design). our findings show that nurses experience significant asd and psychological distress amid the covid- pandemic. coping self-efficacy is found to ameliorate the effect of psychological distress on nurses' traumatic experience. such findings warrant intensive efforts from healthcare institutions to provide psychosocial support services for nurses. nurse managers can take a leading role in implementing stress-reduction strategies for nurses through providing consecutive rest days, rotating allocations of complex patients, arranging support services, and being accessible to staff. of importance, nurse managers need to take an active role in ensuring the personal safety of their staff through working closely with their hospital's management in securing and providing personal safety measures. they also may undertake briefings to ensure their staff's physical and mental well-being. steps to improve nurses' coping self-efficacy are considered another avenue where nurse managers can intervene. self-efficacy is found to correlate positively with adaptive coping and thus reduces individual's psychological distress (park, folkman, & bostrom, ) . nurse managers can improve nurses' self-efficacy through verbal persuasion (i.e., providing positive feedback on the tasks that are accomplished appropriately and safely) and act as role models in handling the crisis of covid- in an empowering way. given that individuals suffer from asd are this article is protected by copyright. all rights reserved aging and emotional memory: the forgettable nature of negative images for older adults a validity and reliability study of the coping self-efficacy scale amultinational multicenter study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak age differences in depression and anxiety symptoms: a structural equation modeling analysis of data from a general population sample coping with post-traumatic stress: young, middle-aged and elderly comparisons biostatistics: a foundation for analysis in the health sciences the brief symptom inventory: an introductory report factor structure of the acute stress disorder scale in a sample of hurricane katrina evacuees acute stress disorder as a predictor of posttraumatic stress disorder in physical assault victims polyvictimization, psychological distress, and trauma symptoms in college men and women gender differences in mental health: evidence from three organizations this article is protected by copyright. all rights reserved key: cord- - b vfv b authors: hao, fengyi; tam, wilson; hu, xiaoyu; tan, wanqiu; jiang, li; jiang, xiaojiang; zhang, ling; zhao, xinling; zou, yiran; hu, yirong; luo, xi; mcintyre, roger s.; quek, travis; tran, bach xuan; zhang, zhisong; pham, hai quang; ho, cyrus s. h.; ho, roger c.m. title: a quantitative and qualitative study on the neuropsychiatric sequelae of acutely ill covid- inpatients in isolation facilities date: - - journal: transl psychiatry doi: . /s - - - sha: doc_id: cord_uid: b vfv b this study examined the neuropsychiatric sequelae of acutely ill patients with coronavirus disease (covid- ) infection who received treatment in hospital isolation wards during the covid- pandemic. ten covid- patients who received treatment in various hospitals in chongqing, china; age- and gender-matched psychiatric patients; and healthy control participants residing in the same city were recruited. all participants completed a survey that collected information on demographic data, physical symptoms in the past days and psychological parameters. face-to-face interviews with covid- patients were also performed using semi-structured questions. among the covid- patients, % had abnormal findings on the chest computed topography scan, % had dysosmia, % had dysgeusia, and % had repeated positivity on covid- reverse-transcription polymerase chain reaction testing. covid- and psychiatric patients were significantly more worried about their health than healthy controls (p = . ). a greater proportion of covid- patients experienced impulsivity (p = . ) and insomnia (p = . ) than psychiatric patients and healthy controls. covid- patients reported a higher psychological impact of the outbreak than psychiatric patients and healthy controls, with half of them having clinically significant symptoms of posttraumatic stress disorder. covid- and psychiatric patients had higher levels of depression, anxiety and stress than healthy controls. three themes emerged from the interviews with covid- patients: (i) the emotions experienced by patients after covid- infection (i.e., shock, fear, despair, hope, and boredom); (ii) the external factors that affected patients’ mood (i.e., discrimination, medical expenses, care by healthcare workers); and (iii) coping and self-help behavior (i.e., distraction, problem-solving and online support). the future direction in covid- management involves the development of a holistic inpatient service to promote immune and psychological resilience. the world health organization (who) declared the coronavirus disease (covid- ) outbreak a pandemic on march . as of may , the number of confirmed cases was more than six million, with the number of death cases at > , , and the number of recovered cases at more than two million worldwide . the symptoms of covid- include general symptoms, such as fever; chills and malaise; respiratory symptoms including cough, breathing difficulty and coryza; gastrointestinal symptoms including vomiting and diarrhea; and neurological symptoms including headache and giddiness . in a recent report, some patients with covid- complained of olfactory and taste disorders . differential levels of psychological distress as a result of vicarious traumatization from covid- were found in different groups of people, ranging from the general public , to psychiatric patients , individuals under quarantine and healthcare workers . however, there is currently limited research on the neuropsychiatric sequalae and psychological impact of covid- patients, with one study so far reporting that most clinically stable patients suffered from significant posttraumatic stress disorder (ptsd) symptoms . the emotional and psychological needs of covid- patients could be very much different from those with pre-existing psychiatric illnesses and people in the community. several hypotheses exist to explain why covid- patients may suffer from neuropsychiatric ramifications. covid- is postulated to infect the central nervous system via the peripheral trigeminal or olfactory nerves following intranasal inoculation . it then invades regions of the cerebral cortex, basal ganglia, and midbrain that are closely linked to the olfactory bulb. from psychological perspectives, the perceived threat, susceptibility, and illness severity coupled with physical discomfort, loneliness and psychosocial stressors may evoke emotional disturbances, such as anger, fear, hysteria, depression, anxiety, and other psychological issues, in patients acutely infected with covid- . these psychological factors may in turn reduce innate immunity through cell-mediated immune activation via the release of several inflammatory markers, such as il- , il- , and tumor necrosis factoralpha, which are implicated in the pathogenesis of depression and ptsd . this therefore suggests the possibility of immune dysregulation as a shared pathogenesis in covid- infection and psychiatric disorders. there has been an increasing number of qualitative studies that examined the in-depth effects of covid- pandemic on the feelings, behavior, and attitude of healthcare workers and caregivers . however, there is still a paucity of research on the psychological mechanisms and impact of covid- on infected patients, and how they cope through the isolation period. this highlights a pertinent knowledge gap that needs to be addressed that is essential for holistic management. the present study performed a quantitative evaluation of the neuropsychiatric sequelae of patients with acute covid- infection who received treatment in the hospital isolation wards, and compared these patients with psychiatric patients and healthy controls during the covid- pandemic. we hypothesized that covid- patients would exhibit more neuropsychiatric symptoms than psychiatric patients and people in the community. we also performed face-to-face semi-structured interviews with patients to explore other possible symptoms that may be missed in quantitative studies , understand their subjective experience, and the psychological impact of contracting covid- . findings obtained from this study will be invaluable in setting up a service that can adequately address the biopsychosocial needs of the covid- pandemic , . the present study obtained the best quality data using face-to-face interviews with acutely ill covid- patients during their hospitalization in various hospitals in chongqing, china. the interviews were performed from to march . interviewers wore full personal protective equipment (ppe) when performing the interviews with covid- patients in the isolation ward. patients were interviewed while they were still covid- positive in status and that they were on supportive treatment. a series of standardized validated questionnaires were used for the quantitative component of the study. for the qualitative component of the study, the interviewers performed semi-structured interviews using open-ended questions to examine patients' perception and feelings during the current outbreak. patients were encouraged to speak openly, highlight issues pertinent to them, and elucidate their responses with examples. patients were allowed to withdraw their consent at any time during the interview. the interviews were audiorecorded and kept strictly confidential. each interview took~ - mins and the interviewers were instructed to remain neutral during the data collection process and establish a rapport with the patients using the techniques of acceptance, active listening and clarification to ensure the authenticity of the information and minimize bias. in the event that the patients became emotional during the interview, psychological support and intervention were provided to them. age-and gender-matched psychiatric patients and healthy control participants residing in the same city were recruited during the covid- epidemic and used as a comparison. they did not undergo confirmatory covid- testing as they did not have any symptoms that were suggestive of covid- infection or had positive contact history, and the supplies of confirmatory kits in the hospital were limited. the ethics review committee of the first people's hospital of chongqing liang jiang new area approved this project (irb no. - - ). informed consent was obtained from all subjects. covid- patients were aged years or older and hospitalized during the time of assessment. the diagnosis of covid- was made using reverse-transcription polymerase chain reaction (rt-pcr) testing and chest computed tomography (ct) for evaluation of covid- . to be included, patients could not have any pre-existing psychiatric illnesses or unstable medical conditions. patients with severe complications requiring oxygen supplementation or who were medically unstable were excluded from the study. the inclusion criteria were different for psychiatric patients and healthy controls. all the psychiatric patients were aged years or older and were previously diagnosed by psychiatrists with f , major depressive disorder -single episode; f , major depressive disorder-recurrent episodes; f , other anxiety disorders, including generalized anxiety disorder and panic disorder; and f . , mixed anxiety and depressive disorder, based on the th revision of the international statistical classification of diseases and related health problems (icd- ) criteria. healthy control subjects were aged years or older and did not have a history of psychiatric illnesses. the exclusion criteria included the presence of chronic medical disorders, including neurological, cardiovascular, respiratory, endocrine and inflammatory disorders, or suspected or confirmed cases of covid- . the structured questionnaire covered several areas: (i) demographic data; (ii) physical symptoms and self-rated physical health status in the past days; (iii) impact of event scale-revised (ies-r), (iv) depression, anxiety and stress scale (dass- ), (v) the insomnia severity index (isi), and (vi) other psychiatric symptoms. sociodemographic data were collected regarding gender, age, education, and household size. physical symptom variables in the past days included fever, chills, headache, myalgia, cough, difficulty breathing, dizziness, coryza, sore throat, persistent fever, nausea, vomiting and diarrhea. respondents were asked to rate their physical health status. the psychological impact of the covid- outbreak was measured using the ies-r. the ies-r is a selfadministered questionnaire that is well-validated in the chinese population for determining the extent of the psychological impact after exposure to a public health crisis within one week of exposure . this -item questionnaire is composed of three subscales and aims to measure the mean avoidance, intrusion and hyperarousal . the total ies-r score was divided into - (normal), - (mild psychological impact), - (moderate psychological impact) and > (severe psychological impact). mental health status was measured using the depression, anxiety and stress scale (dass- ), and the scores were calculated based on previous studies . the total depression subscale score was divided into normal ( - ), mild depression ( ) ( ) ( ) , moderate depression ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , severe depression ( ) ( ) ( ) ( ) ( ) ( ) ( ) and extremely severe depression ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the total anxiety subscale score was divided into normal ( - ), mild anxiety ( - ), moderate anxiety ( ) ( ) ( ) ( ) ( ) , severe anxiety ( ) ( ) ( ) ( ) ( ) , and extremely severe anxiety . the total stress subscale score was divided into normal ( - ), mild stress ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , moderate stress ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , severe stress ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and extremely severe stress ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the dass is a reliable and valid measure for assessing the mental health of the chinese population , . both the ies-r and dass were previously used in research related to the covid- pandemic [ ] [ ] [ ] [ ] . the sleep quality of respondents was measured using the insomnia severity index (isi) . the isi has seven questions that are summed to produce a total score. the total isi score was divided into no clinically significant insomnia ( - ), subthreshold insomnia ( ) ( ) ( ) ( ) ( ) ( ) ( ) , moderately severe clinical insomnia ( ) ( ) ( ) ( ) ( ) ( ) ( ) and severe clinical insomnia ( ) ( ) ( ) ( ) ( ) ( ) ( ) . as for the semi-structured interviews for covid- patients, eight questions were included: (i) describe a situation in which you experienced negative emotions (unpleasant feelings) during the outbreak and how you felt and thought at the time; (ii) describe a situation in which you experienced positive emotions during the outbreak and how you felt and thought at the time; (iii) how did you feel and react after your first infection (thinking, feelings, behavior, any bodily sensation)?; (iv) how did you feel and react after you were tested positive again (thinking, feelings, behavior, any bodily sensation)?; (v) what worries do you have about the future?; (vi) what enlightenment will this experience bring to your life and why is that so?; (vii) what advice, if any, would you give to countries and people experiencing a new epidemic?; and (viii) what do you think you, your family and friends did to help you recover physically and emotionally? all the interviews were audio-recorded with prior consent given by the patients. the audio recordings were transcribed within hours of each interview and reviewed by the interviewers to safeguard accuracy. as the interviews, transcriptions, and analyzed data were in chinese, they were translated into english by some study team members and back translated by another group of study team members to ascertain that the meaning was retained. descriptive statistics were used to summarize the variables, means and standard deviations were used for continuous variables, and frequencies and percentages were used for categorical variables. inferential statistics, including the independent sample t test and pearson's chi-squared test, were used to examine differences in the outcome variables between the psychiatric patient and healthy subject groups. multiple linear regression with a backward selection method was used to examine the association between the outcome variables, the two groups of subjects and the demographic variables. all analyses were performed using ibm spss statistics , and the level of significance was set at %. as for the qualitative component of the study, the interview was transcribed, and a detailed reading and re-reading of the transcripts was performed to identify significant key words and phrases. understanding and validating the expressed meanings of these words and phrases were done through research team meetings to arrive at a consensus. then, codes were assigned and arranged into themes and sub-themes using the concepts of grounded theory for data analyses. the sociodemographic characteristics of the patients and healthy control participants are presented in table . covid- and psychiatric patients were age-and gendermatched with healthy subjects. patients significantly differed from healthy controls with regards to the physical symptoms experienced (p = . ), with a higher proportion of covid- patients than psychiatric patients and healthy controls reporting at least one symptom ( % vs % vs %). there was no difference between the three groups in self-reported health status. all of the covid- patients were clinically stable without the need for respiratory support. they were given supportive treatment and there was no clinical indication for any specific intervention. % of patients had abnormalities on chest ct, % had dysosmia, and % had dysgeusia. % of patients had repeat positivity for covid- in rt-pcr testing and had been in isolation for months when interviewed. the remaining % of patients were in isolation few days prior to the interview. the psychological symptoms experienced by the study participants in the last days are presented in table . covid- and psychiatric patients were significantly more worried about their health than healthy controls (p = . ), with more covid- patients reporting moderate levels of worry ( %) and some psychiatric patients reporting serious level of worry ( %). although the three groups were not statistically significant in regard to the parameter of discrimination, more covid- patients reported feeling discriminated, ranging from a mild to very serious level (p = . ). more covid- patients were impulsive as compared with psychiatric patients and healthy controls (p = . ), with half of the covid- patients experiencing a mild level of impulsivity, and % of psychiatric patients experienced moderate to very serious levels of impulsivity. the psychological impact of the covid- pandemic on participants are presented in table . the psychological impact as measured using the ies-r scale, revealed that the covid- patients had a higher mean score ( . , sd = . ) than psychiatric patients ( . , sd = . ) and healthy controls ( . , sd = . ), although there was no significant difference between the three groups. a greater proportion of covid- patients ( %) than the other two groups experienced a psychological impact of at least mild and above severity in keeping with clinically significant symptoms of ptsd, as indicated by ies score of and above, although this result was not statistically significant. covid- and psychiatric patients had higher dass- sub-scores of anxiety, depression and stress than healthy controls, with higher scores of anxiety ( . vs . ) and depression ( . vs . ) for psychiatric patients than for covid- patients. the dass- sub-score of stress was higher for covid- patients than for psychiatric patients ( . vs . ). all three p values were however insignificant. there were also no significant differences in the severity dichotomization of anxiety, at least one symptom ( %) ( %) ( %) self-reported health status . healthy or better ( %) ( %) ( %) very serious ( %) ( %) ( %) felt anxious . very serious ( %) ( %) ( %) felt upset . very serious ( %) ( %) ( %) felt meaningless . very serious ( %) ( %) ( %) worried about health . felt being discriminated . very serious ( %) ( %) ( %) heard voices . very serious ( %) ( %) ( %) felt being followed . very serious ( %) ( %) ( %) felt impulsive . serious ( %) ( %) ( %) depression, and stress among the three groups. for sleep quality, a higher proportion of covid- patients ( %) reported insomnia than psychiatric patients ( %) and healthy controls ( %), and this difference was statistically significant (p = . ). three main themes emerged from the covid- patients' accounts of their experiences of the outbreak: (i) emotions of the patients after covid- infection; (ii) external factors that affected patients' mood; (iii) coping and self-help behavior. each main theme and its subthemes are discussed and illustrated in some of the participants' verbatim accounts. theme : emotions of the patients after covid- infection . . emotions generated by the infection all patients reported that the covid- infection was a major stress event for them. this stress was particularly due to the high infectivity and potential lethality of the viral infection. emotional disturbances occurred in patients, especially in the initial period after diagnosis with the infection, and some of the first emotions included surprise, fear, bewilderment, and questioning why the virus had infected them. "i feel so scared and stressed. i'm afraid that i'm going to break down and i won't be able to hold on anymore." (patient ) "i was actually quite surprised i got infected because i did a good job protecting myself… i had no contact with anyone from foreign countries, i only went downstairs to buy daily necessities twice in days, and i wore a mask the whole time. so, i was surprised to find out i was infected." (patient ) after the initial realization and acceptance of contracting the disease, patients began to feel depressed, and some individuals had desperate thoughts, such as the fear of being unable to leave the hospital or of dying. very serious ( %) ( %) ( %) however, once past the initial phases, some patients accepted their predicament and adjusted their mindset to receive treatment. "at first, i was very worried and felt miserable…then i stopped thinking about these because i knew it was meaningless to think about them now. the key was to get well quickly." (patient ) patients who tested positive for covid- repeatedly during their stay in the hospital might have experienced a sense of hopelessness and helplessness that their chances for recovery had been "dashed". this feeling might have triggered previous fears and worries of their condition deteriorating. there was also increased stress of waiting for repeated test results. with the absence of a viable cure and the limited understanding of the consequences of the novel viral infection, there was much apprehension, and some patients diverted excessive attention to their body, which led to the manifestation of somatic symptoms. "i have always been a little worried about my health. but now, my concerns about my health are more serious. i previously had high levels of uric acid, so i stopped eating meat or drink any soup… despite the doctor telling me that it is actually appropriate to eat. in the hospital, i don't eat the apples that they provide me at night… i think they are cold, and it is bad to eat at night. i also don't let my wife eat fruits at night. i'm worried that my illness is because of my underlying poor health constitution." (patient ) with the stabilization of their disease, patients started worrying about people close to them and also longer-term issues, such as employment, financial problems and vaccine development. the long hours that patients spent alone in a closed environment with their freedom limited may have led to a feeling of isolation, boredom, and a depressed mood. "it is too boring staying here, and it is making me irritable and restless, which i wasn't before. if i test positive again, i'm going to go crazy. and i'll find a way to get out somehow…." (patient ) "the accommodation conditions in the last hospital was very limited. after my neighboring patients were discharged, i was alone in the room, with weak cell phone signal and no tv, so i was really bored. every day i wonder -when will this life ever end?" (patient ) during this unprecedented time of the covid- pandemic, and living in a relatively special environment, various events might have affected the patients' mood. the provision of systematic and sound national policies on protective and supportive measures for citizens might have mitigated the psychological burden of patients. patients felt their own safety was guaranteed when the country that they lived in demonstrated it cares about the well-being of its people. "the government has exempted the medical expenses of patients suffering from this disease, so that people can concentrate on recovering without worries. the government has developed the right policies to guide us in the fight against the epidemic, and we are moving towards the right path. this shows the merits of the whole country in being able to focus on big things. what is there to worry about living in such a country and with such people?" (patient ) furthermore, the care and warmth of the medical staff experienced by the patients made them realize that their feeling of isolation was due solely to the virus and not due to a lack of love and comradeship. the care and assistance provided by the medical staff made patients feel solidarity and warmth between people. "the nurse sister made me feel a lot of warmth every day… telling me to take my medicine and checking my temperature. during my illness, i learned that everyone was helping and supporting each other in need." (patient ) "the nurses are like angels. one day, i was hungry before the scheduled mealtime as i had diarrhea prior. i asked for a bowl of noodles, and the nurse immediately brought me noodles. the medical staff taught us to dance and sing… it was really fun, and we learned a lot. these nurses are very young in their s to s, and they haven't been home for more than days… it's pretty hard for them too." (patient ) despite the inability to physically meet, family members and friends also provided psychological support and motivation to the patients via remote communication. patients were also able to more deeply appreciate the value of kinship and friendship in the midst of this outbreak. "i am very grateful to my wife for her continued encouragement. during the period when i was staying in isolation, i felt lonely and sad. due to changes in the environment, my state was worse than before, but she was always there encouraging me." (patient ) "i received a bunch of flowers and a letter from my friend. the content of the letter was simple and reassuring, which moved and made me feel good. i did not expect to encounter so many heartening moments during my stay in the hospital." (patient ) there is much panic about the infectivity and lethality of the virus. patients reported discrimination and abuse by non-infected individuals. excessive worry for family members also increased the psychological burden of patients. "after being discharged from the hospital the last time, we returned to our neighborhood and continued to be quarantined at home. somehow our private information including our address and telephone number was leaked. residents in the neighborhood said a lot of nasty things in the neighborhood wechat group and regarded us as monsters. people who live in the same building are very worried about getting infected merely by passing by our door. in the group chat, they even talked about their fear to go downstairs. in the future, when we want to visit your clinic for review, i wonder if you will also avoid us?" (patient ) "…he (family member) calls me every day and then passed the negativity to me. he feels better after talking to me, but it is actually hard for me. i absorbed his negative emotion and passed positive emotions to him." (patient ) in addition to the negative comments of other people, patients spent more time on the internet due to the lack of face-to-face communication opportunities during their stay in the hospital. when they saw negative news on the internet, such as foreign communities' lack of understanding of the chinese measures and discrimination against chinese people, they also felt angry and upset. "i have some foreign friends who believe that china's reaction to the outbreak is an overkill and overly paranoid. perhaps they underestimated the epidemic or they have never experienced the situation in wuhan. they think that china is making a mountain out of a molehill and its measures are ridiculous. there are those who laugh at our policies and precautionary measures. these make me feel uncomfortable." (patient ) "from the beginning of the outbreak, leaders of some countries claimed that the virus originated from china and that china spread the virus across the world. as a result, the chinese are loathed by other ethnic groups overseas. many of china's efforts to combat the outbreak have been deliberately ignored. i felt hated, discriminated against and that my life is threatened." (patient ) due to the isolation, patients felt anxious and worried about their unfinished matters. their original social role was replaced by the patient sick role, which caused them to feel bored, irritated, and depressed. "i have been living here for two months, and i feel that there is no longer meaning to life. sometimes i feel that my life and memories are not real, and i don't know what i can achieve in the future. i used to be a person who's very active with activities." (patient ) "over the past two months, i have to pay my house mortgage, and my small business has been affected by the economic situation. my children have to go to school… my son is still very young… i worry that when i am not around, he cannot take care of himself." (patient ) in the face of stressful events, such as the pandemic, patients sought ways to adjust their emotions to help themselves. first, they comforted themselves by believing that the government and the medical staff would do their best to help them. "i try not to think too much. i constantly tell myself that young people such as myself don't have medical illnesses, so covid- will have a very small impact on me. i have confidence in my body, so i don't have to worry so much, and this is the most important." (patient ) "i will always encourage myself to think positively and try my best to adjust my mindset. an integral part of recovery is the mental attitude, so psychologists play a key role in the process. (patient ) in addition to comforting themselves, patients also tried to maintain a regular routine that included proper exercises and an adequate mastering of disease knowledge to feel more empowered and in control. "i am one of the younger patients in isolation. at present, the inpatient isolated lifestyle requires one to go to bed and wake up early, and doing some gentle physical exercises planned by the ward team, which are more for middle-aged people and not particularly suitable for me… i have to find ways to enrich my life. other people whom i know who are also in isolation are actively looking for ways to adjust." (patient ) patients also attempted to divert their attention from their situation via other activities. "distraction is a great way, whether it's talking to someone or finding something to do on your own. for example, when i was first admitted to the hospital, i always felt that i had breathing difficulties. but when i talked to you on the phone, i didn't feel any difficulty at all. when i get distracted, the physical symptoms disappear…the more attention i pay to my breathing, the more obvious the shortness of breath becomes." (patient ) with limited interpersonal communication during isolation, some patients created ways to make friends with other patients to expand their social contact and comfort one another. "when i just got admitted, i remembered walking along a corridor and seeing the door of a ward open. there was a fellow patient inside. i said: "friend, let's add each other on wechat." at that time, i needed friends, someone to understand me, to talk to me." (patient ) our study sample of covid- patients had mild-moderate severity with less than half of them having abnormal findings on the chest ct. the paucity of abnormal findings on chest ct could possibly be due to an earlier pick-up rate with a shorter time after the onset of symptoms . furthermore, only a small proportion of them had olfactory and gustatory dysfunction. there has been increasing reports of smell and taste alterations as concurrent symptoms of covid- infection. interestingly, those with dysnomia and dysgeusia were found to have less-severe manifestations of other symptoms and tended to recover more quickly , raising the possibility of olfactory and gustatory dysfunctions as potential markers of structural or functional morbidities . the majority of our patients were retested positive for covid- . although the exact causes of this phenomenon remain uncertain, there is a possibility that the viral infection can provoke an inflammatory milieu that results in aberrant immune responses. such immune responses may trigger the propagation of host antibodies and lymphocytes that cross-react with both viral antigen and self-antigen, causing persistent infections, and potentiate the development of autoimmune neuropsychiatric sequelae particularly impulsivity and insomnia , . a higher proportion of covid- patients was found in our study to be impulsive as compared to psychiatric patients and healthy controls. these feelings might have been related to patients staying in isolation rooms for a prolonged duration with limited social interaction, lack of stimulation and loss of freedom, which may result in anger, fear, restlessness, and irritability. staying in isolation rooms can negatively impact psychological wellbeing, in which previous studies highlighted higher scores for anger-hostility , in addition to depression, anxiety, fear, and loneliness , . the acute stress experienced by patients can activate immune system responses via amplification of the corticotropin-releasing factor system that regulates impulsivity and releases pro-inflammatory cytokines such as il- and tnf-α that evoke behavioral changes aimed to protect self from injury or harm . sleep disturbances was also a prominent feature found in covid- patients compared with psychiatric patients and healthy controls. this finding was consistent with other studies that found sleep problems occurring in people with naturally occurring respiratory infections . physical stress inflicted on the body by the infection coupled with psychological stress trigger off a cascade of system responses including cortisol release from the hypothalamic-pituitary-adrenal axis, and catecholamine, norepinephrine, and epinephrine release by the peripheral sympathetic-adrenomedullary system . these systems in turn stimulate pro-inflammatory cytokine release targeting sleep-related functions among others such as metabolic and cardiovascular changes. although these physiological mechanisms in the acute phase facilitate stress adaptation to "fight-or-flight" in the event of adversity, chronic activation of these mechanisms may cause detrimental bodily and psychological effects, such as obesity, depression, and even elevating the risk of developing a rhinovirus infection . higher levels of depression, anxiety, stress, and ptsd were found in covid- patients than healthy people, though in our study, these results were not statistically significant. several reasons for the depressive and anxiety symptoms in our study include the perception of vulnerability to the virus, uncertainty and fear about the consequences of the infection, treatment outcome and death in the absence of a definitive treatment, the inability to resume their routine activities, worries about unfinished matters and loved ones, worries about their financial situation and stigma. cognitive features of depression such as helplessness and hopelessness , , and somatic symptoms as part of the anxiety spectrum with hypervigilance on bodily sensations were also exemplified in the interviews. as for ptsd symptoms in covid- patients, many expressed concerns about their health, family, livelihood, and future, which was disrupted, and displayed emotions that resembled the various stages of grief, ranging from denial, anger, bargaining, and depression to acceptance. with the possible shared immune dysregulation pathogenesis of covid- and psychiatric disorders with bidirectional implications, it may be worthwhile to stabilize each condition to prevent worsening of the other, and medications that modulate the immune system to counteract covid- could potentially be used as an antidepressant and vice-versa . anti-inflammatory drugs have been found to have antidepressant effects in clinical trials , whereas antidepressants are also found to reduce central and peripheral levels of il- β with the alleviation of depressive symptoms , suggesting their anti-inflammatory properties. antidepressants with its relatively safe side-effect profile and affordability than other immunomodulators could therefore be a potential new therapeutic candidate in the treatment of covid- . psychiatric patients on the other hand, had higher scores of depression and anxiety than covid- patients, which may be owing to their pre-existing poorer adaptive coping to acute stressful events. this result also raised the concern that more psychological support should be rendered to psychiatric patients despite their lack of infection; and psychiatric patients if infected with covid- , could be at higher risk of complications considering their emotional state and lowered immunity status. it is important to reiterate that we were unable to measure the inflammatory markers of participants and correlate them with the psychological parameters in our study, and owing to the crosssectional nature of the study, it would not be possible to elucidate the causal relationship between mental illness and the inflammatory effects of covid- infection. nevertheless, this is an important research area that warrants further investigation. there is a wide spectrum of emotions experienced by patients, and the heterogeneity in disease response could be contributed by various psycho-socio-economic factors, pre-existing medical comorbidities, differences in the immune system maturity that underline the immune response differences to the infection, temperament, and attachment styles , . those with pre-existing chronic medical conditions and older adults may have lower innate immunity with greater susceptibility to the virus and risk having worse outcomes. anxious, depressive, and cyclothymic temperaments as well as the insecureanxious attachment dimension temperament have been found to predict psychological distress, whereas secure and avoidant attachment styles are protective . shock, fear, despair, and hope as found in our study are wellrecognized symptoms of traumatization , whereas boredom in relation to restlessness and irritability are especially relevant for those in isolation and quarantine. boredom if entrenched and severe, can manifest as a neurotic disorder that may erode self-control, leading to impulsivity, and risk-taking behavior . feeling discriminated was a pertinent issue encountered by covid- patients, which is consistent with previous studies that highlighted the stigma experienced by infected patients who may be shunned by their loved ones, friends, and communities for being a carrier of the virus, or as part of a nationality or ethnic group that contributed to its transmission . in addition, internalized stigma may also occur in which infected people view themselves as inferior to others, which leads to self-loathing as a result of their disease status , . discrimination and stigmatization often lead to feelings of abandonment and loneliness , which are further compounded in covid- patients by staying in an isolation room and may last beyond discharge from the hospital . in our study, covid- patients utilized the tripartite framework of positive coping style, cognitive appraisal, and social support to mitigate stress, promote positive emotions, and enhance perceived self-efficacy . these factors facilitate psychological adaptation and resilience in the backdrop of an infectious outbreak . the pressure of the pandemic prompted them to utilize coping strategies, which included distraction techniques (exercise, talking to others, engaging in activities) and mental avoidance to keep themselves busy while disengaging from their own plight. problem-solving strategies such as mastering knowledge of the disease allowed patients to proactively empower themselves and gain control of their health, which minimized their feelings of uncertainty and improved their mental health . positive cognitive appraisals of the outbreak situation together with a positive mindset enable one to seizure control of the situation and constructively plan ahead. some patients re-evaluated the situation based on past outbreaks and experiences in life to anticipate possible scenarios, and assessed the situation to be manageable, which reduced distress . some patients placed confidence in the government and healthcare systems to manage the outbreak and believed that they would receive good treatment if they needed it . having faith and trust in the government and health authorities to manage covid- may reduce their fears and perceived vulnerability to the virus . seeking support from various sources, including family and friends, fellow patients and healthcare providers, are integral in cushioning the psychological complications of the outbreak. the dedicated care and concern shown by healthcare workers positively impacted patients and made them feel supported. all of these factors contribute to enhanced optimism, which favorably alleviates psychological trauma in disasters, and enhances psychological rehabilitation of ptsd . guided by findings of this study, which identified the psychological distress and mental health needs of covid- patients, it is paramount for hospitals moving forward, to set up a novel holistic inpatient service with appropriate prevention measures to promote immune and psychological resilience. this is done by catering to the individualized physical and mental health needs of covid- patients who are kept in prolonged isolation. several principles of this service that could be considered are as follow. ( ) maintain regular physical exercise regimes, especially those that elevate cardiorespiratory fitness at moderate intensity, as they have been found to reduce inflammation and boost immunity . exercise can be delivered through online instructor-led platforms or via exergaming, which is a hybrid form of physical activity that combines exercise and video games. ( ) develop healthy lifestyle habits with proper nutrition that includes antioxidants, high fiber content, whole grains, and unsaturated fats, which have rapid anti-inflammatory effects that boost immunity, counteract vulnerability to covid- and promote recovery . ( ) educate on proper safety precautions including hand hygiene, wearing of face masks and social distancing to minimize community spread after hospital discharge. ( ) use of online and smartphone-based platforms to deliver various types of psychotherapy to enhance patients' adaptive and coping capability. an example is trauma-focused-cognitive behavior therapy with emphasis on cognitive reframing of the mindset to help remove unhelpful thoughts about covid- and perceived discrimination, trauma narrative to process personal traumatic experiences during the pandemic, grief therapy to handle potential losses, and relaxation techniques to counteract anxiety, irritability, anger, and ptsd-like symptoms . sleep hygiene advice can also be provided to improve circadian rhythm and sleep quality. ( ) allow patients the peace of mind to recover from the infection. this includes ensuring data protection and confidentiality of patient details to minimize potential discrimination by others, and ensure affordability of medical care. ( ) provide emotional support to healthcare workers taking care of covid- patients. the mental health of healthcare workers can directly impact the quality of care and psychological wellbeing of patients. ( ) monitor the association of blood pro-inflammatory cytokine levels with severity of covid- physical and neuropsychiatric symptoms. this may have implications in monitoring disease progression and treatment response, considering the potential bidirectional relationship between covid- and psychiatric disorders. furthermore, the application of biological markers may better elucidate the yield of using antidepressants as a novel treatment modality for covid- . the present study has merits in being the first study to quantitatively and qualitatively evaluate the neuropsychiatric sequalae and psychological impact of patients with active covid- infection. the qualitative component of the study provides a more personalized account of the perspectives and challenges faced by patients, and strengthens the findings obtained from quantitative measures. the study performed face-to-face interviews as compared with other studies , and was challenging logistically and safety-wise for the interviewers. nevertheless, this study provided patients with a better interview experience to elicit more authentic information. furthermore, the comparison of covid- patients to psychiatric patients and healthy individuals in the community provided further clarity that covid- patients had more neuropsychiatric psychiatric symptoms than psychiatric patients and the general population, which could be due to their enhanced pro-inflammatory state and increased stress. on the other hand, this study has several limitations. first, the sample size of the study was small, and thus results from our study are at risk of type errors and could not be generalizable to all psychiatric and covid- patients. we were unable to recruit a larger sample owing to the potential risk of infection to the interviewers. furthermore, the psychiatric and covid- patients whom we recruited had low to moderate severity of their psychiatric condition and stable medical condition without complications, respectively. it would not be ethical and feasible to recruit patients who were psychiatrically and medically unstable. therefore, our sample participants were not representative of the spectrum of psychiatric disorders and covid- infection. second, no biological markers such as cytokines were measured to correlate with the neuropsychiatric symptoms. thus, we were unable to elucidate the relationship between the two, and whether the psychiatric symptoms experienced by covid- patients were the result of the inflammatory effects of covid- infection or owing to other causes such as the psychological effects from being isolated. third, this study was a cross-sectional study that performed assessments at a particular time point. it would be pertinent to longitudinally review their condition with monitoring of their cytokine levels and neuropsychological data as part of the intervention. nevertheless, the current data are valuable to provide a preliminary in-depth understanding of the psychological issues faced by covid- patients and serve as a foundation for further studies in this area. this study has provided a comprehensive and in-depth exploration of the neuropsychiatric sequalae and psychological impact of acutely infected covid- patients through quantitative and qualitative approaches. covid- patients had higher levels of neuropsychiatric symptoms than psychiatric patients and healthy individuals in the community in terms of impulsivity and insomnia, which could be secondary to their enhanced pro-inflammatory state. covid- patients also experienced emotions including shock, fear, boredom, and hope during their course of treatment, and common concerns about discrimination, medical expenses, care by healthcare workers, and means of self-help behavior were highlighted. the future direction for covid- management involves the setting up of a dedicated holistic service that incorporates preventive measures on exercise, nutrition, safe hygiene practices, psychotherapy, and use of cytokine markers to monitor disease progression and treatment response, coupled with financial and healthcare support. world health organization. who director-general's opening remarks at the media briefing on covid- covid- coronavirus pandemic nervous system involvement after infection with covid- and other coronaviruses self-reported olfactory and taste disorders in sars-cov- patients: a cross-sectional study immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china do psychiatric patients experience more psychiatric symptoms during covid- pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry is returning to work during the covid- pandemic stressful? a study on immediate mental health status and psychoneuroimmunity prevention measures of chinese workforce a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with covid- in china nervous system damage after covid- infection: presence or absence? dysosmia and dysgeusia due to the novel coronavirus; a hypothesis that needs further investigation. maxillofac inflammatory markers in depression: a meta-analysis of mean differences and variability in , patients and , controls symptom severity impacts sympathetic dysregulation and inflammation in post-traumatic stress disorder (ptsd) experiences and psychosocial problems of nurses caring for patients diagnosed with covid- in turkey: a qualitative study experiences and needs of caregivers of persons with dementia in india during the covid- pandemic-a qualitative study medically unexplained symptoms in the times of covid- pandemic: a case-report using psychoneuroimmunity against covid- usage of social media and smartphone application in assessment of physical and psychological wellbeing of individuals in times of a major air pollution crisis methodology of developing a smartphone application for crisis research and its clinical application multi-level predictors of psychological problems among methadone maintenance treatment patients in difference types of settings in vietnam relationship of anxiety and depression with respiratory symptoms: comparison between depressed and non-depressed smokers in singapore misophonia in singaporean psychiatric patients: a crosssectional study validation of the insomnia severity index as an outcome measure for insomnia research chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection traumatic brain injury and olfaction: a systematic review nervous system involvement after infection with covid- and other coronaviruses are we facing a crashing wave of neuropsychiatric sequelae of covid- ? neuropsychiatric symptoms and potential immunologic mechanisms psychological impact of the management of methicillin-resistant staphylococcus aureus (mrsa) in patients with spinal cord injury adverse effects of isolation in hospitalised patients: a systematic review impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis innately activated tlr signal in the nucleus accumbens is sustained by crf amplification loop and regulates impulsivity anger and fear responses to stress have different biological profiles sleep during naturally occurring respiratory infections: a pilot study exploring the multidimensional complex systems structure of the stress response and its relation to health and sleep outcomes association of insufficient sleep with respiratory infection among adults in the united states psychological distress among ebola survivors discharged from an ebola treatment unit in monrovia, liberia-a qualitative study adjustment to severe acute respiratory syndrome (sars): roles of appraisal and post-traumatic growth adjustment outcomes in chinese patients following onemonth recovery from severe acute respiratory syndrome in hong kong three insights on psychoneuroimmunology of mood disorders to be taken from the covid- pandemic chronic administration of fluoxetine and pro-inflammatory cytokine change in a rat model of depression current status of potential therapeutic candidates for the covid- crisis one size does not fit all-patterns of vulnerability and resilience in the covid- pandemic and why heterogeneity of disease matters affective temperament, attachment style, and the psychological impact of the covid- outbreak: an early report on the italian general population vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid- control risk-taking increases under boredom addressing disease-related stigma during infectious disease outbreaks the h n pandemic: media frames, stigmatization and coping towards a sustainable theory of health-related stigma: lessons from the hiv/aids literature from conceptualizing to measuring hiv stigma: a review of hiv stigma mechanism measures narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the covid- pandemic an exploratory study of nurses suffering from severe acute respiratory syndrome (sars) mental health and emotional impact of covid- : applying health belief model for medical staff to general public of pakistan a qualitative study on the psychological experience of caregivers of covid- patients qigong practice among chronically ill patients during the sars outbreak the effect of training problem-solving skills on coping skills of depressed nursing and midwifery students the h n pandemic: media frames, stigmatization and coping population-based post-crisis psychological distress: an example from the sars outbreak in taiwan the singaporean response to the sars outbreak: knowledge sufficiency versus public trust effects of optimism on recovery and mental health after a tornado outbreak the immunological case for staying active during the covid- pandemic the impact of nutrition on covid- susceptibility and long-term consequences a longitudinal study on the mental health of general population during the covid- epidemic in china the research was supported by chongqing science and technology dissemination and popularization project (cstc kpzx-kphda ) for fengyi hao the authors declare that they have no conflict of interest.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.received: june revised: september accepted: october key: cord- - iqp u authors: bozdağ, faruk; ergün, naif title: psychological resilience of healthcare professionals during covid- pandemic date: - - journal: psychol rep doi: . / sha: doc_id: cord_uid: iqp u the covid- pandemic as a public health issue has spread to the rest of the world. although the wellbeing and emotional resilience of healthcare professionals are key components of continuing healthcare services during the covid- pandemic, healthcare professionals have been observed in this period to experience serious psychological problems and to be at risk in terms of mental health. therefore, this study aims to probe psychological resilience of healthcare workers. the findings of this study showed that in order to raise psychological resilience of healthcare professionals working during the covid- pandemic their quality of sleep, positive emotions and life satisfaction need to be enhanced. psychological resilience levels of healthcare workers in their later years were found to be higher. doctors constitute the group with the lowest levels of psychological resilience among healthcare workers. the current study is considered to have contributed to the literature in this regard. primary needs such as sleep which are determinants of quality of life, life satisfaction and psychological resilience should be met. the covid- pandemic, which emerged in the chinese city of wuhan in december and has since spread to the rest of the world, has been described as a public health issue causing international concerns. the covid- disease has caused and still causes health problems in over . million people worldwide as of may , (world health organization, ). healthcare professionals have been observed in this period to experience serious psychological problems and to be at risk in terms of mental health (black dog institute, ; inchausti et al., ; lai et al., ) . defined as a global pandemic, covid- can lead to stress, apprehension and anxiety. mood management is required to avoid exacerbation of stress and anxiety (australian psychological society, ) . it is essential that potential psychosocial impact of covid- on healthcare workers is investigated (arden & chilcot, ) . healthcare workers constitute the most affected group of people in the fight against the covid- virus. among the common mental effects of the pandemic are anxiety, panic, depression, anger, confusion, ambivalence and financial stress. healthcare workers were observed to experience similar problems during previous pandemics (black dog institute, ) . depression, anxiety and posttraumatic stress disorder are the most common psychological disorders that were reported particularly in healthcare professionals during the sars and ebola virus pandemics (dong & bouey, ; maunder et al., ; tam et al., ) . studies have also shown that healthcare professionals are considerably more worried about catching the infection during a pandemic (chua et al., ) . exposure to covid- patients raises anxiety and fear of virus infection. as a result, levels of stress, depression and anxiety rise in healthcare workers and they might become traumatized (mcalonan et al., ) . according to cullen et al. ( ) , particularly those working in public health, primary care, emergency service and intensive care are at the risk of developing psychological symptoms. studies conducted in china have revealed that healthcare workers are exposed to work overload, isolation and discrimination, and therefore they experience exhaustion, fear, affective disorders and sleep problems (w. . in a study conducted with healthcare workers, more than half of the workers ( . %) reported depression symptoms, . % anxiety and . % sleep disorder . in a similar study carried out in singapore, healthcare professionals were reported to experience depression, stress, anxiety and posttraumatic stress disorder . as the research studies cited above show, it is crucial that mental health of healthcare workers is protected during the covid- pandemic. in this regard, numerous reports coming out of china stress the importance of protecting mental health of healthcare workers (denis et al., ) . achieving a sustainable success in the provision of healthcare services depends on the morale and sound mental wellbeing of healthcare workers (low & wilder-smith, ) . in the pandemic period, psychological resilience in particular rises in prominence (g. smith et al., ) . the covid- pandemic is considered a threat to psychological resilience . according to the american psychological association ( ), it is particularly crucial to promote psychological resilience of healthcare professionals during the pandemic. individuals who may be exposed to numerous hardships as well as shocking, destructive and stressful incidents differ in their reactions and coping strategies. some individuals react to stressful and traumatic situations by yielding to psychological disorders such as anxiety and depression while others recover from negative mental state in a short time and resume their normal lives. this power that people who recover and resume their lives possess is referred to as psychological resilience in positive psychology approach (do gan, ) . studies point to optimistic perspectives whereby most people become stronger fighting the difficulties they face through psychological resilience (polizzi & lynn, ) . psychological resilience can be defined, in the broadest sense, the individual's ability to withstand hardship (jackson et al., ) . defined as adapting to changes caused by stressful events in a flexible way and recovering from negative emotional experiences (tugade & fredrickson, ) , psychological resilience impacts on the illness process and the subsequent health (naeem et al., ) . psychological resilience is reported to be related to symptoms of anxiety and depression in healthcare professionals (foureur et al., ) . previous studies have argued that psychological resilience needs to be investigated through a systems approach that utilizes a multilevel interaction process between the individual and the environment. psychological resilience is an ecological phenomenon and therefore it ought to be developed through environmental interactions such as family, community and society. the spaces individuals occupy contain the risk of producing various problems. however, the possibility of engendering positive outcomes may rise as well. creating positive environmental conditions is likely to eliminate the risks for the individual (brown & westaway, ; greene, ) . according to fergus and zimmerman ( ) , it is essential that psychological resilience is approached with an ecological perspective. such an approach should consider the impact of environmental factors, as well as individual factors, in reducing risk elements. therefore, any investigation of psychological resilience of healthcare workers needs to consider both environmental and individual factors. the wellbeing and emotional resilience of healthcare professionals are key components of continuing healthcare services during the covid- pandemic, as stated by the national center for ptsd ( ). thus, it is critical to anticipate the stresses linked to this process and providing support to healthcare professionals. tracking and assessing the wellbeing of healthcare workers is important in terms of ensuring their successful reintegration with their coworkers in case they get infected. at this point, both institutional supports and selfcare strategies come into play. therefore, a holistic assessment confirms the need to research psychological resilience of healthcare workers both at individual and environmental level. in turkey, the number of people infected by the covid- virus is as of may (world health organization, ) and this number is growing each day. this increase naturally affects the quality of healthcare services. psychological resilience of healthcare workers needs to be improved and sustained in order to maintain the quality of healthcare services. resilient mental state of healthcare workers influences not only their professional lives but their social and personal lives as well. although the importance of healthcare workers has become established in turkey, occasionally certain negative incidents occur. healthcare workers are from time to time psychologically traumatized as they are stigmatized and discriminated against by certain segments of the society. on the other hand, the positive impact of the support offered to healthcare workers cannot be overlooked either. during the pandemic, for instance, the society in turkey has been clapping from balconies in show of its appreciation to healthcare workers. to extend the effect of this positive atmosphere and enhance psychological resilience of healthcare workers at environmental and personal level, the current study attempts to investigate the factors impacting on psychological resilience of healthcare workers. a wide gap has been reported in the literature concerning psychological resilience practices during long-term pandemic periods (buheji et al., ) . a related search of the literature revealed only a single research study examining psychological resilience of healthcare professional during the covid- virus outbreak. considering the knowledge gap in the literature and with a view to improving the effectiveness of psychological support to be provided to healthcare workers, this study aims to probe psychological resilience of healthcare workers. the ecological framework was utilized to determine the variables impacting on psychological resilience. accordingly, among the probed individual variables are gender, age, having children or not, taking personal precautions against the risk of becoming infected with the covid- virus, worry about transmitting the virus to family/relatives, quality of nutrition and sleep, positive-negative affective state and life satisfaction, while environmental psychological reports ( ) variables include weekly workload, organizational measures against the risk of becoming infected with the covid- virus, perceived social support (perceived support by family, friends and someone special) and perceived organizational support. data were collected online for four days between and april . the brief resilience scale (brs). the scale was developed by b. smith et al. ( ) to measure individual psychological resilience. it consists of six items (three questions reverse) measured on a -point scale ( never suitable and completely suitable). the total score range was between and . higher scores on the scale indicate a higher level of psychological resilience. the turkish version of the scale was adapted by do gan ( ). the adapted scale was highly sufficient in terms of cfa values (v /df ( . / ) ¼ , , nfi ¼ . , cfi ¼ . , gfi ¼ . , srmr ¼ . , rmsea ¼ . ) and internal consistency coefficient (a ¼ . ). in this study, the internal consistency coefficient was found as . . survey of perceived organizational support (spos) brief form. the original scale of spos consists of items and was developed by eisenberger et al. ( ) . however, they later recommended using a shorter version of the scale consisting of items (eisenberger et al., ) . the turkish version of spos was adapted by azaklı ( ) . indeed, first the longer version of the scale was adapted to turkish with the adaptation of the shorter version coming afterwards. in the turkish version of the brief scale, there were items in a -point likert type scale ( : completely disagree and : completely agree) with high internal reliability (a ¼ . ). in this study, the shorter version of the scale was used. the internal reliability of the scale in this study was also excellent (a ¼ . ). multidimensional scale of perceived social support (mspss). mspss was developed by zimet et al. ( ) and adapted to turkish by eker and arkar ( ) . satisfaction with life scale (swls). swls consists of five items measured on a -point likert type scale ( : strongly disagree, : strongly agree). it was developed by diener et al. ( ) and adapted to turkish by k€ oker ( ) . higher scores on the scale indicate higher levels of life satisfaction. the test-retest reliability coefficient of the scale was found . . in the current study, the cronbach alpha value was excellent (a ¼ . ). positive and negative affect schedule (panas). panas is a self-report measurement tool and consists of items (ten items measure positive and other ten items measure negative affect) measured on a -point likert type scale ( : very slightly or not at all, : extremely). it was developed by watson et al. ( ) and adapted to turkish by genc¸€ oz ( ). scores range from to for both sets of items. higher scores of positive items indicate having a high positive affect and lower scores of negative items indicate a less negative affect. the internal consistency coefficient of the turkish version was . for negative affect and . for positive affect. in this study, internal reliability was . for positive affect and . for negative affect. questionnaire. eight questions were prepared by the researchers to assess the situation of healthcare professionals during the covid- pandemic. these questions included quality of sleep and nutrition, the risk of being infected by the virus, worry about transmitting the virus to their relatives etc. the questions were measured by a -point likert type scale. the questions are: "do you think adequate precautions are taken against the risk of coronavirus transmission in your institution? ( : the precautions are very poor, : the precautions are extremely enough)", "do you take adequate precautions individually to protect yourself against coronavirus? ( : never, : extremely)", "what is your risk of getting coronavirus in the unit you work in? ( : not at all, : extremely)", "have you ever worked with someone who has a coronavirus infection? ( : never, : extremely)", "are you worried about being infected due to the risk at your work? ( : never, : extremely)", "are you worried to transmit coronavirus to your family members/relatives/friends because of your job? ( : never, : extremely)", "how do you evaluate your nutritional quality? ( : pretty inadequate, : quite enough)" and "how would you rate your sleep quality for the last few weeks? ( : pretty inadequate, : quite enough)". psychological reports ( ) the entire surveys were prepared online and the link was shared with anyone who could voluntarily participate in the study. the participants from around cities across turkey filled out the questionnaire. the participants were informed about the study aims and procedures of the research. no reward was offered for participating. no personally identifiable information was requested. for the analysis of the study, pearson's correlation analysis and hierarchical linear regression analysis were used. before conducting the analysis, the normality of the items and the scale were checked. it was seen that skewness and kurtosis value of most of the items were between À to þ and some items' skewness and kurtosis value were between À to þ . the data can be considered to be normally distributed (kim, ; kline, ) . moreover, sample size, univariate and multivariate outliers, normality, linearity, homoscedasticity, multicollinearity and independence of errors assumptions were calculated for hierarchical linear regression (hair et al., ) . no outliers were found in the data set and the sample size of participants can be considered as sufficient in accordance with the criteria [n ! þ m (the number of independent variables in m)] (tabachnick and fidell, ) . the scatter plots of the residues were examined, and it was observed that the assumptions of normality, linearity and homoscedasticity were met. for multicollinearity, it was assumed that the correlation coefficient between variables is less than . , vif (variance inflation factor) is less than and tv (tolerance value) is greater than . (field, ) . bivariate correlations between the variables are given in table . the fact that vif values of independent variables were between . and . (just three measurements were higher than ) and tvs were between . (just one measurement was lower than . ) and . showed that multicollinearity assumption was met. finally, the durbin-watson value was calculated as . and the assumption of independence of errors was met (field, ) . means and standard deviation intercorrelation between variables were calculated and shown in table . psychological resilience significantly and positively correlated with life satisfaction, positive affect, sub-scales of perceived social support, participants' age, taking personal precautions against coronavirus, nutrition and quality of sleep, meaning that an increasing level of psychological resilience leads to a higher level of the variables and vice versa. however, psychological resilience significantly and negatively correlated with negative affect, personally feeling in risk because of being healthcare professional, and worrying about being infected by the virus, meaning that decreasing level of psychological resilience leads to a rising level of the variables and vice versa. before regression analysis, t test for psychological resilience of women and men, and one-way anova for types of occupations (doctors vs nurses vs other healthcare professionals) were calculated. the result of t test showed that differences between psychological resilience of women (m ¼ . , sd ¼ . ) and men (m ¼ . , sd ¼ . ) were statistically significant t ( ) ¼ - . , p ¼ . . the level of psychological resilience of men was higher than that of women. difference between types of occupations in terms of the psychological resilience level indicated that although there were differences between the level of psychological resilience among the types of healthcare workers, the model was not statistically significant f ( , ) ¼ . , p ¼ . . however, bonferroni test showed that the level of psychological resilience of doctors (m ¼ . , sd ¼ . ) and other healthcare professionals (m ¼ . , sd ¼ . ) statistically and significantly differs, p ¼ . . but there were no statistical differences between doctors and nurses (m ¼ . , sd ¼ . ), and nurses and other healthcare professionals. a high correlation between psychological resilience and other variables showed further analysis was warranted (see table ). in table , the hierarchical regression model was calculated to see how psychological resilience was predicted in terms of demographic variables, questions related to covid- , and variables related to perceived support and personal feeling that were used in the study. in model , demographic variables were calculated and it was found that gender, age, the types of occupation (doctors, nurses and other healthcare professionals), and having a child/children significantly predicted psychological resilience. but, having children (b ¼ -. ) and being a doctor (b ¼ -. ) negatively predicted psychological resilience. overall, model significantly predicted and explained % of the variance in the psychological resilience of healthcare professionals. model showed that demographic variables and questions related to covid- together significantly predicted and explained % of the variance in the psychological resilience of healthcare professionals. in model , age, occupation, worry about becoming infected by the virus and quality of sleep significantly predicted the psychological resilience of healthcare professionals. finally, model showed that all variables shown in table significantly predicted the psychological resilience of healthcare professionals and explained % of the variance. in model , age and occupation (doctor), quality of sleep, positive and negative affect, and life satisfaction significantly predicted the psychological resilience of healthcare professionals. healthcare professional are forced to work under extremely difficult conditions owing to the covid- virus outbreak (greenberg et al., ) . under such circumstances, many essential healthcare workers become psychologically traumatized and need psychological support. it is argued that psychological bozda g and ergün supports to be offered to these workers ought to be based on psychological resilience models (maunder et al., ) . it is critical that psychological resilience of healthcare workers is protected and maintained during the pandemic (bc centre for disease control, ; santarone et al., ) . this study too aimed to determine the factors impacting on psychological resilience with the hope of aiding psychological support services to be provided to healthcare workers. three models were tested through hierarchical regression analysis that was performed to specify the factors influencing psychological resilience of healthcare professionals. the first model looked into whether certain demographic variables predicted healthcare workers' psychological resilience. the results showed that, in order of importance, age, having children, occupation and gender variables significantly predicted healthcare workers' psychological resilience. older age and being male heightened psychological resilience while being a doctor and having more children lowered psychological resilience. the second model revealed that, in order of importance, quality of sleep, age, worry about becoming infected by the virus and occupation variables significantly predicted healthcare workers' psychological resilience. thus, as the quality of sleep and age rose, so did healthcare workers' psychological resilience whereas heightened worry about becoming infected by the virus and being a physician lowered psychological resilience level. the final model concluded that, in order of importance, the quality of sleep, positive affective state, age, negative affective state, life satisfaction and occupation significantly predicted psychological resilience of healthcare workers. accordingly, higher levels of quality of sleep, positive affective state, age and life satisfaction raised the level of psychological resilience while higher negative affective state and being a doctor meant lower psychological resilience level. according to the results of the last model, particularly the quality of sleep, positive emotional state, age and life satisfaction were found to have a crucial impact on improving psychological resilience of healthcare workers. it has been frequently noted in the literature that quality sleep acts as a protective factor against the psychological problems that healthcare workers might experience (center for the study of traumatic stress, ; dewey et al., ; inter-agency standing committee, ; lai et al., ; liu et al., ; siyu et al., ) . healthcare workers face serious pressures that may cause psychological disorders, including anxiety, phobia, depression and insomnia (w. . according to lai et al. ( ) , a significant number of healthcare workers experience insomnia and develop symptoms of depression, anxiety and distress during the covid- pandemic. in another study conducted with healthcare professionals, over half of them reported depression symptoms ( . %), . % anxiety and . % insomnia . similarly, a research study with participants showed that healthcare workers experienced depression, anxiety and insomnia (siyu et al., ) . psychological reports ( ) going without sleep for a long period of time is a risk factor for healthcare professionals (inter-agency standing committee, ). therefore, it is crucial that healthcare workers' basic needs such as food, fluids and sleep are met during quarantine time. administrators of medical institutions need to ensure that healthcare workers get enough sleep (dewey et al., ) , thereby helping them stay psychologically more resilient. on the other hand, positive emotional state has been found to contribute to healthcare workers' psychological resilience. naeem et al. ( ) argue that individuals who actively develop positive emotions have higher psychological resilience. positive emotions have been found to decline in the wake of covid- pandemic (s. . governments and particularly medical leaders can focus on changing people's minds and thus heightening their psychological resilience levels (buheji et al., ) . busy work schedule and frequent exposure to negative incidents (deaths etc.) are considered as risk factors for healthcare workers. healthcare workers at their later years, however, have been observed to manage this time better and to be psychologically more resilient. a positive relationship between age and psychological resilience indicates that healthcare workers cope better with crises as they get older. as they gain more experience, healthcare workers become more skilled at handling negative situations and grow psychologically more resilient. during the pandemic, one of the primary objectives should be taking necessary precautions to improve positive emotions and psychological resilience of healthcare workers. research findings have shown that healthcare workers face mental health issues during the covid- virus outbreak (lai et al., ; liu et al., ; siyu et al., ) and this naturally impacts on their life satisfaction. the s. study has found an overall decline in life satisfaction following the covid- pandemic. the present study also revealed that healthcare workers who are at risk and the most affected group by the pandemic grow more resilient as their life satisfaction rises. accordingly, precautions ought to be taken to fight mostly commonly experienced problems such as anxiety, depression and apprehension in order to raise life satisfaction and thereby psychological resilience of healthcare workers. another result that came out of the current study is that negative affective state in healthcare workers significantly lowers their psychological resilience. furthermore, doctors were found to have considerably lower psychological resilience levels compared to other healthcare workers. individuals tend to develop negative emotions to protect themselves. people have reported heightened negative emotions during the covid- virus outbreak. prolonged negative affective state, however, may lead to various problems (s. . a negative relationship has been found between depression and anxiety, which are considered negative emotions in healthcare workers, and psychological resilience . this is consistent with the current study's findings. it is possible to heighten healthcare professionals' psychological resilience by lowering their negative emotions. however, this study's finding that doctors have lower psychological resilience levels contradicts what lin et al. ( ) found. in their study with healthcare professionals, lin et al. ( ) found that doctors' psychological resilience is higher than other healthcare workers'. on the other hand, a study conducted in singapore reported that during the sars virus outbreak doctors carried more psychological symptoms risk compared to nurses (chan & huak, ) , while another study revealed that frontline doctors in direct contact with patients developed even more serious symptoms of anxiety and depression (siyu et al., ) . these findings are consistent with the findings of the current study. being in direct contact with patients, assuming more responsibilities and having a busy work schedule cause doctors to become exhausted and thus psychologically less resilient. the findings of this study revealed that in order to raise psychological resilience of healthcare professionals working during the covid- pandemic their quality of sleep, positive emotions and life satisfaction need to be enhanced. psychological resilience levels of healthcare workers in their later years were found to be higher. on the other hand, higher levels of negative emotional state lower psychological resilience level. doctors constitute the group with the lowest levels of psychological resilience among healthcare workers. the research findings have revealed a significant portion of the variables impacting on the psychological resilience of healthcare workers in order that they could offer more quality service during the covid- and similar pandemics. the current study is considered to have contributed to the literature in this regard. in addition, the result of the current study showed that quality of sleep, which is one of the primary needs, life satisfaction and positive-negative affairs are important prediction for the psychological resilience of healthcare professionals. therefore, it can be indicated that for taking quality healthcare services and raise healthcare performance at work, primary needs such as sleep, and life satisfaction should be provided and healthcare professionals are to work in good conditions. the current study also concludes that in order to enhance positive emotions and weaken negative emotions of healthcare professionals, the workers' needs ought to be prioritized in any practice. the comparatively small number of participants who provided data can be considered a limitation in terms of generalizability of the results. future studies may reveal more generalizable results by collecting data from a higher number of healthcare professionals. considering the current study is an example of psychological reports ( ) cross-sectional research, it is necessary to conduct longitudinal studies that examine long-term effects of the pandemic. positive and negative emotions were found to play a significant role in the model as the variables that predict psychological resilience of healthcare workers were analyzed. therefore, further studies may have a better understanding of the issue through investigation of determinants of healthcare workers' positive and negative emotions during the covid- pandemic. in addition, life satisfaction and first needs such as sleep which can imply the quality of life were other important roles of impacting psychological resilience of healthcare professionals. therefore, it can be worked relationships between healthcare workers' quality of lives and psychological resilience during covid- . the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. faruk bozda g https://orcid.org/ - - - naif ergu¨n https://orcid.org/ - - - psychological research on past crises can help people cope with the daily-sometimes hourly-newsflashes about the coronavirus health psychology and the coronavirus (covid- ) global pandemic: a call for research tips for coping with coronavirus anxiety psychometric evaluation of the survey of perceived organizational support (spos) (doctoral dissertation) supporting the psychosocial well-being of health care providers during the novel coronavirus (covid- ) pandemic mental health ramifications of covid- : the australian context agency, capacity, and resilience to environmental change: lessons from human development, well-being, and disasters minimising stress exposure during pandemics similar to covid- psychological effects of quarantine during the coronavirus outbreak: what healthcare providers need to know? psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore stress and psychological impact on sars patients during the outbreak mental health in the covid- pandemic overview of information available to support the development of medical countermeasures and interventions against covid- supporting clinicians during the covid- pandemic the satisfaction with life scale kısa psikolojik sa glamlık € olc¸e gi'nin tu¨rkc¸e uyarlaması: gec¸erlik ve gu¨venirlik c¸alıs¸ması [adaptation of the brief resilience scale into turkish: a validity and reliability study public mental health crisis during covid- pandemic perceived organizational support Ç ok boyutlu algılanan sosyal destek € olc¸e gi'nin fakt€ or yapısı, gec¸erlik ve gu¨venirli gi adolescent resilience: a framework for understanding healthy development in the face of risk discovering statistics using spss enhancing the resilience of nurses and midwives: pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress pozitif ve negatif duygu durum € olc¸e gi: gec¸erlik ve gu¨venirlik c¸alıs¸ması managing mental health challenges faced by healthcare workers during covid- pandemic human behavior theory: a resilience orientation multivariate data analysis briefing note on addressing mental health and psychosocial aspects of covid- outbreak-version personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review statistical notes for clinical researchers: assessing normal distribution ( ) using skewness and kurtosis principles and practice of structural equation modeling normal ve sorunlu ergenlerin yas¸am doyumu du¨zeyinin kars¸ılas¸tırılması [comparison of normal and problematic adolescents' life satisfaction level factors associated with mental health outcomes among health care workers exposed to coronavirus disease the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users progression of mental health services during the covid- outbreak in china factors influencing resilience of medical workers from other provinces to wuhan fighting against novel coronavirus pneumonia online mental health services in china during the covid- outbreak. the lancet infectious respiratory illnesses and their impact on healthcare workers: a review computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training long-term psychological and occupational effects of providing hospital healthcare during sars outbreak immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers coping with covid- : urgent need for building resilience through cognitive behaviour therapy managing healthcare workers' stress associated with the covid- virus outbreak stress and coping in the time of covid- : pathways to resilience and recovery preserving mental health and resilience in frontline healthcare workers during covid- mental health status and coping strategy of medical workers in china during the covid- outbreak the brief resilience scale: assessing the ability to bounce back covid- : emerging compassion, courage and resilience in the face of misinformation and adversity using multivariate statistics severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers psychological impact of the covid- pandemic on health care workers in singapore resilient individuals use positive emotions to bounce back from negative emotional experiences immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china development and validation of brief measures of positive and negative affect: the panas scales statement on the second meeting of the international health regulations ( ) emergency committee regarding the outbreak of novel coronavirus ( -ncov the multidimensional scale of perceived social support author biographies faruk bozda g works as a researcher at _ istanbul university-cerrahpas¸a at guidance and psychological counseling his research interests include social psychology, addiction, school psychology and identity key: cord- - qh efs authors: inchausti, felix; macbeth, angus; hasson-ohayon, ilanit; dimaggio, giancarlo title: psychological intervention and covid- : what we know so far and what we can do date: - - journal: j contemp psychother doi: . /s - - -w sha: doc_id: cord_uid: qh efs the coronavirus covid- and the global pandemic has already had a substantial disruptive impact on society, posing major challenges to the provision of mental health services in a time of crisis, and carrying the spectre of an increased burden to mental health, both in terms of existing psychiatric disorder, and emerging psychological distress from the pandemic. in this paper we provide a framework for understanding the key challenges for psychologically informed mental health care during and beyond the pandemic. we identify three groups that can benefit from psychological approaches to mental health, and/or interventions relating to covid- . these are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with covid- , or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with covid- or whose experience of social distancing exacerbates existing vulnerabilities. drawing on existing literature and our own experience of adapting treatments to the crisis we suggest a number of salient points to consider in identifying risks and offering support to all three groups. we also offer a number of practical and technical considerations for working psychotherapeutically with existing patients where covid- restrictions have forced a move to online or technologically mediated delivery of psychological interventions. the coronavirus (covid- ) is a newly emergent infectious disease caused by the novel severe acute respiratory syndrome coronavirus (sars-cov- ) virus, originated in december from mainland china, with initial cases emerging from the city of wuhan, hubei province (cdcp ; li et al. ) . although most individuals diagnosed with covid- present with mild to moderate respiratory symptoms, a substantially minority present with severe symptomatology, with accompanying need for hospital treatment, a further proportion needing intensive care unit (icu) admission, and an elevated fatality rate. risk of mortality follows a clear age gradient (verity et al. ). on th january , world health organization (who) officially declared the covid- epidemic as a public health emergency of international concern, followed by designation as a pandemic on th march (i.e., presence of illness across multiple continents). the rapid spread of covid- places huge strain on capacity, responsiveness and resilience of public and private healthcare systems worldwide (emanuel et al. ; legido-quigley et al. ) . across multiple countries this has been accompanied by implementation of public health policies significantly altering everyday life, such as the quarantine of citizens for significant periods of time, with both short-and longer-term consequences for psychological distress and wellbeing . at time of writing, the worldwide cases of covid- are steadily increasing across all continents. on th april , the cumulative total of individuals presenting with confirmed covid- was , , people, with a total of , deaths (who ). in many countries testing is limited to hospitalised cases, therefore these numbers are likely to significantly underestimate the true prevalence of covid- in the population, given they do not cover mild presentation and asymptomatic cases. there is emerging evidence of the psychological impact of covid- on populations, both directly due to the distress accompanying confirmed cases in individuals and their loved ones, and indirectly due to population health interventions such as quarantine. however, it should be emphasized that the majority of people are not expected to suffer from mental disorders emerging from the pandemic and its impact (taylor ). however, a significant percentage will experience intense emotional adjustment reactions, including fear of contagion (zhou ) , impact of prolonged quarantine xiao ) , the death of relatives , or increased social adversity as a consequence of geopolitical instability to civil society associated with the economic crisis (silva et al. ) . in china, a survey of people found that . % assessed the psychological impact of the situation as moderate-severe, . % reported moderate to severe depressive symptoms, . % moderate to severe anxiety symptoms, and . % moderate to severe stress levels. most respondents ( . %) spent between and h a day confined at home and the main concern ( . %) was that his/her relatives would become infected with covid- . based on our survey of preliminary current research and on previous literature on coping with past coronavirus-based epidemics (e.g. severe acute respiratory syndrome, sars; and middle east respiratory syndrome, mers) we identify three groups at risk for psychological morbidity during and after the covid- pandemic. the first group are healthcare professionals, particularly those working in inpatient physical health settings, who experience higher frequency of exposure to the virus and higher viral load in the workplace; compounded by significantly increased workload, high risk procedures and the low availability of necessary personal protective equipment (ppe). thus, health professionals are at risk of elevated levels of depression, anxiety and sleep disorders , and many among them harbour fears of being infected during work shifts. recent findings on medical students in the current crisis supporting this (al-rabiaah et al. ) . this is also in line with previous experiences from sars/ mers, showing frontline health professionals constitute a unique risk group, especially after pandemic containment ends and systems move towards mitigation of the disease impact (gardner and moallef ; lee et al. ) . of note, many other workers are exposed to the same risk and fear of contagion, such as police officer, postal carrier, emergency medical technicians or trash collectors. the second elevated risk group that should be considered include individuals who, as a result of the crisis, have been exposed to potentially traumatic events such as loss of a loved one, threats to one's health and to the ability to work and make a living, and concerns about their future capacity to maintain a sufficient income. these people may express symptoms of post-traumatic stress disorder (ptsd), depression or complicated grief disorder, consistent with the literature on psychological and psychiatric sequelae of global emergencies or disasters (goldmann and galea ) . this group may not emerge immediately within the pandemic, and presentations may only become apparent after several months, even after the incidence of covid- has peaked. a third group of people at increased risk for psychological problems consists of people with pre-existing psychopathology, especially those with severe or complex psychiatric disorders. their existing presentation may be exacerbated by extreme isolation due to exposure to either the virus or associated social distancing. in this sense, social distancing may exacerbate existing social isolation in this vulnerable group. there is conflicting evidence from previous studies on the responses of people with severe psychiatric disorders to different types of disasters such as earthquakes, with some evidence for higher levels of avoidance-related coping being associated with higher distress (horan et al. ), but other studies showing that this risk is somewhat disorder specific with pre-disaster mood and anxiety disorders, but not psychotic disorders, predicting further psychological distress (katz et al. ) . this group also includes individuals with more common psychopathologies (e.g. depression and anxiety) who were receiving primary care mental, health treatment or psychotherapy prior to the onset of covid- restrictions. other people exposed to psychological suffering are those who have to live alone during the quarantine, who has been recently bereaved by the coronavirus, but the bereavement process has been disrupted by the lockdown, and ones that are not allowed to visit their loved ones who are in hospital for whatsoever medical conditions. as duan and zhu ( ) highlight, specialized psychological intervention for covid- should be dynamic and flexible enough to adapt quickly to the different phases of the pandemic. in the early stages, clinical psychologists, psychotherapist and psychological intervention specialists should actively collaborate with the rest of the multi-professional healthcare system in the treatment of the immediate impacts of covid- presentations (mohammed et al. ) . this may take the shape of organising or enabling healthcare systems to orientate towards psychological impacts of a pandemic, facilitate public mental health approaches to increasing population awareness of mental health; or organizing systems for psychologically informed interventions. this may also include task-shifting of psychological interventions either to delivery through digital means, or by different professional groups. potential therapeutic targets include: . training and support for health professionals at 'high exposure risk' to identify and manage emotional reactions, that may hinder their clinical work in frontline health delivery. this includes, for instance, managing anxiety, fear of contagion, episodes of acute stress or promoting self-care/reducing burnout. the main objective of this approach is to maximise psychological resilience in as many professionals as possible who have frontline duties during a pandemic (chen et al. ). importantly, in the peak of a pandemic, interventions such as psychological debriefing, critical incident stress debriefing or any other single session intervention mandating staff to talk about their thoughts or feelings are not recommended. that said, compassionate and sensitive awareness of the impact of critical care on health care professionals can be used to facilitate one on one support, should that person wish it (nice ). . next it is important to engage emotionally vulnerable groups, especially people with previous psychopathology. the main goal here is to support individuals undergoing covid- treatment or preventative quarantine. the mental health symptoms of this group of patients with covid- should also be monitored, although the presence of non-essential professionals such as psychiatrists, clinical psychologists or social mental health workers in isolation rooms for covid- patients is completely discouraged. therefore, front-line psychological support either needs to be facilitated by medical staff involved in immediate care (which may not be possible if the health system is at capacity) or be implemented indirectly through telecare systems. serious psychiatric emergencies such as aggression, self-harm or suicide attempts will still need to be addressed in person. for patients with acute symptomatology and diagnosed or suspected covid- , professionals who assist them face-to-face should be protected to minimize the risk of contagion (e.g. via appropriate ppe) and ensure both their safety and that of the patient. all other outpatient psychological interventions can be effectively carried out by digital care. phone and internet enabled psychological interventions have been demonstrated to be clinically effective in a wide variety of mental disorders (irvine et al. ). related to this, it is also important to tailor standard mental health delivery for individuals with pre-existing psychiatric disorders to acknowledge the impact of social isolation and distancing on mental health as part of adaptation to 'life under lockdown' or quarantine. . relatives of patients admitted by the coronavirus in a severe condition, poorly prognosed or who have already died. in such interventions it is essential not to pathologize the normal emotional reactions of family members and it is important to establish clear and consensual criteria with all the professionals involved to determine whether intervention is more beneficial than not to do so (von blanckenburg and leppin ). as the pandemic plateaus, and societies begin to emerge from distancing, mental health symptoms such as hypochondriasis, anxiety, insomnia or acute stress, as well as symptoms consistent with ptsd are expected to present across health systems. in these cases, the first-line intervention should be psychological, minimizing as far as possible the use of drugs (nice (nice , . furthermore, the literature emphasizes the importance of not starting formal psychological treatments quickly and without careful assessment, including active monitoring. as noted above, although well intentioned, intervening in individual's natural coping mechanisms too early can be detrimental. there is evidence that these interventions may be ineffective or even increase the likelihood of developing ptsd (nice ) . special attention should also be paid to: potential for "re-traumatization" of ptsd presentations where trauma-focused therapies are implemented without adequate psychotherapeutic frameworks and structures (duckworth and follette ) ; and guarding against the development of interventions for those that have recovered from covid- that stigmatize or block access of the to a new functional identity as survivors of the pandemic (muldoon et al. ) . going forward it is also crucial to ensure individuals affected by covid- retain a sense of their overall identity, and that this is not subsumed into an explanatory model reduced to the illness. any intervention should be based on a thorough assessment of possible risk factors that may maintain the problem, the patient's prior state of mental health, the history of bereavement, the presence of a history of self-harm or suicidal behaviours in both the patient and his/her family, the history of previous traumas, and the socio-economic context of the patient. at this stage, it is also important to recognise the likely profound impact of covid- on economic, social, and political levels at all levels from the individual to international. this may, therefore, require mental health systems to adopt new ways of working with structural inequalities emerging from the aftermath of covid- and consistent with a social determinants of mental health model (e.g., lund et al. ). in organizing psychological assistance within and across various stages of the pandemic, we highlight four major challenges: . healthcare system deficits, both in terms of material and human resources (i.e., lack of adequate ppe, infrastructure for digital interventions, staffing) or in mental health professionals not specialized in the psychological approach of crises and emergencies (shultz et al. ; shultz and neria ) . in china, the scarcity of human resources led to individual professionals accumulating multiple responsibilities, reducing the effectiveness of their interventions (duan and zhu ) . for this reason, government, policy makers and health managers need to be aware of health systems strengthening for increasing the capacity of mental health professionals, facilitate training for emergency intervention, and monitor workload burdens, especially when sustained over time. . societal underestimation of the (short-and long-term) psychological consequences of pandemics and, consequently, limited resources to cope with them (bitanihirwe ). there is evidence that individuals exposed to public health emergencies have increased psychopathological vulnerability both during and after the potentially traumatic event (fan et al. ) . although the international covid- pandemic response has been unprecedented in terms of mobilisation of resource and finance, there will also be long-term impacts in terms of treatment burden, including mental health, particularly in low resource and conflict settings (un ). in china, the progression of covid- aggravated the mental health of infected patients, the general population and health professionals (duan and zhu ). therefore, it is important to evaluate and identify all risk groups and adapt interventions to their specific needs. among the variables to consider are disease trajectory, severity of clinical symptoms, place of treatment (inhome or out-of-home isolation, icu, etc.), history of previous trauma and, previous history of mental health problems. having this information will help classify people at risk and enable specific preventive mental health measures to be put in place. . poor planning and coordination of psychological interventions, especially when they are applied at different levels and by different professionals (zhang et al. ). in china, at the start of the covid- outbreak, the absence of adequate planning of psychological interventions led to fragmented or disorganized implementation, compromising effectiveness and efficacy, and hampering access to available health resources. any psychological intervention should be planned and coordinated together with all the social-health stakeholders involved, particularly primary healthcare services and specialized mental health services. this maximised the potential for adequate continuity of care even after acute phase of the pandemic recedes. . finally, there is also a risk attached to early crisis responses, leading to a proliferation of interventions and frameworks associated with an oversupply of well-intentioned but potentially non-evidence based, psychological assistance, often non-governmental organizations (ngo) and the third sector. this is not to say all ngo interventions are compromised, and indeed prevention in mental health is highly desirable. that said, delivery of preventive interventions must be balanced by delivery and/or supervision applied by appropriately qualified professionals (loewenstein ; ogden ). as previously noted, where health systems have sufficient flexibility, for those with existing mental health conditions should continue their psychological interventions by technology enabled means. this can include telephone consults, or increasingly via digital platforms such as skype, zoom or health provider developed platforms. this presents a number of specific challenges including familiarity with the technology (both therapist and client), adaptation of the therapeutic intervention, awareness of the additional parameters of delivering therapy in lockdown conditions, and the accompanying question of the purpose of therapy in such unusual circumstances. there are thus several difficulties that psychotherapists and practitioners have in adjusting their practice to technology enhanced therapy, which is now delivered from their own homes, as opposed to familiar public facilities or private practices. the following suggestions of how to adapt psychotherapy to this unique condition have emerged from our everyday clinical experiences over the adaptation to lockdown in several countries, and represent an attempt to systemize clinical practice for the duration of the emergence and of social life restrictions. therefore, we provide a number of key points to guide clinicians in adapting practice. -draft a new contract. many patients will have difficulties in accepting digital psychotherapy. clinicians must be clear that this is pragmatically the only option available (if this is the case), but also acknowledge and selfregulate their own difficulties with changes such as worry for the client's mental health, irritation with the option of discontinuing face to face psychotherapy or guilt at the idea of not being available enough. in all of these cases the clinician remains open for phone/video contact where the patient experiences psychological problem, but negotiation is required over whether sessions are for crisis-management only; or whether regular sessions are still possible and/or desirable to both parties. this can help retain a balance between acceptance of difficulties and the maintenance of a robust treatment framework. -raise the bar for what we consider psychopathology. reactions of distress, such as fear, rage, anxiety, obsessions, guilt, constriction, rebellion against authority, emotion and behavioural dysregulation, albeit transitory, are to a certain extent normal during a crisis. the clinician must first and foremost help the patients understand that their suffering is human and mostly unavoidable, this is not to say that they should be ignored or minimised. when patients can note how their mind is overwhelmed by symptoms, affect or relational problems, this creates a basis for agreement to work on them. -common factors (e.g., norcross and lambert ) are even more important than usual. in particular, we think that validation, sharing and self-disclosure become of uttermost importance. validation follows from the above, that adjustment to the 'new normal' is normal and patients experience is human. therapists can note how experiencing fears for their own and their loved ones health is understandable, that to be worried about the future of the economy is reasonable, how to behave with a certain degree of obsessions is adaptive (e.g. hand hygiene) or that unexpected losses of temper are to be expected in confinement. where sharing is appropriate, the clinician may provide examples of witnessing the same experiences and noting this is part of what the humanity is experiencing now. this is aimed at reducing feelings of self-shaming, self-criticism stigma, or guilt for one's own weaknesses. self-disclosure is unique in this aspect. above all, it is one of the most powerful interventions (safran and muran ) and in this moment becomes even more necessary. therapists may need to strategically disclose moments of their own personal vulnerability during the outbreak. we contend that in this moment clinicians should mindfully and tactically not stick to one of the principles of good self-disclosures (e.g., dimaggio et al. ) , that is clinicians should disclose well-regulated feelings and thoughts. in this moment, still having command over their own experi-ences, clinicians may disclose moments in which they experienced momentarily feelings of fear, even moving closer to panic, worry, anger, sadness, rebellion and irritation than one ordinarily would. this helps create a sense of human connection and reduces in session risk, on the client's side of self-blaming or setting unrealistic standards of good mental health for the self (safran and muran ; inchausti et al. ). this can be balanced in session with learning from these experiences of momentary dysregulation. -create the therapeutic environment. we are not working in our offices but often from our homes. the therapy space must be therefore be created anew. for video-therapy the clinician should choose what part of their home they want to show beyond their shoulders and possibly consider the patients' personality. equally, the therapists will be projecting a sense of their own identify in these choices. with some patients it is better to choose a more neutral/professional background, for example bookshelves or a working table. with other patients there is less this need, and they experience a sense of familiarity even when they see the kitchen of the windows of the therapists' home. in any case, asking patients for feedback about how they experience the therapist in this new environment is crucial. another issue is how to present oneself in the camera. absence of embodied intersubjectivity deprives the session of face-to-face aspects of the human connection. we consider that adjusting zoom of the webcam, which means placing oneself at some distance can be helpful. showing only one's face is artificial and deprives the client of gestures and nonverbal markers from the therapist. conversely, at least a halflength shot (e.g. breaking news conductors) is better and some background must be present, so the patients retains a sense of a human being in context. this way therapists can use arms and hands and chest and shoulders to convey nonverbal signals making communication more natural. alternatively, some patients may feel more comfortable without using a camera and the use of audio might suit them better. coping with such anxiety disorders as social anxiety might lead patients to avoid video. as in any form of coping, if using video is too much of an emotional burden to that client, the clinician accepts phone consultation, but keeps exploring the possibility to switch to video, which would be a kind of behavioural exposure. a compromise would be using a web platform with video disabled. simply accepting coping deprives the clinician the possibility to counteract psychopathology. whereas, gently asking if the patient feels ready to switch to video, and explore the cognitive-affective antecedents of the possible refusal gives precious information about residual maladaptive interpersonal schemas which are one fundamental therapy target. -help patients build their own environment. clinicians may offer suggestions for how to create a therapeutic space, safe and protected from interference. of course, having a private, distraction-free room is best, but even in this case patients can be suggested to use headphones and a microphone, and maybe some background music, so reducing the risk others listen. alternatively, sessions can be conducted over smartphone in the open, for example a private garden, the parking lot or one's car. trivial as they may sound, we have found these suggestions help many patients to accept and practice therapy even after initial reluctance. -therapeutic focus -only self-regulation and overcoming distress or exploration of opportunities for building healthy parts and pursuing autonomy, exploration and expanding the healthy self (dimaggio et al. ) . we have noted that in majority of cases where we have adjusted delivery of psychotherapy to fit the pandemic restrictions, patients are seeking a balance between acceptance of the current condition, whilst still trying to challenge maladaptive schemas and develop an emergent healthy part of the self. indeed, once issues relating to the present crisis have been dealt with, patient and therapist may explore how the current distressing conditions create suffering not only for their direct traumatic effects, but also because they may indirectly bring existing personality, cognitive and emotional vulnerabilities to the fore. thus, clinicians may help the patients connect their present experiences to lifelong vulnerabilities, enabling therapeutic work to continue as they did before the emergency, albeit with specific adaptations. for example, prior to lockdown patients with avoidant personality disorders may have started questioning schemas of themselves as inferior and others are judging and therefore, they coped with social avoidance (inchausti et al. ) . in this moment behavioural experiments aimed at increasing social contact and thus further challenging the schemas are more difficult to enact. yet, the clinician may still explore opportunities, and build more basic steps for future real-life exposures. patients looking for employment may be able to access online courses or training for life after. patients searching for romantic partner may use dating apps or explore the feelings and thoughts they experience when chatting with some new acquaintance. even the home may be a test ground for new experiments. one client related difficulty in showing personal vulnerabilities to significant persons because she had learned that if she revealed these emotions others either became unavailable or distressed; therefore, she had avoided disclosure, or felt guilty for burdening them. lockdown and having to live with her partner : helped her realize that there was no point in her concealing her personal feelings, thus she burst into tears with her partner; relating afterwards in therapy that she felt relieved as she realized that that was possible. this enabled schema-driven difficulties in continuing with disclosure of feelings could be addressed as a current therapeutic issue. finally, some practices like two-chairs, sensorimotor work, guided imagery exercises, can regularly be performed simply adjusting the zoom in the patient room. the therapists may ask the client to step back so the whole body can be observed and then ask to close their eyes and engage in guided imagery, or use bodily oriented work like grounding (lowen ) to enhance self-regulation or connecting with feelings of strength and personal agency. that said, for some patients that are unwilling or do not want to use this platform for treatment. if they are content to postpone specific elements of treatment until restrictions are lifted, the therapist should be sensitive in recognizing distress but also respecting the decision-making process. it is still possible to remain open to the patient recontacting the therapist to recommence therapy. to conclude, the covid- pandemic and associated disruption to society poses major challenges to the provision of mental health services. these challenges include the need to identify and monitor possible risk groups for psychological morbidity as well as exploring new ways of providing services. as a heuristic, it is useful to consider three (potentially overlapping) groups that can benefit from psychological frameworks for mental health, and/or treatment approaches. these are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with covid- , or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with covid- or whose experience of social distancing exacerbates existing vulnerabilities. there are yet limited data on the mental health impacts of the current crisis, but evidence from past epidemics (e.g., mers and sars) offer a basis for identifying risk groups and preparing management strategies. the current crisis is the first global crisis in the age of mass internet supported communication, and this offers opportunities and challenges for delivering high-quality psychological therapies online. practical and technical adjustments to therapy can and have already been made, but as the pandemic unfolds it will be important to generate a corpus of knowledge both on the effectiveness of technologically supported psychotherapy, and to share technique in working with patients in an environment where technological changes intersect with societal changes due to the pandemic. middle east respiratory syndrome-corona virus (mers-cov) associated stress among medical students at a university teaching hospital in saudi arabia monitoring and managing mental health in the wake of ebola the psychological impact of quarantine and how to reduce it: rapid review of the evidence coronavirus disease (covid- ) mental health care for medical staff in china during the covid- outbreak metacognitive interpersonal therapy for personality disorders: a treatment manual psychological interventions for people affected by the covid- epidemic retraumatization: assessment, treatment, and prevention fair allocation of scarce medical resources in the time of covid- longitudinal trajectories of post-traumatic stress disorder symptoms among adolescents after the wenchuan earthquake in china psychological impact on sars survivors: critical review of the english language literature mental health consequences of disasters stress and coping responses to a natural disaster in people with schizophrenia el trastorno de personalidad por evitación: una propuesta de tratamiento especializado en la sanidad pública española [the avoidant personality disorder: a proposal for specialized treatment in the spanish national health system proceso psicoterapéutico en los trastornos del espectro psicótico tratamientos psicológicos para la psicosis are there interactional differences between telephone and face-to-face psychological therapy? a systematic review of comparative studies research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature psychological impact of the mers outbreak on hospital workers and quarantined hemodialysis patients. comprehensive psychiatry the resilience of the spanish health system against the covid- pandemic early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia dissociation debates: everything you know is wrong the language of the body. london: macmillan general reference social determinants of mental disorders and the sustainable development goals: a systematic review of reviews mental health in emergency response: lessons from ebola. the lancet anxiety disorders. quality standard. retrieved march , , from www.nice.org.uk/guida nce/qs . national institute for health and care excellence (nice) psychotherapy relationships that workevidence-based therapist contributions do no harm: balancing the costs and benefits of patient outcomes in health psychology research and practice negotiating the therapeutic alliance: a relational treatment guide the ebola outbreak and mental health: current status and recommended response trauma signature analysis impact of economic crises on mental health care: a systematic review the psychology of pandemics. preparing of the next global outbreak of infectious disease covid- global humanitarian response plan estimates of the severity of covid- disease psychological interventions in palliative care immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china coronavirus disease (covid- ) technical guidance: infection prevention and control/ wash a novel approach of consultation on novel coronavirus (covid- )-related psychological and mental problems: structured letter therapy recommended psychological crisis intervention response to the novel coronavirus pneumonia outbreak in china: a model of west china hospital psychological crisis interventions in sichuan province during the novel coronavirus outbreak publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest we have no conflicts of interest to disclose. key: cord- -yi vbgwj authors: saladino, valeria; algeri, davide; auriemma, vincenzo title: the psychological and social impact of covid- : new perspectives of well-being date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: yi vbgwj the recent covid- pandemic has had significant psychological and social effects on the population. research has highlighted the impact on psychological well-being of the most exposed groups, including children, college students, and health workers, who are more likely to develop post-traumatic stress disorder, anxiety, depression, and other symptoms of distress. the social distance and the security measures have affected the relationship among people and their perception of empathy toward others. from this perspective, telepsychology and technological devices assume important roles to decrease the negative effects of the pandemic. these tools present benefits that could improve psychological treatment of patients online, such as the possibility to meet from home or from the workplace, saving money and time and maintaining the relationship between therapists and patients. the aim of this paper is to show empirical data from recent studies on the effect of the pandemic and reflect on possible interventions based on technological tools. the covid- pandemic led to a prolonged exposure to stress. as a consequence, researchers showed an increased interest in measuring social and community uneasiness in order to psychologically support the population. this increased attention might help in managing the current situation and other possible epidemics and pandemics. the security measures adopted in managing the pandemic had different consequences on individuals, according to the social role invested. some segments of the population seem to be more exposed to the risk of anxious, depressive, and post-traumatic symptoms because they are more sensitive to stress. the following article has two focuses of interest: ( ) the evaluation of the psychological and social effects of the pandemic on the population, mostly children, college students, and health professionals; and ( ) the identification of new perspectives of intervention based on digital devices and in line with the social security measures and mental health promotion. telepsychology, for instance, is a valid tool, effective in taking charge of the psychological suffering caused by the pandemic and in preventing the chronicity of the disease. the prolonged stress could involve anxiety, depression, and the inability to manage traumatic and negative emotions. furthermore, the constant fear of contagion affects daily life and leads to social isolation, modifying human relations. studies of pandemics faced over time, such as sars, ebola, h n , equine flu, and the current covid- , show that the psychological effects of contagion and quarantine is not limited on the fear of contracting the virus (barbisch et al., ) . there are some elements related to the pandemic that affect more the population, such as separation from loved ones, loss of freedom, uncertainty about the advancement of the disease, and the feeling of helplessness cao et al., ) . these aspects might lead to dramatic consequences (weir, ) , such as the rise of suicides (kawohl and nordt, ) . suicidal behaviors are often related to the feeling of anger associated with the stressful condition widely spread among people who lived/live in the most affected areas (miles, ; suicide awareness voices of education, ; mamun and griffiths, ) . in light of these consequences, a carefully evaluation of the potential benefits of the quarantine is needed, taking into account the high psychological costs (day et al., ; mazza et al., ) . as reported in a recent survey administered during the covid- pandemic, children and young adults are particularly at risk of developing anxious symptoms (orgilés et al., ) . the research involved a sample of , parents of italian and spanish children (range - ). in general, parents observed emotional and behavioral changes in their children during the quarantine: symptoms related to difficulty concentrating ( . %), boredom ( %), irritability ( %), restlessness ( . %), nervousness ( %), sense of loneliness ( . %), uneasiness ( . %), and worries ( . %). from the comparison between the two groups-spanish and italian parents-it emerged that the italian parents reported more symptoms in their children than the spanish parents. further data collected on a sample of college students at the time of the spread of the epidemic in china showed how anxiety levels in young adults are mediated by certain protective factors, such as living in urban areas, the economic stability of the family, and cohabitation with parents (cao et al., ) . on the contrary, having infected relatives or acquaintances leads to a worsening in anxiety symptoms. furthermore, the economic problems and the slowdown in academic activities are related with anxious symptoms (alvarez et al., ) . in addition, an online survey conducted on the general population in china found that college students are more likely to experiencing stress, anxiety, and depression than others during the pandemic . these results suggest monitoring and promoting mental health of youths in order to reduce the negative impact of the quarantine (csts, ; fessell and goleman, ; . health-care workers (hcws) are another segment of population particularly affected by stress (garcia-castrillo et al., ; lai et al., ) . hcws are at risk to develop symptoms common in catastrophic situations, such as post-traumatic stress disorder, burnout syndrome, physical and emotional exhaustion, depersonalization, and dissociation (grassi and magnani, ; mache et al., ; Øyane et al., ) . however, an epidemic presents different peculiarities compared to a catastrophic event, for instance, the stigmatizing attitudes in particular toward health professionals, who are in daily contact with the risk of infection (brooks et al., ) . during sars, up to % of health-care professionals suffered from acute psychological stress, exhaustion, and post-traumatic stress, caused by the fear of contagion of their family members and the prolonged social isolation (tam et al., ; maunder et al., ) . as a consequence of the pandemic, the health professionals who were overworked suffered high level of psychophysical stress (mohindra et al., ) . health professionals also lived/live in daily life a traumatic condition called secondary traumatic stress disorder (zaffina et al., ) , which describes the feeling of discomfort experienced in the helping relationship when treatments are not available for all patients and the professional must select who can access them and who cannot (roden-foreman et al., ; rana et al., ) . data from a survey on , hcws who assisted patients in covid- wards and in second-and third-line wards showed high percentages of depression ( %), anxiety ( . %), insomnia ( %), and distress ( . %) (lai et al., ) . also, the constant fear of contagion leads to obsessive thoughts (brooks et al., ) , increasing the progressive closure of the person and reducing social relationships. in line with these results, rossi et al. ( ) evaluated mental health outcomes among hcws in italy during the pandemic, confirming a high score of mental health issues, particularly among young women and front-line workers. furthermore, spoorthy et al. ( ) conducted a review on the gendered impact of covid- and found that . - . % of medical staff is composed of women, and the mean age ranged between and years. also, women are more likely to be affect by anxiety, depression, and distress (lai et al., ; zanardo et al., ) . liang et al. ( ) also found a relation between age and depressive symptoms associated with the pandemic. indeed, the medical staff at younger ages (< years) reports higher self-rated depression scores and more concern about infecting their families than those of older age. staff > years of age reported increased stress due to patient's death, the prolonged work hours, and the lack of personal protective equipment. cai et al. ( ) also found that nurses felt more nervous compared to doctors. as emerged by the recent literature, the promotion of psychological interventions on the specific population who is more likely to develop pathologies and suffering is needed. the lancet global mental health commission's observation (patel, ) reported that the use of digital technologies can provide mental health interventions in order to reduce anxiety and stress levels and increase self-efficacy (kang et al., ; xiao et al., ) . in order to reduce anxiety and depression symptoms widespread among the population, the world health organization ( ) and the centers for disease control and prevention ( ) proposed specific guidelines on the correct use of health protection with the aim to minimize the distress associated with health-care professions. at the same time, as a consequence of the emerging issues, psychotherapists provided psychological support online, addressing the technological challenge ; liu et al., ) . in line with the technological progress, professional organizations promoted specific guidelines and policies related to customer protection, privacy, screening, evaluation, and development of self-help products (duan and zhu, ; zhou et al., ) . technological development in mental health foreshadows future trends that include "smart" mobile devices, cloud computing, virtual worlds, virtual reality, and electronic games in addition to the traditional psychotherapy tools. in this perspective, it is important to help future generations of psychologists and patients to collaborate in the potential growth areas, through education and training on the benefits and effectiveness of telepsychology (maheu et al., ) . indeed, more awareness of the potentials of the online services is needed, exploring the main differences between the devices (chat, video-audio consultation, etc.) in order to use them in relation to the specific purposes identified by the professional. for example, the italian service of online psychology conducted a study based on a service of helpdesk on facebook. this service guided people in asking for psychological help, working on their personal motivation. at the same time, another helpdesk on skype provided some psychological sessions via webcam (gabri et al., ) . in this line, telecounseling is a diffuse online method used by counselors and psychologists during the recent pandemic (de luca and calabrò, ). one of the future goals of public and private psychological organizations should be the promotion of specific training for psychologists and psychotherapists, with the following aims: ( ) developing the basic skills in managing the effects of a pandemic and of emergency situations; and ( ) sensitizing patients to online therapeutic relationship, providing the main rules and benefits of the process (stoll et al., ; joint task force for the development of telepsychology guidelines for psychologists, ). on this line, a significant example is the virginia commonwealth university (vcu) which proposed phds in telepsychology, with the aim of training future psychologists in managing the psychological effects of the pandemic through an online psychology service (baylor et al., ) . the service provided by the vcu had been effective in reducing anxiety, depression , and hospital recoveries (lanoye et al., ) . as shown, telepsychology assumes a key role in the improvement of health care. online psychological services avoid geographical barriers and are suitable to become a useful integrated tool in addition to traditional psychotherapy (aps, ; perrin et al., ). online psychological services provide several advantages, especially in the current situation of pandemic. first of all, online services help people in a short period of time, reducing the risk of contagion and the strong feeling of anxiety in both psychotherapists and patients, who feel uncomfortable in doing traditional psychotherapy due to the pandemic (békés and aafjes-van doorn, ). furthermore, pietrabissa et al. ( ) identified some of the main advantages of telepsychology, such as the decrease in waiting for the consultation, because it takes place from home or from the workplace, saving time and expense, less travel and rental costs for the office, for those who provide the service and for those who use it. as reported by the authors, online psychological services facilitate access to people who struggle to find support close to their social environment, avoiding difficulties related to mobility. also, online services help people who have less confidence in psychotherapy. indeed, mostly online psychotherapy takes place in one's comfort zone, facilitating the expression of problems and feelings. according to the situations, online services could provide a different medium. for instance, the chat is a useful tool to establish a first assessment of a person who feels uncomfortable in using video. indeed, the online psychotherapy is perceived as more "acceptable." suler ( ) defined the term online disinhibition effect demonstrating how the web, unlike the real life, leads to the failure of the hierarchical relationship based on dominant-dominated among individuals; this aspect, according to the author, allows a greater sense of freedom in expressing oneself and less concern related to judgment (ibid.). other researchers (mantovani, ; tosoni, ) have integrated to the construct of online disinhibition effect the concept of social space, emphasizing the role of the "situation, " of the "social norms" (brivio et al., , p. ) , of the tools ("artifacts"), and of the cyberplace, which allow different levels of interaction. each person has a different experience of the network and several levels of disinhibition. for instance, a mild disinhibition could be a person who chooses to ask for help talking with a psychologist about their problems; while a high disinhibition could be represented by flaming, an expression of online bullying or cyberstalking. online psychological services should be integrated with the various territorial services in order to provide the patients local references in relation to the specific health and economic needs. finally, the possibility for the therapist and for the patient to record the sessions via chat and in audio/video modewith the informed consent of the participants (wells et al., ) -provides another useful tool to compare the sessions and to underline the positive outcomes and the effectiveness of the therapeutic process. according to this perspective, online psychological support and psychotherapy become a resource for psychotherapists and patients in a co-build relationship (algeri et al., ) . in analyzing the psychological impact of the quarantine, the importance for individuals to feel integral part of the society emerged, an aspect often undervalued in psychological wellbeing. experts of public health believe that social distancing is the better solution to prevent the spread of the virus. however, although it is not possible to predict the duration of the pandemic, we know very well the serious impact of these measures on the society, on relationships and interactions, in particular on the empathic process. in the early s, empathy was described as a form of identification in the psychological and physiological states of others. this definition led to a debate between the disciplines of philosophy of psychology and philosophy of the mind (franks, ) . willard van orman quine ( quine ( - renewed attention to the debate on empathy with a thesis on the development of language and mind in the analytical philosophy. according to quine, the attribution of the so-called intentional states, through which the psychology commonly explains human behavior, is based on empathy (treccani, ) and leads people to attribute beliefs, desires, and perceptions (quine, , , pursuit of truth: revised edition, . analyzing this aspect within the recent situation of the pandemic, an increment of antithetical positions and attitudes could be noticed. on the one hand, people identify themselves with those who suffer (neighbors, friends, relatives who are living stressful events), promoting activities such as the so-called "suspended expenses." for instance, solidarity and humanitarian activities, food, and medicine delivery for people who are unable to go to the supermarket. on the other hand, there is a part of the population who experiences a feeling of "forced empathy." this aspect could be also emphasized by the use of technological devices that might lead to a depersonalization of relationships, forcing the sense of closeness, at least virtually. the hyperconnection of feelings becomes a way to reduce the self-isolation and its consequences, representing the contrary of the idea of durkheim ( durkheim ( - , who considered society as a specific entity, built on social facts (durkheim, ) . the sensation "to be forced to feel" could lead people to distance themselves from others after the emergency situation, incrementing social phobias. also, human communication is changing. the formal question "how are you?" at the beginning of a conversation is no longer just a formality, as before the pandemic. for example, the relationship between employee and the manager is different, leading to more responsibilities in listening and understanding feelings expressed during the video call, generating a forced reciprocity. hence, the aforementioned "forced empathy" may be common in this period because the social distance and the emergency situation make people want to be heard and appreciated, and the simple question "how are you?" becomes an anchor to express fears and emotions (pasetti, ) . the covid- pandemic has affected the way people live interpersonal relationships. the lockdown was characterized of a different organization of daily life, with an incrementation of time at home and a reduction of distance through digital devices. this period was also seen as an evolution in the concept of empathy, producing new perspectives in the study of the phenomenon according to a sociological and neurological points of view. indeed, empathy-defined as the ability to understand and share the feelings of another-involves several elements, such as: (a) social context and historical period of the individual, (b) neurological mechanisms, and (c) psychological and behavioral responses to feelings of others. the neurosociological perspective analyzes the mechanisms involved in the empathic process, focusing on human communication and interpersonal relationships (singer and lamm, ; decety and ickes, ) . specifically, in this historical period characterized by an increment in the man-machine relationship, neurosociology could become one of the principal sciences for the study of human relations and technology. "we live increasingly in a human-machine world. anyone who doesn't understand this, and who is not struggling to adapt to the new environmentwhether they like that environment or not-is already being left behind. adapting to the new, fast-changing, technologically enhanced context is one of the major challenges of our times. and that certainly goes for education" (prensky, , p. ) . according to the abovementioned considerations, our suggestion consists in: primary prevention. studying the impact of the pandemic toward an at-risk population to reduce symptoms related to stress and providing specific online psychological counseling based on the target (students, medical staff, parents, and teachers). secondary prevention. overcoming the limitations of the human interaction based on digital devices: ( ) developing new spaces of inter-and intrasocial communication and new tools of support and psychological treatment, reproducing the multisensory experienced during the face-to-face interaction (virtual reality, holograms, serious game etc.); ( ) training the next generation of psychotherapists in managing online devices and in implementing their adaptive and personal skills; and ( ) sensitizing the general population on telepsychology and its advantages. research according to the neurosociological perspective. studying human interaction mediated by new technologies and the role of empathy, associating neuroscience, sociology, and psychology. vs, da, and va conceptualized the contribution. vs wrote the paper, reviewed the manuscript, and provided the critical revision processes as pi. all authors approved the submission of the manuscript. this work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. consulenza psicologica online. esperienze pratiche, linee guida e ambiti di intervento. firenze: giunti editore a simple planning problem for covid- lockdown psychologists welcome health fund telehealth support of australians' mental health during covid- outbreak is there a case for quarantine? perspectives from sars to ebola teaching medical students skills for effective communication with patients who have communication disorders psychotherapists' attitudes toward online therapy during the covid- pandemic an integrated approach to interactions in cyberplaces: the presentation of self in blogs the psychological impact of quarantine and how to reduce it: rapid review of the evidence psychological impact and coping strategies of frontline medical staff in hunan between the psychological impact of the covid- epidemic on college students in china immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china when is quarantine a useful control strategy for emerging infectious diseases? how the covid- pandemic is changing mental health disease management: the growing need of telecounseling in italy the social neuroscience of empathy psychological interventions for people affected by the covid- epidemic education et sociologie. milano: ledizioni how healthcare personnel can take care of themselves neurosociology the nexus between neuroscience and social psychology. londra the request for psychological help in the digital age: offering counseling through chat and video counseling european society for emergency medicine position paper on emergency medical systems' response to covid- psychiatric morbidity and burnout in the medical profession: an italian study of general practitioners and hospital physicians managing mental health challenges faced by healthcare workers during covid- pandemic joint task force for the development of telepsychology guidelines for psychologists impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study covid- , unemployment, and suicide factors associated with mental health outcomes among health care workers exposed to coronavirus disease the impact of integrated psychological services in a safety net primary care clinic on medical utilization prevalence and predictors of general psychiatric disorders and loneliness during covid- in the united kingdom analysis of influencing factors of anxiety and emotional disorders in children and adolescents during home isolation during the epidemic of novel coronavirus pneumonia screening for chinese medical staff mental health by sds and sas during the outbreak of covid- online mental health services in china during the covid- outbreak stress, health and satisfaction of australian and german doctors-a comparative study future of telepsychology, telehealth, and various technologies in psychological research and practice first covid- suicide case in bangladesh due to fear of covid- and xenophobia: possible suicide prevention strategies comunicazione e identità: dalle situazioni quotidiane agli ambienti virtuali long-term psychological and occupational effects of providing hospital healthcare during sars outbreak nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors kaci hickox: public health and the politics of fear issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid patients immediate psychological effects of the covid- quarantine in youth from italy and spain associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of norwegian nurses smart-working, costretti all'empatia da convenevoli forzati. tratto da sole ore the lancet commission on global mental health and sustainable development rapid telepsychology deployment during the covid- pandemic: a special issue commentary and lessons from primary care psychology training facebook use as access facilitator for consulting psychology what isn't technology good at? empathy for one thing! pursuit of truth pursuit of truth: revised edition mental health of medical workers in pakistan during the pandemic covid- outbreak prospective evaluation of posttraumatic stress disorder and depression in orthopaedic injury patients with and without concomitant traumatic brain injury mental health outcomes among frontline and second-line health care workers during the coronavirus disease (covid- ) pandemic in italy initial and follow-up evaluations of integrated psychological services for anxiety and depression in a safety net primary care clinic the social neuroscience of empathy mental health problems faced by healthcare workers due to the covid- pandemic-a review ethical issues in online psychotherapy: a narrative review preventing suicide during and after the covid- pandemic the online disinhibition effect severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers identità virtuali: comunicazione mediata da computer e processi di costruzione dell'identità personale einfuhlung. tratto da treccani grief and covid- : mourning our bygonelives the informed consent process for therapeutic communication in clinical videoconferencing emergency global supply chain system (covid- ) catalogue the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china disturbo post traumatico da stress in operatori sanitari coinvolti in un incidente rilevante avvenuto in ambito ospedaliero psychological impact of covid- quarantine measures in northeastern italy on mothers in the immediate postpartum period the role of telehealth in reducing the mental health burden from covid- the authors declare that the research was conducted in the key: cord- -qi gilkr authors: dawson, david l.; golijani-moghaddam, nima title: covid- : psychological flexibility, coping, mental health, and wellbeing in the uk during the pandemic date: - - journal: j contextual behav sci doi: . /j.jcbs. . . sha: doc_id: cord_uid: qi gilkr the covid- pandemic has profoundly altered the daily lives of many people across the globe, both through the direct interpersonal cost of the disease, and the governmental restrictions imposed to mitigate its spread and impact. the uk has been particularly affected and has one of the highest mortality rates in europe. in this paper, we examine the impact of covid- on psychological health and well-being in the uk during a period of ‘lockdown’ ( (th)– (st) may ) and the specific role of psychological flexibility as a potential mitigating process. we observed clinically high levels of distress in our sample (n= ). however, psychological flexibility was significantly and positively associated with greater wellbeing, and inversely related to anxiety, depression, and covid- -related distress. avoidant coping behaviour was positively associated with all indices of distress and negatively associated with wellbeing, while engagement in approach coping only demonstrated weaker associations with outcomes of interest. no relationship between adherence to government guidelines and psychological flexibility was found. in planned regression models, psychological flexibility demonstrated incremental predictive validity for all distress and wellbeing outcomes (over and above both demographic characteristics and covid- -specific coping responses). furthermore, psychological flexibility and covid- outcomes were only part-mediated by coping responses to covid- , supporting the position that psychological flexibility can be understood as an overarching response style that is distinct from established conceptualisations of coping. we conclude that psychological flexibility represents a promising candidate process for understanding and predicting how an individual may be affected by, and cope with, both the acute and longer-term challenges of the pandemic. residents permitted to leave home: • to shop for basic necessities only • to exercise once per day (alone or with members of same household) • to attend to own or others' medical needs to travel for work purposes if unable to work from home (expectation that only 'critical workers', such as healthcare professionals, delivery drivers, refuse collectors, food operative, etc. should continue working outside of the home) • to move children between separated parents/carers schools*, colleges, and universities closed. all non-essential businesses closed (except food retailers + , hardware stores, and essential goods and services suppliers) all public gatherings of more than two people prohibited (except where the gathering consists of one household or for work purposes) th may ongoing (at time of study) residents permitted to leave home: • to shop at retailers that are permitted to open (extended to some nonessential businesses such as garden centres) and to collect goods preordered online • to exercise or spend time outdoors for recreation (now time limited) alone or with members of same household) • to attend to own or others' medical needs • to travel for work purposes if unable to work from home (non-critical workers now expected to travel to work if not working from home, with occupational social distancing measures in place) • to move children between separated parents/carers schools*, colleges, and universities closed. some non-essential businesses allowed to open, but restaurants ++ , cinemas, cafés ++ etc. remain closed. all public gatherings of more than two people prohibited (except where the gathering consists of one household or for work purposes) but some exceptions (e.g., funerals, house moves) and people also now able to meet with one person from another household at -meter distance. note: *schools remain open where possible for children of critical workers and children considered vulnerable only; + restaurants and café's able to provide delivery only; ++ restaurants and cafés able to provide delivery or physically distanced service (e.g., drivethru; take-out) the impact of these changes on the psychological health and wellbeing of the population is significant. data from the uk office of national statistics (ons) suggests that around % of people in the uk are currently worried about the effect of covid- on their life, with many reporting high levels of anxiety ( %), diminished well-being ( %), and loneliness ( %) (ons; ). these elevated distress indices (anxiety prevalence amongst the uk population is usually around %; mcmanus, meltzer, brugha, bebbington, & jenkins, ) cohere with findings from elsewhere. in a recent study from china, for example, half of respondents rated the psychological impact of covid- as moderate to severe, and approximately one-third reported moderate to severe levels of anxiety during the first two weeks of the pandemic (wang et al., ) . comparable reports have emerged from italy, spain, and other deeply affected countries (e.g., gonzález-sanguino et al., ; odriozola-gonzález, planchuelo-gómez, irurtia-muñiz, & de luis-garcía, ; orgilés, morales, delvecchio, mazzeschi, & espada, ; ozamiz-etxebarria, dosil-santamaria, picaza-gorrochategui, & idoiaga-mondragon, ; also see rajkumar, , for an early review). studies that have tracked the long-term sequelae of previous coronavirus pandemics (such as severe acute respiratory syndrome [sars] in ) suggest that psychological difficulties -including ptsd, depression, anxiety, stress, and impaired quality of life -can sustain for months and even years post-outbreak, particularly for those who contract the virus or who are directly exposed to it through their occupational roles (e.g., bonanno et al., ; chan & huak, ; hui et al., ; kwek et al., ; a. m. lee et al., ; liu et al., ; maunder et al., ; wu, chan, & ma, ) . there is additional evidence to suggest that the measures enforced to mitigate virus spread (such as quarantine and social isolation) can also contribute to lasting psychological distress, including elevated levels of depression, stress, irritability, and ptsd-type symptoms (see brooks et al., for a review) . identifying the psychological processes that can help to protect well-being and psychological health under such exceptional circumstances is therefore of utmost importance. understanding these processes has implications for how individuals might be helped to manage the current pandemic, but also how we might best intervene in the coming months to prevent nascent psychological difficulties from developing into serious long-term mental health conditions. understanding alone, however, is insufficient; these processes also need to be malleable and responsive to psychological intervention if they are to have functional utility (e.g., holmes et al., ) . psychological flexibility, the ability to recognise and adapt to situational demands in pursuit of personally meaningful longer-term outcomes, is one such process. across a broad range of populations and presentations, greater psychological flexibility has consistently been associated with reduced stress, anxiety, depression, and increased well-being (e.g., bluett, homan, morrison, levin, & twohig, ; francis, dawson, & golijani-moghaddam, ; gloster, klotsche, chaker, hummel, & hoyer, ; kashdan & rottenberg, ; masuda & tully, ; mccracken & morley, ; tyndall et al., ) . conversely, psychological inflexibility, particularly in the form of experiential avoidance (an excessive tendency to avoid difficult experiences, thoughts, feelings, and situations; s. c. hayes, wilson, gifford, follette, & strosahl, ) , and/or a propensity to engage rigid and inflexible psychological, emotional, or behavioural strategies, has been found to relate to poorer coping and impaired psychological and emotional health across an array of psychological literature (e.g., bardeen, fergus, & orcutt, ; bonanno, papa, lalande, westphal, & coifman, ; chawla & ostafin, ; cheng, ; karekla & panayiotou, ; kashdan, barrios, forsyth, & steger, ; kashdan & rottenberg, ; nielsen, sayal, & townsend, ) . moreover, of particular pertinence to the current context, it has been found that psychological flexibility can buffer the adverse impact of recent life stressors on psychological health and wellbeing (fonseca, trindade, mendes, & ferreira, ; gloster, meyer, & lieb, ). an individual's level of psychological flexibility appears related to, but distinct from, their particular ways of coping. while psychological inflexibility (in the form of experiential avoidance) strongly relates to a tendency to deploy avoidant coping strategies, such as distraction, disengagement, or substance use, which can become dysfunctional, it has also been found to account for a greater proportion of psychological distress outcomes over and above a person's typical coping-style alone (e.g., karekla & panayiotou, ; nielsen et al., ) . this distinction is important as it implies that psychological flexibility (or lack thereof), rather than a specific coping style or proclivity, is likely to be more important for understanding (and influencing) how people successfully navigate the impact of the pandemic now and in the future (e.g., cheng, ; karekla & panayiotou, ; kashdan & rottenberg, ; nielsen et al., ) . conceptually, psychological flexibility can be understood as a generalised or higher-order ability to respond effectively to situational demands in the pursuit of longer-term goals, enabling selection of coping responses as apt to the situation. thus, psychological flexibility may partly affect outcomes via its influence on selection of coping behaviours (including, but not limited to, facilitation of more open/less avoidant ways of responding). this notion has been supported by mediational modelling demonstrating indirect effects of psychological flexibility on wellbeing and distress outcomes, via coping strategies (rueda & valls, ) . notably, rueda and valls ( ) found direct effects of psychological flexibility in addition to indirect (mediated) effects: these direct effects may reflect unique aspects of psychological flexibility as a functional-contextual process (adapting responding according to situational demands/affordances and desired consequences) which may not be captured by traditional measures of coping. psychological flexibility is also the key process targeted by acceptance and commitment therapy (act; s. c. hayes, strosahl, & wilson, ) -the empirically established third-wave cognitive-behaviour therapy with demonstrated efficacy for improving psychological health and wellbeing outcomes across a multitude of clinical and non-clinical populations and presentations (e.g., bluett et al., ; brown, glendenning, hoon, & john, ; hacker, stone, & macbeth, ; e. b. lee, an, levin, & twohig, ; powers, vörding, & emmelkamp, ; veehof, oskam, schreurs, & bohlmeijer, ) . psychological flexibility thus represents a promising candidate process for both understanding and predicting how an individual may be affected by, and cope with, the significant challenges of the pandemic, while also offering a potential intervention target should theorised functional relationships be confirmed. the aims of this study were to ( ) provide a rapid snapshot of how psychological flexibility interacts with coping, psychological health, well-being, and government restrictionadherence during the covid- pandemic in the uk ; and ( ) investigate psychological flexibility -as conceptualised within act -as an overarching response style that may lead to improved psychological outcomes by facilitating flexible (rather than restrictive or stereotyped) coping behaviour during this period of acute global uncertainty. participants were adults living in the uk ( % female, m age = . ; table provides detailed sample characteristics), recruited to an online questionnaire-based study via snowball sampling and advertising on uk-directed forums (reddit), social media (facebook and twitter), and a research-recruitment site (callforparticipants.com). participants were required to confirm that they were years or over, were currently residing in the uk (england, scotland wales, or northern ireland), and consented to take part. no other inclusion or exclusion criteria were applied. of individuals who accessed the survey, consented to participation and provided basic demographic data. of these, completed all measures and formed the final study sample. completers were compared to non-completers on available data (using ttests or fisher's exact tests as apt) -the only significant difference was in age (t [ ] = - . , p = . ) with non-completers being younger (m = . , sd = . ) than completers (m = . , sd = . ) on average. to be able to compare our sample to the wider uk population at this extraordinary time, we asked our participants a question that was being used in contemporaneous weekly representative polling of the uk general population (ons, ): "how worried or unworried are you about the effect that coronavirus (covid- ) is having on your life right now?" our sample (with % reporting that they are very or somewhat worried about appear similar to the broader uk population; the proportion of uk adults very or somewhat worried about the effect of covid- on their life ranged from . % to . % during the study data collection period (ons; ). we aimed to recruit a minimum sample-size of , to obtain stable estimates of sample correlation coefficients (converging on population values; schönbrodt & perugini, ) . our analysis plan is predicated on multiple correlational analyses and ensuring the stability of estimated coefficients provides foundational confidence for contingent modelling. specifically, we powered our study to achieve a corridor of stability of ±. for any coefficients ≥ . (i.e., any associations of greater than negligible magnitude; cohen, ) enabling ( %) confidence that our estimated coefficients would be within ±. of the true population value (i.e., only fluctuations of small magnitude would be tolerated). to maximise domain coverage while minimising participant burden, we utilised shortform versions of established measures where possible. in addition to the measures outlined below, demographic information including age, gender, ethnicity, and current living and working arrangements was also collected. the patient health questionnaire- (phq- ) is a -item self-report measure assessing symptoms of depressed mood (kroenke, spitzer, & williams, ) . frequency of symptoms is assessed on a -point scale, ranging from = "not at all" to = "nearly every day"; the summed score ranges from - , with higher scores indicating greater severity. in the current study, respondents were asked to report symptom frequency over the last week. the phq- performs as well as clinician-administered assessments for detecting depression in primary care (gilbody, richards, & barkham, ) and has been found to be valid for assessing depression severity in research and practice (kroenke et al., ) . scores ≥ indicate clinical levels of depression (levis, benedetti, & thombs, ). the generalized anxiety disorder scale- (gad- ) is a -item self-report measure assessing symptoms of generalised anxiety (spitzer, kroenke, williams, & löwe, ) . frequency of symptoms is assessed on a -point scale, ranging from = "not at all" to = "nearly every day"; the summed score ranges from - , with higher scores indicating greater severity. in the current study, respondents were asked to report frequency over the last week. the gad- has been found to be valid for detecting generalised anxiety in primary care settings (scores ≥ indicate clinical levels of anxiety) and for assessing severity in research and practice (spitzer et al., ; löwe et al., ) . the impact of event scale- (ies- ; thoresen et al., ) is a -item abbreviated version of the impact of event scale-revised (ies-r; weiss, ) and measures the principal components of ptsd (intrusion, avoidance, and hyperarousal; giorgi et al., ) . items are rated on a -point scale, ranging from = "not at all" to = "extremely"; the summed score ranges from - , with higher scores indicating greater ptsd symptomology. in the current study, respondents were asked to complete the measure in relation to the covid- pandemic and its impact on them during the previous week. the scale has good internal consistency (α = . ), and good construct and convergent validity with the ies-r (giorgi et al., ; thoresen et al., ) . the brief cope (carver, ) is a -item self-report measure of coping styles in response to a stressful experience. different coping responses are rated on a -point scale, ranging from = "i haven't been doing this at all" to = "i've been doing this a lot". instructions were adapted to focus on coping in the context of covid- ("please indicate how much you have engaged in the following during the past week in relation to the covid- pandemic"). factor analysis indicates that the various coping styles reflect two core factors (eisenberg, shen, schwarz, & mallon, ) : ( ) brief cope was scored accordingly, deriving summary scores for both avoidant and approach coping, with higher scores reflecting greater use of the respective class of coping responses. the brief cope has been used to assess coping amongst a community sample following the sars pandemic (sim, chan, chong, chua, & soon, ) and has adequate validity and reliability (carver, ) . we asked participants additional questions related to covid- . to gauge worry about the personal impact of covid- , we asked participants: "how worried or unworried are you about the effect that coronavirus (covid- ) is having on your life right now?" (ons, ) . participants respond on a -point scale ranging from "not at all worried" to "very worried". we also asked respondents to confirm their covid- status (e.g., whether they have been tested or confirmed to have contracted the virus). finally, participants were presented with an outline of current government restrictions (tailored according to location within the uk) and asked how closely they were adhering to the guidance, ranging from: "not closely (i don't follow the above)" to "very closely (i follow all of the above at all times)". institutional ethical approval was obtained for all aspects of the study. potential participants were directed to study information via a weblink; those who wished to take part (after being reminded about their right to withdraw) were required to confirm that they met eligibility criteria and consented to take part. participants then proceeded to complete the above-described measures online. we used the survey platform qualtrics for study hosting and data collection. all data collection for the current report took place between th- st may (see table for an overview of restrictions in place at the time of data collection). preliminary analyses allowed for data exploration and assumption-checking, using ibm spss statistics (version ). assumptions were met for all parametric tests conducted. correlational analyses (pearson's r) were carried out to examine any zero-order relations among psychological flexibility, covid- coping behaviours, and focal outcome variables. to correct for multiple testing of focal relations, we applied a benjamini-hochberg adjustment to p-values using a false discovery rate of . . we additionally tested whether predictor and outcome variables of interest were associated with demographic characteristics (applying anovas for nominal demographic variables and correlational analyses for continuous or binary variables) to inform selection of control variables for subsequent regression analyses. to more inclusively identify potential control variables, these exploratory analyses were not adjusted for multiple testing. research aims were met using hierarchical multiple regression analyses. five models were run, one for each outcome/dependent variable of interest: ( ) wellbeing (swemwbs); ( ) depression (phq- ); ( ) anxiety (gad- ); ( ) event-specific (i.e., covid- ) distress (ies- ); ( ) covid- worry; and ( ) adherence (to applicable government guidance on social distancing). psychological flexibility (compact- ) and covid- coping behaviours (avoidance and approach coping; brief cope) were included as a priori predictors of interest in all regression models. we controlled for any demographic variables (e.g., gender, age, and work status) demonstrating significant associations with one or more of the identified predictor and outcome variables of interest; control variable selection was thus data-driven, based on preliminary analyses of association (described above (dattalo, ) . to examine whether relationships between psychological flexibility and covid- outcomes could be accounted for in terms of covid- -specific coping responses (i.e., engagement in avoidance and/or approach behaviours) we conducted mediational analyses at the time of responding, participants ( %) met criterion for clinical depression and ( %) met criterion for clinical anxiety (scores ≥ on the phq- and gad- respectively); overall, % of participants met criteria for anxiety and/or depression, with % meeting criteria for both. these findings reflect broader uk trends, with - % of the population reporting high levels of anxiety in ons surveys over the study period (ons; ). table presents correlations among the focal (predictor and outcome) variables, descriptive statistics, and internal consistency (cronbach's ɑ) coefficients. all statistically significant inter-correlations between a priori focal variables of interest survived correction for multiple testing (benjamini-hochberg adjustment to preserve a % false discovery rate among correlations). table additionally presents demographic variables that were found, in unadjusted exploratory analysis, to be significantly associated with one or more focal variables. . * -. * -. ** . -. * -. -. ** -. * -. l w/partner . ** -. ** . . ** -. ** -. ** -. * -. . * l w/child . -. * . . * -. -. ** -. * -. . l w/parents -. ** . ** -. -. ** . ** . ** . ** . . note. swemwbs = short warwick-edinburgh mental well-being scale. gad- = generalized anxiety disorder scale- . phq- = personal health questionnaire- . ies- = impact of event scale- . l w/ = living with. male is coded such that male = and other genders = . l w/ variables are coded such that = yes and = no. ɑ = cronbach's alpha (internal consistency in the present sample). *p < . , **p < . as expected, psychological flexibility was significantly and positively associated with wellbeing; negative relationships were found between psychological flexibility and distress (anxiety, depression, and covid- -related distress and worry). psychological flexibility was not associated with adherence to government social distancing guidance. engaging in avoidant coping behaviours was positively associated with all indices of distress and negatively associated with wellbeing. moreover, avoidance coping was inversely associated with adherence to current social distancing guidance -albeit that this association (whilst statistically significant) was of small magnitude. engagement in approach coping demonstrated weaker associations with outcomes of interest. the only significant relationships were with wellbeing, covid- distress, and covid- worry; all were positive and of small magnitude (suggesting that approach coping had both adaptive and maladaptive functions). in terms of inter-relationships between psychological flexibility and covid- coping behaviours, psychological flexibility demonstrated a large, inverse relationship with avoidant responses to covid- -and a small, positive relationship with approach coping behaviours (including use of external supports). when examining the focal predictor and outcome variables in relation to sample demographic characteristics, there were no significant associations with work status or ethnic group (ps = . -. ). however, predictor and outcome variables varied by age, gender (specifically, male versus other gender identities), and living arrangements (specifically, living with a partner, a child, or with parents versus other arrangements). consequently, consistent with planned analyses, these demographic variables were entered as control variables in subsequent regression models (and relevant relationships to outcome are reported therein). hierarchical regression results are displayed in table . the multivariate multiple regression omnibus test was significant (pillai's trace, f = . , p < . ), permitting progression to examine regression models for each outcome. the addition of psychological flexibility (compact- , in block three) produced statistically significant increases in r for five of the six outcome models. in these five models, psychological flexibility explained an additional - % of outcome variance -over and above demographic characteristics and covid- -specific coping responses (as measured by the brief cope). whilst associations generally (inversely) paralleled those observed for avoidant coping, psychological flexibility accounted for unique variance in both distress and wellbeing -including covid- -specific distress (ies- ) and worry. based on absolute values of standardised coefficients, psychological flexibility demonstrated a particularly strong relationship with wellbeing in the context of lockdown (other significant associations were of moderate magnitude). avoidant coping was an independent predictor of outcome in all final models (with all variables entered); avoidant responses to the covid- context were associated with poorer wellbeing and distress outcomes -and lower restriction adherence -consistent with correlational results. unique associations were of small-to-moderate magnitude. approach coping demonstrated small unique associations with depression, wellbeing, and covid- distress. some of the unique outcome variance in final models was explained by demographic characteristics (although all coefficients were of small magnitude). specifically, age remained positively associated with wellbeing and negatively associated with depression; living with a partner was negatively associated with depression and positively associated with restriction adherence; and living with parents was positively associated with both covid- distress (ies- ) and adherence. living with others (a partner and/or parents) therefore appeared to support adherence to restrictions. note. standardised beta coefficients are reported for comparability. pf = psychological flexibility (compact- ). l w/ = living with. avoidant = avoidant coping (brief cope). approach = approach coping (brief cope). male is coded such that male = and other genders = . l w/ variables are coded such that = yes and = no. *p < . , **p < . . as outlined above, mediation analyses were conducted to determine whether relationships between psychological flexibility and covid- outcomes were (to some extent) mediated by coping responses to covid- . table illustrates that, for all outcomes except adherence, there were significant indirect effects (of small magnitude) alongside significant direct effects (of moderate-to-large magnitude) for psychological flexibility. thus, consistent with regression analyses, psychological flexibility retained direct (unique) relationships with outcomes of interest when modelled alongside coping responses. however, these models also extend the regression analyses by clearly outlining (theory-and logic-based) indirect pathways to outcome via coping responses to covid- ; specifically, through a lower propensity to respond avoidantly. with respect to adherent social distancing, mediation modelling demonstrated no significant direct or indirect effect of psychological flexibility. . [-. ,. ] . [-. ,. ] . [-. ,. ] note. standardised beta coefficients are reported for comparability. dv = dependent variable in each outcome model. pf = psychological flexibility (compact- ). avoidant = avoidant coping (brief cope). approach = approach coping (brief cope). *p < . (adjusted significance level applied to mediational analyses). indirect effect-sizes are significant when % cis do not include . in this study, we examined psychological flexibility in the proximal uk context of the covid- pandemic. specifically, we assessed how psychological flexibility relates to psychological health and wellbeing outcomes within this context -and whether individual differences in psychological flexibility account for differences in coping behaviours and adherence to government restrictions. moreover, we explored a potential mediational model of psychological flexibility as an overarching ability that may facilitate improved outcomes via more adaptive use of coping strategies. the elevated prevalence of clinical distress in our general population sample (e.g., % meeting criterion for generalised anxiety -versus typical estimates of %; mcmanus et al., ) evinces the detrimental psychological impact of the pandemic and highlights the importance of identifying (malleable) factors that may contribute to outcomes in this context. results showed that, barring restriction adherence, psychological flexibility was directly related to all focal outcomes of interest -demonstrating a positive relationship with wellbeing and negative relationships with distress (depression, anxiety, and covid- distress and worry). these relationships were somewhat unique, providing incremental explanatory power over and above the contributions of demographic and coping-style variables. thus, generalised psychological flexibility (as measured by the deceptively brief but theoretically coherent compact- ) accounted for meaningful situational outcomes in the context of the covid- pandemic. the valence and relative magnitude of these associations (e.g., the fact that the strongest [positive] relationship was with wellbeing) were congruent with theoretical expectations, and consistent with the strong body of evidence highlighting the critical role of psychological flexibility in facilitating psychological health and adjustment (kashdan & rottenberg, ) . thus, although the current study was cross-sectional, and unable to determine the directionality of associations, observations are compatible with broader theoretical assumptions and empirical evidence. the unique contribution of this study is in the situational specificity of our assessments of coping behaviours and outcomes, allowing us to make contextualised inferences about responses to the pandemic in particular, versus in participants' lives more broadly. examining focal variables at this time of acute stress arguably provides a more critical test of the relevance of psychological flexibility than when assessing in a global way under general conditions. psychological flexibility demonstrated substantive associations with coping variables (a large negative association with avoidant coping and a small positive association with approach coping) and mediational analyses identified significant indirect pathways to outcomes of interest through reduced avoidance. where identified, for distress and wellbeing outcomes, these indirect pathways were present alongside significant direct effects. this finding of both unique and mediated effects of psychological flexibility is consistent with previous work demonstrating that psychological flexibility is independent of, but overlapping with, coping response (karekla & panayiotou, ) . our findings also mirror mediational analyses by rueda and valls ( ) , who demonstrated indirect effects of psychological inflexibility on distress and wellbeing via coping strategies -with psychological inflexibility disposing greater use of avoidant coping strategies and poorer outcomes. so, although psychological flexibility is related to coping, it does not appear to be a form of coping. psychological flexibility is partly defined as an ability to respond effectively to situational demands in the pursuit of longer-term goals and can thus be conceptualised as a higher-order response style (e.g., nielsen et al., ) that may facilitate the selection of coping responses (and other behaviours) as apt to the situation. accordingly, while effective action might be harder to take when we are driven primarily by efforts to avoid unwanted experiences, psychological flexibility is not simply the inverse of avoidant coping. effective, situational responding requires an extensive repertoire of behaviours, including avoidance behaviours, which can be functional and adaptive in various contexts (e.g., taking breaks from emotionally burdensome covid- news stories may improve short-term wellbeing without any significant longer-term cost). complete eschewal of avoidance strategies is a further manifestation of inflexibility. the ability to respond successfully is therefore dynamic and situated, requiring an openness (to experience difficult situations without habitually deploying avoidance strategies) and an awareness (sensitivity to context) that discriminates when behaviour change may be necessary to achieve a valued outcome. this coheres with theoretical and empirical coping literature that highlights the need to gauge overarching coping flexibility (capacity to select from a broad repertoire of coping strategies as apt to each situation), and the observation made by others that traditional coping measures are limited in their sensitivity to such flexibility (zimmer-gembeck et al., ) . it is notable that the magnitude of association between psychological flexibility and avoidant coping was greater in the current study than has been identified in previous studies. we observed a large zero-order association (-. ) whereas previous studies have reported small-to-moderate associations (with comparable rs ranging from -. to -. ) across both community and clinical samples (hulbert-williams, storey, & wilson, ; karekla & panayiotou, ; kashdan et al., ) . this contrast may reflect differences in study measures or populations but may also reflect something more particular about the current context. we directed participants to focus on coping behaviours used specifically in relation to the covid- pandemic. thus, the observed strength of association here may reflect a contextual strengthening of the inverse relationship; where, under the unfamiliar and challenging conditions of lockdown, those lacking in flexibility are tending towards more extensive avoidance. the isolative and restrictive pandemic context may mean that many individuals are unable to successfully draw on their usual repertoire of responses/ways of coping and default to behaviours that attenuate stress in the short-term; those with greater psychological flexibility may be relatively able to adapt and orient to alternative, personallyeffective ways of responding. it is also possible that the strengthened association arises from the more situated assessment of coping used in the current study, which may have helped to delineate individual differences that are less apparent in global assessments. however, we would generally expect stronger correlations in studies where both measures of psychological flexibility and coping are at the same global/trait-like level (hudson, anusic, lucas, & donnellan, ) . there are important limitations that must be considered when interpreting the findings of this study. our ability to draw robust conclusions about directionality was restricted by the cross-sectional, correlational nature of the data. when constructing and testing mediational models of indirect effects, we have relied on logical and theoretical bases for selecting and interpreting variables as predictor, mediator, or outcome variables. in practice, any observed concurrent relationship between psychological flexibility and outcomes of interest (e.g., wellbeing) could reflect multiple possibilities (e.g., psychological flexibility influences wellbeing, wellbeing influences psychological flexibility, bidirectional influence, a third variable [such as common method variance] influences both wellbeing and psychological flexibility, or a spurious correlation). going forward, we aim to collect data longitudinally to enable further testing of these relationships over time, more apt to establish temporal precedence (and to reflect the dynamic nature of psychological flexibility; kashdan & rottenberg, ) . notwithstanding the anonymous nature of data collection, the dependability of selfreport data on 'adherence' to social distancing guidelines was likely subject to social desirability and demand artefacts. more broadly, the self-report nature of the study limits our ability to infer relationships between ways of coping or psychological flexibility and subjective outcomes of interest, because respondents may struggle to accurately report on their coping behaviours or propensity to respond with flexibility. again, the strength of observed relationships between variables of interest is likely inflated by similarities in applied selfreport formats (common method bias) particularly given their spatial and temporal contiguity in cross-sectional survey designs. the subjective nature of the explanatory and outcome variables of interest would make it difficult to meaningfully apply alternative methods, but longitudinal measurement may help to reduce the additional proximity bias (pieters, ) . whilst our selection of focal variables and measures was informed by theoretical interests, relatability to extant literature, and consideration of response burden, we have doubtlessly excluded variables and measures that may have enabled additional insight into our outcomes of interest. the majority of variance in our focal outcomes remains unexplained by the measures used in this study, and it is likely that we are missing important explanatory information in terms of individual historical and situational contexts. moreover, expanded examination of coping and self-regulatory repertoires may have helped to account for relationships between psychological flexibility and health and wellbeing outcomes. whilst we can say that those higher in psychological flexibility are tending to make less use of avoidant coping, we know less about the form and frequency of any alternative behaviours that they are using -again, we would expect that contextual responsiveness is key here, and this is unlikely to be reflected in unconditional measures of coping 'styles'. whilst the applied chain-referral approach to recruitment is susceptible to bias, and might limit confidence in the broader representativeness of our sample, it was notable that responses from our participants converged with those from representative national surveys over the same timeframe (ons, ; e.g., proportion reporting that they are very or somewhat worried about covid- ). direct and systematic replications (across different contexts, populations, and measurement strategies) would enable appreciation of whether/to what extent our findings apply more broadly. strengths of the study include its focus on explanatory variables (psychological flexibility and coping styles) that are amenable to interventional change. whilst we found that some demographic variables (age, gender, and living arrangements) accounted for variance in outcomes of interest, the incremental explanatory power of (malleable) behavioural variables has clear implications for further research -indicating the potential value of examining whether interventions targeting psychological flexibility may be useful for promoting better psychological outcomes in the context of a pandemic. through explicit exploration of inter-relationships between explanatory variables of interest (psychological flexibility and coping styles) and their combined role in relation to important individual outcomes, another strength of the study is its empirical contribution to conceptual understanding. it is important to explore these relationships in the context of a naturalistic stressor, to understand whether theory-and logic-based assumptions hold under critical real-world conditions (i.e., the situations where our models become practically meaningful and potentially useful). the current covid- pandemic presents multiple potential stressors -including fears for the health and welfare of self and others, social isolation, loss of routine and contact with usual sources of positive reinforcement, and rapidly changing behavioural demands -in a context of indeterminate uncertainty. taken together, our findings demonstrate the value of psychological flexibility for understanding and predicting individual differences in how people proximally respond to -and are impacted by -these stressors. moreover, understanding these differences in terms of psychological flexibility has clear research implications: supporting testing of scalable contemporary cognitive-behavioural approaches that target psychological flexibility -whether in addressing individual support needs as they arise, equipping groups (e.g., key workers) with skills that may foster resilience, or promoting psychological health in the broader population. such approaches warrant further investigation and may hold promise for managing the current and longer-term psychological impact of the covid- pandemic. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. experiential avoidance as a moderator of the relationship between anxiety sensitivity and perceived stress acceptance and commitment therapy for anxiety and ocd spectrum disorders: an empirical review psychological resilience and dysfunction among hospitalized survivors of the sars epidemic in hong kong: a latent class approach the importance of being flexible: the ability to both enhance and suppress emotional expression predicts long-term adjustment the psychological impact of quarantine and how to reduce it: rapid review of the evidence effectiveness of webdelivered acceptance and commitment therapy in relation to mental health and wellbeing: a systematic review and meta-analysis you want to measure coping but your protocol'too long: consider the brief cope psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore experiential avoidance as a functional dimensional approach to psychopathology: an empirical review assessing coping flexibility in real-life and laboratory settings: a multimethod approach a power primer analysis of multiple dependent variables avoidant coping moderates the association between anxiety and patient-rated physical functioning in heart failure patients evaluating and establishing national norms for mental wellbeing using the short warwick-edinburgh mental well-being scale (swemwbs): findings from the health survey for england the buffer role of psychological flexibility against the impact of major life events on depression symptoms the development and validation of the comprehensive assessment of acceptance and commitment therapy processes (compact) diagnosing depression in primary care using self-completed instruments: uk validation of phq- and core-om psychometric properties of the impact of event scale- in a sample of victims of bank robbery assessing psychological flexibility: what does it add above and beyond existing constructs? psychological flexibility as a malleable public health target: evidence from a representative sample mental health consequences during the initial stage of the coronavirus pandemic (covid- ) in spain. brain, behavior, and immunity acceptance and commitment therapy-do we know enough? cumulative and sequential meta-analyses of randomized controlled trials introduction to mediation, moderation, and conditional process analysis: a regression-based approach acceptance and commitment therapy open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science. the lancet psychiatry comparing the reliability and validity of global self-report measures of subjective well-being with experiential day reconstruction measures the -year impact of severe acute respiratory syndrome on pulmonary function, exercise capacity, and quality of life in a cohort of survivors psychological interventions for patients with cancer: psychological flexibility and the potential utility of acceptance and commitment therapy coronavirus resource center coping and experiential avoidance: unique or overlapping constructs experiential avoidance as a generalized psychological vulnerability: comparisons with coping and emotion regulation strategies psychological flexibility as a fundamental aspect of health the phq- : validity of a brief depression severity measure quality of life and psychological status in survivors of severe acute respiratory syndrome at months postdischarge stress and psychological distress among sars survivors year after the outbreak an initial meta-analysis of acceptance and commitment therapy for treating substance use disorders. drug and alcohol dependence depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic the role of mindfulness and psychological flexibility in somatization, depression, anxiety, and general psychological distress in a nonclinical college sample long-term psychological and occupational effects of providing hospital healthcare during sars outbreak the psychological flexibility model: a basis for integration and progress in psychological approaches to chronic pain management adult psychiatric morbidity in england: results of a household survey development and validation of a short form of the comprehensive assessment of acceptance and commitment therapy processes (compact-sf). (doctorate in clinical psychology exploring the relationship between experiential avoidance, coping functions and the recency and frequency of self-harm psychological symptoms of the outbreak of the covid- crisis and confinement in the population of spain coronavirus and the social impacts on great britain data immediate psychological effects of the covid- quarantine in youth from italy and spain stress, anxiety, and depression levels in the initial stage of the covid- outbreak in a population sample in the northern spain meaningful mediation analysis: plausible causal inference and informative communication acceptance and commitment therapy: a meta-analytic review covid- and mental health: a review of the existing literature. asian journal of psychiatry is the effect of psychological inflexibility on symptoms and quality of life mediated by coping strategies in patients with mental disorders? at what sample size do correlations stabilize? psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease a brief measure for assessing generalized anxiety disorder: the gad- internal construct validity of the warwick-edinburgh mental well-being scale (wemwbs): a rasch analysis using data from the scottish health education population survey. health and quality of life outcomes brief measure of posttraumatic stress reactions: impact of event scale- . social psychiatry and psychiatric epidemiology profiles of psychological flexibility: a latent class analysis of the acceptance and commitment therapy model acceptancebased interventions for the treatment of chronic pain: a systematic review and metaanalysis immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the impact of event scale: revised cross-cultural assessment of psychological trauma and ptsd journal of traumatic stress: official publication of the international society for traumatic stress studies the self-perception of flexible coping with stress: a new measure and relations with emotional adjustment the authors have no competing interests to declare key: cord- -of w xr authors: dan, zhaokui title: china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: of w xr nan china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia. clinical medical college, hubei university of science and technology, xianning , china e-mail address: @qq.com a novel coronavirus pneumonia outbreak occurred in wuhan, hubei province, china in december , and was followed by worldwide concern. like all outbreaks, the first possible psychological response of the general population is fear and panic of being infected. they also fear that the epidemic will continue. at present, there is a lot of information about the epidemic on the internet. we don't know whether it is true or false. because of the novel coronavirus pneumonia, we cancelled all kinds of parties and could only stay at home, so life was boring. at this time, some people may have anxiety, depression, despair, anger and other emotional reactions (xiang et al., ) . people buy a lot of things by hearsay, such as masks, disinfectants and even vegetables in supermarkets. therefore, in fighting novel coronavirus ( -ncov) in , special attention should be paid to the mental health issues of the public (zandifar and badrfam, ) . how to alleviate the mental health of ordinary people is very important to control the epidemic situation and their own long-term health. for most of the public, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful (folkman and greer, ) . iranian scholars believe that what is important is that controlling the disease requires proper and comprehensive management (zandifar and badrfam, ) . as the chinese government has strong cohesion and efficiency, it has just an advantage in this respect. on january , , the national health committee of china released the guidance on national psychological crisis intervention in , which provided various guidances for people's mental health in epidemic areas. in order to better cope with the mass psychological injury and social impact caused by the epidemic, on march , , the national health commission of china announced the psychological counseling for novel coronavirus pneumonia. to solve these mental health problems, the local government of xianning city, which is adjacent to wuhan city, implemented the helpful policies in time. as psychiatrists can play pivotal role in supporting the well-being of those affected and their families, the at-risk healthcare staff as well as the public (banerjee, ) , the local government have organized psychological consultation team and mental health team to provide free psychological consultation service to relieve j o u r n a l p r e -p r o o f the psychological pressure of the masses. because people are isolated at home, the traditional face-to-face psychological consultation becomes impossible. basically, all psychological counseling is carried out through non-contact way. contacting by phone, qq or wechat, "one-to-one" psychological counseling can be carried out. the network also provides a variety of free movies and tv plays for the public to enjoy. as an affiliated hospital of the local medical college, our hospital has set up a psychological intervention group. the professional psychological doctors who have received the psychological assistance training in response to the -ncov provide psychological consultation for the public. some experts argue that it is debatable whether such interventions are universally appropriate for targeted populations, which include lay people, frontline responders, and family members of patients with covid- (yao et al., ) . but in the case of isolation of the whole country, online psychological consultation is the only way to be adopted, which is better than nothing. our practice also proves that most of the psychological pressure of the people who accept these interventions has been relieved. in march , , novel coronavirus pneumonia case was confirmed in hubei province, including in wuhan and in other cities. most of the local citizens have successfully overcome the psychological discomfort caused by the isolation period. the non-contact free psychological consultation has played the key role and may be used j o u r n a l p r e -p r o o f for reference for the efficiency and quality of future crisis intervention by the chinese government and other governments around the world. this work is supported by the doctor initiated fund project of hubei university of science and technology (bk ). the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. none of the authors have any conflicts of interest to disclose. the covid- outbreak: crucial role the psychiatrists can play promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other timely mental health care for the novel coronavirus outbreak is urgently needed rethinking online mental health services in china during the covid- epidemic iranian mental health during the covid- epidemic pay tribute to all health workers who are battling with the epidemic. key: cord- -d h ugpa authors: o’donovan, róisín; van dun, desirée; mcauliffe, eilish title: measuring psychological safety in healthcare teams: developing an observational measure to complement survey methods date: - - journal: bmc med res methodol doi: . /s - - -z sha: doc_id: cord_uid: d h ugpa background: psychological safety is a dynamic team-level phenomenon which exists when team members believe that it is safe to take interpersonal risks. in healthcare teams, the presence of psychological safety is critical to delivering safe care. scholars have highlighted a need for alternative measures which compliment survey-based measures of psychological safety in healthcare teams. methods: the exploratory phase of this study raised concerns about whether current survey measures could provide a sufficient understanding of psychological safety within healthcare teams to inform strategies to improve it. thus, previously validated psychological safety surveys and a meeting observation measure were adapted for use in healthcare teams. first, two group feedback sessions were held with healthcare professionals, as well as a systematic literature review. then, the members of eleven healthcare teams in ireland and the netherlands (n = ) took part in the pilot test of the adapted composite measure. results: the final composite measure has two parts: a team meeting observation measure and an adapted survey. the observation measure has observable behaviours fitting seven categories: voice, defensive voice, silence behaviours, supportive, unsupportive, learning or improvement-oriented and familiarity type behaviours. the survey part consists of items in three sub-dimensions related to; the team leader, other team members and the team as a whole. three additional items capture the perceived representativeness of the observed team meeting compared to other similar meetings. final adaptations were made in order to integrate the observation and survey measure. conclusions: the resulting composite measure combines the strengths of observational and survey measures and is tailored for use in healthcare teams. it is uniquely co-developed with healthcare professionals and grounded in the psychological safety and healthcare literature. this composite measure can enable longitudinal research on psychological safety and inform future research to develop and test interventions to improve psychological safety. psychological safety is fundamental to effective teamwork, communication, and collaboration at work. it is "a team level phenomenon where all team members believe they are safe to take interpersonal risks" ( [ ] , p. ). psychological safety is particularly relevant to healthcare teams because they work in a highly complex, dynamic, and high stakes work environment that requires them to work interdependently to co-ordinate safe patient care [ ] . healthcare teams need to be psychologically safe in order to maintain and encourage key outcomes, such as: patient safety [ ] [ ] [ ] , learning [ ] , and team performance [ ] . psychological safety also facilitates "teaming", an active process which allows multidisciplinary healthcare teams to work together to deliver increasingly complex patient care [ , ] . in psychologically safe team's essential teamwork processes can evolve, including mutual performance monitoring, mutual trust, decision making, team cohesion, team motivation, and conflict resolution [ ] . moreover, how healthcare professionals relate to their co-workers is deemed an antecedent of job satisfaction [ ] . to date, surveys have dominated the measurement of psychological safety [ ] . relying only on survey instruments can be burdensome for respondents and is limited by self-report bias [ ] [ ] [ ] . within a healthcare context, surveys are characterized by challenges such as respondent exhaustion and, consequently, low and declining response rates [ , ] . this is likely to have worsened recently as the ongoing covid- pandemic has increased both physical and mental exhaustion among healthcare professionals [ , ] . a recent paper by mathieu and colleagues [ ] calls for new methods of measurement which can complement surveys by providing additional insights into team dynamics. the observation measure presented as part of this paper addresses this need and allows for repeated tracking of healthcare team dynamics without requiring their time. observation measures can complement surveys as they provide a more objective understanding, that is not hindered by low response or high attrition rates [ ] . being able to assess changes in psychological safety over time is particularly important as healthcare teams adapt to the challenges of the pandemic through developing new collaborative practices and evolving models of care delivery. to date, empirical research has relied on cross-sectional, quantitative survey data to measure psychological safety [ ] . known survey measures of psychological safety ranged from three-to eight-item self-report scales [ , , [ ] [ ] [ ] [ ] . while these scales have strong psychometric properties for measuring psychological safety and have been used within a healthcare setting, they were not developed within a healthcare setting. as a result, they may need to be adapted to fit different cultural and/or professional settings [ ] . healthcare settings are characterised by unique concerns related to patient safety and the increasing complexity of the care. these issues highlight the importance of having measures which can offer an in-depth understanding of psychological safety which is specific to healthcare settings [ , ] . the current study presents the first survey measure of psychological safety which involved the target audience (healthcare professionals) in the process of adapting survey items. previous studies have highlighted that involving end users in survey development can improve accuracy, quality and relevance of survey research [ ] . to provide a more holistic understanding of psychological safety in healthcare teams, we also present an observational measure which complements the adapted survey. relying purely on survey measures is a key shortcoming of organisational behaviour research [ ] . welp and manser [ ] found that survey studies which examine teamwork, clinician well-being and patient safety, have failed to take a holistic approach which accounts for the complexity of healthcare teams and have focused on the individual profession rather than the entire multi-professional team. similarly, a recent systematic review of interventions aiming to improve psychological safety in healthcare teams, concluded that, in order to fully understand whether these interventions are successful, more holistic, objective measures are needed [ ] . observational techniques may offer insights into team psychological safety that the team themselves are not fully aware of and that complement findings from survey measures [ , , ] . recent literature reviews have highlighted the need for mixed-methods approaches to explore teamwork in healthcare and psychological safety [ , ] . the complementary strengths of survey and observational methods of measurement can offer a more holistic understanding of psychological safety at both individual and team levels [ ] . in this study, we respond to calls for improved, mixed method measures of psychological safety [ , ] . below we explicitly describe the methodology used to develop an observation measure that is grounded in the psychological safety and healthcare literature, to involve healthcare professionals in the adaptation of a psychological safety survey measure, and to pilot test both of these measures with healthcare teams. the present study aims to add to the existing body of literature by adapting current observational and survey measures, in collaboration with healthcare professionals, to provide a triangulated approach to measuring psychological safety at the team and individual level. for the purpose of this paper, a team will be defined as two or more healthcare professionals who: "socially interact (face-to-face or, increasingly, virtually); possess one or more common goals; are brought together to perform organizationally relevant tasks; exhibit interdependencies with respect to workflow, goals, and outcomes; have different roles and responsibilities; and are together embedded in an encompassing organizational system, with boundaries and linkages to the broader system context and task environment" ( [ ] , p. ). team leaders will be included as part of the team because of the influence they have on psychological safety and collaboration within their teams [ ] [ ] [ ] [ ] [ ] ] this is especially the case in healthcare teams where team leaders typically function as actively involved foremen or -women [ ] . in the exploratory phase of this study, psychological safety was measured in an acute hospital in ireland. while staff spoke about issues related to low psychological safety in their team or organisation, survey results did not reflect these issues. the full details of this exploratory phase can be found in appendix a, which is included as a supplementary file. feedback from participating healthcare professionals raised questions about the suitability of the survey questions for a healthcare context, as they experienced some difficulty in understanding and interpreting how the questions related to their context. in order to gain a more in-depth understanding of psychological safety within the case study hospital, the current study adapted the original survey items and developed a corresponding observation measure. various steps were taken to develop a composite measure of psychological safety for use within healthcare teams. the composite measure consists of two parts: an observational measure and a survey measure. both elements of the composite measure are adapted versions of previously used measures of psychological safety. figure illustrates the process through which the composite measure was developed, in two parallel streams. developing the observation measure component through reviewing the literature the observation measure was developed based on behaviours which were identified from seminal research outlined below and are presented in table . when developing an observation measure for team psychological safety, hoenderdos [ ] drew on conflict and information or knowledge sharing literature and identified behaviours relevant to psychological safety (see table ). these were observed in workplace teams. because these teams were not from a healthcare setting, the observation measure requires further development and validation for use with healthcare teams. since psychological safety may also be inferred from the extent to which people adopt learning behaviours within teams, the items developed by edmondson [ ] were included (see table ). these learning behaviours were identified during a study of teams in a manufacturing company. voice behaviours were also included, based on the work conducted by le pine and van dyne [ ] and van dyne et al. [ ] (see table ). the framework proposed by van dyne et al. [ ] is particularly helpful because it provides examples and definitions of behaviours associated with different types of employee silence and voice. to ensure that the observation measure was directly relevant to healthcare teams, behaviours were identified in a systematic review of enablers of psychological safety within a healthcare context [ ] (see table ). these behaviours were integrated into the observation measure to ensure it was suitable for use in a healthcare setting. the behaviours presented in the above literature generated a long list of potential items to be included in the observation measure. draft versions of the observation measure were reviewed and refined by the authors to ensure that each behaviour was observable and relevant to measuring psychological safety. as a criterion for inclusion the authors adhered to bergner's ( [ ] , p. ) definition, "behavior is any observable overt movement of the organism generally taken to include verbal behavior as well as physical movements". to ensure that healthcare staff could conduct routine, naked-eye observation assessments, [ ] , the observation measure had to fit on a single page and be easy to understand and use in the field. adapting the survey component through feedback sessions with healthcare professionals firstly, the survey component of the composite measure was adapted in consultation with healthcare professionals. involving service users in healthcare research can identify research priorities, frame more rigorous research questions and produce higher levels of participation [ ] . we conducted feedback sessions to adapt previously used psychological safety scale items for use in a healthcare context. the items which were adapted are presented in table . two group feedback sessions were conducted with healthcare staff, working in irish hospitals (session , n = ; session , n = ). all participants worked within different teams and were from different disciplines, including, nurses, consultants and physiotherapists. given that the focus of these sessions was on gaining feedback on the survey items, no further specific demographic details were collected from participants. the first session lasted min and the second session lasted min. the process for conducting these feedback sessions is presented in table . a pilot test was conducted to finalise the adapted composite measure. this pilot test was conducted within both irish and dutch hospitals. in ireland, six hospital teams, ranging from management to clinical teams, took part and in the netherlands, five nursing teams took part. the demographics of these teams are presented in table . the teams' weekly or monthly team meetings were observed, and team members completed the adapted survey. the pilot test was conducted over two phases (see fig. ). three irish and five dutch teams took part in phase one. in phase two, the composite measure was updated based on the results from phase one and was then pilot tested with three other irish teams. the adapted observation measure thirty behaviours were identified in the literature on conflict, information and knowledge sharing learning and voice behaviours and enablers of psychological safety in healthcare teams. these behaviours were grouped according to the following categories: voice behaviours, defensive voice behaviours, silence behaviours, supportive behaviours, unsupportive behaviours, learning or improvement-oriented behaviours, familiarity behaviours and safety oriented behaviour (see appendix b in supplementary files). users of the observation measure can track the behaviours being observed by making the appropriate mark in the "behaviour count" box. team members and team leaders' behaviours are placed in separate columns in order to account for differences in psychological safety according to status or hierarchy and to observe whether leadership behaviours are influencing levels of psychological safety in the team [ , ] . the observation measure also includes a section for capturing observers' overall ratings after the meeting. following the first feedback sessions, the items which at least % of the participants chose to include in their survey were identified. this was done in order to reduce the volume of items to be reviewed at the second session. thirteen items were retained (see table ) and were given to the second group of healthcare professionals. a second feedback session was conducted to check if other healthcare professionals agreed with the items chosen by the first group. more than % of the participants chose to include all survey items presented in the second feedback session (at least . % of participants agreed on retaining each item). only one reverse scored item was included in the final set of items. this was done in order to remain consistent with feedback from healthcare professionals, to keep items as close as possible to their original wording and to reduce any negative impact on reliability and validity [ ] . comments from both sessions were incorporated into the adapted set of survey items. the following section presents the main topics discussed during the feedback sessions. overall, the participants felt that the original scale items did not capture enough detail to accurately measure psychological safety within healthcare teams. in particular, three key points were raised by them: the sensitivity of certain words in healthcare settings, the importance of the target of voice, and the difference between speaking up about personal or work issues. first of all, the word "risk" was identified as a misleading word to use within a healthcare setting because it implies risky behaviour that could harm patients. the word "risk" appears in one of the items developed by edmondson [ ] ; "it is safe to take a risk on this team". participants suggested that this item could be broken down into specific interpersonal risks, such as making suggestions for change, asking questions or reporting mistakes. this would avoid the use of the word "risk" and would give more detail of the kinds of interpersonal risks respondents feel safe taking. healthcare professionals gained an understanding of psychological safety and the role it plays in teams. each participant was given items from six previously validated psychological safety scales (see table ). each item was printed on individual slips of paper. participants were invited to build their own measure of psychological safety by choosing the items they felt, based on their experience of working on healthcare teams, were most relevant. they could make any changes to the wording of items and add any relevant questions they felt were missing. each participant developed their own scale made up of the items they felt where most relevant to understanding psychological safety in healthcare teams. the scales they developed were collected and there was a group discussion. feedback from the group, along with the items they chose to include in their scales were recorded and used to inform the adaptation of the survey. check-up with literature the final scale was also reviewed to ensure the new items were in line with theoretical definitions of psychological safety from the literature ( , ) . adapted survey to be used in the pilot tests (see table ). moreover, participants noted that it can be more difficult to engage in speaking up behaviour when it is directed at a superior, rather than team members who they consider to be their peers. therefore, they suggested that items referring to feeling safe to voice opinions should be split into whether the respondent is voicing their opinion to their peers or to a superior. in line with this suggestion, questions referring to speaking up specified whether it was to a peer or a team leader. finally, healthcare professionals said that they would feel differently depending on whether they needed to speak up about a personal issue or a work issue. based on their discussion, they suggested that questions specify whether people feel safe speaking up about a) personal issues and b) work issues. the final list of items incorporated this feedback and can be seen in table . this adapted scale is an extended version of the six previously published and validated psychological safety scales presented in table . the items from these six scales are still present in our adapted version. the main difference between the adapted psychological safety scale and the original scales is that items are split into three sub scales: ) questions related to psychological safety in relation to the team leader; ) questions related to psychological safety in relation to peers/other team members of the team; and ) questions related to psychological safety in relation to the team as a whole. an iterative approach was taken to pilot testing the adapted composite measure (see fig. ). based on these experiences and initial reliability testing of the adapted survey scales the following changes were made to the original measures. behaviours which were observed during the team meetings and were not captured by the observation measure were added. these were: correcting others, sharing future plans, acknowledging achievements/ congratulating and delegating tasks. the behaviour "no eye contact (with speaker)" was deleted as it was already captured under "facial expressions indicate disengagement". the behaviour "leaders' words and deeds align" was deleted as it was not possible to observe this during team meetings. the category of behaviours originally labelled "safety-oriented behaviour" was removed and the remaining behaviour in that category, "informing the team about issues or mistakes related to patient safety" was moved to the category "learning or improvement-oriented behaviour". a section was added to record the duration of the observed meeting. this was done in order to allow future studies to standardize observations and compared them across teams. clear definitions of each behaviour in the observation were decided upon (see appendix c in supplementary files). the final observation measure had items which were grouped according to the following categories: voice behaviours, defensive voice behaviours, silence behaviours, supportive behaviours, unsupportive behaviours, learning or improvement-oriented behaviours and familiarity behaviours. changes made to the survey measure (see table ) the reliability outcomes from the teams which took part in pilot tests are presented in table . based on these pilot outcomes, the survey part of the measure was adapted in the following ways: for irish teams d-f and dutch teams g-k, the original likert scale of - was replaced by a scale of - , with one indicating strongly disagree and indicating strongly agree. the idea was to give participants an even wider spectrum of response options which allows the survey to capture more variability in participants' responses [ ] . the pilot tests conducted with irish teams a-c used a -point likert scale. moving to a -point scale did not improve reliability outcomes, compared to the teams which used a -point scale. when compared to point scales, -point scales have shown no marked difference in variance but have shown slightly lower mean scores [ ] . lastly, using a -point likert scale facilitates easier comparison between the adapted survey and the original psychological safety surveys. therefore, the adapted survey reverted to the - likert scale. section of the survey, referring to the team as a whole, had a cronbach's alpha which was below . for both dutch and irish teams (see table ). the low cronbach's alpha for this section can be explained by the fact that it had only three items [ , ] . in addition, this was the only section which included a reverse scored item, which may have negatively impacted reliability [ ] . the alpha if item deleted score revealed that the cronbach's alpha could be improved by removing the reverse scored item (question ). if question was removed the cronbach's alpha for section would have increased to . for irish teams a-c (full scale α: . ), . for dutch teams g-k (full scale α: . ) and . for irish teams d-f (full scale α: . ). therefore, it is recommended that this item should be changed to have the same polarity as the other items: "it is easy to ask other members of this team for help". three extra questions were added in order to capture participants' perceptions of the representativeness of the observed meeting compared to other similar meetings [ ] . participants responses to these questions suggested that the meeting observed was not very different from other similar meetings. this outcome is also consistent with the fact that there was little reactivity to the researcher's presence during the regular team meeting. a final adjustment was made to the observation measure in order to ensure that the observation and the survey measure could be integrated together, as well as to ease the analysis and comparison between the two. this final version of the observation measure included the target of each behaviour, specifically, whether the actor was directing their behaviour towards the team leader, other team members, or the team as a whole. in this version of the observation measure, there are two separate sections for recording team member behaviours and team leader behaviours. in addition, there is space for calculating the total score for both team leader and team survey results for irish teams d-f and dutch teams g-k were rescaled to a - scale for this analysis, in order to make all teams comparable members in categories that indicate a high score of psychological safety (voice behaviours, supportive behaviours, learning or improvement behaviour and familiarity behaviours) and the total score for the categories that relate to lower psychological safety (defensive voice behaviours, silence behaviours and unsupportive behaviours). this final observation measure is integrated with survey results and is presented in table . table contains dummy data in order to visualise one of the various ways the data can be represented within the composite measure. we designed the composite measure such that the data collected through the observation and survey methods can be triangulated during data analysis. to highlight the complementary components of the observation and survey measure, table presents the items which theoretically correspond to one another. in the final version of the composite measure, both the observation and survey data are split according to psychological safety related to; team leaders, other team members and the team as a whole. presenting the results in this form facilitates comparison and triangulation of the results from both the observation and survey measures. while it would not be appropriate to combine the observation and survey results into one score, it is possible to triangulate both outputs to gain a more robust understanding of psychological safety within teams. for example, by comparing team members response to section of the survey to the behaviours team members display towards their team leader during the observed meeting we can gain a better understanding of team members feelings of psychological safety in relation to their team leader. triangulating the results from both measures can also facilitate exploration of whether team members feel more psychologically safe around their team leader or with other team members. we can better understand any differences in psychological safety by comparing the amount of voice behaviour team members direct towards other team members and their scores in the second section of the survey to the first section of the survey and the behaviour directed towards their team leader. previous studies identified the need to adapt and triangulate existing measures of psychological safety in healthcare teams to capture a more accurate and nuanced understanding of it at both individual and team levels [ , ] . building on previous research and feedback from healthcare professionals, this study describes the methodology used to adapt observational and survey measures of psychological safety, specifically for use within healthcare teams. the resulting adapted composite measure addresses concerns raised by healthcare professionals during the exploratory phase of this study, namely, that survey respondents may not have fully understood the questions, that the questions may not have been suitable for a healthcare context or that only the staff members with high psychological safety had responded to the survey. the adapted composite measure addresses these issues; since the survey items were adapted based on feedback from healthcare professionals, they are easily understood by healthcare professionals and directly relevant to a healthcare context. the observation measure provides a way to capture a team level measure of psychological safety that also includes staff members who do not complete the survey. in addition, the observation measure addresses calls for new methods of measurement that can complement survey measures and provide further insights into team dynamics, while minimising intrusiveness [ ] . the similarities between the feedback from healthcare professionals and the psychological safety literature highlight the relevance and importance the adapted measure. the healthcare professionals highlighted a concern for patient safety, which has been found to facilitate psychological safety in healthcare teams [ , ] . the importance of the target of voice was also highlighted as an issue. as noted by amy edmondson in her academy of management conference keynote speech, rolebased status in teams may explain differences in team psychological safety. healthcare professionals at the lower end of the hierarchy find it more difficult to speak to their superiors [ , ] . since the participating healthcare professionals recognised this, the resulting composite measure clarifies who participants feel comfortable speaking up to -their peers or their team leader. the deliberate inclusion of common components across the survey and observation elements are a key strength of this adapted measure as it facilitates triangulation. the survey provides an understanding of individuals' perceptions of psychological safety in relation to different organisational levels and regarding both professional and personal issues, while the observation measure targets observable behaviours associated with psychological safety at both the individual and team level. as previously mentioned, survey measures can be vulnerable to self-report bias, low response rates and are less suitable for longitudinal research due to response fatigue [ , , ] . the observation measure compensates for these shortcomings by offering a more objective measure of psychological safety which can be repeated multiple times during longitudinal studies of psychological safety [ ] . given that psychological safety is seen as a state that can fluctuate over time, such longitudinal studies are called for [ ] . the observation measure also talking about personal, non-work matters laughing about a joke total observed behaviour offers an opportunity to capture data from employees who do not complete the survey and, as a result, reduce non-response bias. using the observational and survey measures together also respects that the behaviour associated with silence and voice can contain elements of ambiguity [ ] , which make them challenging to interpret. to address this issue, the observation measure includes both verbal and non-verbal behaviours and individuals' survey responses can further clarify any ambiguity in the observed behaviours. the results from both measures can be triangulated to understand the differences and similarities between self-reported levels of psychological safety and a more objective group level measure, thus providing a more robust and accurate assessment. a key strength of this study is that we have adapted and further developed existing measures of psychological safety rather than developing entirely new ones. the observation component is equally grounded in the healthcare and psychological safety literature and offers a dynamic, team-level measure of psychological safety. the survey component is based on valid and reliable survey items and has been adapted based on feedback from healthcare professionals to ensure it is tailored for healthcare settings. it is the first survey measure of psychological safety to have involved the target audience (healthcare professionals) in the developmental stage. this improves the accuracy, quality and relevance of the adapted survey [ , ] . although a limitation of this study is the relatively small number of healthcare professionals who participated in the feedback sessions, the same issues came up in both sessions, suggesting a sufficient level of data saturation. in addition, all members of the second feedback session agreed on the use of the scale items included in the final survey. as well as explicitly describing the methodology used to adapt an observational and a survey measure of psychological safety, which is tailored for use within healthcare teams, this study pilot tests the resulting composite measure. this pilot test was conducted in both dutch and irish hospitals, offering preliminary evidence that the composite measure is suitable for use within different cultural contexts. in addition, the pilot test was conducted with a variety of healthcare team types, including uni-disciplinary nursing, physiotherapy and speech and language teams as well as multidisciplinary clinical and management teams. as a result, the composite measure is also suitable for use within a wide variety of healthcare team types. given that this study covers the process of developing and pilot testing the adapted composite measure of psychological safety, future more rigorous testing with larger samples is necessary in order to examine its construct validity and reliability and further develop it. this future testing will enable the incorporation of feedback from a larger sample of healthcare professionals and will contribute to the development of normative data for the instrument. further testing of the composite measure should also build on the theoretical link between the observation and survey items to test whether scores on the observation measure items are statistically correlated with behaviour counts for the corresponding survey items. individual interviews with members of the healthcare teams are needed to gain information on individuals' experiences on the team, their experience of completing the survey and of their team being observed. in subsequent stages we hope to observe regular team meetings with a video camera to enable the involvement of multiple independent raters, including the calculation of inter-rater reliability coefficients [ , ] . the observational component of this measure will facilitate longitudinal research on psychological safety, which has been limited to date [ ] . longitudinally applying this new composite measure will allow researchers to gain a more dynamic and holistic perspective of psychological safety which will expand our knowledge of how psychological safety works within healthcare teams. this will address the call made by welp and manser categories indicating lower psychological safety: (defensive voice behaviours, silence behaviours and unsupportive behaviours). use of inclusive language such as "we" na agreeing/responding positively or enthusiastically to input q , q acknowledging achievements/ congratulating one another q delegating tasks q , q interrupting q , q discussions within small sub-groups q , q reacting cold/ignoring a joke na reviewing own progress and performance q , q , q , q , q asking for feedback q , q asking for help or solutions q , q , q asking for input from all meeting participants q , q , q informing the team about issues or mistakes related to patient safety q , q , q , q , q , q looking for improvement opportunities and speaking up with ideas q , q , q acknowledging own mistake q , q talking about personal, non-work matters q , q laughing about a joke na there was enough opportunity for participants to ask for help q , q , q there was enough opportunity for participants to speak up q , q , q , q , q , q , q , q , q , q , q , q , q there was enough opportunity for participants to discuss with the team leader q , q , q , q , q , q , q certain team members dominated the discussion q , q psychological safety and learning behavior in work teams making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study psychological safety: the history, renaissance, and future of an interpersonal construct psychological safety: a systematic review of the literature teaming: how organizations learn, innovate, and compete in the knowledge economy teaming: an approach to the growing complexities in health care: aoa critical issues measuring teamwork and taskwork of community-based "teams" delivering life-saving health interventions in rural zambia: a qualitative study an instrument to measure job satisfaction of nursing home administrators a century of work teams in the journal of applied psychology understanding self-report bias in organizational behavior research towards an observational measure for team psychological safety recruiting general practitioners for surveys: reflections on the difficulties and some lessons learned health care provider surveys in the united states, - : a review patient safety recommendations for covid- epidemic outbreak covid- : protecting health-care workers the development and construct validity of a team processes survey measure the personality of teamworking. pers manag understanding outcomes of organizational learning interventions leadership behavior and employee voice: is the door really open? is yours a learning organization? cross-cultural adaptation of research instruments: language, setting, time and statistical considerations understanding psychological safety in health care and education organizations: a comparative perspective user involvement in designing a survey of people directly employing care and support workers integrating teamwork, clinician occupational well-being and patient safety-development of a conceptual framework based on a systematic review a systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour development and testing of the cancer multidisciplinary team meeting observational tool methodological fit in management field research finding common ground? evaluating an intervention to improve teamwork among primary health-care professionals a systemic approach to developing frontline leaders in healthcare predicting voice behavior in work groups conceptualizing employee silence and employee voice as multidimensional constructs* a systematic review of factors that enable psychological safety in healthcare teams what is behavior? and so what? cross-disciplinary care: a systematic review on teamwork processes in health care the case for user involvement in research: the research priorities of cancer patients careless responding to reverse-worded items: implications for confirmatory factor analysis choosing response scale labels and length: guidance for researchers and clients do data characteristics change according to the number of scale points used? an experiment using -point, -point and -point scales what is coefficient alpha? an examination of theory and applications making sense of cronbach's alpha a complex adaptive systems approach to real-life team interaction patterns, task context, information sharing, and effectiveness systematic behavioral observation for emergent team phenomena: key considerations for quantitative video-based approaches leadership behaviors during lean healthcare implementation: a review and longitudinal study reflections on leadership in the time of covid- enhancing the effectiveness of work groups and teams publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank es for her contribution to the data collection in the dutch teams.authors' contributions all authors were involved in the design and planning of this study. rod completed data collection and developed the first draft of the adapted measures. rod conducted the pilot tests of the adapted measure in ireland and dvd supervised the pilot testing in the netherlands. all authors were involved in editing and finalising the adapted measures. rod drafted the manuscript, dvd and emca contributed to writing and revising the paper. all authors read and approved the final manuscript. this research is funded by the irish research council and the ireland east hospital group under the employment based partnership scholarship. the funders did not play a role in the design of the study, data collection, analysis and interpretation or in writing the manuscript. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. [ ] , for measures of teamwork in healthcare to account for temporal instability of healthcare teams. healthcare teams can use this composite measure to learn about and improve psychological safety within their team. harris et al. [ ] suggest that it is feasible for healthcare professionals to undertake structured observational assessment and teams find feedback from such observations useful. we anticipate healthcare professionals using our observation measure to observe teams within their hospital to better understand psychological safety and stimulate team learning accordingly. it can also be used by team leaders or their coaches to identify observable behaviours related to psychological safety in their team. being more conscious about such behaviours enables team leaders to find the root causes and act upon them. the outcomes of our work also inform human resource professionals. they can train team members to detect psychologically unsafe work situations and adopt relations-oriented behaviours that support a more psychologically safe, inclusive work climate instead [ ] .given the important role of psychological safety in healthcare teams, there is a need to understand the concept fully in order to consider how it can be improved [ , ] . creating and maintaining psychological safety will be paramount in dealing with the covid- crisis [ ] . healthcare teams will be required to draw on knowledge and learning from all parts of the healthcare system in order to make quick decisions, learn from mistakes and implement changes that will facilitate the safe delivery of care [ ] . by gaining a better understanding of psychological safety in healthcare teams and using this knowledge to develop and implement interventions to improve psychological safety, we can increase team's ability to learn, co-ordinate care and make decisions that will ultimately result in higher team performance. to date, there has been little guidance on how teams can introduce, improve, and maintain psychological safety. a recent systematic review identified both a lack of interventions targeting psychological safety and a lack of objective measures for identifying improvements in psychological safety [ ] . the adapted measure presented in this article can be used to both inform the development of interventions to improve psychological safety, by gaining a more holistic understanding of it, and to assess the effectiveness of these interventions. this study describes the methodology used to adapt observational and survey measures of psychological safety for use within healthcare teams, by building upon the feedback retrieved from the target audience: healthcare professionals. it also reports on a pilot test of the resulting composite measure. the adapted composite measure combines the strengths of observational and survey measures in order to gain a more holistic, nuanced understanding of psychological safety within healthcare teams, enable longitudinal research on psychological safety and inform future research to develop and test interventions to improve psychological safety. supplementary information accompanies this paper at https://doi.org/ . /s - - -z.additional file : appendix a. exploratory phase description. not applicable. the authors declare that they have no competing interests.author details key: cord- -be q authors: das, nileswar title: psychiatrist in post-covid- era – are we prepared? date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: be q • first communication from india with psychiatry residents perspective. • authors had first-hand experience of working in the covid designated areas. • highlights the need of the hour. at the time of writing this letter (end march ) the world is facing one of the most feared pandemic of all time named -covid- , caused by a novel corona virus, sars-cov- (anon., ). although the disease started in december in china, but rapidly progressed to affect more than half a million people across countries (till . . ) and these numbers are only expected to rise further. a time when world's best health-care facilities and global public-health researchers are in dare setback, it's worth raising the question that, are we prepared enough to handle the psychological ill-effect and psychiatric issues that are anticipated in post-pandemic periods? fear and anxiety are common psychological response during disastrous situations like this (dong and bouey, ) . but undue prolonged stress with social isolation can act as a table niche for developing a pathological mental state (goyal et al., ) . while higher income countries already apprehending worse recession and socioeconomic setbacks, low-and-middle income countries like india is high likely to face the worse. many already proven social factors like: being sick, prolonged hospitalization, death of loved ones, loss of job, months of forced quarantine, lack of supply, stigma -is likely to hit us all, especially those who are more vulnerable to stress and already suffering from mental illness (mak et al., ; brooks et al., ) (table ) . we are among few, in our institute, being involved since beginning in active management of covid- cases. we found, many patients in the designated isolation ward had reported -excessive fear, restlessness and sleep disturbances during hospital stay. many frontline healthcare workers had shown signs of anxiety and depression. therefore, we as psychiatrists need to take urgent action in finding and managing such issues. acute medical emergency may last many months and may be year (s) -and therefore until we have an effective preventive or curative treatment for covid- , primary focus would continue to be manpower development and resource allocation for detection and management of active cases. however, at the same time we cannot ignore the psychological aftermath of this pandemic. three primary concerns to be addressed by fellow psychiatrists are: ( ) generating evidence by well conducted studies, ( ) generating awareness and psychological preparedness among common men and essential service providers, ( ) delivering active psychological and psychiatric intervention to those in need. well-conducted studies are needed to assess, (i) the magnitude (i.e. spectrum and severity) of various psychological problems -aiding the policymaking process, (ii) the immediate and long term psychological consequences of such life-changing events in various subgroups of the population, and (iii) the response to various therapeutic interventions. we believe, use of digital media (telepsychiatry) for early and active search of individuals with psychological infirmity, and also as mode of delivering information and psychological interventions can be an effective tool to reduce the sufferings of all vulnerable individuals (liu et al., ) . later, integration of public mental health -delivering essential psychiatric and psychological services may become pivotal. humanity has faced worse during two previous world-wars but we cannot wait until we heal. psychiatrists have to be the flag-bearer of the best known medicine of all time -hope. the present study was non-funded. the authors do not have financial disclosures the authors do not have any conflicts of interest to report table possible vulnerable groups, risk factors and psychological symptoms in the aftermath of pandemic. naming the coronavirus disease (covid- ) and the virus that causes it the psychological impact of quarantine and how to reduce it: rapid review of the evidence early release -public mental health crisis during covid- emerging infectious diseases journal -cdc fear of covid : first suicidal case in india! online mental health services in china during the covid- outbreak long-term psychiatric morbidities among sars survivors dr siddharth sarkar, assistant professor of psychiatry, aiims, new delhi -for his constant encouragement and constructive inputs. key: cord- -gtvi gh authors: flesia, luca; monaro, merylin; mazza, cristina; fietta, valentina; colicino, elena; segatto, barbara; roma, paolo title: predicting perceived stress related to the covid- outbreak through stable psychological traits and machine learning models date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: gtvi gh the global sars-cov- outbreak and subsequent lockdown had a significant impact on people’s daily lives, with strong implications for stress levels due to the threat of contagion and restrictions to freedom. given the link between high stress levels and adverse physical and mental consequences, the covid- pandemic is certainly a global public health issue. in the present study, we assessed the effect of the pandemic on stress levels in n = italian adults, and characterized more vulnerable individuals on the basis of sociodemographic features and stable psychological traits. a set of psycho-social variables, generalized regressions, and predictive machine learning approaches were leveraged. we identified higher levels of perceived stress in the study sample relative to italian normative values. higher levels of distress were found in women, participants with lower income, and participants living with others. higher rates of emotional stability and self-control, as well as a positive coping style and internal locus of control, emerged as protective factors. predictive learning models identified participants with high perceived stress, with a sensitivity greater than %. the results suggest a characterization of people who are more vulnerable to experiencing high levels of stress during the covid- pandemic. this characterization may contribute to early and targeted intervention strategies. sars-cov- (severe acute respiratory syndrome coronavirus ; henceforth referred to as covid- ) is a strain of coronavirus that can infect humans, attacking the lungs and causing symptoms ranging from those of the common cold to those of severe acute respiratory syndrome (sars) [ ] . while approximately % of those who are infected recover with no special treatment (i.e., they are either asymptomatic or suffer from mild pneumonia) [ ] , recent data have confirmed that older persons ( + years old) [ ] and persons with certain pre-existing medical conditions are more likely to develop serious respiratory distress that can lead to death ( - % of the population) [ ] . covid- spreads very easily between persons and, at the time of writing, no drugs or biologics have proven effective for preventing or treating the virus [ , ] . covid- was first identified in the chinese region of wuhan in december [ ] . between december and april , the virus spread throughout the world, causing more than , , infections and over , deaths [ ] . on march , the world health organization (who) declared covid- a pandemic [ ] . to contain the number of victims and prevent the collapse of the healthcare system, most national governments imposed strict restrictions on residents' freedom, forcing those infected with the virus to self-isolate and requiring all residents (infected or not) to stay at home and move through public areas only for reasons of absolute necessity. among western governments, the italian government was the first to apply such restrictions [ ] . a few weeks after the spread of covid- in china, the first scientific studies investigating the psychological impact of the outbreak highlighted a mild to severe negative psychological impact of the event within a significant proportion of the chinese population ( . %); specifically, this impact on mental health was reported to include symptoms of anxiety, depression, and stress [ , ] . more broadly, the literature on the impact of infectious outbreaks on mental health shows that pandemics are extremely stressful events that force people to cope with totally unexpected, ambiguous, and uncertain situations [ ] . specifically, two main aspects of pandemics have been found to affect people's mental state. the first relates to danger (i.e., the fear of contagion), which can increase perceived threat and sometimes lead to panic, behavioral contagion, and an emotional epidemic [ , ] . the second regards the multiple and rapid changes to social, working, and familiar habits, due to self-isolation and social distancing measures [ ] [ ] [ ] [ ] [ ] . the longer the duration of self-isolation, the more people experience frustration and boredom, along with concerns about infection [ ] . well-documented psychological reactions to epidemics include emotional distress, anxiety behaviors, sleeping disorders, fear, anger, depression, health concerns, a sense of powerlessness, and uncertainty [ , , [ ] [ ] [ ] [ ] [ ] . furthermore, studies examining the long-term consequences of infectious epidemics have shown that some individuals may even develop symptoms of post-traumatic stress disorder (ptsd) [ , , ] . one review indicated that those who develop ptsd may experience the symptoms for years following the end of the epidemic [ , ] . stress is defined as an adaptive psycho-physical reaction to a physical, social or psychological stimulus, called a stressor [ ] . stress-related responses may be cognitive, emotional, behavioral, or physiological. depending on the type, timing, and severity of exposure to a stressor, the resulting stress may become a risk factor for a number of illnesses, including those of a psychiatric or cardiovascular nature [ ] [ ] [ ] [ ] [ ] . an emergency such as the covid- outbreak might rightly be considered a severe stressor, as it is a new and unexpected situation with a potentially serious impact on health (experienced both personally and through loved ones) that also involves social restrictions [ ] . nevertheless, no event, in and of itself, is the precipitating cause of pathology and illness. rather, it is the perception of stress (i.e., the degree to which one considers the event stressful) that accounts for the varying physical and mental responses to the situation [ ] . in this sense, it is important to detect vulnerable persons early, and to promote effective preventive programs in order to treat such persons rapidly and limit negative psychological outcomes. the identification of psycho-social risk and resilience factors for psychological distress during the covid- emergency comprises a significant step in this direction [ ] . to date, studies on the psychological impact of covid- have mainly focused on the role of sociodemographic variables (e.g., gender, age, education level, and social connections) in moderating reactions to the outbreak [ , , , , ] . the identified sociodemographic risk factors for psychological distress include gender (female), age ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or + years old), student status, education level, perception of the public health system, specific physical symptoms (e.g., coryza, cough, sore throat, headache), and a low reported level of health [ , , ] . for chinese students, living in an urban area, having a stable family income, living with parents, and having good social support were also found to protect against anxiety [ ] . in addition to investigating sociodemographic factors, many studies have also outlined the role of certain dispositional traits in modulating responses to stressful events. however, these constructs have been poorly investigated in relation to the psychological impact of epidemics and, specifically, covid- . more generally, research has shown how individual differences, including dispositional traits, can explain life outcomes [ ] . according to the theory of traits (or dispositional theory), individual differences may be explained by certain predispositions (traits), which are expressed in a relatively stable way across situations and time. traits comprise a person's manner of thinking, feeling, perceiving, and relating to others [ ] . based on these considerations, dispositional traits might play a relevant role in predicting perceived stress in relation to coping is one of the most widely studied dispositional traits, and it has been found to be significant in modulating responses to stressful events. coping is defined as the effort to solve personal and interpersonal problems in an attempt to master, minimize, or tolerate stress and conflict [ ] . distinct coping strategies have been found to be differentially associated with specific emotional responses [ ] , physiological stress responses [ ] , and self-efficacy [ , ] . one investigation into the role of coping strategies during a virus outbreak ( h n flu pandemic) found coping style to influence the perceived risk of contagion and vaccination intentions among canadian adults [ ] . another study, based in singapore, found coping strategies to be associated with post-traumatic outcomes within visitors to community health care services during the national outbreak of sars [ ] . as regards emotional self-regulation and adaptation to the world, self-control may represent a significant protective factor. there is empirical evidence that people with high dispositional self-control have better psychological adjustment and impulse control [ ] ; this suggests that good self-control may mitigate the influence of a negative environment. similarly, perceived control over life outcomes has been shown to be positively associated with well-being and health-related quality of life, and negatively associated with emotional distress, in the context of stressful events [ , ] . in this regard, locus of control [ ] is a relevant concept, describing the degree to which an individual believes that they have control over the outcome of life events, as opposed to feeling that their life is subject to external forces beyond their control. finally, among the many individual difference variables that might influence reactions to covid- , personality traits merit significant attention. several studies have highlighted an association between the big five personality traits [ ] and various health behaviors, such as sedentary behavior [ ] , sexual health behavior [ ] , physical activity [ ] , and alcohol consumption [ ] . the first aim of the present study was to investigate the impact of the covid- pandemic and the related government-imposed restrictions on perceived stress in a western country (i.e., italy). as reported above, most studies on the psychological impact of covid- have related to the chinese population. however, countries differ from one another in many important aspects (i.e., social, cultural, political, and economic aspects, to name only a few); consequently, psychological responses may also vary between contexts and communities, revealing unique qualitative and quantitative psychological reactions and psychological needs. our sample of italian adults, collected during the covid- outbreak, would show higher levels of perceived stress compared to italian normative values. the second aim of the study was to confirm the role of certain sociodemographic factors in modulating stress responses to the covid- pandemic, as reported in the recent literature. (a) participants who were female, younger, and students, with a lower level of education and lower income, would report higher levels of stress, and (b) participants who were living with others would report lower levels of psychological distress. the third aim of the work was to investigate the association between certain stable psychological traits and psychological distress relating to the current situation. to this end, participants were tested for coping strategies, self-control, locus of control, and select personality traits. (a) participants with positive coping strategies, higher levels of self-control, an internal locus of control, and higher levels of emotional stability would report lower levels of stress, and (b) participants with negative coping strategies, lower levels of self-control, an external locus of control, and lower levels of emotional stability would report higher levels of stress. finally, with the goal of anticipating persons in need of treatment and improving the targeting and overall effectiveness of preventive programs, we aimed at developing machine learning models to predict individual psychological responses to the covid- pandemic, based on sociodemographic and psychological variables with maximal sensitivity in classifying subjects with high versus low levels of perceived stress. to summarize, the study was novel in the following two respects: first, it considered the role of not only sociodemographic variables, but also stable psychological traits, as predictors of a stressful reaction to covid- ; and second, it leveraged machine learning techniques to identify people at the greatest risk of developing severe and negative psychological outcomes due to the pandemic. to test the abovementioned hypotheses, we implemented a cross-sectional study. using google forms, we designed an ad hoc online questionnaire to collect data on participants' stress reactions to covid- , demographical variables, and psychological traits. the questionnaire also assessed the following sociodemographic factors: gender, age, education, number of family members and/or others living in the household, monthly household income, and student status. subsequently, we administered five standardized questionnaires, as follows: • the italian version of the -item perceived stress scale (pss- ; cronbach's alpha = . ) [ ] . the pss- is a frequently used psychological instrument to measure perceived stress [ ] . respondents are asked to answer questions pertaining to the frequency of experiences of stressful situations during the last month on a five-point scale ranging from (never) to (very often) [ , ] . example items include "in the last month, how often have you been upset because of something that happened unexpectedly?" higher scores indicate higher levels of perceived stress. moreover, in the present study, the score corresponding to . sd above the italian normative score [ ] was used as a cut-off to divide participants into two classes: low perceived stress (males: pss- score < . ; females: pss- score < . ) and high perceived stress (males: pss- score ≥ . ; females: pss score- ≥ . ); • the italian shortened version of the coping orientations to the problems experienced (cope-nvi- ; cronbach's alpha of factors range . - . ) [ ] . the cope-nvi- is a multi-dimensional inventory that assesses individual differences in coping styles. it is comprised of items, which are rated on a -point scale ranging from (i usually don't do this at all) to (i usually do this a lot) [ ] . the instrument includes five subscales corresponding to five different coping styles: social support, avoidance strategies, positive attitude, problem solving, and turning to religion [ ] . an example item is "i admit to myself that i can't deal with it, and quit trying" (avoidance strategies). a higher score on a particular subscale indicates a greater use of that specific coping strategy. the italian translation of the brief self-control scale (bscs; cronbach's alpha = . ) [ ] . the bscs measures individual differences in dispositional capacity for self-control. the scale is comprised of items that are rated on a five-point scale ranging from (not at all) to (very much). an example item is "i do certain things that are bad for me, if they are fun." higher scores on the bscs indicate a greater capacity for self-control, and they are also correlated with better psychological adjustment, interpersonal skills, and emotional responses [ ] ; • the italian short version of the locus of control (loc) scale [ ] . this -item questionnaire is used to measure generalized expectancies relating to an internal versus external locus of control, rated via dichotomous options ("yes" vs. "no"), similar to rotter's original internal-external locus of control scale [ ] . an example item is "to do well in life, luck is more important than commitment." respondents with an internal locus of control (i.e., a high score on the internal loc scale) tend to attribute life outcomes-and general life events-to their own behavior, whereas those with a prevalent external locus of control (i.e., a high score on the external loc scale) tend to attribute life events to fate, others, or external causes beyond their control [ , ] ; • the italian version of the -item big five inventory (bfi- ; spearman-brown coefficients ≥ . ) [ ] . the bfi- assesses personality traits according to the five-factor approach [ ] . it is comprised of items rated on a five-point scale ranging from (strongly disagree) to (strongly agree), measuring five dimensions of personality, which are extraversion, agreeableness, conscientiousness, neuroticism (or, if reversed, emotional stability), and openness [ ] . an example item is "i see myself as someone who is outgoing, sociable" (extraversion). the higher the score on a particular subscale, the more that specific dimension represents a characteristic trait of the respondent's personality. the complete list of variables that were extracted from the responses to the questionnaire is provided in the supplementary materials. the present research was designed in accordance with the declaration of helsinki and approved by the ethics committee for psychological research at the university of padova (protocol number , unique code b fe f a d b d bb). data were collected during the period of - march, . participants were recruited online through an invitation posted on social media (facebook and whatsapp). this approach of online recruitment was selected primarily due to the lockdown situation, which prevented us from collecting data in the laboratory. according to the aim of the study, it was necessary for us to capture the psychological state of participants at the time of the pandemic; thus an a posteriori study would not have provided useful and reliable information. participants were invited to complete an anonymous online questionnaire to report their personal experiences with the covid- emergency and their mental state. the inclusion criteria were the following: (a) living in italy at the time of data collection and (b) being aged + years ( years is the legal age in italy, defined by the capacity to act and be emancipated). participation was voluntary. all participants were required to read and provide informed consent before beginning the online questionnaire. they received no compensation for their participation. in total, volunteers took part in the study. of these, were excluded on the basis that they responded to the questionnaire twice (we kept only their first response). thus, the final sample was comprised of participants, of whom were female, were male, and were reported as "other." the participants' average age was . (sd = . ; range: and their average education level was . years (sd = . ; range: - ). a more detailed description of the sample's demographic characteristics is provided in the supplementary materials. it has been calculated that a sample size of is sufficiently large to achieve at least a statistical power ( -β) = . in a linear multivariable regression analysis involving predictors, given a significance level α = . and an effect size of . [ ] . data are provided in the supplementary materials. data analysis was conducted using the jasp software [ ] . a single sample t-test (t, two-sided) was performed in relation to the pss- score, in order to determine whether the sample's true mean (µ) was statistically different from that of the known population (m ). a multivariable regression analysis was run to investigate the relationship between the pss- score and the independent variables that were hypothesized to impact the level of perceived stress. the collinearity assumption was checked prior to running the model, using the tolerance and variance inflation factor (vif). as a rule of thumb, if vif > and tolerance < . , the assumption is greatly violated, whereas if vif > and tolerance < . , the model may be biased [ ] . the results indicated that the collinearity assumption was not violated by any of the independent variables entered in the regression model. the analysis was performed using the stepwise variable selection method, which identified predictors with a significant (p < . ) individual association with the outcome (pss- score). the results were reported using unstandardized coefficients, as recommended by friedrich [ ] . recently, researchers in different scientific fields, including the clinical and social sciences, have emphasized the utility of focusing on prediction, rather than explanation, during data analysis [ ] [ ] [ ] [ ] . this increased attention to predictive models may be largely attributed to the significant spread of machine learning (ml)-a branch of artificial intelligence that trains algorithms on data samples (i.e., training sets) in order to make predictions on completely new data (i.e., test sets) without being explicitly programmed to do so [ ] . as regards psychology, ml techniques have been shown to be particularly useful for predicting human behavior, including high-risk behavior; thus, they may be applied to improve the effectiveness and targeting of preventive programs and interventions [ ] . in brief, ml models are capable of predicting the behavior of individual subjects, allowing greater attention to be paid to those considered most critical [ ] . in the present study, ml algorithms were trained on psycho-social data to identify subjects who were more likely to present high levels of perceived stress during the covid- emergency, and who were consequently at the greatest risk of developing psychological symptoms, including those of ptsd. for this purpose, participants were split into two classes: high perceived stress and low perceived stress. the high perceived stress class included participants with a pss- score of more than . sd above the italian population mean (n = ) for men and women, respectively. conversely, the low perceived stress class included participants whose pss- did not exceed . sd above the italian normative value (n = ). it should be noted that participants who reported their gender as "other" (n = ) were excluded from this analysis, as the italian normative values were available for males and females only [ ] . as ml models are built to fit particular data, it is important to test how each model fits new (i.e., unseen) data. for this reason, part of the data (the training set) is generally used to train and validate the model, while another part (the test set) is used to test the model's accuracy on new examples [ , ] . this procedure guarantees the model generalization and increases the replicability of the results [ , ] . in the present study, % [ , ] of the participants were randomly chosen and retained as the test set. accordingly, the training set consisted of participants ( with high perceived stress and with low perceived stress), and the test set consisted of participants ( with high perceived stress and with low perceived stress). in the first step, feature selection was performed to remove redundant and irrelevant features and to increase model generalization by reducing overfitting and noise in the data [ ] . a good strategy for feature selection is to identify the subset of features that are highly correlated with the class to predict, but not correlated with each other [ ] . this procedure was performed in the present study using the correlation-based feature selector (cfs) in the weka . software [ ] . the problem of class imbalance was addressed while running the classification algorithms. the ratio between participants with high perceived stress and those with low perceived stress was approximately : . as ml methods work best with balanced datasets, it is necessary to account for any class imbalance, especially when training examples are limited-a condition that is frequently met by datasets in health and clinical psychology [ ] . at the same time, it is equally important for ml models to be built on samples that are representative of the population, reflecting real distribution [ ] . one strategy to overcome these two limitations consists of altering the relative costs associated with misclassifying the minority and majority classes, in order to compensate for the class imbalance [ ] . in the present study, ml algorithms were set in such a way that any algorithmic error made in classifying the minority class (high perceived stress) was weighted four times more than any error in classifying the majority class (low perceived stress). this cost-modifying strategy has been shown to provide better results than other methods in addressing the class imbalance problem [ ] . moreover, it should be noted that, for the goal of the present task, it was more beneficial to minimize false negatives than to minimize false positives (i.e., to have a model with high sensitivity rather than high specificity). in other words, it was more important to identify people who were truly at risk than to avoid misclassifying people who were not truly at risk. ml models were trained and validated on the training sample (n= ) through a -fold cross-validation procedure using the weka . software [ ] . the different algorithms (i.e., logistic regression [ ] , support vector machine (svm) [ ] , naïve bayes [ ] , random forest [ ] ) were chosen as representatives of different classification strategies, to ensure that the results would be stable across classifiers and not dependent on specific model assumptions (details on the parameters of the ml classifiers are reported in the supplementary materials). k-fold cross-validation is a resampling procedure that seeks to reduce the variance in model performance relative to the performance that may be obtained from a single training set and a single test set. the procedure consists of portioning the sample into k subsets (i.e., folds; in the present study, k = ), and using k- (i.e., ) subsets to train the model and the remaining subset to validate the model's accuracy. this is repeated k (i.e., ) times [ ] . the final model metrics are obtained by averaging the metrics obtained in all validation subsets. in the present study, the models developed from the -fold cross-validation procedure were tested on the test sample (n = ). the main results of the data analysis are reported in this section. a more complete descriptive analysis of each variable, including the composition of high perceived stress versus low perceived stress samples, is reported in the supplementary materials. the average pss- score of the entire sample was . (sd = . ). analyzing the responses of males and females separately (note that participants who reported a gender of "other" were excluded from this analysis due to a lack of normative data), males obtained an average score of . (sd = . ) and females obtained an average score of . (sd = . ). to determine whether the sample mean statistically differed from that of the italian normative population (males: average = . , sd = . ; females: average = . , sd = . ) [ ] , a one-sample t-test was run separately for each gender. a first multiple regression analysis was run, including sociodemographic variables that have been shown to potentially impact the level of perceived stress during a pandemic [ , , , , ] . the pss- score was set as the dependent variable, while gender (male), age, education, monthly income, number of family members, and student status (student) were entered as covariates. the final model accounted for a significant proportion of the variance in the level of perceived stress (r = . , adjusted r = . , f-change ( , ) = . , p < . ). all of the aforementioned variables, with the exception of student status, were found to contribute to the level of perceived stress. results are reported in table . to better understand the role of stable psychological traits in predicting the level of perceived stress (pss- score), a second multiple linear regression was run, adding to the previous model the scores of the five coping styles measured by the cope-nvi- (cope positive, cope problem, cope avoidance, cope religion and cope support), the bscs total score, the internal loc score, and the scores for the five personality traits measured by the bfi- (bfi- agreeableness, bfi- conscientiousness, bfi- emotional stability, bfi- extraversion and bfi- openness). this second model accounted for a larger proportion of the variance in the level of perceived stress (r = . , adjusted r = . , f-change ( , ) = . , p < . ) compared to the previous model. bfi- emotional stability, cope positive, age, bcsc total score, gender (male), cope avoidance, internal loc, number of family members, cope support, monthly income, and bfi- conscientiousness were identified as significant predictors of the level of perceived stress during the covid- epidemic (see table ). education, cope religion, cope problem solving, bfi- agreeableness, bfi- extraversion and bfi- openness were excluded. ultimately, the questionnaire variables were considered predictors of perceived stress. the entire list of predictors, along with their descriptions, is provided in the supplementary materials. of these variables, the following were identified as the best set of predictors using correlation-based feature selection: age, monthly income, cope avoidance, cope positive, bscs total score, bfi- emotional stability, and bfi- agreeableness. using these predictors, ml algorithms were trained and tested according to the procedure described in the "data analysis" section. classification results for the test set are reported in table , which quantifies predictive performance according to the following metrics: receiver operating characteristic curve (roc) area, precision, recall and f-measure (f score). it is worth noting that the classifiers showed an roc area ranging from . to . in the test set. however, the random forest algorithm highlighted the lower sensitivity (recall) of the high perceived stress class compared to the other classifiers, making it a weaker model for the purposes of prediction. the present study measured the impact of the covid- emergency on perceived levels of stress, taking into account sociodemographic variables and stable psychological traits. the results confirmed that participants perceived the covid- crisis as a stressful experience; in the present sample, the level of perceived stress was higher than that of the general population in a non-emergency condition. indeed, almost % of the sample scored above the results from the normative data on measures of perceived stress. these results are in line with the findings of recent studies on the psychological impact of covid- [ , , ] and the international literature on epidemic outbreaks [ ] . the mean values of the single items of the pss- suggest that, in addition to nervousness and stress, feelings of being unable to control one's personal life accounted for the majority of participants' perceived stress. this suggests that the unpredictability and uncontrollability of the pandemic may play a significant role in determining levels of perceived stress during the crisis. moreover, it may reflect participants' attitudes toward the significant lifestyle changes demanded of them due to the lockdown and other restrictive measures. as regards sociodemographic variables, the results suggest that the female gender is associated with higher levels of stress. this is consistent with the literature indicating gender differences in the psychological response to covid- [ , ] and other epidemics [ ] ; it is also in line with the normative data for the general population. consistent with other studies ( , ) , the present study found an association between higher incomes and lower levels of perceived stress. one explanation for this is that higher incomes might be related to less concern about the economic effects of self-isolation and/or with more comfortable housing solutions (e.g., larger living spaces, access to outdoor spaces (such as gardens), and access to leisure activities). moreover, people with higher incomes may be more likely to perform work that can easily and fully transition to the online environment, thereby reducing some sources of stress. in the present sample, older age was found to be associated with lower levels of stress. this finding might appear surprising, since it contradicts both the results of studies on the chinese population [ , ] and the association between older age and higher covid- mortality. however, the result is in line with recent italian data [ ] . several studies have indicated age-related differences in coping and locus of control, with older adults presenting greater self-control and emotional self-regulation relative to younger adults [ ] [ ] [ ] . considering the current pandemic, older people may be more used to staying at home, so their daily routines might be less impacted by mandatory self-isolation measures. data from previous investigations on age differences in stress responses to the sars epidemic reflect inconsistencies [ , ] , but sociopolitical and cultural aspects, such as differences in elder care services and policies, might account for these discrepancies. the present study did not find education to be a significant predictor of the level of perceived stress. the large percentage of highly educated participants in the sample might partially explain this finding. however, prior research on this subject has generated mixed results-recent studies on the chinese population [ , ] have found that education does not seem to affect mental health, while data from a spanish sample [ ] and from previous studies on psychological adjustment to sars [ ] have confirmed an association between a higher level of education and better mental health. the present study also found that living alone or with few family members was a protective factor against perceived stress. we might argue that this condition both conveys a sense of protection from contagion and offers continuity with pre-epidemic economic and social conditions. moreover, when cohabiting with family members, concern for loved ones might contribute to increasing perceived stress. as regards psychological variables, emotional stability was found to be an important protective factor. according to the five-factors model [ ] , people with high emotional stability remain calm in response to stressful situations, and view problems in proportion to their importance. as a result, they tend to worry less about problems than do people with low emotional stability [ ] . many studies have found that emotional stability is able to buffer stress responses to adverse events [ , ] . in the present study, conscientiousness and agreeableness were found to predict psychological distress. generally speaking, individuals who score high on agreeableness tend to dislike conflict and be less suspicious of others; generally, they seek to pacify and mediate. in this sense, agreeable people might be more flexible and accepting when faced with unexpected and undesired situations, such as restrictions and changes to daily routines. conscientious people are more likely to perceive lower levels of stress (see correlation analysis). according to the literature, they are more aware of their actions and tend to exhibit more goal-oriented behavior. in this sense, in times of self-isolation, conscientious people might have a greater tolerance for frustration and imposition relative to less conscientious people, who might engage in more impulsive behavior [ ] . moreover, previous research has indicated that conscientiousness may influence adaptive behavior, especially in health-related programs [ , ] . the present study found higher levels of dispositional self-control to predict lower levels of psychological distress in response to the covid- emergency. personal self-control skills may play a role in determining tolerance to restrictions to personal freedom during self-isolation. this result further suggests that self-regulatory processes may have a strong influence on responses to the outbreak. the results regarding dispositional self-control are consistent with those relating to the emotional stability trait of the big five model. in fact, these dimensions are often correlated [ ] , and this specific pattern may indicate the importance of personal skills, such as the ability to remain calm, and maintain emotional balance and a sense of acceptance. in this sense, practices that enhance emotional stability and acceptance, such as mindfulness, could be useful in reducing the stressful impact of the emergency [ , ] . the results concerning coping styles are also in line with this. besides confirming the protective effect of functional coping styles and the adverse impact of dysfunctional coping styles, the results of the present study suggest that people who use a positive attitude as a coping strategy may be much less likely to experience psychological distress during the present emergency. such persons may appraise the emergency as a unique opportunity, and feel less need for psychological support. in contrast, the present findings suggest that people who use avoidance strategies may be more likely to experience higher levels of stress during the emergency. these results are consistent with the findings of previous investigations into the relation between coping style and response to an epidemic [ , , , ] . the results relating to dispositional locus of control indicate that people with an internal locus of control may be less likely to feel stressed. again, these results suggest that the more people are inclined to confidently rely on themselves, the better they will cope with uncertainty and change. several studies have indicated an association between an internal locus of control and self-efficacy and emotional stability [ , ] . furthermore, previous studies have found a relation between an internal locus of control and the positive appraisal of an emerging infectious disease outbreak [ ] . it could be hypothesized that people with an internal locus of control interpret self-isolating as something that they determine and enact for themselves as a protective behavior, rather than something that is imposed on them; this might account for their lower levels of perceived stress. overall, the results of the present study identify some population subgroups that may be more vulnerable to experiencing stress during the covid- emergency. specifically, a set of seven psycho-social variables may identify a high percentage of people experiencing high stress during the covid- pandemic, with sensitivity approaching . (roc area of predictive models ranging between . and . ). according to this model, we may develop targeted preventive interventions. furthermore, self-regulatory skills (including emotional stability, an internal locus of control, and self-control) were shown to be a protective factor, indicating the importance of raising awareness of these skills during the emergency and offering training and education to increase personal abilities in these areas (e.g., mindfulness programs). the present research aimed at improving our understanding of the possible risk and protective factors for high perceived stress during the covid- outbreak. it is worth noting that all data were collected from an italian population. therefore, the findings were inevitably influenced by specific contextual and socio-cultural aspects. further investigations involving people of different ethnicities and residents of other countries would deepen our understanding of the generalizability of these results, and the effective influence of psychological traits. in this regard, the open access data reported in the supplementary materials may contribute to facilitating comparisons between ethnicities, countries, and specific traumatic events. some further limitations should be considered when interpreting the findings of this research. first, participants were recruited via an online link posted on social networks. while online recruitment guarantees large samples, it does not guarantee sample representativeness. for this reason, very vulnerable groups, such as homeless or low-income persons, may not be well represented in this study. similarly, the average age of the sample was young, predominantly female, and largely well educated, as indicative of a sample that is more likely to participate in an online survey. second, the use of self-report measures did not enable us to verify the reliability of the responses, or to ensure that participants correctly understood the questions. future research should aim at overcoming these shortcomings. finally, future research should also investigate the interplay and mutual interrelationship between protective and risk factors, to improve the targeting and overall effectiveness of preventive programs and interventions. indeed, the literature suggests that, during a pandemic, it is extremely important for people to sustain their use of psychological services, either online or in the context of social distancing [ , ] . this is particularly essential for those who are more vulnerable to experiencing high levels of stress, and it is important that we ensure that such persons can access timely and high-quality psychological services in order to prevent the development of chronic outcomes, including ptsd. supplementary materials: the following are available online at http://www.mdpi.com/ - / / / /s , table s : descriptive statistics, table s : item by item analysis of the pss- , table s : list of predictors, table s : details on ml classifiers parameters. funding: this research received no external funding. the authors declare no conflict of interest. the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china supporting older people during the covid- pandemic is everyone's business unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures treatment of covid- : old tricks for new challenges the sars-cov- outbreak: what we know who coronavirus disease (covid- ) dashboard. available online who director-general's opening remarks at the mission briefing on covid- pandemic and lockdown: a territorial approach to covid- in china, italy and the united states immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the psychological impact of the covid- epidemic on college students in china long-term psychiatric morbidities among sars survivors psychiatry of pandemics: a mental health response to infection outbreak vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control the psychological impact of quarantine and how to reduce it: rapid review of the evidence timely mental health care for the novel coronavirus outbreak is urgently needed how personality relates to distress in parents during the covid- lockdown: the mediating role of child's emotional and behavioral difficulties and the moderating effect of living with other people the effect of the covid- lockdown on parents: a call to adopt urgent measures how to improve compliance with protective health measures during the covid- outbreak: testing a moderated mediation model and machine learning algorithms psychological responses to outbreak of severe acute respiratory syndrome: a prospective, multiple time-point study how health anxiety influences responses to viral outbreaks like covid- : what all decision-makers, health authorities, and health care professionals need to know the psychological burden experienced by hong kong midlife women during the sars epidemic psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease prevalence and predictors of ptss during covid- outbreak in china hardest-hit areas: gender differences matter predictors of symptoms of posttraumatic stress in chinese university students during the h n influenza pandemic individual differences, economic stability, and fear of contagion as risk factors for ptsd symptoms in the covid- emergency neurobiological and systemic effects of chronic stress effects of lifetime stress exposure on mental and physical health in young adulthood: how stress degrades and forgiveness protects health the effects of psychological stress on depression chronic stress, hair cortisol and depression: a prospective and longitudinal study of medical internship heightened biological stress response during exposure to a trauma film predicts an increase in intrusive memories a direct test of the diathesis-stress model for depression psychological stress and coping in adaptation and illness recommended psychological crisis intervention response to the novel coronavirus pneumonia outbreak in china: a model of west china hospital. precis a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users the power of personality: the comparative validity of personality traits, socioeconomic status, and cognitive ability for predicting important life outcomes an analysis of coping in a middle-aged community sample coping as a mediator of emotion coping as a moderator of relations between reactivity to interpersonal stress, health status, and internalizing problems human agency in social cognitive theory self-efficacy: the exercise of control h n influenza pandemic: the role of threat, coping, and media trust on vaccination intentions in canada high self-control predicts good adjustment, less pathology, better grades, and interpersonal success harpaz-rotem, i. locus of control in us combat veterans: unique associations with posttraumatic stress disorder -factor model symptom clusters locus of control', health-related quality of life, emotional distress and disability in parkinson's disease generalized expectancies for internal versus external control of reinforcement personality in adulthood personality and sedentary behavior: a systematic review and meta-analysis. health psychol linking big five personality traits to sexuality and sexual health: a meta-analytic review personality and physical activity: a systematic review and meta-analysis alcohol involvement and the five-factor model of personality: a meta-analysis psychometric evaluation of three versions of the italian perceived stress scale the perceived stress scale (pss- ) in women experiencing infertility: a reliability and validity study a global measure of perceived stress positive events and social supports as buffers of life change stress cope-nvi- : validazione italiana della versione ridotta della coping orientation to the problems experienced (cope-nvi) assessing coping strategies: a theoretically based approach coping orientation to problems experienced-nuova versione italiana (cope-nvi): uno strumento per la misura degli stili di coping vivere con il sole in tasca: cos' è la psicologia positiva e cosa può fare per noi contributo alla taratura italiana della scala di controllo interno-esterno (i-e) di rotter an italian version of the -item big five inventory: an application to hedonic and utilitarian shopping values the stability of personality: observations and evaluations measuring personality in one minute or less: a -item short version of the big five inventory in english and german power : a flexible statistical power analysis program for the social, behavioral, and biomedical sciences statistical analysis in jasp: a guide for students in defense of multiplicative terms in multiple regression equations choosing prediction over explanation in psychology: lessons from machine learning indicators to distinguish symptom accentuators from symptom producers in individuals with a diagnosed adjustment disorder: a pilot study on inconsistency subtypes using sims and mmpi- -rf introducing machine learning to detect personality faking-good in a male sample: a new model based on minnesota multiphasic personality inventory- restructured form scales and reaction times the development of a short version of the sims using machine learning to detect feigning in forensic assessment machine learning in psychometrics and psychological research machine learning approaches for clinical psychology and psychiatry nonlinear system identification replication and p intervals: p values predict the future only vaguely, but confidence intervals do much better the reusable holdout: preserving validity in adaptive data analysis correlation-based feature selection for machine learning the weka data mining software the class imbalance problem: significance and strategies the class imbalance problem: a systematic study ridge estimators in logistic regression improvements to platt's smo algorithm for svm classifier design estimating continuous distributions in bayesian classifiers random forest a study of cross-validation and bootstrap for accuracy estimation and model selection a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors association of self-perceptions of aging, personal and family resources, and loneliness with psychological distress during the lock-down period of covid- narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the covid- pandemic dynamic integration: affect, cognition, and the self in adulthood social and emotional patterns in adulthood: support for socioemotional selectivity theory population-based post-crisis psychological distress: an example from the sars outbreak in taiwan relations of sars-related stressors and coping to chinese college students' psychological adjustment during the beijing sars epidemic social support and psychological adjustment to sars: the mediating role of self-care self-efficacy the "big five questionnaire": a new questionnaire to assess the five factor model emotional stability is associated with the maoa promoter uvntr polymorphism in women self-efficacy and emotional stability buffer negative effects of adverse childhood experiences on young adult health-related quality of life the influence of personality on trajectories of distress, health and functioning in mild-to-moderately depressed adults with type diabetes impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy higher-order factors of the big five let's conquer covid- and sustain our abilities mindfulness mediates the physiological markers of stress: systematic review and meta-analysis coping responses of emergency physicians and nurses to the severe acute respiratory syndrome outbreak the importance of coping appraisal in behavioural responses to pandemic flu relationship of core self-evaluations traits-self-esteem, generalized self-efficacy, locus of control, and emotional stability-with job satisfaction and job performance: a meta-analysis perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior psychological interventions for people affected by the covid- epidemic the role of telehealth in reducing the mental health burden from covid- key: cord- - ygbyiz authors: hernández-sánchez, brizeida raquel; cardella, giuseppina maria; sánchez-garcía, josé carlos title: psychological factors that lessen the impact of covid- on the self-employment intention of business administration and economics’ students from latin america date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ygbyiz background: the coronavirus disease epidemic (covid- ) is a public health emergency of international concern and poses a challenge to the labor market. the pandemic has a devastating and disproportionate effect on young workers, their interest in entrepreneurship, and their mental health. research is needed to develop evidence-based strategies to improve coping and reduce adverse psychological problems. the objective of this study was to analyze the impact that covid- pandemic perception and psychological need satisfaction have on university students and their self-employment intention. in addition, we also analyzed the role of moderation played by psychological aspects. these psychological factors (i.e., optimism and proactiveness) can also improve young people’s mental health and well-being. methods: an explorative study (online survey) was conducted in march university students from latin america. regression analysis models were built to examine the relationships between covid- pandemic perception, personality variables, and entrepreneurial intention. mediation models, through the bootstrapping method, were performed to analyze the mediating role of proactiveness and optimism. results: results indicate that students’ perception of covid- and psychological need satisfaction are associated with entrepreneurial intention. additionally, the present study argues that proactiveness and optimism mediate these relationships. conclusions: this study identifies psychological factors associated with a lower level of covid- impact and that can be used for psychological interventions that result in an improvement in the mental health of these vulnerable groups during and after the covid- pandemic. theoretical and practical implications are discussed. entrepreneurship is a determining factor for economic and social development [ , ] , enhances the creation of wealth and value [ ] , and improves the well-being in nations [ ] . over the years, entrepreneurship has received a broad consensus in the academic and international communities on its importance, however, research on its relevance in uncertain and adverse situations is rather scarce [ ] . covid- (coronavirus disease ) is a serious disease caused by a new type of coronavirus (sars-cov- ) first detected in wuhan, china in december . the virus has spread rapidly throughout the world [ ] , registering more than , , cases and more than , deaths. on march , with countries involved, the who officially decreed a state of pandemic [ ] . not surprising that, due to their crucial role as a preliminary stage in the business creation process, researchers have focused their efforts on researching the factors that positively influence people's intention to start a business [ , ] . despite the considerable contribution of the scientific literature on the processes that favor entrepreneurship, personality factors, and their relationship with the intention to start a business have not received enough attention in situations of uncertainty, catastrophes, pandemics, etc. [ ] [ ] [ ] [ ] . psychological need satisfaction, in previous researches, has been considered an interesting intrinsic motivational factor for understanding the business process [ ] and that could act as a driver to face a crisis. the satisfaction of basic psychological needs has a positive effect on the well-being and growth of the individual, while the lack of satisfaction translates into low motivation and a feeling of discomfort that can even lead to the onset of mental illness. as many academics point out [ , ] , the satisfaction (or lack thereof) of basic psychological needs depends on the environment in which the subject lives. in general, supportive environments promote well-being in a subject, while frustrating environments generate malfunction and discomfort [ ] . studies have analyzed these relationships in safe situations. little or nothing is known of the effect they could have on situations perceived as dangerous. furthermore, the perception of the pandemic itself could influence individuals' entrepreneurial intentions through the subjective perception of danger, blocking the positive behaviors, and frustrating the basic psychological needs satisfaction. this is one of the main objectives of this work, which tries to fill this gap in the literature. in an environment perceived as uncertain and dangerous, the effect of covid- pandemic perception and psychological need satisfaction may depend on additional factors. one of them is proactiveness. only in recent years have some studies shown a positive association between proactive personality and entrepreneurial intentions [ , ] . for example, in the study by hansen et al. [ ] , proactiveness, which is related to the ability to find opportunities and possible solutions in uncertain situations, was considered one of the main factors that influence entrepreneurial intentions. ideologically connected with proactivity, optimism appears to also be considered (especially in adverse situations, such as the current pandemic) a particularly important factor for entrepreneurs to pursue their long-term goals [ , ] . having a positive perspective on future results, focusing attention on positive stimuli, and avoiding those that are perceived as threatening leads to an increase in entrepreneurial intention and, consequently, predisposes the individual to implement a specific behavior [ ] and generated well-being. a study by kleiman et al. , [ ] demonstrated the multidimensional nature of optimism which appears to be related to fewer depressive episodes as a consequence of stressful and anxiety-provoking life events. given the historical period we are experiencing, characterized by the covid- pandemic, we conducted this study to increase our understanding of the factors that influence entrepreneurial intentions in situations of crisis and uncertainty, examining, in particular, the influence of covid- pandemic perception and psychological need satisfaction in entrepreneurial intentions, as well the possible mediating role of proactiveness and optimism. understanding the dynamics of these relationships is particularly important for the numerous governments and companies present in the area facing this economic shock. by understanding what drives entrepreneurial intentions in adverse conditions, we can design better programs to effectively improve business efforts. to meet these goals, we conducted an explorative study with a sample of college students to examine the effects of covid- pandemic perception, psychological need satisfaction, proactiveness, and optimism are in entrepreneurial intentions. in this work, we first develop the theoretical background of our research. based on this, we present the hypotheses, which are then empirically tested with the data from a survey carried out in university students. the methods are described in the next section, after which we provide the results of our empirical study. we conclude with a discussion of the main results in relation to the previous literature, as well as suggest some recommendations for future policies and lines of research. theoretical models that analyze the entrepreneurial process [ , ] emphasize the importance of personal, cognitive, and prescriptive factors to determine the probability that an individual would be willing to start a new business. among the main factors related to entrepreneurial intentions are personality traits associated with entrepreneurs [ , , ] . the results of previous studies suggest that personality traits substantially influence how entrepreneurs think, the objectives they set, and, through their actions, what they achieve [ , ] . in particular, previous studies have established that an entrepreneur generally has an optimistic orientation towards the future and seems more capable of finding opportunities and achieving the desired objectives [ , , ] . this research will focus on four characteristics, namely proactiveness, optimism, the covid- pandemic perception, and psychological need satisfaction, to quantify the relationship between these four traits of the students and their entrepreneurial intention. in summary, this approach will allow this research to determine the relative importance of the four business characteristics to predict the ei of students in an adverse situation. despite literature supporting the link between psychological and personality factors and entrepreneurial intentions, these four characteristics have been ignored in the literature. the four dimensions are briefly described below. entrepreneurial intention has been considered the most important predictor of behavior [ , , ] . by intention, we can understand "a state of mind directing a person's attention (and therefore experience and action) towards a specific object (goal) or a path to achieve something (means)" (bird [ ] p. ). intentions are related to a plurality of factors (beliefs, values, habits, needs) which also include cognitive factors, which can improve or decrease these intentions. over the years, different models of intentions have been developed in the field of entrepreneurship [ , [ ] [ ] [ ] [ ] . in general, scholars who have analyzed the gap between intentions and behaviors tend to consistently demonstrate this, as much as % of the variance in actual behavior can be explained by intentions [ ] [ ] [ ] . therefore, more than half of the variance remains unexplained. several studies [ , , ] have tried to remedy this lack, through the inclusion of some factors and moderators additional. some studies indicate that other predictors, on a personal or social level, may influence entrepreneurial intentions. for example, according to krueger et al., [ ] the intentions are developed from the perceptions of desirability and viability of the entrepreneurial action. after this, a situation perceived as uncertain or dangerous can influence a person's intention to start a business. for example, considering the current pandemic situation, the perception of the lack of safety in travel, for commercial reasons, combined with the fact that many aspects of public and private life have become online [ ] , could have a negative impact on the viability of behavior. krueger et al., [ ] also argue that self-efficacy positively influences the viability of entrepreneurship and that the personal propensity to seek opportunities and act on these opportunities (proactiveness in this study) can facilitate the development of intentions. as proactivity is closely linked to identification opportunities, it plays an important role in encouraging new businesses. in other words, in the case of contexts perceived as dangerous or adverse, other variables associated with the individual's psychological, cognitive, and personality traits can still help develop entrepreneurial intentions. some studies on entrepreneurial intentions [ ] [ ] [ ] [ ] [ ] have laid the foundations for a deeper examination of the intentions of people in situations of insecurity. specifically, the strength of the intention to become a self-employed person would depend on the tolerance that the subjects show for the risk and on their preference for independence. according to the approach of social-cognitive theory [ ] , the surrounding environment influences the behavior of the individual through personal perceptions. not all people perceive the same situation with the same degree of severity. taking these differences into account and understanding them is important to analyze behavioral responses, especially in adverse situations. in the literature, few studies have focused on perceptions derived from an unsafe, dangerous, and risky environment, and the impact these perceptions can have on the intention of starting a business. for example, gaibulloev and sandler [ ] suggest that terrorism and other violent events could hinder business growth by increasing business costs that reduce profits and returns, discouraging the creation of new businesses. among the few studies relating to dangerous situations, we find those related to the scenarios of war [ , ] , terrorism [ ] , and natural disasters [ , ] . currently, there is no empirical evidence that has analyzed the psychological and cognitive factors that could influence entrepreneurial intention in relation to a pandemic situation. current studies have focused more on the general economic aspect [ , ] . to describe the literature on the subject, we will refer explicitly to the more general concept of perception of danger. previous studies have shown the negative relationship between perception of danger and intention for business. bullough, renko, and myatt [ ] examined the effects of perceived danger, self-efficacy, and resistance on business intentions under unfavorable conditions during the war in afghanistan. their results suggest that perceived danger was negatively related to an individual's entrepreneurial intentions but marginally less among highly resistant individuals. jahanshahi, zhang, and gholami [ ] also in afghanistan, studied the antecedents of the persistence of companies run by female entrepreneurs. the results showed that female entrepreneurs with a high level of internal locus of control have higher levels of resilience. furthermore, the perceived danger and influence of supporting family businesses (the first negatively, the second positively) resulted in the persistence of female-led businesses. these studies highlight the importance of the interaction of psychological, social, and environmental factors in shaping the entrepreneurial capacity of people in uncertain situations. motivational factors have proven to be an important paradigm for the study of the determinants of an entrepreneurial career choice. on the one hand, personal motivational factors act to seek, through business, a possible form of self-realization and to escape the unemployment trap. on the other hand, there is a strong and profound interaction between family, social and institutional factors, within which the entrepreneurial career choice appears as a "response" linked to the satisfaction of basic psychological needs. according to self-determination theory (sdt) [ , ] , motivation is a vital source that makes people persistent and active in implementing their behaviors [ ] . specifically, sdt classifies motivation on a continuum, ranging from extrinsic motivation to intrinsic motivation. what leads to intrinsic motivation is the satisfaction of three basic psychological needs conceptualized by sdt: autonomy, competence, and relatedness. it is argued that these needs are necessary for the well-being and persistence of behavior [ ] and that they play a role in defining aspirations and, therefore, in professional choices [ ] . when these needs are not met, intrinsic motivation will be hampered, which is called psychological need frustration [ , ] and, as a result, people could develop health problems and persist less in purposeful behaviors. conversely, if these needs are met, they are more likely to engage persistently in entrepreneurial behavior [ ] . in this case, we speak of the psychological need satisfaction, which is the factor we will refer to in the present study. the perception of autonomy, of being competent, and of having a sense of closeness with others, is at the heart of entrepreneurial research, but, surprisingly, this has rarely been explored in previous studies on entrepreneurship, meaning the mechanisms behind motivations have been ignored [ ] . however, the few studies carried out have highlighted its indisputable relevance. for example, baluku et al., [ ] found that the need for autonomy satisfaction is positively related to entrepreneurial intention (ei) and that business mentoring is related to ei in individuals who show higher levels of autonomy. in an interesting study with university students in yemen, al-jubari [ ] tested the influence of satisfying the basic psychological needs of sdt on business intention through the factors of the theory of planned behavior. the results of the study support the theoretical integration of the model, in which the satisfaction of basic psychological needs has a positive effect on the attitude towards entrepreneurship, subjective norms, and perceived behavioral control and these, in turn, have a positive effect in the entrepreneurial intention. bateman and crant [ ] discussed the importance of proactiveness in organizational behavior, defining it as the ability to achieve significant change in the environment by identifying opportunities. in reality, it is not just about important attributes of flexibility and adaptability towards an uncertain future. being proactive is taking the initiative in improving business as well. for years, researchers have debated the nature of proactiveness. according to some scholars, it is a stable disposition of the individual [ ] , others have considered it a model of general behavior [ ] , and others, lastly, a specific attitude in the workplace [ ] . in general, the proactive approach considers the possibility that individuals create their own environment, that behavior is controlled by factors internal and external to the individual, and that situations are a function of people and vice versa [ ] . there are mutual causal links between the person, the environment, and the behavior [ ] , therefore, individuals can intentionally and directly change their current circumstances and given situations. this proactive orientation has been discussed in the entrepreneurial process. much research has found a significant relationship between proactive personality and entrepreneurial behavior [ ] [ ] [ ] , even during the economic crisis [ ] . shapero and sokol [ ] discussed a trend towards action and initiative to describe the social dimensions of business events. krueger and brazeal [ ] included the concept of "propensity to act" in their study of business intentions and potential. furthermore, becherer and maurer [ ] related proactiveness with the decision to start a business, as well as with the legacy of a company. proactive personality has been linked to professional success [ , ] and as an employability asset [ , ] . crant et al., [ ] in the bibliographic review carried out on proactiveness in the organizational field, provide empirical evidence on a wide spectrum of favorable results linked to higher performance and innovation, emotional commitment, and job satisfaction. bell [ ] in a study conducted with uk university students, showed that proactiveness, along with risk, are the key factors in positively influencing entrepreneurial intentions. kumar and shukla [ ] have also achieved similar results. these studies confirm the importance that personality traits, such as proactiveness, have in the entrepreneurial intention. optimism has been studied little in relation to entrepreneurial intentions. the few studies in the literature have suggested that optimism may play an important role in the entrepreneurial process [ , , ] . in a crisis, optimistic entrepreneurs believe more in the success of their actions and, therefore, may be more likely to establish a new business [ ] . some have concluded that optimism is a key requirement for entrepreneurship [ , ] . furthermore, as krueger & day [ ] states: "some of the most promising recent models of entrepreneurship focus on cognitive processes, showing the importance of an opportunity-friendly cognitive infrastructure" (p. ). for example, lee et al., [ ] discovered that optimism is associated with self-confidence among students. overall, positive attitudes toward entrepreneurship, such as a possible career choice, and confidence in one's skills were found to be significantly related to entrepreneurial intentions. a few years earlier, giacomin, janssen, and shinnar [ ] found that the students who most expected positive results in entrepreneurship showed higher levels of business intentions. furthermore, in general, employers have a greater tendency to be more optimistic than other workers [ , ] . however, as far as we know, only the studies by bernoster et al. [ ] and madar et al. [ ] documented a positive relationship between optimism and entrepreneurial intention among students. in summary, despite the theoretically positive relationship suggested by the literature between optimism and entrepreneurial tendencies, little attention has been paid to the empirical investigation of the relationships between the two constructs [ ] . as discussed in the previous sections, this study is the first attempt to analyze entrepreneurial intentions in a pandemic situation. first, through a representative sample of latin american university students, this study aims to analyze the relationships between proactiveness, optimism, covid- pandemic perception, psychological need satisfaction, and entrepreneurial intention in an adverse situation, as it is this current pandemic. second, the current study focuses primarily on how the covid- pandemic perception and need satisfaction mediate the predictive effects of student proactivity and optimism on entrepreneurial intention. consequently, this study raises the following hypotheses: hypothesis : the covid- pandemic perception are negatively associated with entrepreneurial intentions (h a) and psychological need satisfaction are positively associated with entrepreneurial intentions (h b). proactiveness is positively related to entrepreneurial intentions. optimism is positively related to entrepreneurial intentions. the relationship between covid- pandemic perception and entrepreneurial intentions is mediated by the proactiveness (h a) and optimism (h b). the relationship between psychological need satisfaction and entrepreneurial intentions is mediated by the proactiveness (h a) and optimism (h b). these hypotheses are represented in figure . to recruit participants, we contacted several professors from various universities in latin america, to motivate their students and involve them in completing the questionnaire. our sample includes university students from latin american countries ( . % from ecuador, . % from panama and % from other countries), of whom . % are female, and . % male. regarding the area of knowledge, most of the students are enrolled in the faculty of business and administration ( . %) and the faculty of economic sciences ( . %). the remaining % is enrolled in the faculty of social and health sciences. the age range is between and years, with an average of . (sd = . ). with previous permission and authorization from authorities, the students were informed about the purpose of the study. the questionnaires were administered online, participation was voluntary, and the data were processed anonymously and confidentially following the ethical criteria established by the a.p.a. (american psychological association). considering the data collection method (online questionnaire), the only possible method due to the pandemic, the researchers were unable to check the characteristics of the sample, therefore it is not representative of the population studied (latin america). self-report questionnaires were used to collect data on the study variables. the responses on all scales followed a -point likert format ranging from strongly disagree ( ) to strongly agree ( ) . to measure covid- pandemic perception, we created an ad hoc questionnaire. the scale consisted of items: items measure the impact of covid- in the country, and the other items measure the impact of the pandemic on the person itself surveyed. the country's scale did not show good internal consistency, probably because many of the students interviewed live far from their homelands. for this reason, we decided to use only the personal subscale. examples of items were: "the covid- negatively affects my future" or "the covid- will decrease my job opportunities". the scale showed good validity with a cronbach's alpha value of . . psychological need satisfaction was measured using the version developed and validated by chen et al. [ ] . the scale has been translated into several languages, including spanish. the entire scale is made up of items, to measure need satisfaction, and another to measure need frustration. for our study, we decided to use the items corresponding to the need satisfaction. examples of some of these items are: "i feel free to choose the things i do", "i feel connected to the people who care for me and who are important to me". the scale has a cronbach alpha value of . . entrepreneurial intention was measured with the six-item scale of the entrepreneurial orientation questionnaire (eoq; coe in spanish) [ ] . some items on this scale are: "i will make any effort to start and develop my own firm"; "i have thought very seriously about creating a firm." the scale showed a cronbach alpha value of . . to measure proactive personality, the corresponding scale of the entrepreneurial orientation questionnaire (eoq; coe in spanish) was used [ ] . this scale is made up of items and measures the tendency of the respondents to exhibit proactive behavior. the construction of this subscale was based on the work of seibert et al. [ , ] . some items on this scale are: "i am constantly looking for new ways to improve my life", "if i believe in an idea, no obstacle will prevent me from making it come true". the cronbach alpha value for the scale was . . finally, to measure optimism, we used the optimism scale of the proe questionnaire [ ] . the scale consists of likert-type items and measures the tendency of an individual to have positive expectations about the future. examples of the items that make up the scale are: "i see the positive aspects of things"; "i think i will achieve the main goals of my life." the scale showed good reliability (cronbach's alpha of . ). in line with previous studies on entrepreneurship [ ] , data were collected on demographic variables such as age, sex, country, and faculty department. data were analyzed using spss version (imb corp., armonk, ny, usa) and amos version (ibm corp., armonk, ny, usa). first, descriptive statistics were produced using standard means and deviations for all variables. correlations between variables were evaluated using pearson's correlations. hierarchical regression analyzes were performed to analyze the impact of the variables on entrepreneurial intention. to examine the indirect effect of covid- pandemic perception and psychological need satisfaction on entrepreneurial intention through proactiveness and optimism, we used the bootstrap method. the key principle underlining the bootstrap procedure is that it allows the researcher to simulate repeated subsamples from an original database, allowing the stability of the parameter estimates to be evaluated and their values to be reported with a higher degree of precision. bootstrap evaluates the indirect effect in each data set and establishes confidence intervals for each indirect effect [ ] . in this study, we used the following indices to evaluate model fit: the comparative fit index (cfi) and the bollen fit index (ifi), both with adequate values greater than . and the root mean square error of approximation (rmsea) which must have a value of less than . [ , ] . the level of significance (p-value) will be %. the acceptability of the measurement model was assessed by the reliability of individual items, internal consistency between items, the model's convergent, and discriminant validity. the literature suggests . as the acceptable value for cronbach's alpha. average variance extracted (ave) is higher than . but we accepted . . according to fornell and larcker ( ) [ ] , if ave is less than . , but composite reliability is higher than . , the convergent validity of the construct is still adequate. for discriminant validity, the analysis can be performed by the square root of the ave value. when the square root of the mean variance extraction rate (ave value) of each measurement question is greater than the correlation coefficient between the variables, it indicates that there is a strong discriminant coefficient between the variables, that is, the difference between each measurement variable is better (see tables a and a ). before testing the hypotheses, the mean, standard deviations (sd), and correlations between the variables were calculated ( table ). the average scores indicate that the students in our sample show medium to high levels of optimism, proactiveness, psychological need satisfaction, and entrepreneurial intention. the covid- pandemic perception variable obtained the lowest score (m = . , sd = . ). the dependent variable, entrepreneurial intention, was significantly and negatively correlated with covid- pandemic perception (r = − . , p < . ), suggesting that high levels of pandemic perception negatively affect its career choice. psychological need satisfaction (r = . , p < . ), proactiveness (r = . , p < . ) and optimism (r = . , p < . ) were positively and significantly related to entrepreneurial intentions. these results give us initial support of our hypotheses. asymmetry and kurtosis were calculated under the assumption of normal data distribution. all univariate asymmetry values varying between . and − . , while kurtosis values, which must vary between − . y . , thus, meeting with the univariate normality criterion [ ] . in accordance with "for sample sizes greater than , depend on the absolute values of skewness and kurtosis without considering z-values". either an absolute skew value larger than or an absolute kurtosis (proper) larger than may be used as reference values for determining substantial non-normality" (hae-young [ ] p. ) . given that the variables of our study show significant correlations, variance inflation factors (vif) were calculated to investigate multicollinearity. all vif values were well below the threshold of . [ ] . furthermore, none of the correlations exceeded . [ ] . we can, therefore, conclude that multicollinearity is not an issue in this analysis. the next step of data analysis was to test the goodness-of-fit of the model, using the amos graphics . software. the fit indices for the proposed model were: χ = , , , df = , p < . , cfi = . , ifi = . , rmsea = . . the confirmatory factorial analysis showed an adequate adaptation of the data to the model. although the chi-square was significant (χ ( ) = , , , p < . ), due to the large sample size, the other adaptation measurements made confirmed good compatibility. to examine whether the variables in our study predicted entrepreneurial intention in a statistically significant way, a hierarchical regression analysis was performed ( table ). the first model includes the control variables: gender, age, country of origin, and faculty department. all variables had a significant effect on business intentions. in model , we added the independent variables. as the results show, covid- pandemic perception (β = - . , p < . ) is negatively related to entrepreneurial intentions and psychological need satisfaction, (β = . , p < . ) is positively related to entrepreneurial intentions, which supports hypothesis . furthermore, the relation of intention with proactiveness (model ) was positive (β = . , p < . ), providing support for hypothesis . lastly, model supported hypothesis . optimism was positively related to entrepreneurial intentions (β = . , p < . ). to calculate the mediation effect by the proactiveness and optimism (h and h ) , the bootstrap method was used according to the recommendations of preacher and hayes [ ] . during the mediation test, bootstrap was performed with iterations and the bias-corrected confidence interval was adjusted to %. if the % confidence interval does not include , then the mediation effect is considered statistically significant at the level = . . table understanding what factors contribute to support entrepreneurship as a career choice in a crisis seems to be of fundamental importance as it translates into the desire for growth and resilience that people can face when faced with an adverse situation. specifically, we hypothesized that proactiveness and optimism would mediate negative relationships between covid- pandemic perception and intention, and the positive relationship between psychological need satisfaction and entrepreneurial intention. our results support the mediation hypotheses and suggest that optimism and proactiveness are particularly important in the entrepreneurial process. furthermore, we found that psychological need satisfaction supports entrepreneurial intention, but also that the covid- pandemic perception hinders them. our model, and the results obtained, are a first attempt to close the gap in our knowledge of what drives entrepreneurship in highly adverse conditions (for example, in economies subject to pandemics). our suggested mediation model expands on previous literature, which is mainly focused on the direct relationship between personality and intentions [ ] . in particular, the current study joins the few studies in the literature about possible mediation processes that influence the relationship between personality and entrepreneurial behavior [ , ] in situations perceived as negative and high in uncertainty. in addition to its positive and direct effect on intentions, proactiveness, and optimism interact with the pandemic's perception and with psychological need satisfaction. furthermore, and this is an important contribution of this study, optimism and proactiveness attenuate the negative relationship between covid- perception and intentions. optimism and proactiveness significantly strengthen the positive relationships with entrepreneurial intention, indicating that both traits are important to understand entrepreneurship given dangerous situations such as a pandemic scenario. as such, according to this study, influencing the entrepreneurial intention of students (potential entrepreneurs), who are hampered by the pandemic situation, means analyzing the psychological and social factors that influence intentions and understanding how they relate to entrepreneurial behavior in the practice. previous studies have demonstrated a positive influence of proactive personality on entrepreneurial intentions [ ] . therefore, it is highly important to appreciate proactive traits in students so that they can think of entrepreneurship as a possible career option. we have also shown that optimism is significantly and positively related to entrepreneurial intentions, specifically in difficult times. this importance of optimism for the development of entrepreneurial intentions complements previous studies in which entrepreneurs have been considered individuals who remain optimistic and persist even in adverse situations [ , ] . however, it should be noted in this regard that studies have not always produced consistent results in the literature [ , ] . while some studies have found a positive relationship between optimism and entrepreneurial orientation [ ] , others have found a negative one [ ] . these latest studies have concluded that excessive optimism may be a factor behind wrongful decisions with high levels of risk-taking. however, the conclusions of james and gudmundsson [ ] , in line with our study, suggest that moderate levels of optimism have a positive impact on the entrepreneurial process and, consequently, increase the chances of success for a new company. furthermore, our results are in line with psychological theories that suggest having an optimistic orientation (positive psychology) and an ability to find alternative solutions are valuable psychological resources that can help deal with stress and facilitate coping strategies [ ] , especially during crises. an environment that is perceived as highly dangerous and uncertain is negatively related to the intentions for starting a business of its people. however, the individual perception of a negative situation differs between individuals, with different consequences for their intentions [ ] . certainly, beyond individual specificities, what must be taken into account is the role that the variables of our study have in entrepreneurial intentions. previous research has described proactiveness as a resource that people can mobilize in a time of stress or adversity, which allows them to overcome the barriers of various areas of life [ , ] . it seems that having optimistic thoughts about the future is an important factor, especially in uncertain situations. it appears that these effects may have a similar role in the entrepreneurial spirit, allowing the development of entrepreneurial intention in environments of uncertainty. this study presents an innovative approach because it examines the psychological aspects of entrepreneurial intention in a pandemic situation. furthermore, our work confirms previous studies that also show the positive role of need satisfaction, which acts as an accelerator of an entrepreneurial initiative by increasing entrepreneurial intention. in this way, it joins the growing literature that explores how basic psychological needs act as motivational drives that positively influence one's future, including career choice [ ] . our findings have shown that satisfaction of needs is positively related to entrepreneurial intentions in support of the consensus that, to be successful, an entrepreneur must express and use various skills, including those aimed at satisfying his needs and at achieving your own well-being in general [ , ] . our results come from a sample of latin american students who are experiencing the consequences of the pandemic, and for whom decisions about ways to rethink their future, including work and entrepreneurship, are important. the entrepreneurial intention in our sample is high. this result is not entirely surprising, both, because of the specificity of the sample composed mainly of students from the business and management and economics fields, but also because of the high rates of youth unemployment that affect the areas of latin america, which stands at % [ ] , and for which job opportunities seem limited and entrepreneurship represents a solution capable of generating higher economic returns than alternative job opportunities. according to the multilateral investment fund (a member of the inter-american development bank), small and medium-sized enterprises (smes) are responsible for % of jobs worldwide, on average [ ] . in general, the stronger the ability to cope with adverse situations and the greater their optimistic orientation towards the future, their proactiveness and the satisfaction of their basic needs, the greater the probability that people will successfully face a negative event or moment of crisis as a learning experience [ ] , with positive repercussions on their psychological health. as competent actors in their future, they can develop intentions to change the status quo of the communities in which they live by undertaking entrepreneurial initiatives. this study has some limitations. first, in this study, one limitation concerned how the sample was recruited. the fact that we contacted the professors for the recruitment of the participants did not allow us to monitor their characteristics, generating an unrepresentative sample. in addition, the use of self-report data and a single method of data collection raises questions about the variation of the method. however, multicollinearity was not a problem in our study, so we believe that according to siemsen et al. [ ] should not inflate the meaning of the interaction effects. furthermore, data collection at a time like this has created certain problems for the research team. the online administration method dictated the use of scales with few items, focusing the research objectives on analyzing the variables considered more important for hypothesis purposes. this could probably be a limitation since longer scales could have led to more robust results [ ] . this study could represent a limitation for those who are specifically interested in analyzing entrepreneurial behavior (not simply intention). however, the link between intention and behavior has been widely documented in the literature [ , , ] . we believe that future research that also focuses on behavior could help improve our understanding of the intention-behavior relationship, even under critical conditions. our study offers important implications for all those who are called to promote entrepreneurship in notoriously difficult situations, such as in economic crises. all governments are making great efforts to face the economic crisis and help countries to overcome the challenges that the pandemic situation has imposed. institutional support seems important both to preserve the businesses present in the area and to launch new businesses that could work as a solution to the discouragement that the current pandemic is generating. therefore, the main objective of these adverse conditions should be based on creating a social and institutional environment that potential entrepreneurs can perceive as safe. economic growth has raised living standards worldwide. modern economies have often used the standard metric of economic growth, the gross domestic product (gdp), as a unit to indicate the development of a nation, combining its economy with the well-being of society. as a result, policies leading to economic growth are considered beneficial for society. furthermore, considering the close relationship between health and economic growth, this study represents a moment of reflection about the psychological factors that can influence people's lives and their well-being. when the environment is uncertain, people are likely to draw on their skills and develop entrepreneurial intentions when they believe they have the skills to find alternative solutions to overcome obstacles (to be proactive) by taking advantage of more positive aspects of the situation (to be optimistic). proactiveness helps people focus on long-term goals and productive activities, even when times are tough. of course, improving people's confidence about the future and their proactive behavior does not guarantee that they will be successful as entrepreneurs, it only increases the probability that they will consider an entrepreneurial path. for example, since both proactiveness and optimism can be encouraged, entrepreneurship study programs should be intensified within schools and universities [ ] . for example, educators should work directly training students and promoting curriculum projects that foster the development of useful personal skills to develop an entrepreneurial mindset [ ] . these activities are particularly important in developing high standards of personal performance and expectations for performance-based results [ ] . entrepreneurship and education, if interconnected, have extraordinary potential because by developing the human capital necessary to build the society of the future, as they generate employment and economic growth [ ] . in addition to the contribution of this study to the importance of the social and institutional sphere; and the acquisition of skills among young people, these results also have important implications at the organizational level. times of crisis can become an opportunity for enterprises to become more innovative. faced with outside pressures, the challenge for business leaders is to break out of their comfort zone and routine to become creative problem solvers and rediscover their entrepreneurial spirit. generating innovation in companies in a constantly changing market is essential for the survival and success of a company. as tellis [ ] suggested, the key to innovation is human capital, therefore, understanding these elements of personality that drive innovation among employees will certainly contribute to the success of businesses. longitudinal research analyzing who has embarked on an entrepreneurial career in situations characterized by uncertainty and adversity is an important direction for future research, especially given the importance of entrepreneurship for the economic and sustainable development of a community. in this study, we analyze the perceived effects of the covid- pandemic in a specific context (latin america). naturally, the perception of the pandemic can be felt differently in many other parts of the world. an interesting path for future research could include analyzing several nations so that the results can be compared with countries with different economies, as well as with countries that are considered entrepreneurial-friendly. such research could address issues related to the importance of proactiveness and optimism based on the level of perceived adversity, and if whether the most proactive and optimistic entrepreneurs are the ones who are best able to overcome the challenges posed by the pandemic. this study is particularly important in the current moment of international economic crisis as a consequence of the covid- pandemic as it involves the production structures of many countries, which are at risk of an implosion in terms of economic growth, the most evident effects of which they can already be seen in the processes of a reduction in the labor market of numerous employees, and by the increasing phenomena of discouragement and/or resignation from job participation, especially in younger generations. our study found that the perception that university students have of the covid- pandemic is decreasing their intentions to start a business, with repercussions on their psychological needs. how can we solve this? in our study, we have considered two personality traits that manifest themselves as keys to enhancing the intention to undertake in this specific situation: proactiveness and optimism. these traits can dampen the effect of covid- 's negative perception on the intention to start a business, and also enhance the well-being and mental health of these young people to be able to self-employ. the authors declare no conflicts of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. note. the bold number is the square root of ave. the bold numbers listed diagonally are the square root of the variance shared between the constructs and their measures. the off-diagonal elements are the correlations among the constructs. for discriminate validity, the diagonal elements should be larger than the off-diagonal elements. entrepreneurship and economic development in cities in quest of legitimacy: the theoretical and methodological foundations of entrepreneurship education research global entrepreneurship monitor entrepreneurship, global competitiveness and legitimacy another day, another dollar: enterprise resilience under terrorism in developing countries coronavirus covid- global cases by the center for covid- : trump threatens to stop funding who amid "china-centric" claims gda (global data analysis). coronavirus (covid- ) executive briefing. global data related health factors of psychological distress during the covid- pandemic in spain immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china towards an economics of wellbeing. camb poverty, sustainability and human wellbeing: a social wellbeing approach to the global fisheries crisis researching wellbeing: communicating between the needs of policy makers and the needs of people wellbeing in developing countries: from theory to practice the great transformation understanding the economic shock of coronavirus the business effects of pandemics-a rapid literature review. enterprise research centre covid- observatory in latin america and the caribbean economic and social impact perceptions, expectations, and entrepreneurship: the role of extreme events special issue on entrepreneurship and crises: business as usual? an introduction and review of the literature understanding attitudes and predicting social behavior the relationship of personality to entrepreneurial intentions and performance: a meta-analytic review predicting entrepreneurial behaviour: a test of the theory of planned behaviour from entrepreneurial intentions to actions: self-control and action-related doubt, fear, and aversion entrepreneurial orientation and firm performance in different environmental settings: contingency and configurational approaches the impact of entrepreneurship education on the entrepreneurial intention of students in science and engineering versus business studies university programs the impact of entrepreneurship education: a study of iranian students' entrepreneurial intentions and opportunity identification determinants of entrepreneurial intent: a meta-analytic test and integration of competing models a systematic literature review on entrepreneurial intentions: citation, thematic analyses, and research agenda the relationship of entrepreneurial traits, skill, and motivation to subsequentventure growth personality aspects of entrepreneurship: a look at five meta-analyses effects of emotional intelligence on entrepreneurial intention and self-efficacy a downside to the entrepreneurial personality? psychological need satisfaction as a pre-determinant of entrepreneurial intentionality basic psychological need satisfaction, need frustration, and need strength across four cultures basic psychological need theory: advancements, critical themes, and future directions on psychological growth and vulnerability: basic psychological need satisfaction and need frustration as a unifying principle predicting entrepreneurial intentions: incremental validity of proactive personality and entrepreneurial self-efficacy as a moderator garcía-pérez-de-lema, d. the effects of personal abilities and self-efficacy on entrepreneurial intentions defragmenting definitions of entrepreneurial opportunity optimism and chance: the elephants in the entrepreneurship room optimism, hope, and attention for emotional stimuli optimism and well-being: a prospective multi-method and multi-dimensional examination of optimism as a resilience factor following the occurrence of stressful life events the social dimensions of entrepreneurship entrepreneurial intentions: applying the theory of planned behaviour born to be an entrepreneur? revisiting the personality approach to entrepreneurship looking forward, looking backward: from entrepreneurial cognition to neuroentrepreneurship personality traits of entrepreneurs: a review of recent literature individual entrepreneurial intent: construct clarification and development of an internationally reliable metric factors determining desirability of entrepreneurship in implementing entrepreneurial ideas: the case for intention. acad the influence of self-efficacy on the development of entrepreneurial intentions and actions competing models of entrepreneurial intentions the entrepreneurial event efficacy of the theory of planned behavior: a meta-analytic review intention-behavior relations: a conceptual and empirical review predicting and explaining intentions and behavior: how well are we doing? from offline to online: challenges and opportunities for entrepreneurship education following the covid- pandemic self-employment as a career choice: attitudes, entrepreneurial intentions, and utility maximization institutional environments for entrepreneurship: evidence from emerging economies in eastern europe the role of gender stereotypes in perceptions of entrepreneurs and intentions to become an entrepreneur development and cross-cultural application of a specific instrument to measure entrepreneurial intentions exploratory study of job insecurity and entrepreneurial intention as correlates of counterproductive work behavior social foundations of thought and action: a social cognitive theory the impact of terrorism and conflicts on growth in asia adb institute discussion paper no. ; adbi institute self-employment and conflict in colombia danger zone entrepreneurs: the importance of resilience and self-efficacy for entrepreneurial intentions the open society assesses its enemies: shocks, disasters and terrorist attacks business vulnerability to earthquakes and other disasters positive and negative postdisaster psychological adjustment among adult survivors of the southeast asian earthquake-tsunami startups in times of crisis-a rapid response to the covid- pandemic entrepreneurs in dark ages: persistence of females entrepreneurs in afghanistan the empirical exploration of intrinsic motivational processes motivation, personality, and development within embedded social contexts: an overview of self-determination theory self-determination theory and the facilitation of intrinsic motivation, social development, and well-being exercise, physical activity, and self-determination theory: a systematic review why the self-employed are happier: evidence from european countries differentiating autonomy from individualism and independence: a self-determination theory perspective on internalization of cultural orientations and well-being entrepreneurial intention among university students in malaysia: integrating self-determination theory and the theory of planned behavior the impact of autonomy on the relationship between mentoring and entrepreneurial intentions among youth in germany, kenya, and uganda college students' entrepreneurial intention: testing an integrated model of sdt and tpb the proactive component of organizational behavior: a measure and correlates proactive behavior in organizations personal initiative (pi): an active performance concept for work in the st century modeling the antecedents of proactive behavior at work proactive personality and proactive behaviour: perspectives on person-situation interactions self-efficacy: toward a unifying theory of behavioral change proactive personality and entrepreneurial intention: employment and student level as moderators bin, p. creativity, proactive personality, and entrepreneurial intention: the role of entrepreneurial alertness from entrepreneurial intentions to behavior: the role of anticipated regret and proactive personality firms' proactiveness during the crisis: evidence from european data entrepreneurial potential and potential entrepreneurs the proactive personality disposition and entrepreneurial behavior among small company presidents what do proactive people do? a longitudinal model linking proactive personality and career success proactive personality and career success: what's the connection? unpacking the link between entrepreneurialism and employability: an assessment of the relationship between entrepreneurial attitudes and likelihood of graduate employment in a professional field improved academic performance and enhanced employability? the potential double benefit of proactivity for business graduates proactive personality: a twenty-year review predicting entrepreneurial intention across the university creativity, proactive personality and entrepreneurial intentions: examining the mediating role of entrepreneurial self-efficacy. glob the impact of entrepreneurship education in higher education: a systematic review and research agenda the nature of entrepreneurial experience, business failure and comparative optimism entrepreneurial optimism in the market for technology inventions yaron sela, i. optimism and entrepreneurial intentions among students: the mediating role of emotional intelligence university-based education and the formation of entrepreneurial capabilities university students and their faculty: perceptions of entrepreneurial optimism, overconfidence and entrepreneurial intentions entrepreneurs' optimism and new venture performance: a social cognitive perspective cognitive biases, risk perception, and venture formation: how individuals decide to start companies evaluación de la personalidad emprendedora: validez factorial de cuestionario de orientación emprendedora (coe) proactive personality and career success reconstructing entrepreneurial intentions to identify predisposition for growth asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models structural equation modeling with amos amos user guide: amos development corporation evaluating structural equation models with unobservable variables and measurement error statistical notes for clinical researchers: assessing normal distribution ( ) using skewness and kurtosis comparing logit and probit coefficients across groups freeze tolerance of bermudagrasses impact of personality traits and entrepreneurship education on entrepreneurial intentions of business and engineering students how do female entrepreneurs in developing countries cope with role conflict? retail entrepreneurs' exit intentions: influence and mediations of personality and job-related factors are individuals entering self-employment overly optimistic? an empirical test of plans and projections on nascent entrepreneur expectations does entrepreneur dispositional optimism bias affect small firms' technical efficiency? exploring the impact of entrepreneur optimism on the new venture process proactive aging: a longitudinal study of stress, resources, agency and well-being in late life proactive coping as a personal resource in the expanded job demands-resources model entrepreneurship and well-being: the role of psychological autonomy, competence, and relatedness youth unemployment is a huge problem for latin america: how entrepreneurship could be a solution with the right p environment a guide to multilateral development banks psychological capital development: toward a micro-intervention common method bias in regression models with linear, quadratic, and interaction effects entrepreneurial self-efficacy: refining the measure the relationship between entrepreneurial intention and action: the effects of fear of failure and role model assessing the impact of the "entrepreneurs" education program on participants' entrepreneurial intentions the development of an entrepreneurial mindset in primary education the development of entrepreneurial competences for students of mathematics and the science subjects: the latvian experience unlocking entrepreneurial capabilities to meet the global challenges of the st century; executive summary; global education initiative unrelenting innovation: how to create a culture for market dominance the authors would like to thank the students that participated in the study and the chair of entrepreneurs university of salamanca for administrative and technical support. key: cord- -crsii pu authors: zhao, fuqiang; ahmed, fawad; faraz, naveed ahmad title: caring for the caregiver during covid- outbreak: does inclusive leadership improve psychological safety and curb psychological distress? a cross-sectional study date: - - journal: int j nurs stud doi: . /j.ijnurstu. . sha: doc_id: cord_uid: crsii pu background: public health emergencies and epidemics shatter the assumptions of the world as a safe place. healthcare workers are at the forefront of such pressures resulting from a persistent threat to their safety and well being. it is therefore important to study such mechanisms that can influence and predict the psychological distress of nurses objectives: while there is an increasing number of studies on positive outcomes of leadership styles, their influence on curbing unwanted adverse outcomes is scarce. this study aims to observe the influence of an inclusive leadership style on psychological distress while assessing the mediating role of psychological safety. it uses the theoretical lens of job demands-resources theory and the theory of shattered assumptions to develop and test hypotheses. design: cross-sectional study with temporal separation settings and participants: the researchers recruited on-duty registered nurses from hospitals providing patient care during the highly infectious phase of covid- in january in wuhan city, the epicentre of the outbreak in china methods: after obtaining permission from hospital administration, data were collected through an online questionnaire survey in three stages with temporal separation to avoid common method bias. partial least square structural equation modelling was used to analyze data. the study controlled for effects of age, gender, experience, working hours and education. results: hypothesized relationships proved significant. inclusive leadership has an inverse relationship with psychological distress with a strong path-coefficient. psychological safety mediates the relationship between inclusive leadership and psychological distress while explaining . % variance. multi-group analysis results indicate no significant differences between respondents based on these control variables conclusions: recurring or prolonged experiences of stress and anxiety at the workplace, without a mechanism to counter such effects, can culminate into psychological distress. inclusive leadership style can serve as such a mechanism to curb psychological distress for healthcare workers by creating a psychologically safe environment. the novel coronavirus disease outbreak was first reported in december in wuhan city, p.r. china. at the time of writing this paper, there were five new cases on the mainland during the second week of may , one month after the lockdown restrictions were lifted (xinhua, ) ; bringing the overall confirmed cases to , ( , in hubei) including , patients discharged after recovery and , deaths (china daily, ) . covid- has spread beyond china as a global pandemic across continents. as of july , , there are over . million confirmed cases, including , deaths. the usa reported over , , cases, russia , , spain , , the united kingdom , , italy , , germany , and france , , to name a few countries. the usa and the uk had the highest death toll with , and , deaths, respectively (who, ) . epidemiological work links the onset of depression to exposure to different stressors (stuke & bermpohl, ) . healthcare workers are involved in physical as well as emotional work with social encounters during routine job tasks (eriksen et al., ) . the threat to safety at the workplace brings psychological distress for the healthcare workers as they face both psychosocial and mechanical stress at work (wall et al., ) . among the various psychiatric disorders, depressive disorder is one of the most prevalent. it is associated with a significant decline in quality of life as well as an economic loss at the workplace (kessler, ) . nurses are exposed to life-threatening occupational risks during covid- pandemic; face loneliness as they stay isolated and contained due to the highly contagious nature of the virus (mo et al., ) . some even refrain from food intake to avoid taking toilet breaks as this would require changing protective gear; and some shaved their heads to reduce irritation from sweating (smith et al., ) . their sound mental health is essential to their ability to care for patients of infectious disease. it is vital to identify factors that can cause depressive disorders at the workplace to prevent such disorders. leadership roles should be studied because leaders can significantly influence employees' psychological distress levels. fair leadership has been found to affect anxiety and stressors stemming from job tasks (nielsen et al., ) . transformational leadership has proven to help nursing staff in avoiding adverse events at hospitals, to ensure quality care and better patient outcomes (asif et al., ) . hannah et al. ( ) argue for the need to go beyond the traditional concepts of leadership such as managerial ability or support to the informal leadership roles such as head nurses. hutchinson and jackson ( ) opine that researchers should explore a new line of thinking with respect to nursing leadership. it is important to explore the influencing mechanisms and multilateral explanations of the impact of leadership for the novel notions of the inclusive, responsible, servant or shared leadership styles. this can help address various drivers in multiple contexts of healthcare in modern times. wong ( ) lays more emphasis on research that helps develop and test theories encompassing the leadership of such personnel who are not in formal leadership roles. this study adds to the literature by focusing on the importance of clinical leadership's inclusive behaviour at the centre of healthcare services. nurses face higher psychological job demands due to occupational hazards during infection control, isolation and containment. inclusive leadership support and psychological safety can serve as external and internal resources to handle these job demands, respectively (janoff-bulman, ) . inclusive leaders are accessible and open to having conversations with subordinates about the things that are important to them. it helps create a positive environment with a sense of psychological safety and lower levels of distress. mutual trust and respect are the core tools of inclusive leadership that improve psychological safety beliefs (hassan & jiang, ) . research on the outcomes of inclusive leadership is comparatively in early stages and empirical evidence on the influences of this leadership style in healthcare is scarce. while studies have been carried out on the influence of positive leadership styles on employee behaviour in the health sector (brooks et al., ; kessel et al., ) , there is a scarcity of studies on the influence of inclusive leadership style. specifically, its impact on employees' mental health, safety and well being during a public health emergency , disaster or traumatic event (birkeland et al., ) requires further research. most prior research on covid- focuses on measuring psychological distress levels and comparison across groups such as age and gender (huang & zhao, ; lee & you, ; mazza et al., ; smith et al., ) . these do not address the mechanisms that influence psychological distress. this study makes a contribution to the literature in three ways. first, it fills the existing gap in research on the impact of inclusive leadership on psychological distress instead of merely measuring the existence of psychological distress levels. second, it focuses on the mediating mechanism of psychological safety due to its impact in helping reduce psychological distress in work settings. third, it responds to call for research by birkeland et al. ( ) to examine psychological distress and leadership behaviour during a traumatic event i.e. the epidemic in wuhan in this study, as compared to most studies that focus on behaviours at the workplace after such an event. fourth, it addresses the gap in literature with respect to the impact of various styles of leadership on the level of health-related problems amongst nurses working in critical care. this study is of significance because it will also enable authors to study whether the impact of these factors will vary in the long run after the epidemic is over, by means of extending this research into a longitudinal study through data collection at another point in time in future. nembhard and edmondson ( ) define inclusive leadership as "words and deeds by a leader or leaders that indicate an invitation and appreciation for others' contributions". it refers to "leaders who exhibit visibility, accessibility, and availability in their interactions with followers (carmeli et al., ) . inclusive leaders try to minimize these differences between themselves and subordinates and ensure the employees are acknowledged for their contributions irrespective of their hierarchical level at the workplace (hassan & jiang, ) . to that end, inclusive leaders focus on practices that value employee diversity in decision-making processes. inclusive leaders make employees feel comfortable and encourage them to share opinions without being afraid of power distance or status differences. inclusive leadership is somewhat comparable to participative leadership style; yet it is different because it conceptually lays a broader focus on work contexts with inherent power distance and status differences (javed et al., ) . max weber's theory of charismatic leadership posits that natural leaders who come to save the day in moments of distressbe it psychological, physical, ethical, religious, economic or even politicalwere such persons who neither held office nor were formally appointed professionals, but rather were gifted people with extraordinary talents (weber, ) . inclusive leadership is similar to one of the key dimensions that make up charismatic leadership i.e. the relational dimension. inclusive leadership's core skills are based on the relationship and support between the leaders and subordinates (nembhard & edmondson, ) . charisma is the "affectual relationship between leader and followers developing as the historical product of the interaction between person and situation" (epley & christi, ) . it has been argued that subordinates play a key role during different stages of a charismatic relationship process (howell & shamir, ) ; indicating that followers should have a voice. this aspect also translates into inclusive leadership style which encourages subordinates to be open. however, more recently, literature has called to forego the labels such as charismatic leadership style claiming them empirically less distinct and have favored the study of other clearly defined aspects of leadership (van knippenberg & sitkin, ) . inclusive leadership is one such clear and distinct style that evolved partly from charismatic style. psychological distress refers to "general symptoms of depression and anxiety and reflects both a stable trait component and a state component susceptible to changes after external events" (ormel & schaufeli, ) . work-related stress activates "dysfunctional intermediate psychological and physiological processes" which can lead to an adverse impact on employee health (nielsen et al., ) . ultimately, recurring exposure to stressful situations can prolong the psychological activation of such dysfunctional processes. this causes increased worrying, sulking, and rumination which eventually culminates in the form of psychological distress (horwitz, ) . during the severe acute respiratory syndrome (sars) outbreak in , the predecessor to covid- , chan and huak ( ) reported that approximately % of nurses in particular, and % of healthcare workers in general, suffered from post-traumatic stress disorder. the frontline healthcare workers during the sars outbreak displayed chronic stress as well as higher levels of depression and anxiety (mcalonan et al., ) . although the term inclusive leadership was coined much later in , the coping strategies evidently used by healthcare workers during the sars outbreak were very similar to the characteristics of inclusive behaviour. most important strategies that proved significant in reducing psychological distress among nurses included clarity in communicating directives for precautionary measures, feedback by subordinates in order to obtain support from their managers and support from co-workers (chan & huak, ) . the theory of shattered assumptions (janoff-bulman, ) postulates that when individuals are exposed to traumatic events, it shatters their basic cognitive schemas of how they see the world, perceive others people, and themselves. abrupt changes in the core schemas are a threat to employees' psychological conditions, and there is a need for a stable mechanism in the conceptual systems to buffer such events. in case no such mechanism is devised, it may result in trauma and health problems (birkeland et al., ) . public health emergencies and epidemics change the cognitive schemas and employee perceptions of the world as a safe place (janoff-bulman, ) . the behaviour of leadership can be instrumental in how such traumatic events impact the health of affected employees (birkeland et al., ) . positive forms of leadership such as inclusive leadership help in rebuild the confidence of employees through interaction and trustworthiness (george & zhou, ) . inclusive leadership contributes to the re-creation of employee perceptions of the world as a safe place by enhancing psychological meaningfulness and vitality (binyamin & brender-ilan, ) ; thereby diminishing the negative impact of the adverse events such as public health emergencies and epidemics. the relationship of leaders with their subordinates develops and changes over time (bluedorn & jaussi, ; shamir, ) . especially during testing periods, such as public health emergencies and epidemics, nurses experience feelings of vulnerability. during such times subordinates may be more eager to scrutinize leaders (hurst, ) . it is possible that they process stress in a way that helps make sense of current threat and fears i.e. appraising others' reactions during the epidemic in a negative way (ehlers & clark, ) . how the workplace responds to traumatic events can result in a strong influence on psychological distress (byron & peterson, ) . the behaviour of leaders either intensifies or soothes the outcome of extreme situations and stressful events (hannah et al., ) . a study on the psychological effects resulting from a terrorist attack in oslo concluded that a higher level of supportive leadership is associated with a lower level of psychological distress (birkeland et al., ) . several studies in the extant literature examine the relationship between the work environment and psychological distress. however, almost all of these are limited to general daily routines where employees have rare chances of suffering from high psychological distress (elovainio et al., ; ybema & van den bos, ) . in contrast, nurses who have undergone the experience of covid- outbreak may be more susceptible to psychological distress due to the extreme situation at the workplace. this paper examines the baseline research question stemming from past research about the influences of inclusive leadership and links it to psychological distress among healthcare workers based on the propositions put forth in the job demands-resources theory (bakker arnold & demerouti, ) . building on job demands-resources theory's fundamental principle, nurses are more likely to undergo work-related stress because their job demands are greater than the resources available to meet those demands. this resources insufficiency causes feelings of anxiety while employees try to achieve targeted performance goals (bakker & demerouti, ; crawford et al., ) . in their review of the literature, stuke and bermpohl ( ) found that high job demands had a significant influence on job stress level among employees. more recently, cheng et al. ( ) observed that job demands are related to the mental health of healthcare workers. gleason et al. ( ) found that disruptive behaviour and low job resources are related to psychological conditions. based on , observations, oshio et al. ( ) proved that job demands-resources factors have a significant effect on psychological distress. during the epidemic in wuhan, the job demands of nurses have increased and intensified. they had to face a shortage in medical supplies and safety materials such as masks, protective gear and goggles, which are compulsory during interaction with patients (yu & li, ) . further to these previous arguments, this study posits that psychological distress has relatively increased in recent times. the time-trend effects require a significant consideration due to the repeated instances of epidemic outbreaks in the past two decades. the review of the literature on service theory shows that healthcare workers are increasingly performing roles that demand additional competencies such as being more collaborative and more risk-tolerant (bowen, ; stuke & bermpohl, ) . from a psychological point of view, job demands are higher during an epidemic and require more mental exertion. inclusive leadership plays a role in curbing such psychological pressures by providing the employees with ease and peace of mind because they believe there is someone they can turn to in times of need. inclusive leaders are inherently keen listeners; thus, most situations of hypertension or mental stress can be alleviated through regular interaction of subordinates with such leaders. the supportive behaviour of inclusive leaders minimizes uncertainty, anxiety, and role stress. therefore, this study hypothesizes that: hypothesis : inclusive leadership has an inverse relationship with the psychological distress of healthcare workers during an epidemic. edmondson ( ) jokes while explaining psychological safety, "it turns out no one wakes up in the morning and jumps out of bed because they can't wait to get to work today to look ignorant, incompetent, intrusive, or negative". psychological safety is defined as "individuals' perceptions that they shall not be humiliated for voicing their concerns or punished for mistakes at the workplace" (edmondson, ; edmondson, ) . scholars have noticed that "the degree of psychological safety varies across medicine" (edmondson & lei, ; nembhard & edmondson, ; rosenbaum, ) , thus indicating a need for more research on its role and influencing factors in healthcare services. in the field of medicine, it is frequently observed that managers try to manage others' impression of them to protect their professional image (edmondson, ) . a recent study on head nurses in china found that leaders were more focused on improved work efficiency instead of paying attention to their leadership roles and expectations . leaders in clinical settings need to focus on adding meaning to work. they must remind people about the nature of their work and the potential of things to go wrong (edmondson, ) . inclusive leaders' openness ensures these aspects, which in turn create psychological safety at the workplace. inclusive leaders extend not just intellectual support but also connect with subordinates at an emotional level (hirak et al., ) . this maintains such a work context that helps employees experience a higher level of psychological safety and motivates them towards proactive behaviour (hassan & jiang, ; javed et al., ; mikyoung & moon, ) . inclusive leadership refers to such leaders who interact with subordinates in a culture of openness, accessibility, and availability to help them at any time (nembhard & edmondson, ) . this inclusive behaviour helps bring about a positive mood among employees and at the workplace in general (hollander, ) which in turn, as a pleasant affective state, reduces the potential of employee psychological distress. inclusive leadership promotes inclusiveness through openness (choi et al., ) , allowing for employees to thrive at the workplace. if leaders are not open and hide information or knowledge, this can lead to negative outcomes through deteriorated psychological safety . in a recent study, mikyoung and moon ( ) proved that inclusive leadership is positively related to psychological safety, which in turn plays a mediating role between inclusive leadership and employee extra-role behaviours. javed et al. ( ) demonstrated a positive relationship between inclusive leadership, psychological safety and the mediating role of psychological safety between inclusive leadership and employees' extra-role behaviour. inclusive leadership promotes a forgiveness climate which affects the service recovery performance of employees. another study by guchait et al. ( ) found that psychological safety mediates between forgiveness climate and employees' service recovery. along the same lines, this paper argues that psychological safety can mediate between inclusive leadership and psychological distress, such that inclusive leadership reduces psychological distress amongst employees during an epidemic due to the positive environment of psychological safety created by inclusive leadership. this study makes a contribution in the context of public health emergencies involving epidemics. it helps understand the mechanism that links il's influence on psychological distress by fostering employees' occupational wellbeing. therefore, we assume that psychological safety is a connecting mechanism in the relationship between inclusive leadership and positive outcomes such as extra role behaviour (javed et al., ) and a positive mindset with lower levels of psychological distress. the above discussion leads us to hypothesize that: the researchers met with nursing staff co-chiefs at five hospitals in wuhan and explained the purpose of the research in order to obtain permission, and explained the procedure. at least one head nurse was also present in the meeting. a web-based questionnaire with a crosssectional study design was used due to restrictions on the mobility of unrelated personnel in the hospitals. a group chat was created by one of the authors on the wechat platform, the application which is most commonly used by the chinese population. the qr code of this group was printed on an a sized paper along with a disclosure statement explaining that the purpose of the group was to find participants for an academic research survey; that it was voluntary and results were to be analyzed in aggregate without identifying any individual; assured them of confidentiality; and clearly stated that joining the group would constitute their informed consent to participate in the research. head nurses placed this qr code and disclosure statement on the notice boards near nurse reporting desks and duty stations. a total of nurses joined the group chat (the first by qr code, and subsequently through invitation by the group chat members to their co-workers). the research plan was followed as initially designed with only one change. the researchers had planned to explain the steps of the study in person to the nurses during a meeting in the presence of the head nurses. however, due to a sharp increase in infections and the general public rushing to the hospitals, it became impossible for irrelevant personnel such as the researchers to enter the hospitals. therefore, the instructional meetings were held by the head nurses (who were present in the initial meetings). they explained the procedure of this study to the participants. also, the procedure and dates of the three phases of data collection were also included in the displayed disclosure statements before the data collection. at all three times of data collection, the authors coordinated with the head nurses and asked for feedback from participants in the wechat group to run checks to see if there were any questions or points of confusion. at all times, the researchers ensured respondents felt comfortable and understood the process. the progress of filling out the questionnaire was monitored by the authors and reinforced using reminders in the group chat at least once hours after the initial distribution of the online questionnaire link. it was anticipated that easy access to the questionnaire via website links would require less effort than a paper and pencil method. this proved to be the case as the study received a sufficiently high number of responses as compared to the minimum sample size required statistically. the data were collected with temporal separation to avoid common method bias as per recommendations of cortina and landis ( ) . a multi-stage survey approach helps provide superior quality data and reduces the potential of common-method variance bias. time-variant measures improve the reliability and validity of the measurement model. this temporal separation helps establish causality (podsakoff et al., ) . data for the marker variable were collected at time one on january , , along with demographics; data for psychological distress and psychological safety were collected at time two on january , , while data for inclusive leadership was collected at time three on february , . the interval between time one and time two was shorter (two days) because the data being collected was for variables that were less likely to affect each other's responses. this was so because data collection at time included demographics, marker variable and control variable data, while time involved the dependent variable and the mediating variable. when respondents fill out the questions for all the variables in one go, they may anticipate the nature of the desirable responses and falsify responses in order to appear consistent and rational. this scenario is dubbed as consistency motif (podsakoff & organ, ) which can cause some responses to one variable to affect the responses to another variable in the questionnaire if data were collected simultaneously (podsakoff et al., ) . the interval between time (dependent and mediation variable) and time (independent variable) was kept longer because the variables at these two time points were the main constructs of the study and researchers wanted to ensure that response to time two variables did not affect the responses to variables at time . the authors placed the questionnaire on a third-party chinese service provider's website, and its url was shared to the group chat. no contact information was required except for the wechat id to match the respondents with the nurses in the group chat. nurses had hours to open and fill out the online questionnaire at their convenience following the time of posting the link of the questionnaire in the group chat. a timer was associated with the questionnaires filled out online to assess the time taken by each respondent. this helped researchers screen for unusually faster response times which may indicate that respondents did not exhibit due diligence in reading the statements before answering. the average time taken to fill the questionnaire, ranged between to minutes (time ), to minutes (time ) and to minutes (time ). at time and time , a total of nurses filled out the online questionnaire for demographics, marker variable, psychological safety and psychological distress. twelve responses that took less than minutes were discarded. another four responses were removed while screening for missing data, yielding usable responses. these respondents were retained, and the nurses whose responses were unusable, or those who did not participate, were removed from the group chat. at time , february , , these respondents were asked to fill out the questionnaire related to inclusive leadership out of which responses were received while ( . %) responses were deemed usable after screening for an unreasonably short duration and missing values. hospital nurses in china have five career levels: nurse, senior nurse, supervisor nurse, cochief superintendent nurse and chief superintendent nurse. moreover, most chinese head nurses are supervisor nurses or co-chief superintendent nurses . the data were collected from nurses, senior nurses and supervisor nurses. the respondents included only the on-duty nurses and did not involve those on leave. the participants also invited their co-worker nurses to take part in the study. thus, the sampling technique used for this study was mixed/snowball sampling. to ensure the adequacy of the sample size, the researchers followed the expert advice of hair et al. ( ) , while not dismissing the ' times rule' by gefen and straub ( ) , commonly used in studies using partial least squares (pls)-sem. hair et al. ( ) suggest that the sample size should be based on a power analysis taking into consideration the largest number of predictors pointing towards a single variable. in this study, there were two predictors pointing towards the dependent variable. in such a setting, the minimum recommended sample size is , for two predictors at a five per cent significance level for a minimum . r-square with % statistical power (hair et al., ) . the sample size of is more than satisfactory for a pls-sem analysis there was no common method bias detected in our data after running the full collinearity checks for vif values suggested by kock ( ) . the researchers ran the pls algorithm times by treating each of the variables as dependent variables one by one. on all three occasions, the inner vif values were lower than . at the factor level, suggesting there was no common method bias. additionally, to remove the possibility of common method bias, the researchers also used a priori measured marker variable approach (chin et al., ) . a -item scale of computer self-efficacy adapted from taylor and todd ( ) was selected as a marker variable, and it was theoretically unrelated to model constructs. data were collected for the marker variable before the data for the main constructs. the differences between the values of rsquare in psychological safety and psychological distress before and after adding the marker variable were less than per cent, well below the suggested per cent limit (chin et al., ) . this proves the responses were free from any bias. all measures have been adopted from previous studies and have a well-established reliability over time. inclusive leadership was measured using a -item scale adapted from carmeli et al. ( ) . sample questions included "the leader is attentive to new opportunities to improve work processes" (openness); "the leader is available for consultation on problems" and "the leader is accessible for discussing emerging problems". the reliability was checked using cronbach's alpha (α) and composite reliability which were . and . , respectively. these were above the recommended value of . . validity was assessed with the average variance extracted (ave), which was . , above the minimum required benchmark of . (hair et al., ) . psychological safety was measured with a -item scale developed by edmondson ( ) . sample questions are, "it is safe to take a risk on this team." and "members of this team are able to bring up problems and tough issues". cronbach's α ( . ) and composite reliability ( . ) values were above the required level, and the ave was . . both inclusive leadership and psychological safety were measured on a -point likert-type scale ( = strongly disagree, to = strongly agree). psychological distress was measured using the -item (k ) scale developed by kessler and mroczek ( ) for non-specific psychological distress over preceding days ( =none to =all the time), with the score ranging from zero to . cronbach's α was . , and the composite reliability was . , with an average variance extracted value of . . the chinese and korean versions were recently validated for asian american respondents by jang et al. ( ) . the k scale has been regularly used by national health services in the united kingdom for annual surveys between and (patel et al., ) and multiple studies have shown psychometric properties to be acceptable (jong won & sun hae, ; patel et al., ) . the mean scores for inclusive leadership, psychological safety and psychological distress were . , . and . . based on past studies on psychological distress (eriksen et al., ; stuke & bermpohl, ) , control variables of age, gender, education, experience and working hours were included. the data were analyzed using smartpls software, version . . (ringle et al., ) . partial least square structural equation modelling (pls-sem) was used as it performs better with predictive models (hair et al., ) . moreover, it simultaneously estimates relationships between multiple independent and dependant variables (of the structural models) and the latent, multiple observed or unobserved constructs of the measurement models (sarstedt et al., ) . to check whether control variables had any confounding effect on the dependent variable, the differences between responses were analyzed by splitting data into two groups for each of the control variables and the structural model was run for each control variable separately. the multi-group analysis was run choosing the percentile bootstrap setting in smartpls software to examine the differences between respondents based on working hours (< hours and or more hours); gender (females = , males = ), age (< years and years or older), experience (< years and years or more). the sample and procedure section above clarifies that the prior permissions were obtained from the hospital administration in personal meetings where the nature of the study was explained to be pure academic research. the respondents were provided with full disclosure, voluntary nature, confidentiality statements which indicated that joining the group chat to participate in the survey would constitute informed consent. the psychometric features of the measurement model were assessed using confirmatory factor analysis (hair et al., ) . the item reliability of a construct is determined by its factor loading (the correlation between each item and the respective construct.) the threshold for the factor loading of an indicator was set at . . the factor loadings (table ) ranged between . and . . most of the item values exceeded . , with significant tstatistics (p < . ). however, one item each for inclusive leadership and psychological safety with an outer loading of less than . was removed as per recommendations by experts . the construct-level internal reliability was established using cronbach's alpha and composite reliability (cr). the composite reliability determines how well its own items measure a construct; it is the shared variance among the indicators used to measure a construct. the recommended value is . . all the constructs displayed high cr scores exceeding . , indicating that the constructs had good internal consistency and reliability. the convergent validity of the constructs was confirmed by following the fornell and larcker ( ) criterion, as all the ave values were higher than . (sarstedt et al., ) . the discriminant validity is a measure indicating that the constructs are different from each other (see it was assessed using the fornell-larcker criterion as well as the heterotrait-monotrait (htmt) criterion developed by henseler et al. ( ) and the values were below the recommended conservative threshold of . (sarstedt et al., ) . table displays the square root of ave values along diagonal, while htmt values are above the diagonal. the smartpls-sem technique used in this study is a variance-based technique rather than a covariance-based technique, which is used by other softwares such as statistical package for the social sciences (spss) and amos. it can run multiple relationships between simultaneous multiple independent variables with dependent variables. the model fit in smartpls is termed as model strength and quality. this is assessed by calculating the strength of specific paths signifying hypothesized relationship known as interaction effects denoted by f and predictive relevance denoted by q values (sarstedt et al., ) . the interaction effect obtained using f values was substantially large (> . ) for interaction between inclusive leadership and psychological safety and within an acceptable level ( . or higher) for interactions of both inclusive leadership and psychological safety with psychological distress as per recommendations made by cohen ( ) . a q value of greater than zero implies that the model has good predictive relevance (chin, ; chin, ) . the q values were obtained using the blindfolding function and were above zero, suggesting significant predictive relevance. a -sampled bias-corrected bootstrap was run with a per cent confidence level to generate the t-values sarstedt et al., ) using a two-tailed estimation (hair et al., ) . keeping this in mind, and based on the t-value rule of thumb for the interpretation of a two-tailed test, i.e., . , the hypothesized relationships proved to be significant. inclusive the specific indirect effect was significant (β = - . , t = . ) and proved to be a complementary mediator between inclusive leadership and psychological distress as inclusive leadership also has a significant negative effect on psychological distress. table displays rsquare values before and after adding the maker variable to the model, proving that the results were not affected by method bias. a percentile bootstrap with subsamples was run for pls-mga. benchmarks proposed in the literature state that differences are indicated when the p-value differential column displays values below . or above . (ringle et al., ) . respondents were divided into age groups of young (under years) and old ( years and above); gender ( = female, = male); less experienced (< years) and more experienced ( years or more) and working hours (less than hours and hours or more). the p-values show no significant differences between respondents on the bases of age, gender, education, or experience. however, young respondents differed in their response to the relationship of inclusive leadership and psychological distress. the parametric and welch-satterthwaite results were also found to be consistent with these results. this paper aimed to study the relationship between-inclusive leadership and psychological distress while evaluating the mediating mechanism of psychological safety. inclusive leadership creates an environment of psychological safety, and through this mechanism, the leaders help reduce psychological distress during strenuous conditions such as an epidemic. the results show that inclusive leadership is positively associated with psychological safety which is similar to recent studies by mikyoung and moon ( ) and javed et al. ( ) . it further extends those results by providing empirical evidence that inclusive leadership has a significant negative effect on the psychological distress of nurses during public health emergencies and traumatic events. being exposed to critical epidemic diseases is bound to produce emotional stress and anxiety when healthcare workers feel unsafe. previous researchers have emphasized the management of nurses under normal circumstances (choi et al., ; masood & afsar, ) rather than in situations of public health emergencies such as a pandemic. this study compensates for this gap in the literature. the results suggest inclusive leaders create a more open and psychologically safe environment for healthcare workers. this, in turn, helps maintain and improve employees' vitality and reduce psychological distress, which facilitates contribution and ability to focus at work. the current study's results showed a high level of inclusive leadership behaviour among nursing leaders in wuhan with a mean score of . , which differs from a previous study by wang et al. ( ) that claimed that the head nurses in china exhibit very low level of inclusive leadership. inclusive leadership is one of the positive leadership styles studied in this paper due to its impact on the psychological distress of nurses working during the covid- epidemic. the results show that a positive leadership style reduces distress levels. this result is similar to a previous study's results, which had confirmed the influence of a positive leadership style on the psychological distress of victims of a traumatic event (birkeland et al., ) . on the other hand, this study contradicts the results of a previous study by eriksen et al. ( ) that found there was no relationship between work factors and psychological distress. it also differs from another study's results, which found positive leadership styles were not significantly related to psychological distress (nielsen et al., ) . a longitudinal study by birkeland et al. ( ) also found that there was no relation between positive leadership styles and psychological distress in the long run. however, it can be argued that such studies were conducted under normal conditions and not in public health emergency situations. moreover, although those studies included certain positive leadership styles, they did not study inclusive leadership style directly. although some previous studies have shown differences between respondents based on age (huang & zhao, ) , gender (lee & you, ) , this study showed no differences between respondents based on these confounding variables. this shows that inclusive leadership has a negative impact on psychological distress across all respondents, irrespective of these confounding effects. this study contributes to the existing literature by i) responding to call for research by birkeland et al. ( ) to examine effects of leadership roles during a traumatic event, i.e., the epidemic in wuhan; ii) filling the gap in research on effects of inclusive leadership on psychological distress, and examining the mediating role of psychological safety between inclusive leadership and psychological distress. moreover, it also addresses the gap in the literature with respect to the impact of inclusive leadership style amongst nurses working in critical care, which is a first. this study adds to knowledge by providing indirect support for job demands-resources theory. although this study's empirical context does not measure job demands-resources at the workplace, it was used as a theoretical lens to support hypotheses development and interpret the subsequent results. the difference between available job resources and job demands predicts role stress because nurses perform their tasks using insufficient resources during epidemics. when exposed to increased job demands and diminishing resources, they not only experience stress episodes but also become prone to prolonged psychological distress as well. this study's theoretical expectations proposed during hypotheses development concur with the results of empirical analysis. the shift in the balance between job demands and resources among healthcare workers coincides with increased psychological distress during an epidemic. the strong empirical support suggests that the application of job demands-resources theory can further advance research in the health services sector (gabler et al., ) . this study also validates the theory of shattered assumptions by janoff-bulman ( ), which posits that situations such as epidemics bring trauma and shatter the employee perceptions of the world being a safe place. inclusive leadership can serve as such a mechanism to rebuild these perceptions. with a leader who is open and available, employees appreciate the supervisor's recognition of their emotions of fear and threat. this way, the emotional toll and demands faced by subordinates are subdued, leading to reduced levels of psychological distress (tucker et al., ) . the resources under job demands-resources theory primarily constitute internal resources of psychological capital, work autonomy, and value along with external resources of leadership styles, fringe benefits and social support (bakker & demerouti, ; bakker arnold & demerouti, ) . psychological safety serves as an internal resource, and inclusive leadership serves as an external resource that motivates the development of a positive mood with an open and accessible environment. using these tenets of the job demands-resources theory, hospital leadership can introduce critical remedial practices to ensure an inclusive environment, which may help prevent an imbalance between psychological resources and demands. if such an imbalance can be avoided, it is likely to reduce the occurrence of sudden negative workplace outcomes in general and in particular, under increased risks in epidemiological work. managing nurses has emerged as a key issue in recent research in healthcare . to establish a psychologically safe environment for the healthcare workers, leaders should primarily focus on fear and safety concerns during an epidemic. for nursing leadership, the results of the study prove that an inclusive leadership style can be effective in the implementation of mental health support initiatives as a built-in mechanism for nurses. training programs on inclusive leadership and incentives should be introduced for nurses in informal managing roles to inculcate a culture of openness, availability and accessibility. this study adds to the literature by validating the effectiveness of the inherent functions of an inclusive leadership style in curbing psychological distress during an epidemic. as evident in studies on sars with respect to coping strategies for healthcare workers, supportive behaviours, and clear communication has been the key to ensuring nurses' mental health and well being. these characteristics are similar to the inclusive leadership style, which was only introduced in years after the sars epidemic. in this spirit, this study validates the inclusive leadership style due to its impact during covid- , therefore following the same pattern as observed in the sars epidemic. by creating an inclusive environment, open and accessible leadership inspires psychological safety among co-workers and subordinates to be forthcoming, sharing, and to be helpful to others. this belief stems from the concept of psychological safety, the idea that there is someone to turn to in times of need, and helps reduce psychological distress among healthcare workers. it is important not just for the workers but for the patients as well. a mentally healthy and psychologically relaxed nurse is less likely to make mistakes, which reduces the likelihood of adverse events at hospitals, leading to improved patient outcomes. this study is related to nursing staff only, and caution is advised when generalizing the findings to another cadre, industry or type of firms. this study was conducted in chinese hospitals in wuhan at the epicentre of the covid- outbreak; its generalizability may be improved with further research by drawing samples from american, australian or european regions that are currently suffering from a highly infectious phase of covid- and healthcare workers are highly likely to face psychological distress. a web-based questionnaire was used in this study. although it comes with the advantages of faster and more cost-effective responses, past research shows that it may have some limitations such as lower completion rates and selective participation, which may affect the point estimates of the dependent variable. however, this was not the case in the current study. a cross-sectional design was a limitation of this study with single-source data, although there was no contamination due to common method bias. for future studies, it is suggested that multi-source studies on inclusive leadership in healthcare could be carried out with additional outcome variables related to extra-role behaviours of employees as reported by peers or supervisors. another direction for future research could be extending this research into a longitudinal study on inclusive leadership, comparing its effects on psychological distress during an epidemic with its effects under normal circumstances after the epidemic is over. this would help establish whether the impact of inclusive leadership and psychological safety on psychological distress varies in the long run after the epidemic is over. recurring or prolonged experiences of stress and anxiety at the workplace, without a mechanism to counter such effects, can culminate into psychological distress. this study shows that inclusive leadership in healthcare is vital in avoiding psychological distress and helps nurses maintain sound mental health. weber's charismatic style of leadership informed the development of inclusive leadership in this study. inclusive leadership is distinct from other styles, but it has evolved, in part, based on inspiration from the charismatic leadership style. positive leadership styles, such as inclusive leadership, bring healthcare workers together with sharing and caring behaviour. it makes subordinates feel psychologically safe and helps them stay mentally strong to continue fighting diseases such as covid- , which cause public health emergencies and trauma. linking transformational leadership with nurse-assessed adverse patient outcomes and the quality of care: assessing the role of job satisfaction and structural empowerment job demands-resources theory the job demands-resources model: state of the art leaders's language and employee proactivity: enhancing psychological meaningfulness and vitality associations between work environment and psychological distress after a workplace terror attack: the importance of role expectations, predictability and leader support time-lagged relationships between leadership behaviors and psychological distress after a workplace terrorist attack leaders, followers, and time the changing role of employees in service theory and practice: an interdisciplinary view a systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak the impact of a large-scale traumatic event on individual and organizational outcomes: exploring employee and company reactions to inclusive leadership and employee involvement in creative tasks in the workplace: the mediating role of psychological safety psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore nurses' mental health and patient safety: an extension of the job demands-resources model the partial least squares approach to structural equation modeling how to write up and report pls analyses. handbook of partial least squares: concepts, methods and applications controlling for common method variance in pls analysis: the measured latent marker variable approach inclusive leadership and employee well-being: the mediating role of person-job fit inclusive leadership and work engagement: mediating roles of affective organizational commitment and creativity statistical power analysis for the behavioral sciences modern research methods for the study of behavior in organizations linking job demands and resources to employee engagement and burnout: a theoretical extension and meta-analytic test psychological safety and learning behavior in work teams managing the risk of learning: psychological safety in work teams building a psychologically safe workplace: tedx talk three ways to create psychological safety in health care. institute for healthcare improvement -ihi psychological safety: the history, renaissance, and future of an interpersonal construct a cognitive model of posttraumatic stress disorder perceived organizational justice as a predictor of long-term sickness absence due to diagnosed mental disorders: results from the prospective longitudinal finnish public sector study weber's theory of charismatic leadership: the case of muslim leaders in contemporary indonesian politics work factors and psychological distress in nurses' aides: a prospective cohort study. bmc public health, , article structural equation models with unobservable variables and measurement error: algebra and statistics is there a dark side of ambidexterity? implications of dueling sales and service orientations consumer trust in b c e-commerce and the importance of social presence: experiments in e-products and e-services dual tuning in a supportive context: joint contributions of positive mood, negative mood, and supervisory behaviors to employee creativity the job demands-resources model as a framework to identify factors associated with burnout in surgical residents the influence of perceived forgiveness climate on service recovery performance: the mediating effect of psychological safety and organizational fairness an updated and expanded assessment of pls-sem in information systems research partial least squares structural equation modeling: rigorous applications, better results and higher acceptance assessing measurement model quality in pls-sem using confirmatory composite analysis rethinking some of the rethinking of partial least squares debunking the false dichotomy of leadership idealism and pragmatism: critical evaluation and support of newer genre leadership theories a framework for examining leadership in extreme contexts facilitating learning to improve performance of law enforcement workgroups: the role of inclusive leadership behavior a new criterion for assessing discriminant validity in variance-based structural equation modeling linking leader inclusiveness to work unit performance: the importance of psychological safety and learning from failures distinguishing distress from disorder as psychological outcomes of stressful social arrangements the role of followers in the charismatic leadership process: relationships and their consequences generalized anxiety disorder, depressive symptoms and sleep quality during covid- epidemic in china: a web-based cross-sectional survey. medrxiv crisis and renewal: meeting the crisis of organisational change transformational leadership in nursing: towards a more critical interpretation measurement equivalence of english versus native language versions of the kessler (k ) scale: an examination in three asian american groups shattered assumptions: towards a new psychology of trauma impact of inclusive leadership on innovative work behavior: the role of psychological safety impact of inclusive leadership on innovative work behavior: the role of psychological safety knowledge hiding as a barrier to thriving: the mediating role of psychological safety and moderating role of organizational cynicism validation of the k /k scales of psychological distress and their optimal cutoff scores for older koreans psychological safety, knowledge sharing, and creative performance in healthcare teams final versions of our non-specific psychological distress scale survey research the costs of depression common method bias in pls-sem: a full collinearity assessment approach psychological and behavioral responses in south korea during the early stages of coronavirus disease (covid- ) transformational leadership and innovative work behavior among nursing staff a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers inclusive leadership and creative performance : the role of psychological safety, feedback-seeking behavior, and power-distance work stress among chinese nurses to support wuhan for fighting against the covid- epidemic making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams are leadership fairness, psychological distress, and role stressors interrelated? a two-wave prospective study of forward and reverse relationships longitudinal relationships between workplace bullying and psychological distress stability and change in psychological distress and their relationship with self-esteem and locus of control -a dynamic equilibrium-model associations among job demands and resources, work engagement, and psychological distress: fixed-effects model analysis in japan psychological distress is increasing among customer-facing retail employees: evidence from to sources of method bias in social science research and recommendations on how to control it common method biases in behavioral research: a critical review of the literature and recommended remedies self-reports in organizational research -problems and prospects smartpls cursed by knowledge -building a culture of psychological safety estimation issues with pls and cbsem: where the bias lies partial least squares structural equation modeling leadership takes time: some implications of (not) taking time seriously in leadership research covid- : emerging compassion, courage and resilience in the face of misinformation and adversity which working conditions promote the development of depressive disorders? an integrated work-stress-model understanding information technology usage -a test of competing models employees' perceptions of their own and their supervisor's emotion recognition skills moderate emotional demands on psychological strain a critical assessment of charismatictransformational leadership research: back to the drawing board? minor psychiatric disorder in nhs trust staff: occupational and gender differences the mediating role of inclusive leadership: work engagement and innovative behaviour among chinese head nurses who coronavirus disease (covid- ) dashboard. who. retrieved connecting nursing leadership and patient outcomes: state of the science official sacked following new confirmed covid- cases in china's wuhan. people's daily effects of organizational justice on depressive symptoms and sickness absence: a longitudinal perspective why an acute shortage of masks persists amid the coronavirus outbreak his research interests include strategic human resource management, organizational behavior and inclusive diversity worked earlier as assistant director in the ministry of education for government of pakistan; possesses over years cumulative experience in operations management, business development, hr functions and technological change management with years managerial experience in telecom industry in e-business environments; aims to integrate personal and professional experiences with research issues in hr and technology management. his recent works include ssci indexed paper titled "sustainable change management through employee readiness: decision support system adoption in technology-intensive british e-businesses his recent work includes ssci indexed paper titled "how does servant leadership foster employees' voluntary green behavior? a sequential mediation model the authors wish to acknowledge the help of all the healthcare workers who managed to spare time out of their tough routines to make this research possible during a difficult time. the authors declare there was no conflict of interest. key: cord- - t wc authors: o’donovan, róisín; mcauliffe, eilish title: exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data date: - - journal: bmc health serv res doi: . /s - - -z sha: doc_id: cord_uid: t wc background: psychological safety allows healthcare professionals to take the interpersonal risks needed to engage in effective teamwork and to maintain patient safety. in order to improve psychological safety in healthcare teams, an in-depth understanding of the complex and nuanced nature of psychological safety is needed. psychological safety concepts, including voice, silence, learning behaviour, support and familiarity, informed the current study’s investigation of psychological safety. this study aims to use a mixed-methods approach to develop an in-depth understanding of psychological safety within healthcare teams and to build on this understanding to inform the development of future interventions to improve it. methods: survey, observational and interview data are triangulated in order to develop an in- depth understanding of psychological safety within four healthcare teams, working within one case study hospital. the teams taking part included one multidisciplinary and three unidisciplinary teams. observational and survey data were collected during and immediately following team meetings. individual interviews were conducted with individuals across the four teams. thematic analysis was used to analyse these interviews. results: survey results indicated a high level of psychological safety. however, observations and interviews captured examples of silence and situations where participants felt less psychologically safe. findings from across all three data sources are discussed in relation to voice and silence, learning, familiarity and support. conclusion: the results of this study provide a detailed description and in-depth understanding of psychological safety within four healthcare teams. based on this, recommendations are made for future research and the development of interventions to improve psychological safety. psychological safety is a multi-dimensional, dynamic phenomenon that concerns team members' perception of whether it is safe to take interpersonal risks at work [ ] . it is particularly important within healthcare teams who need to work interdependently to co-ordinate safe patient care within a highly complex, dynamic and high stakes work environment [ ] . however, a culture of fear and low psychological safety still exists within healthcare organisations [ ] [ ] [ ] [ ] [ ] . there is a need to develop and implement interventions to improve psychological safety within these teams [ ] . the ongoing covid- pandemic has highlighted the importance of psychological safety within healthcare teams. cultivating psychological safety is necessary in order to enable healthcare teams to collectively redesign processes and services to cope with new challenges, learn from mistakes and implement changes accordingly [ ] . in order to improve psychological safety, we must first understand the complexity and nuance of psychological safety within healthcare teams [ , ] . to date, there has been a paucity of cross-level and multilevel research on psychological safety [ ] . this has limited our understanding of psychological safety, the concepts related to it and whether it varies across teams within the same organisation [ ] . within organisational research, collecting different kinds of data on the same phenomenon and triangulating this data can help researchers assess complex phenomena, such as psychological safety, more accurately [ , [ ] [ ] [ ] . in the current study we use survey, observational and interview data to develop an in-depth understanding of psychological safety within healthcare teams. building on this understanding, we aim to inform the development of an intervention to improve psychological safety. the constructs which informed our study design our outlined below. these include constructs which have been linked to either low or high psychological safety (voice and learning behaviour) and which have been found to support psychological safety (positive interpersonal relationships). these constructs play a particularly important role within the context of healthcare teams. psychological safety promotes voice and learning behaviour. speaking up and voice behaviour are interpersonally risky behaviours which play an important role in healthcare teams [ ] . feeling psychologically safe can enable team members to engage in speaking up behaviour, such as asking questions, pointing out a mistake or near miss and making suggestions for improvement [ , [ ] [ ] [ ] [ ] . psychological safety also enables learning behaviours, such as seeking help or feedback [ , , ] . learning behaviours are integral to healthcare teams' ability to manage demanding conditions, with rapidly evolving knowledge and practice as well as their ability to learn from failure [ , ] . when healthcare professionals prioritise patient safety by engaging in speaking up and learning behaviours, it is indicative of their levels of psychological safety [ ] . on the other hand, lack of psychological safety inhibits team members from speaking up and causes them to opt for avoidance behaviours, such as silence [ ] . it is important to acknowledge that although employees may frequently engage in voice behaviour, they could also be withholding other ideas, suggestions or concerns [ ] . this highlights the need to go beyond observable behaviours to explore the nuance and complexities of individuals' experience of psychological safety. in order to do so, this study uses a combination of survey, observation and interview data to gain a full understanding of psychological safety. positive interpersonal relationships drive psychological safety [ , ] . within healthcare teams, having positive relationships, effective role models and better teamwork climates encourages healthcare professionals to speak up for safety [ ] . team members relationship with the team leader has been found to influence their sense of psychological safety. for example, when leaders engage in supportive behaviour, such as inclusiveness and openness, they foster psychological safety for other team members [ ] [ ] [ ] . peer support and trust among team members also improves psychological safety within teams [ ] . psychological safety can build across time, increasing as team members become more familiar with one another and have positive experiences of engaging in interpersonally risky behaviour [ , , , ] . while positive, supportive and trusting interpersonal relationships can foster psychological safety, it is important to note that psychological safety does not imply a team without any conflict or problems [ ] . psychological safety is needed in order for productive conflict, such as task conflict, to occur [ ] . task conflict concerns disagreements related to differences in viewpoints, ideas and opinions about the task being performed and can result in learning and improved performance [ , , ] . in this study, focusing on a single hospital as a case study, we use a mixed methods approach to further our understanding of psychological safety within four healthcare teams. we combine data collected through surveys, observations and individual interviews to gain a holistic understanding of psychological safety in these teams. building on this understanding, we aim to inform the development of future interventions to improve psychological safety in healthcare teams. this study was undertaken by the authors as part of a wider body of research aiming to develop an intervention to improve psychological safety in healthcare teams. this research was conducted with healthcare professionals working on one of four healthcare teams from within the same acute, suburban hospital. three of the teams were unidisciplinaryphysiotherapists, nurses and speech and language therapistsand one was multidisciplinary. the authors collaborated closely with hospital management in order to recruit healthcare teams from within the hospital. these teams were selected in collaboration with hospital management using purposive sampling in order to identify different team types as well as teams that held meetings amenable to observation. the lead researcher contacted the leader of each team to ask if their team would be interested in taking part in the team observation and survey. before beginning observations, team members from within each team were asked to consent to the meeting being observed and to completing the survey following the meeting. for interviews, a combination of purposive sampling and snowball sampling were employed to recruit team members from within each team. after the observation and surveys were complete, the researcher informed the team that anyone who was willing to take part in an interview could contact them (the researcher) or their team leader who would then refer them to the lead researcher. team members were recruited from across all staff grades and included team leaders as well as senior and junior team members [ ] . the total number of participants who took part in each phase of data collection can be found in table . the team as a whole were observed during regularly scheduled team meetings. of those who attended the meeting, there was % participation rate in the survey within teams a and b. there was one team members in team c and another in team d who was part of the observations but did not complete a survey. since surveys were kept completely anonymous, it was not possible to assess whether the same participants who completed the survey also took part in an interview. in teams a (n = ), b (n = ) and d (n = ), participants who were not present during observations and who did not complete a survey were recruited by the team leader to take part in an interview. within case study designs, the use of multiple sources of evidence in recommended in order to capture a holistic understanding of the phenomena being studied [ ] . the current study triangulates multiple sources of data in order to gain an in-depth understanding of psychological safety in healthcare teams. rather than adopting the commonly used approach to triangulation to gain more credible or valid results, we draw on a postmodern paradigm which views reality as having multiple, fractured dimensions and being socially constructed. this approach requires acknowledgment that all research findings are shaped by the approach used to collect them and that different methods of data collection will offer different results [ ] . therefore, we use multiple methods to deepen our understanding of psychological safety by encouraging re-interpretation of findings as data sources reveal new insights and, thus, facilitating a more complex and in-depth exploration of healthcare professionals experiences of psychological safety. this approach to triangulation of data has been termed crystallization [ ] . survey and observational data were collected using the composite measure developed and presented in a recent paper focused on measuring psychological safety in healthcare teams [ ] . for each team, one weekly meeting was observed using the observation measure, which captured voice, silence, supportive or unsupportive and familiarity behaviours. the observational data were collected as part of a pilot test of the measure and, as a result, behaviours were amended following each observation, however the overall categories remained the same. observations were completed by one researcher who sat at the table or in the room where each meeting was conducted. the observer tracked the behaviours displayed by the team leader and team members by making a mark in the "behaviour count" box for the relevant behaviour. observations were made by only one researcher in order to reduce the inhibiting effect the presence of two researchers might have on the team's behaviour. the observed team meetings varied in length. the meeting held by team a lasted min, team b's meeting lasted min, team c's meeting lasted min and team d had a meeting which lasted min. all meeting were the teams regularly scheduled team meetings. each discussed clinical and/or management issues that were relevant to their team. following the meeting, team members were asked to complete the survey component of the composite measure. there were three sections in the survey which assessed participants' psychological safety in this was done in order to check if using a point likert scale would give participants an even wider spectrum of response options and, thus, allow the survey to capture more variability in participants' responses [ ] . surveys did not ask for any identifiable information and were kept completely anonymous. participants completed their survey in the same room as one another. there was plenty of space for them to move freely in order to complete their survey in private and surveys were handed directly to the researcher once completed. semi-structured interviews were conducted with participants from across the four teams. the full interview schedule is presented as a supplementary file. this interview data was collected in order to gain an in-depth understanding of individuals' experience of psychological safety and explore whether there were any emerging differences compared to the team level observations or survey responses. interviews were conducted in a private room located within the case study hospital and lasted an average of min. a full description of the process used to collect and analyse the interview data can be found in o'donovan, de brún & mcauliffe (in preparation). hybrid inductive-deductive thematic analysis was used to identify themes which correspond to the concepts covered in the observations and survey data. descriptive, open codes were assigned to each interview. these codes were then reviewed and refined, with reference to the psychological safety literature, in order to identify overarching themes. analysis also compared findings from individuals in the same team to explore the consistencies and inconsistencies across cases. thematic analysis was chosen because it is a theoretically flexible approach to qualitative analysis which allows the combination of inductive and deductive methods [ , ] . as highlighted by braun and clarke [ ] , thematic analysis is a useful method for working within a participatory research paradigm, with participants as collaborators, and for producing qualitative analysis which can inform policy development. since the overarching aim of this study was to inform the development of an intervention to improve psychological safety which is grounded in the experiences of healthcare professionals, thematic analysis was particularly suitable. our analysis focused on themes which captured participants' experiences of speaking up or remaining silent, engaging in learning behaviour and their experience of support, or lack of support and familiarity within the team. ethical approval was obtained for this study from the human research ethics committee in university college dublin (reference number: ls- - ). written informed consent was obtained from all participants prior to each stage of data collection. in order to maintain anonymity, no identifiable information was collected during observations or surveys. interviews were assigned a code made up of p (participant), interview number (e.g. the first interview conducted within each team was given the number ) and team letter (a, b, c or d) and any identifiable characteristics were removed from the interview transcripts. all survey responses are displayed in table . they indicated that team members felt psychologically safe. in team a, a mean response of . was given for section , . for section and . for section . a positive, constructive atmosphere was observed during the team meeting. while the team leader spoke the most, team members were given opportunities to speak up. however, five to six team members dominated the discussion and not all team members spoke. these observations indicated that both team members and team leaders engaged in voice, learning, supportive and familiarity behaviours. there were no counts of defensive voice, silence or unsupportive behaviour. the specific behaviours displayed can be seen in table and observer ratings can be seen in table . team members described an open team atmosphere where they felt listened to, respected and psychologically safe. they felt comfortable speaking up about work issues or things "they felt very strongly" about and would go to their team leader if they were "frustrated" or "struggling". interviews highlighted that there were opportunities to speak up during meetings. however, team members remained silent about certain issues. some team members believed that discussing conflict, personal or confidential issues within a team setting may not be "appropriate". they would discuss these issues outside the team setting instead. "but i would say maybe it's when the group disassembles that some of those opinions come out, you know, it mightn't always be that effective." conflict was "pushed under the carpet" because team members wanted to avoid insulting or questioning others or didn't want to "rock the boat or cause issues". conflict avoidance was linked to small team size which meant that "everybody knows each other" and it would "make it harder for yourself" to speak up about conflict. one junior team member felt uncomfortable speaking up about confrontational issues with more experienced team members due to a fear that they would be dismissive and think "sure what does {team member} know". however, junior team members all felt comfortable or "confident" asking for help. a senior member of team a suggested that explicitly asking for input from junior team members could improve psychological safety and speaking up. "looking for people's opinions rather than waiting for somebody to offer, like asking, maybe some of the younger members, because i actually do think their opinion is really valuable." learning a relaxed atmosphere was deliberately cultivated to encourage learning behaviour. "we're very aware of trying to create an environment, em, like relaxed environment because you know when they're relaxed, they're going to learn more, they'll ask more questions" team members considered patient care to be their "focus" and felt they could speak up about patient safety issues. they recognised that speaking up about errors was important for learning and improvement within the team. "there's lots of different failures in the system that probably will lead to that happening again but it is important that we try, i suppose, to remedy them." members of team a talked about their team having a solution-focused approach to problem solving and highlighted that the team's supervision model created a psychologically safe space for learning. the team leader advocated for the importance of trying new things and learning from them. however, three team members said there was not enough time for learning and there was a need to schedule time for supervision, where concerns and ideas could be voiced. "it's just something that kind of does get put on the longer finger a little bit, so that, it probably would be good to actually have time like an actual scheduled time to do that." members of team a talked about feeling supported by their team leader and their peers. this encouraged them to speak up. "you can go to the group and they'll have your back, in terms of, yeah, your kind of professional role." the team leader provided support in relation to career development as well as personal and work needs. team members were confident they would be supported by their leader if/when they asked for it. "whatever small little rubbish is going on in your life, she will take that, you know, really into consideration and she is really so much about the staff member." familiarity between team members facilitated psychological safety. team members found it easier to speak openly as they got to know one another better and worked together for longer. "yeah she's very easy to talk to… because i've worked with her for about x years.". lack of familiarity had a negative impact on team members' feelings of psychological safety. one team member identified themselves as being new to the team. in addition, team members whose roles were more separate from the rest of the team felt less comfortable. "i probably wouldn't feel as comfortable getting involved in some of their discussions." team members highlighted the need to build relationships with those who work in these separate roles. survey results indicated that team members felt psychologically safe. participants gave a mean response of . for section , . for section and . for section . at first, the team leader gave feedback, then each team member had an opportunity to contribute. at the end of the meeting, team members were given an opportunity to raise any concerns. there were some tense moments where there may have been an undertone of confrontation. jokes were used to defuse these moments. during these instances the observer felt that people could be holding back. all participants engaged in voice, supportive, learning and familiarity behaviours but also displayed unsupportive behaviours. team members displayed defensive voice and silence behaviours. according to interviews, the leader of team b created an open, inclusive team atmosphere which made team members feel psychologically safe. "it's an open forum and i've never really felt that i couldn't say anything." team members prioritised patients and would speak up about patient safety issues. "because i would kind of be out for the patient, you know, so i would have enough {confidence}, to say that's not acceptable, or it's not acceptable behaviour." however, according to the team leader, meetings could be "more participative" without certain team members. this suggests that the presence of these team members reduces psychological safety for others. participants described negative reactions to people speaking up during meetings, such as "tut tutting", "rolling eyes" or "sighing". the team leader highlighted the need for improving people's behaviour during team meetings. "i suppose people are less likely to contribute if they feel like that's a risky response or there is the risk of that being a response." according to the team leader, improving psychological safety would involve making it clear to all team members that they play a valuable role in the team. "it's to convince, like everybody at that table has a critical role to play." similar to team a, conflict, personal or confidential issues were not deemed "appropriate" for the group setting and were discussed outside of team meetings. while conflict existed within the team it was not "open" and was "sometimes ignored". team members would withhold their "true feelings" to try to "keep the peace", "incubate the mess in front of everybody" and to avoid making other team members feel attacked. when asked why conflict isn't addressed, the team leader said, "we're not there yet". team members felt comfortable admitting mistakes and considered it to be the "whole point of the forum {team meeting}" and necessary for learning. however, they also referred to individuals who have not admitted when they haven't done something and have covered it up because "they don't like to show up they're not doing {something}." interviews indicated that the team was going through an "evolution" and trying to become more focused on learning. this involved having dedicated time within and outside regular team meeting to discuss errors and concerns. according to the team leader, this improved speaking up and psychological safety in the team. "we have had people say 'i completely messed up'." team members said that their leader is " % behind you" and that leadership support played an important role in creating a psychologically safe environment. "i think too it's down to having the confidence in our leaders, in our leader as well. that you know that it's kind of a safe space to talk." there was one reference to lack of peer support on the team. according to one participant, another team member has complained about a lack of support within the team, but this individual has not given support to others. this presented peer support as a reciprocal relationship between members. "he wants support, he's not giving support on the other side of it, he's not giving support to us." one team member said they have received support in the form of other team members' expertise. "i'm not the expert in that field, i would be kind of guided by our {lists specific roles}." most team members have worked in the hospital for long enough to be familiar with their colleagues. this made it easier for them to speak up. "maybe because i'm here so long that maybe it's a thing with age (laughs). you know, i don't have a problem really in that kind of a setting speaking." there were three team members who identified themselves as being new to the team. a new team member didn't feel the same level of comfort as others because she felt the team didn't know her well enough. this team member highlighted the need for time with the team in order for her to become more comfortable. "i'm still not % comfortable, i don't think they know me yet." survey results indicated that team members felt psychologically safe. participants gave a mean response of . for section , . for section and . for section . there was a collaborative, inclusive and constructive atmosphere during the team meeting. while there were opportunities for participants to speak up, certain individuals dominated the discussions. all participants displayed voice, supportive, learning and familiarity behaviours. team members displayed one count of unsupportive behaviour. there were no defensive voice or silence behaviours recorded. interviews referenced a historical culture of fear which lead to a lack of honesty and low psychological safety. one team member said that it has been difficult to change this culture completely, since the same people are still working there. as a result, some of this culture remained and team members reported silence and a lack of encouragement to speaking up. "i think overall, the consensus was not to speak, there was never encouragement to speak so i can't think of any occasion where i actually felt comfortable, there may have been occasions where i became so frustrated, that then i would have, you know, given my opinions, but that would not have been done in a comfortable environment." position in the hierarchy influenced speaking up behaviour. the team leader was aware that team members may remain silent because of her role as leader. according to one team member, there was a reluctance to speak up when the team leader was present. this team member thought that there would be more open discussions and more things would "come out" if they could run their own meetings and meet their leader less regularly. "they don't want to say with the management there, because it will show them to be not coping as well." however, team c was going through a "transition" and was changing from the historically "negative" culture. the team leader aimed to make the team more inclusive and let ideas "come from them {team members} up". team members felt psychologically safe with the leader because she is "reasonable" and they felt valued by her. "i actually would be % confident, that if i did have to challenge any of her, em, any concerns that there wouldn't be a problem that she's extremely reasonable and yeah." team members discussed patient safety and actively raised issues in order to have an open discussion and avoid creating tension or misunderstandings. "i can voice it and everyone knows what my opinion is and i know what other people's opinion is rather than them go to a one to one, and say, i don't agree with x, y and z, because i think that's kind of going behind people's backs, in a certain way." however, like the other teams, they would discuss personal or confidential issues outside of the team setting. the team leader said that by speaking up about mistakes, she could foster trust and encourage other team members to do the same. "so i think the more they see me owning up to mistakes, the more they're going to trust me {…} and the more they'll own up to mistakes." one team member referred to the team as being very "pro-learning" and that team members were encouraged to speak up so they could learn from every "meeting or conflict". "they're very much encouraging you to say it, it's a safe space we're not going to go back and, and talk about it, and we can learn, because i might be struggling with something, that someone else mentions, and i go, 'oh god, i'm actually struggling with that area too, how are you going about it?'" team members referred to the leader being supportive, inclusive and "open". one team member has learned from experience that she was more likely to get support if she approached team members one to one, rather than in a group setting "i realised you're better off actually going from one to one to one before than bringing it up {in a group setting}, and then you might get some support behind you." familiarity between team members and the fact that they were all part of the same discipline, encouraged psychological safety. "most of us have worked together for a while so we know what's going on." one team member identified themselves as being new to the team. there was a lack of familiarity between the team leader and the other team members and there was still a need for trust to build between them. "going to take a while though, {…} for me to be able to say to you, you know, tell you what, they do trust me and we're open." one team member said that if the team had been given more opportunities to become familiar with one another when they first joined the team, they would feel more comfortable within team meetings. "to get more familiar with each other and not to be as worried about somebody else being in the room." survey results indicated that team members felt psychologically safe. based on pilot testing, survey responses were altered to provide participants with a wider spectrum of response options (o'donovan et al., in press). responses could be between and , being "strongly disagree" and being "strongly agree". participants gave a mean response of . for section , . for section and . for section . there was a positive, friendly and constructive atmosphere during the team meeting. while some tension was noted between the senior team members, there were opportunities for speaking up and most team members communicated openly. decisions were made together, and team members seemed not be holding anything back. all participants displayed voice, silence, supportive, learning and familiarity behaviours. there was one count of unsupportive behaviour for the team leader. all team members felt there were opportunities to speak up within team meetings and gave examples of speaking up about work related issues, including patient safety issues. "the staff meeting, the biggest decisions are made at those and i think everyone gets an opportunity to weigh in." however, team members also noted that meetings mostly focused on operational issues. as a result, the issues that the team members wanted to raise were not given time. "the bits that maybe us minions (laughs) want to talk about is back loaded." participants suggested building time into meetings to discuss team members' concerns and for them to connect in "a meaningful way" and understand where one another's "emotions are at on a daily basis" in order to provide support and reassurance. there was more pressure when raising issues in the group and so team members would speak to the leader about personal issues or would discuss conflict with one other team member. "i would be more likely to bring things to my {team leader}, or to talk to people at an individual level em, if it was something sort of, i don't know, beyond those boundaries." the majority of team members' silence occurred when they gathered together as a group. conflict or disagreements happened "under the covers" or got "brushed away" and were not discussed openly. team members said they remained silent in team meetings to be polite and respectful to one another. they position this as a functional way to maintain good working relationships. "so yeah, i think politeness really underpins a lot of our interactions." the influence of hierarchy and experience was also noted. senior members were aware that junior team members were less likely "to rock the boat or make suggestions". while junior team members were more nervous about speaking up, they became more psychologically safe as they gained experience. "knowing what's too much for one person really helped me figure out when to kind of just get on with it or when to kind of ask around." there were team members who remained silent about their ideas for change rather than risk sharing them with the team. "don't know if i'd feel comfortable suggesting too much change, just because i'd feel like that's not really my remit or you know, everything, there's a lot of well-established routines and i wouldn't really be one to rock the boat too much." however, participants commented that the team has improved and become more open to learning and change. one member said it was easier for them to speak up and share their opinions during the meeting which was observed as part of this study. "people were speaking up and we were able to push what was going to work best for us across." examples were given of peer support. one participant referred to being supported during a difficult experience, explained that the team is very supportive, and that providing support is part of their jobs. "i think this is one of the most supportive teams that i have ever experienced, em like i said there is nobody on the team that i haven't spoken to about one thing or another." the leader was described as approachable, inclusive and supportive. receiving support from the team leader made participants "confident in their choice" to speak up and share their opinion. familiarity between team members influenced psychological safety. they were more comfortable speaking to the team members who they worked closely with or considered good friends. there was one team member who identified themselves as being new to the team. one participant said that she would feel more "conscious" of what she was saying to team members who she didn't work closely with, suggesting lower psychological safety. others said their psychological safety improved as they got to know their colleagues better. "i've become much more comfortable as i've gotten to know people to ask for help." this study provides an in-depth understanding of psychological safety within four healthcare teams working in the same case study hospital. it addresses recent calls for the use of multiple methods to capture a more accurate and nuanced understanding of psychological safety in healthcare teams [ , ] . while survey results from each team reflected high psychological safety, observations and interviews captured exceptional cases and more subtle dynamics within teams. observations captured behaviours displayed during team meetings while interviews offered an insight into psychological safety both within and outside meetings, as well as within a historical context. an overview of the results can be seen in fig. . in this figure, we aim to highlight the indicators of psychological safety identified at both team and individual levels. figure also illustrates the added degree of variance in psychological safety captured by observations and interviews, in comparison to survey results. while survey results indicated medium to high levels of psychological safety within all teams, both observations and interviews captured examples of silence and an absence of learning behaviour. in addition, interviews highlighted examples of low levels of support from other team members and a lack of familiarity between certain team members. survey and observation results captured team level dynamics which gave context to our understanding of individual level perceptions of psychological safety. this was particularly important, given that the overarching aim of this research is to inform the development of a team-level intervention to improve psychological safety. according to interviews, team members felt more psychologically safe speaking up about certain topics. all teams prioritised patient safety and felt comfortable speaking up about concerns related to patient safety, indicating a sense of psychological safety [ ] . however, silence was observed in teams a, b and c, there were lower survey scores for questions referring to speaking up about personal issues or disagreements, and interviews indicated that team members found speaking up about conflict or personal issues difficult. while junior team members could ask senior members for help and advice, they found it difficult to raise issues that could be deemed as challenging or confrontational. the influence of hierarchy was seen in all teams. this corresponds with research illustrating that those with higher status reported higher levels of psychological safety [ , , ] . while team members found it difficult to engage with conflict or disagreements during team meetings, some found it easier during one-to-one discussions with either the team leader or another team member involved in the issue. learning behaviours were displayed throughout team observations, and team members' survey responses indicated that they could ask questions and share ideas. interviews highlight that teams b, c and d are going through transitions, engaging in more learning initiatives, and becoming more psychologically safe. the leaders of teams b and c are both actively creating an open and inclusive team environment. according to interviews, the leader of team c engages in inclusive leadership by explicitly asking team members for their input and sharing her mistakes with the team in order to role model speaking up behaviour. research has shown that doing this encourages psychological safety [ , [ ] [ ] [ ] . in team b, the leader introduced protected time for developing teamwork and discussing concerns or mistakes made. while interviews indicated that team d has become more open, team members highlighted the need for protected time during team meetings for people to raise issues that were important to them, to connect to one another and to discuss their experiences that week. all leaders displayed supportive behaviour during observations. the leader of team b showed the most supportive behaviour, using inclusive language throughout the meeting. survey and interview data indicated that team members felt supported by their team leaders. however, interviews highlighted that there were still examples of team members not feeling comfortable taking interpersonal risks. while past research has highlighted the role of supportive leaders play in promoting psychological safety [ ] [ ] [ ] , supportive leadership alone is not enough. as discussed above, there were still issues that team members didn't feel comfortable discussing and the impact of hierarchy and historical cultures of fear could still be seen. interpersonal dynamics also influenced psychological safety. as outlined in previous literature, peer support improves psychological safety within teams [ ] . during observations of team b, team members showed lower supportive behaviours than their team leader and, during interviews, only one team member mentioned receiving peer support. lower levels of peer support were found in the multidisciplinary team, where team members worked in different departments. when team members worked within the same discipline, it was easier for them to support one another in their roles and this facilitated psychological safety. since members of team b had been working in the hospital for a long time, they were familiar with one another. however, on teams a and d, some team members worked separately from the rest of the team. as a result, they were less familiar with and comfortable around other team members. a member of team c suggested that if team members were given time to get to know one another without the presence of their leader, they would become more comfortable and issues could be discussed more openly. having close and connected working roles facilitates familiarity and, as a result, psychological safety. this highlights the need for teams whose roles are more separate from one another to make deliberate efforts to cultivate familiarity. this corresponds with the need to develop interventions which are suited for use across and between multiple disciplines [ ] . this is particularly important in a healthcare context, where psychological safety is needed for "teaming", an active process which allows multidisciplinary healthcare teams to work together to deliver increasingly complex patient care [ , ] . in addition to gaining an understanding of psychological safety within healthcare teams, this study aimed to inform the development of interventions to improve it. a recent systematic review of such interventions has highlighted that in order to improve their effectiveness, interventions targeting psychological safety need to be grounded in the experiences of the target audience [ ] . this study contributes to a more in-depth understanding of psychological safety within healthcare teams which is needed to develop future interventions. compared to observation and survey data, the data collected through interviews with team members provided the most valuable insights into the specific areas which interventions can target. this is because participants were given the opportunity to discuss areas in which they thought psychological safety in their team could be improved. firstly, the issue of time was raised in each team. this mainly involved giving time during meetings for discussing more personal issues or experiences rather than only focusing on operational issues. this had already been done within team b and the team leader had noticed some improvements in trust and openness as a result. time was also needed for prioritising learning and becoming more familiar with one another. secondly, since team members felt more psychologically safe talking about difficult subjects during one-to-one interactions, these opportunities for interactions outside of a team setting should be encouraged. interviews also highlighted the need to build relationships and foster familiarity with new team members and team members who work separately from the rest of the team. lastly, interventions should encourage an awareness that all team members play a valuable role and explicitly ask for input from team members who are more vulnerable to low psychological safety, such as junior team members. for future research, it is important to note the impact different data collection methods has on our understanding of psychological safety. as can be seen from fig. , surveys provided an overview of the levels of psychological safety within the teams, however, observations and interviews provide more detailed and nuanced understanding. observations provided a more objective view of behaviours relating to psychological safety [ ] and interviews offered insight into team members' past and present experiences both within and outside team meetings. researchers should be aware of the different levels of understanding gained from the use of these different methods of data collection and use this to ensure the type of data they collect is suited to their research question. this study combined survey, observation and interview data to gain an in-depth understanding of psychological safety within four healthcare teams. the deliberate inclusion of common components across the survey, observations, and interview analysis facilitated the triangulation of data. this provided a more detailed and holistic understanding of psychological safety. however, some limitations must also be noted. data was collected within one case study hospital, restricting the generalisability of findings. to address this, we have presented detailed analysis and given as much contextual information as possible for each team, without compromising the anonymity of participants. this should allow readers to determine whether they are applicable in other settings [ , ] . through examining the different outputs using multiple methods of data collection, this study provides a more in-depth understanding of psychological safety in healthcare teams. within observations, it was difficult to accurately observe silence, count individual episodes of silence and determine the motivation behind silence. however, interviews were a valuable source for exploring team members' reasons for remaining silent. while both interviews and surveys are vulnerable to self-report bias [ ] , the observation measure offers a more objective measure of psychological safety. the observation measure also provides information on team-level dynamics related to psychological safety. this team-level understanding aided our analysis of interviews in order to capture individual team members' perceptions of psychological safety. this understanding is important since the overarching aim of the programme of research (of which this study is one component) is to inform the design of an intervention to improve psychological safety at the team level. in order to calculate inter-rater reliability for the observation measure without inhibiting teams by having multiple coders present, future research could use a video camera to record meetings [ , ] . this study examines psychological safety within four healthcare teams. results from surveys, observations and interviews are considered together in order to gain an in-depth understanding of psychological safety within these teams. based on our findings, recommendations are made for future research and the development of interventions to improve psychological safety. supplementary information accompanies this paper at https://doi.org/ . /s - - -z. additional file . psychological safety and learning behavior in work teams making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams to report or not to report? why some nurses are reluctant to whistleblow is inadequate response to whistleblowing perpetuating a culture of silence in hospitals? speaking up in the operating room: how team leaders promote learning in interdisciplinary action teams medical error reporting attitudes of healthcare personnel, barriers and solutions: a literature review burnout in surgery viewed through the lens of psychological safety a systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour reflections on leadership in the time of covid- psychological safety: a systematic review of the literature. hum resour manag rev mixed methods in the organizational sciences: taking stock and moving forward methodological fit in management field research psychological safety: the history, renaissance, and future of an interpersonal construct thick as thieves: the effects of ethical orientation and psychological safety on unethical team behavior speaking up in ad hoc multiteam systems: individuallevel effects of psychological safety, status, and leadership within and across teams behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study how learning leadership and organizational learning from failures enhance perceived organizational capacity to adapt to the task environment linking leader inclusiveness to work unit performance: the importance of psychological safety and learning from failures a systematic review of factors that enable psychological safety in healthcare teams distinguishing voice and silence at work: unique relationships with perceived impact, psychological safety, and burnout. acad manag j. high-quality relationships, psychological safety, and learning from failures in work organizations the psychological conditions of meaningfulness, safety and availability and the engagement of the human spirit at work the effects of power, leadership and psychological safety on resident event reporting finding antecedents of psychological safety: a step toward quality improvement managing the risk of learning: psychological safety in work teams moving toward improved teamwork in cancer care: the role of psychological safety in team communication assertion practices and beliefs among nurses and physicians on an inpatient pediatric medical unit towards an observational measure for team psychological safety [dissertation reaping the benefits of task conflict in teams: the critical role of team psychological safety climate study design in qualitative research- : sampling and data collection strategies case study research and applications: design and methods. thousand oaks: sage publications qualitative quality: eight "big-tent" criteria for excellent qualitative research engaging crystallization in qualitative research: an introduction. thousand oaks: sage measuring psychological safety in healthcare teams: developing a more accurate and nuanced mixedmethods approach choosing response scale labels and length: guidance for researchers and clients using thematic analysis in psychology transforming qualitative information: thematic analysis and code development. thousand oaks: sage trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns the role of continuous quality improvement and psychological safety in predicting work-arounds. health care manag rev facilitating team learning through transformational leadership speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up teaming: how organizations learn, innovate, and compete in the knowledge economy case study method: key issues, key texts understanding self-report bias in organizational behavior research a complex adaptive systems approach to real-life team interaction patterns, task context, information sharing, and effectiveness systematic behavioral observation for emergent team phenomena: key considerations for quantitative video-based approaches publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. both authors were involved in the design and planning of this study. rod completed data collection and analysis. emca analysed % of interviews completed. rod drafted the manuscript and emca contributed to writing and revising the paper. both authors read and approved the final manuscript. this research is funded by the irish research council and the ireland east hospital group under the employment based partnership scholarship. the funders did not play a role in the design of the study, data collection, analysis and interpretation or in writing the manuscript. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. ethical approval was obtained for this study from the human research ethics committee in university college dublin (reference number: ls- - ). written informed consent was obtained from all participants prior to each stage of data collection. not applicable. the authors declare that they have no competing interests.received: april accepted: august key: cord- -f bjsopv authors: arslan, gökmen; yıldırım, murat; tanhan, ahmet; buluş, metin; allen, kelly-ann title: coronavirus stress, optimism-pessimism, psychological inflexibility, and psychological health: psychometric properties of the coronavirus stress measure date: - - journal: int j ment health addict doi: . /s - - - sha: doc_id: cord_uid: f bjsopv the coronavirus (covid- ) pandemic is currently a global health threat attributed to negatively affecting the mental health and well-being of people globally. the purpose of the present study is to examine the mediating role of optimism-pessimism and psychological inflexibility in the relationship of coronavirus stress with psychological problems among turkish adults. the sample of the study included adults ( % women). participants mainly consisted of young adults with a mean age of . years, ranging from to years (sd = . ). a mediation model indicated that coronavirus stress had a significant predictive effect on optimism-pessimism, psychological inflexibility, and psychological problems. further, optimism-pessimism and psychological inflexibility mediated the effect of coronavirus stress on psychological problems in adults. lastly, optimism-pessimism predicted the psychological problems of adults through psychological inflexibility. these results elucidate our understanding of the role of mediators in coronavirus stress and psychological health problems. the findings are useful in terms of providing evidence for tailoring interventions and implementing preventative approaches to mitigate the psychopathological consequences of covid- . based on the present findings, the potential utility of acceptance and commitment therapy is discussed within the context of covid- . hardship, and social isolation. many people experienced stress as a natural response to the adversity. across the world, many clinical studies have been conducted to discover a vaccine for covid- , yet the impact on mental health and associated interventions and services remains largely understudied. the reported increase in mental health issues due to physical distancing, quarantining processes, and social isolation makes further research in this area critical in order to systematically investigate, understand, and tailor appropriate interventions (harper et al. ; satici et al. ; tanhan et al. ) . in turkey, the first covid- case was diagnosed on march , and as of may , the confirmed total statistics related to covid- include , diagnosed cases, deaths, , recoveries, and , , tests (turkish ministry of health ) . covid- is a health threat identified as a significant stressor threatening the mental health and well-being of many individuals around the world (brooks et al. ; bhuiyan et al. ; satici et al. ) . it has been suggested that covid- stress can trigger mild to severe levels of psychosocial problems, such as depression, somatization, and anxiety bhuiyan et al. ; gunnell et al. ; satici et al. ) . recent reports have demonstrated that people have suffered from serious social and mental health problems including depression and anxiety (bao et al. ; Çiçek et al. ; wang et al. ) , poor psychological health (yildirim and arslan ) , suicide (gunnell et al. ; bhuiyan et al. ; mamun and griffiths ) , posttraumatic stress disorders (bao et al. ) , burnout among health care professionals , psychological inflexibility (Çiçek et al. ) , physical isolation and loneliness zandifar and badrfam ) , behavioral problems (cortese et al. ) , and negative consequences associated with spending excessive time on the internet (Çiçek et al. ) . these responses to covid- could lead to chronic psychopathology and affect a large number of people if problems are not identified, acknowledged, and treated effectively. mental health researchers have called for urgent and rigorous research that can address mental health problems and provide concrete solutions for the prevention of emerging problems associated with covid- (liu et al. ; tanhan et al. ; wang et al. ; yao et al. ) . in order to provide appropriate mental health services and develop prevention and intervention strategies for people in response to covid- , it is critical to understand the mitigating factors associated with coronavirus stress and psychological problems. thus, the purpose of the present study is to examine the mediating role of optimism-pessimism and psychological inflexibility on the relationship between coronavirus stress and psychological problems among turkish adults. stressful life events, such as those instigated by the coronavirus pandemic, have significant influence on an individual's psychological functioning and well-being, and can be a catalyst for psychological problems including anxiety, confusion, social withdrawal, and depression (ingram and luxton ; yildirim and arslan ) . although the experience of coronavirus stress may have a negative impact on the mental health and well-being of some individuals, this might not be the case for all people. individual differences in resilience, coping and perceptions may influence how a person responds to adversarial experiences. optimism and pessimism are conceptualized as important constructs in coping with uncontrollable life events (nes ) . optimism-pessimism is considered to be a generalized version of the confidencedoubt dichotomy pertaining to life in general, rather than to just a specific issue (see carver et al. ) . it has received attention in recent years due to the growing field of positive psychology (woldgabreal et al. ) . carver et al. ( ) defined optimism as an individual difference variable that reflects the extent to which people hold generalized favorable expectancies for their future. optimism and pessimism are stable personality characteristics that have important implications for regulating one's behaviors. optimism has been associated with a person's expectancies of good and bad outcomes (scheier and carver ) . previous studies have indicated that optimism is associated with adaptive outcomes and well-being, such as life satisfaction, positive affectivity, self-esteem, and flourishing (duy and yildiz ; gallagher and lopez ; karademas ; peterson and chang ; sapmaz and doğan ; scheier et al. ) , whereas pessimism has been found to correlate with maladaptive outcomes, such as depression and anxiety (andersson ; chang and sanna ; kwok and gu ; scheier and carver ; vickers and vogeltanz ) . for example, carver et al. ( ) found that higher levels of optimism were related to better subjective well-being in times of adversity. optimism enhances people's motivation to pursue goal-oriented behaviors (scheier and carver ) , physical health (carver et al. ) , and positive adjustment to college, and also decreases psychological problems (scheier et al. ) . optimistic individuals have also been reported to employ greater problem-focused strategies, which contribute to better adjustment and functioning in the face of negative life events compared with those who are pessimistic (nes ; taylor and armor ) . nes and segerstrom ( ) found an association between optimism and adaptive coping strategies contributing to the management, reduction, and elimination of negative effects associated with stress. similarly, optimism was negatively related to maladaptive coping strategies including withdrawal, avoidance, or ignoring stressors. optimists are expected to be confident and persistent in the face of diverse life challenges and pessimists are expected to have less confidence in similar situations. optimists are able to adjust their coping strategies depending on the stressors (nes and segerstrom ; reed ) and, thereby, they may experience more positive outcomes compared with pessimistic individuals. understanding one's own thoughts, feelings, and sensations is necessary to address psychopathology and promote well-being (hayes et al. ; hayes et al. ; larson ; tanhan ) . acceptance and commitment therapy (act) is considered to be a third-wave therapy that represents a multidimensional and functional contextual model that considers both wellbeing and psychopathology (hayes et al. ; hayes et al. ) . from the act perspective, stress or pain is inevitable for all people and the psychopathology that emerges from psychological inflexibility can be intervened with (hayes et al. ; hayes et al. ; tanhan ) . psychological inflexibility implies "the rigid dominance of psychological reactions, over chosen values and contingencies, in guiding action" (bond et al. , p. ) . psychological inflexibility is a process in which a person portrays dysfunctional control efforts related to bodily sensations, feelings, or thoughts to avoid experiencing unpleasant internal or external events. this process may worsen an individual's internal and external experience of a negative experience (bond et al. ; levin et al. ; tanhan ) . six core psychological inflexibility processes have been described: experiential avoidance, inflexible attention, disrupted values, inaction or impulsivity, conceptualized self, and cognitive fusion (hayes et al. (hayes et al. , tanhan ) . psychological inflexibility can develop into psychopathology when a person experiences one or more of these six core processes excessively or for a prolonged period of time (hayes et al. ; hayes et al. ). an individual with high psychological inflexibility is thought to approach stressful situations as rigid and reactive rather than meaningful, mindful, and value-driven (arslan and allen ). therefore, psychologically inflexibility may contribute to the development of psychological, behavioral, and social problems. psychological inflexibility is a construct associated with the development and maintenance of a wide range of psychological problems. previous studies have indicated the association between the restrictive nature of psychological inflexibility and various psychological problems, including somatization, depression, anxiety, and posttraumatic stress symptoms (dick et al. ; harris ; masuda and tully ) . levin et al. ( ) reported that psychological inflexibility was significantly associated with a range of current and lifetime psychological and behavioral problems (e.g., depressive symptoms, anxiety, and eating disorders). similarly, woodruff et al. ( ) reported the significant predictive effect of psychological inflexibility on positive and negative psychological health indicators, such as depression, unhappiness, positive affect, and life satisfaction. the literature also supports the mediating role of psychological inflexibility between different constructs, such as maladaptive schemas and depression, help-seeking and stigma (e.g., crosby et al. ; gaudiano et al. ; kurz et al. ; mendoza et al. ) . for example, yadavaia et al. ( ) reported that psychological inflexibility was a mediator of change in self-compassion, anxiety, depression, stress, and general psychological distress. uğur et al. ( ) found that psychological inflexibility mediated the relationship between fear of negative evaluation and psychological vulnerability. psychological inflexibility has also been found to mediate the relationship between depression severity and stigma toward others with depression (gaudiano et al. ) . although the importance of examining the relationship between psychological inflexibility and optimism has been highlighted (woldgabreal et al. ) , few studies have focused on the association between these variables. thus, there is need to advance research in this area. towsyfyan and hossein sabet ( ) emphasized the effectiveness of act on increased optimism for the people with major depressive disorders as well as the importance of high psychological flexibility for increased optimism (woldgabreal et al. ) . high psychological inflexibility is more likely to be related to higher levels of pessimism (masuda and latzman ) . psychologically flexible individuals are able to manage and adjust their feelings and thoughts in a productive and psychologically adaptive way, and this characteristic can positively influence optimism in the face of stressors. therefore, psychological inflexibility may be an important mechanism in enhancing optimism and decreasing pessimism by mitigating the negative effects of coronavirus stress on these constructs. given the theoretical and empirical evidence presented above, the purpose of the current study was to examine the mediating effects of the optimism-pessimism and psychological inflexibility on the association of coronavirus stress with psychological problems among turkish adults. prior to testing the mediation model, we first examined the psychometric properties of the coronavirus stress measure (csm) to enhance the scale's usability for both research and practice using the sample of the present study. subsequently, we addressed the following research hypotheses: (h ) psychological inflexibility would mediate the negative impacts of coronavirus stress on adults' optimism and pessimism; (h ) optimism and pessimism would mediate the association of psychological inflexibility with psychological problems; and (h ) optimism, pessimism, and psychological inflexibility together would mediate the association between coronavirus stress and psychological problems among adults. given the literature indicating the impacts of the coronavirus pandemic on individuals' mental health and functioning, to understand the factors that help explain the association between coronavirus stress and psychological problems is critical to developing prevention and intervention strategies for adults. findings of this study will therefore provide important implications and directions for current and future approaches to prevention and intervention. the sample of the present study comprised adults. participants mainly included young people with a mean age of . years, ranging from to years (sd = . ). slightly more than half of the sample consisted of women ( %). the majority of participants were of an average socioeconomic level ( %) and held a university diploma ( %). an online survey was created using demographic items and the measures of the study. institutional review board approval was obtained prior to the data collection process and the participants were informed that participation in the study was voluntary, the survey was confidential, and they could withdraw from the survey at any time if they did not want to continue. additionally, an electronic assent form was signed by adults who volunteered to participate in the study. coronavirus stress the coronavirus stress measure (csm) was adapted from the -item perceived stress scale (pss, cohen et al. ) to assess covid- related to stress. the csm included eight items with scoring based on a -point likert type scale, ranging between = never and = very often (e.g., "in the last month due to coronavirus, how often have you felt that you were unable to control the important things in your life?"). the psychometric properties of the csm were examined with the present sample to enhance the usability of the scale for use in research and practice, as shown in the "results" section. optimism and pessimism the optimism and pessimism measure (opm) is a -item selfreport rating scale developed to assess optimism and pessimism among turkish youths and adults . all items are rated using a -point likert type scale, ranging from = strongly disagree to = strongly agree (e.g., "i can't be happy with anything, i'm a pessimistic person," i hope many things will be better in the future"). previous research indicated that the scales had strong internal reliability estimates . psychological inflexibility psychological inflexibility was assessed using the acceptance and action questionnaire-ii, which is a -item self-report scale developed to assess psychological inflexibility and experiential avoidance (bond et al. ) . all items of the scale are scored based on a -point likert type scale, ranging from = never true to = always true (e.g., "my painful experiences and memories make it difficult for me to live a life that i would value"). yavuz et al. ( ) investigated the psychometrics of the scale with a turkish sample, indicating a strong internal and test-retest reliability estimate. psychological problems the brief symptom inventory (bsi- ) was used to assess adults' psychological problems (derogatis and fitzpatrick ) . the bsi is an -item self-report measure, comprising six-item subscales: depression, anxiety, and somatization (e.g., "feeling no interest in things," "pains in heart or chest"). all items are responded to using a -point likert type scale, ranging from not at all ( ) to very much ( ). the scale and its subscales have had strong internal reliability estimates for a turkish sample . prior to testing the structural models, preliminary analyses were conducted including descriptive statistics, analysis assumptions, internal reliability (α) estimates, and correlation analysis. first, skewness and kurtosis values fall within | | range, indicating that the variables of the study were fairly normally distributed (d'agostino et al. ; field ). subsequently, we established measurement models to examine factor structure of the measures using a series of exploratory factor analysis (efa) and confirmatory factor analysis (cfa) models. the efa and cfa models were run via psych (revelle ) and lavaan (rosseel ) r packages. first, the factor structure of csm ( items) was explored using the efa and then confirmed using the cfa. the cfa was conducted to examine the factor structure of psychological inflexibility, optimism-pessimism, and psychological problems. finally, we examined the hypothesized structural mediation model and obtained estimates and their bootstrap standard errors via lavaan r package (rosseel ) with dwls estimation option. findings from the hypothesized structural mediation and measurement model were interpreted using common data-model indices and their cut-points: tucker-lewis index (tli) and comparative fit index (cfi) ≥ . = adequate and ≥ . = close data-model fit, standardized root mean square residual (srmr) and root mean square error of approximation (rmsea) ≤ . = acceptable, ≤ . = adequate, and ≤ . = good data-model fit (hu and bentler ; kline ) . preliminary analysis results showed that the variables of the study had skewness values ranging from − . to . , and kurtosis values ranging from − . to . , indicating acceptable distributional properties for further analysis (absolute values less than ). cronbach alphas (α) reliability estimates were computed, as shown in table . all scales had strong reliability estimate with the present sample, with α values ranging from . to . . demographic variables were negatively correlated with maladaptive psychological constructs (mpcs: somatization, anxiety, depression, and overall psychological problems), meaning that being older, coming from higher socioeconomic background, or attaining higher degree were associated with lower values on mpcs. coronavirus stress (r range = − . -. ) and pessimism (r range = . -. ) were moderately and positively correlated with mpcs, meaning that having high level of stress or being pessimistic was associated with higher scores on mpcs, whereas optimism was moderately (but negatively) correlated with mpcs (r range = − . -− . ). psychological inflexibility was moderately and positively correlated with mpcs (r range = . -. ), meaning that having a high score on psychological inflexibility is associated with higher scores on mpcs. correlation analysis results are presented in table . consisting of eight items provisionally, the csm was adapted from the -item pss (cohen et al. ) , for which psychometric properties should be explored further. theoretically, these eight items aim to represent a unidimensional construct. a series of efa models were run on the csm. eigenvalues greater than one rule and scree and parallel plots all suggested two factors. one solution was to discard three items falling into one factor and continue with the remaining five, which could be sufficient for a unidimensional construct. the cfa models presented in table were run to justify the five-item csm based on the efa results. in the first model, all adapted items were included which produced relatively low standardized loadings on three suspected items (. , . , and . ) . in the second model, three suspected items were excluded which leaves us with five items (standardized loadings ranging from . to . ). results indicated that discarding three suspected items improved the model fit without jeopardizing the construct definition. thus, the second model was retained with five items. next, a series of the cfa models were conducted to examine the measurement model of optimism-pessimism, psychological inflexibility, and psychological problem constructs. model fit indices for measurement models and their alternatives are presented in table . after validating the measurement models, a hypothesized structural model was constructed and is presented in fig. . despite marginally acceptable fit for some scales individually, combined together, the structural model provided good data-model fit statistics (χ ( ) = . , p < . , cfi = . , tli = . , rmsea = . , and srms = . ). an rmsea value between . and . indicates an acceptable fit (what kline ( ) refers to as not-closefit), whereas rmsea < . would have indicated a good fit. this is also supported by n = . gender: = man ( %) and = woman ( %). socioeconomic level: = low ( %), = middle ( %), and = high ( %). education level: = high school ( %), = higher education ( %), and = master and upper ( %) combination rule, where tli and cfi ≥ . and srsr ≤ . suggests an acceptable fit (hu and bentler ) . path coefficients were estimated both with the constrained (zero) and unconstrained error variance (negative) to check whether they were sensitive to alternative specifications. parameters and their standard errors appeared to be robust to these two alternative specifications (they were nearly identical). for all effects in the mediation model, including direct and indirect effects, the bootstrap standard errors were used to test statistical significance (preacher and hayes ; preacher and hayes ) . unstandardized path coefficients and their % ci are presented in table , and standardized coefficients are embedded in the fig. . psychological problem is a second-order factor consisting of somatization, anxiety, and depression. ave for psychological problems is proportion of variance extracted from three subscales relative to their error variances cfi comparative fit index, tli tucker-lewis index, rmsea root mean square error of approximation, srmr standardized root mean square residual, ave average variance extracted * retained fig. the structural mediation model depicting relationship between psychological constructs (with standardized coefficients). **p < . ; ***p < . . pp = psychological problems standardized path coefficients revealed that the effect of coronavirus stress on psychological problems was partially mediated through optimism, pessimism, and psychological inflexibility. indirect effect estimates and their % ci and standardized coefficients are presented in table . mediational pathways going through optimism significantly predicted psychological problems (β = . , p < . ). mediational pathways going through pessimism also significantly predicted psychological problems (β = . , p < . ). relatively stronger indirect effect was found through psychological inflexibility (β = . , p < . ). directly or indirectly, in total, experiencing coronavirus stress significantly predicted a moderate to large level of increase in psychological problems (β = . , p < . ). altogether, coronavirus stress, optimism, pessimism, and psychological inflexibility explained % of the variance in the psychological problems. there were also intermediary mediation effects. coronavirus stress and psychological inflexibility significantly predicted optimism (β = − . , p < . and β = − . , p < . , respectively). directly and indirectly the variables explained % of the variation in optimism together. coronavirus stress and psychological inflexibility also significantly predicted pessimism (β = − . , p < . and β = . , p < . , respectively). directly and indirectly the variables explained % of the variation in pessimism together. globally, the covid- pandemic has unprecedentedly caused a human health crisis. it has been responsible for a wide array of psychosocial problems, such as fear, anxiety, depression, stress, panic disorders, and social isolation. with regard to the psychometric properties of the newly adopted csm, the results confirmed that the csm is a valid and reliable measurement tool assessing covid- -related stress, demonstrating satisfactory internal consistency reliability estimate with cronbach's alpha. the construct validity of the csm confirms unidimensional structure comprising items. the scale also showed good evidence of convergent validity with theoretically similar constructs such as anxiety and depression and divergent validity with demographic factors such as age. at the time of writing this manuscript, the covid stress scale (csm) was developed to measure covid- -related distress . the csm includes items corresponding to factors. our scale is undoubtedly advantageous in terms of its brevity, administrability, and cost-effectiveness. these results also expanded the burgeoning literature on the pandemic specific measures such as coronavirus perceived risk scale (yıldırım and güler ) , fear of covid- scale (ahorsu et al. (lee ) . the csm can be used in future studies aiming to examine stress-related factors within the context of covid- . the subsequent purpose of this study was to examine the role of optimism-pessimism and inflexibility in elucidating the underlying mechanism between coronavirus stress and psychological problems during the pandemic. specifically, this study aimed to provide more definitive evidence for tailoring and establishing interventions that contribute to effective coping with the crisis and reduced mental health problems. the results of the study generally support the mediating roles of optimism-pessimism and psychological inflexibility in the association between coronavirus stress and psychological problems. consistent with previous studies, stress was found to correlate positively with pessimism (britton et al. ) , psychological inflexibility (tavakoli et al. ) , and psychological problems (anniko et al. ) and correlate negatively with optimism (britton et al. ) . although some prior research has investigated the role of mediators in stress and psychological health problems (e.g., bargai et al. ) and well-being (e.g., praharso et al. ) , there is scarcity of research that has examined the mediating role of psychological inflexibility on the association between stress and optimism-pessimism. this study demonstrated that psychological inflexibility significantly mediated the negative impacts of coronavirus stress on adults' optimism and pessimism. these results have supported the first hypothesis of the study and are congruent with earlier research on the association between inflexibility and optimism-pessimism (levens and gotlib ) . in support of the second prediction of our study, the results showed that optimism and pessimism significantly mediated the relationship of psychological inflexibility with psychological problems, suggesting that higher optimism and lower pessimism can reduce the negative impact of psychological inflexibility on the experience of psychological problems. although research in this area is limited, the emerging findings are consistent with earlier studies on the association between optimism-pessimism, flexibility, and mental health. in a study, reed ( ) investigated the mediating role of optimism between coping flexibility and psychological problems (e.g., stress) and well-being (e.g., life satisfaction). the results indicated that there were strong relationships between coping flexibility, optimism, psychological problems, and well-being. the interaction between coping flexibility and optimism explained a significant amount of the variance in both psychological problems and well-being. additionally, optimism was found to partially mediate the relationship between coping flexibility and both psychological problems and well-being. importantly, optimism, pessimism, and psychological inflexibility together significantly mediated the relationship between coronavirus stress and psychological problems. these results suggest that the reason people with high levels of coronavirus stress report greater psychological problems is that they have high levels of psychological inflexibility and pessimism and lower levels of optimism. the theoretical underpinnings of this prediction are that stress may lead to greater psychological inflexibility and pessimism, and lower optimism which may in turn lead to greater psychological problems (al jarrah et al. ; ingram and luxton ; levin et al. ; yildirim and alanazi ) . high levels of optimism and low levels of psychological inflexibility and pessimism may help people to cope with coronavirus stress and foster lower levels of psychological problems. with regard to the psychometric properties of the newly developed csm, the results confirmed that the csm is a valid and reliable measurement tool assessing covid- -related stress with as few as five items, demonstrating satisfactory internal consistency reliability estimate with cronbach's alpha. the construct validity of the csm confirms unidimensional structure. the scale also showed good evidence of convergent validity with theoretically similar constructs such as anxiety and depression and divergent validity with demographic factors such as age. the csm can be used in future studies aiming to examine stress-related factors within the context of covid- . the present findings suggest the following recommendations for future studies and interventions. first, researchers, practitioners, health policymakers, and planners need to critically consider the prevention of mental illness by focusing on psychological resources including optimism and psychological flexibility. second, psychological flexibility and optimism could help to reduce the impacts of coronavirus-related stress on the mental health and well-being of adults. third, in light of evidence-based psychological therapies such as act, nationwide strategic planning and intervention for psychological first aid during the covid- pandemic should be urgently developed and implemented. such interventions can potentially be delivered online using social networking sites as they are fast, convenient, and cost-effective approaches in delivering planned interventions to the general public. the feasibility of such strategies during the covid- pandemic have been successfully established in china with a high rate of success in addressing mental health problems among the general public and health care professionals (liu et al. ) . this study has some limitations that need to be considered when interpreting the results. first, the data relied completely on self-reported measures which may prone to bias despite high reliability and validity of the selected measures. for example, participants could have given responses which included a tendency to either underreport or overreport socially desirable attitudes. thus, to address this issue, future research should use multiple assessment techniques for the investigation of the associations among the study variables. second, the present study had a cross-sectional design which cannot ascertain a causal relationship among the study variables. as such, great caution should be given to the interpretation of the results of mediation analysis on cross-sectional design. subsequent studies using longitudinal and experimental designs need to be carried out which may have potential to offer additional insights into the associations between coronavirus stress, optimism-pessimism, psychological flexibility, and psychological problems. finally, further research should be conducted to present more solid evidence and expand psychometric features of the csm to wider populations such as clinical samples and adolescents. establishing psychometric features of the csm in diverse populations and context would contribute to reliability and validity of the scale to be applied in the field of mental health and other relevant fields. in conclusion, these results add to the burgeoning literature suggesting that positive psychological resources, capabilities, and strengths such as optimism and psychological flexibility are key ingredients in contributing to positive mental health during a health crisis. these preliminary findings can be used to tailor and implement effective and efficient psychological health interventions to cope with challenges of covid- . the fear of covid- scale: development and initial validation the level of optimism and pessimism and its relationship to the quality of life in patients with renal failure in the government and private hospitals in irbid the benefits of optimism: a meta-analytic review of the life orientation test sources of stress and worry in the development of stressrelated mental health problems: a longitudinal investigation from early-to mid-adolescence exploring the association between coronavirus stress, meaning in life, psychological flexibility, and subjective well-being coronavirus stress, meaningful living, optimism, and depressive symptoms: a study of moderated mediation model -ncov epidemic: address mental health care to empower society posttraumatic stress disorder and depression in battered women: the mediating role of learned helplessness covid- -related suicides in bangladesh due to lockdown and economic factors: case study evidence from media reports preliminary psychometric properties of the acceptance and action questionnaire-ii: a revised measure of psychological flexibility and acceptance relationships among optimism, pessimism, and posttraumatic growth in the us and japan: focusing on varying patterns of perceived stressfulness the psychological impact of quarantine and how to reduce it: rapid review of the evidence optimism, pessimism, and positive and negative affectivity in middle-aged adults: a test of a cognitive-affective model of psychological adjustment mental health care for medical staff in china during the covid- outbreak psychological inflexibility predicts depression and anxiety during covid- : acceptance and commitment therapy perspective a global measure of perceived stress adhd management during the covid- pandemic: guidance from the european adhd guidelines group. the lancet child & adolescent health examination of the relationship between perfectionism and religiosity as mediated by psychological inflexibility a suggestion for using powerful and informative tests of normality the use of psychological testing for treatment planning and outcomes assessment: instruments for adults examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotion regulation on ptsd symptoms the mediating role of self-esteem in the relationship between optimism and subjective well-being discovering statistics using spss positive expectancies and mental health: identifying the unique contributions of hope and optimism psychological inflexibility as a mediator of the relationship between depressive symptom severity and public stigma in depression suicide risk and prevention during the covid- pandemic functional fear predicts public health compliance in the covid- pandemic act made simple: an easy-to-read primer on acceptance and commitment therapy acceptance and commitment therapy: model, processes and outcomes acceptance and commitment therapy: the process and practice of mindful change cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives vulnerability-stress models. development of psychopathology: a vulnerability-stress perspective self-efficacy, social support and well-being: the mediating role of optimism principles and practice of structural equation modeling mediating the relation between workplace stressors and distress in id support staff: comparison between the roles of psychological inflexibility and coping styles the role of emotional competence in the association between optimism and depression among chinese adolescents positive development in a disorderly world coronavirus anxiety scale: a brief mental health screener for covid- related anxiety. death studies. advance online publicaion the effects of optimism and pessimism on updating emotional information in working memory examining psychological inflexibility as a transdiagnostic process across psychological disorders online mental health services in china during the covid- outbreak first covid- suicide case in bangladesh due to fear of covid- and xenophobia: possible suicide prevention strategies examining associations among factor-analytically derived components of mental health stigma, distress, and psychological flexibility the role of mindfulness and psychological flexibility in somatization, depression, anxiety, and general psychological distress in a nonclinical college sample psychological distress among latina/o college students: the roles of self-concealment and psychological inflexibility optimism, pessimism, and stress dispositional optimism and coping: a meta-analytic review optimism and flourishing stressful life transitions and wellbeing: a comparison of the stress-buffering hypothesis and the social identity model of identity change asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models coping with occupational stress: the role of optimism and coping flexibility ppsych: procedures for psychological, psychometric, and personality research lavaan: an r package for structural equation modeling mutluluk ve yaşam doyumunun yordayıcısı olarak iyimserlik intolerance of uncertainty and mental wellbeing: serial mediation by rumination and fear of covid- optimism, coping, and health: assessment and implications of generalized outcome expectancies effects of optimism on psychological and physical well-being: theoretical overview and empirical update distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the life orientation test optimism, pessimism, and psychological well-being, c acceptance and commitment therapy with ecological systems theory: addressing muslim mental health issues and wellbeing a proposed framework based on literature review of online contextual mental health services to enhance wellbeing and address psychopathology during covid- psychological inflexibility as it relates to stress, worry, generalized anxiety, and somatization in an ethnically diverse sample of college students positive illusions and coping with adversity development and initial validation of the covid stress scales the effectiveness of acceptance and commitment therapy on the improving of resilience and optimism in adolescents with major depressive disorder türkiye'deki güncel durum psychological inflexibility mediates the relationship between fear of negative evaluation and psychological vulnerability dispositional optimism as a predictor of depressive symptoms over time immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china linking positive psychology to offender supervision outcomes: the mediating role of psychological flexibility, general self-efficacy, optimism, and hope comparing self-compassion, mindfulness, and psychological inflexibility as predictors of psychological health naming the coronavirus disease (covid- ) and the virus that causes it using acceptance and commitment therapy to increase self-compassion: a randomized controlled trial rethinking online mental health services in china during the covid- epidemic turkish version of acceptance and action questionnaire-ii (aaq-ii): a reliability and validity analysis in clinical and non-clinical samples gratitude and life satisfaction: mediating role of perceived stress exploring the associations between resilience, dispositional hope, subjective well-being, and psychological health among adults during early stage of covid- development and initial validation of the coronavirus perceived risk scale and its relationship with mental health iranian mental health during the covid- epidemic key: cord- -gotctl d authors: arnout, boshra a. title: predicting psychological service providers' empowerment in the light of the covid‐ pandemic outbreak: a structural equation modelling analysis date: - - journal: couns psychother res doi: . /capr. sha: doc_id: cord_uid: gotctl d this study aimed to investigate the predictors of psychological service providers' empowerment in the light of the covid‐ pandemic outbreak. the researcher prepared a psychological service providers' empowerment scale that consisted of items, and this scale was applied in a random sample consisting of psychological service providers. the results showed that the empowerment scale has acceptable validity and reliability. the results of the exploratory factor analysis indicated that the scale items saturate on seven factors, which accounted for . % of the total variance of the scale: the first factor named expect psychological services effectiveness accounted for . %, the second factor named self‐stimulation accounted for . %, the third factor named responsibilities and duties accounted for . %, the fourth factor named psychological services work environment accounted for . %, the fifth factor named psychological service providers’ decision‐making accounted for . %, the sixth factor named creative psychological service provider behaviour accounted for . %, and the seventh factor named psychological services confidence accounted for . % of the total variance of a psychological service providers' empowerment. in order to study the ability to predict the empowerment among psychological service providers, the researcher developed a structural model for psychological service providers' empowerment and then used the structural equation model analysis. the results showed that the proposed structural model of a psychological service providers' empowerment has goodness‐of‐fit, and these results emphasised the ability to predict psychological service providers' empowerment by seven tested factors. empowering the individual increases their creativity, excellence and innovation. because of the importance of the profession of psychological services in the preparation of members of society psychologically, it is necessary to pay attention to the empowerment of psychological service providers to achieve the quality of psychological services provided to beneficiaries, that is matching the current performance of the psychological service providers with the needs and expectations of psychological service providers at different ages and social and professional levels of society, and accuracy and comprehensiveness. arnout, al-dabbagh, et al. ( ) and arnout, alshehri, assiri, and al-qadimi ( ) discuss the origins of covid- as a new strain of virus that was discovered in and has not been previously identified in humans. common signs of infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. in more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death (who, ) . on march , the director-general of the world health organisation (who) declared the spate of infections caused by sars-cov- (covid- ) a pandemic. as this situation continues without a specific date for the return of life to what it was before covid- , the stresses increase, and many suffer from the inability to adapt to the current circumstances. it is not easy for our professionals and health officials to ask us to 'socialise', but it is incompatible with human nature. man is a social being by nature. social divergence is simply avoiding gatherings and close contact with others. health experts consider it crucial to slow the spread of the virus, to avoid overburdening healthcare systems and perhaps to protect them from collapse if infection rates rise to a level that cannot be dealt with efficiently (arnout, ) . in quarantine, some of the psychological stresses that people suffer from include the following: . longer periods of quarantine were associated with symptoms of post-traumatic stress, reluctance and anger. . quarantined people feel fear for their health or have suffered fears of injuring others. . quarantined people felt angry and bored, due to restrictions, daily routine loss and lack of social and material contact with others. . inappropriate basic supplies (such as food, water, clothing or accommodation) during quarantine caused frustration, which was associated with anger and anxiety. . obtaining inappropriate information, including clarity about the actions to be taken, the purpose of quarantine and the different levels of risk, has proven to be stressful. these stresses are associated with the quarantine. if a person is not able to confront it with effective styles of coping, it may lead him or her to experience psychological problems, and perhaps mental illness. many patients who recovered from the spanish flu in suffered from long-term depression and lethargy, feeling dizzy, experiencing insomnia, hearing or odour loss, and blurring of vision. some believe that an outbreak of coronavirus will lead to a similar explosion in depression after recovering from the virus. caring for mental health in such difficult times is extremely important. that is why the need of community members for psychological services increases under these conditions of quarantine and social separation, and the psychological problems it creates. almutairi, adlana, balkhya, abbas, ( ) stated that the spread of infectious viruses such as sars and others provokes emotional, ethical and cultural conflicts in the healthcare providers' work environment, which affects the quality of care they provide to patients with infection. the findings of arnout, al-dabbagh, et al. ( ) and arnout, alshehri, et al. ( ) indicated that the increased prevalence of covid- has a negative effect on the mental health of individuals. in the same context, infection with deadly viruses results in self-stigma and external stigma. recently, overholt et al. ( ) found that during follow-up, stigma levels were stable. baseline stigma significantly increased during enrolment and following clusters of ebola re-emergence in liberia. survivors encountered primarily enacted and perceived external stigma rather than internalised stigma. in addition, james, wardle, steel, and adams ( ) found that evd-related stigma (internalised and enacted) is prevalent among evd survivors since their return to their communities. almutairi and his colleagues in their qualitative study in found that the healthcare providers who survived mers-cov in saudi arabia perceived prejudice behaviours and stigmatisation, lived moments of traumatic fear and despair, and denial and underestimation of the seriousness of the disease at the individual and organisational levels, and they recommend further studies to investigate the public's perceptions of the nature of the mers-cov infection and their views and reactions. thus, it is clear that the spread of the covid- pandemic negatively affects the professional performance of healthcare providers, and thus reduces the quality of the professional assistance services they provide to the clients and their ability to perform their professional work. previous studies (robinson et al., ) recommended to examine the coping and stress management techniques for healthcare workers in conditions of infectious disease outbreaks. empowerment is a relatively new term, referring to a mental state that qualifies an individual to do something through a sense of inner commitment, self-control and a sense of trust, which contributes to the generation of human activity, the realisation of reason and creativity and the achievement of the desired goals in life in all its aspects. empowerment has therefore become a prerequisite for living in the modern age, full of changes and developments in various aspects of life. empowerment is essential for students, employees, parents and all members of society of all ages and their personal, mental and professional qualities, especially for humanitarian workers (arnout, ) . empowerment refers to the extent to which an individual has control over his or her sources of strength. empowerment is therefore linked to a qualification aimed at assisting an individual with a physical, mental or sensory disability to reach the maximum performance an individual can achieve in his or her personal tasks, for example where he or she is a member of an institution or in the community in which he or she lives. the concept of empowerment has recently entered the field of social sciences, which means that an individual can gather and use all sources of power in his or her social life, including his or her relationships and work (kafafi & salem, ) . empowering the psychological service provider in their work enables them to become aware of all of their responsibilities and duties. the psychological service provider is fully and comprehen- al-nawajhah ( ) stated that empowerment is a broad concept that accommodates many synonyms, meanings and concepts such as strengthening and enhancing efficiency and improving the situation and attribution. the study of the subject of psychological empowerment is a relatively recent topic in the humanities, especially in the science of educational and psychological management. its manifestations are efficiency, self-efficacy, the ability to perform tasks and influence work, a sense of the value and meaning of work, self-motivation and ability to overcome feelings of frustration and despair. empowering the psychological service provider is one of the pillars of the success and excellence of the psychological services process. in the light of the technological development and its implications on the psychological services process on the one hand, and the change in life in all its aspects, and the increasing challenges imposed on members of society, and the responsibilities, duties and burdens imposed on psychological service providers' empowerment as a result of the increasing suffering of the members of the community and the stress on them, there is a need to improve psychological service providers' empowerment in their work, increasing their level of performance and increasing interest in the psychological services process. previous studies emphasised the role of empowerment in the workplace. hardina ( ) and he, murrmann, and perdue ( ) found that employee empowerment has positive effects on job satisfaction and the service quality they provide to their clients. in the light of the increasing stresses resulting from the outbreak of the covid- pandemic, given the importance of empowering mental health service providers, healthcare institutions and organisations are responsible for development of clients through planning training programmes. the theoretical basis of the concept of empowerment is the theory of social exchange. it depends on the process of self-perception of the importance of the individual and his or her role in the work performed. bowen and lawler ( ) defined it as an internal state of mind that needs to be adopted and represented by the individual, in order to have self-confidence and conviction with the cognitive abilities that help them to make decisions and choose the results that they want to reach (al-nawajhah, ) . empowering the psychological service provider means 'giving the psychological service providers the opportunity to perform all his or her duties and responsibilities and fully exercise his or her authority at all stages and aspects of the psychological services work, making him or her able to face the challenges, stresses, professional development and changes in all aspects of life, and overcome obstacles that they may face during the psychological services practice and affect positive effectiveness of the professional guide and increases in his or her loyalty to the profession and motivation towards excellence and creativity in performance'. this empowerment of the psychological service provider is the first building block of creativity in the work of psychological services, because it allows the growth of mutual trust between the service provider and the client, and between them and their colleagues, and provides an opportunity for the psychological service provider to enable themself during the stages of the psychological services process and involve themself in decision-making and taking responsibility and carrying out activities and duties to improve the feelings of motivation, self-efficacy of the individual, positive behaviour, building of positive relationships with clients, rooting respect, trust, understanding, participatory cooperation and enjoying psychological services work. | arnout . | the dimensions of psychological service providers' empowerment kaddour and mohammed ( ) stated that one of the earliest perceptions of the concept of empowerment was developed by zimmerman ( ) , in which they presented three dimensions of measuring psychological empowerment: values, processes and outcomes. in addition, spreitzer ( ) introduced four dimensions to measure psychological empowerment: sense of sense, efficiency, self-determination and impact. menon ( ) envisaged three dimensions of empowerment: perceived control of the individual environment, perceived competence in task accomplishment and goal entry. al-nawajhah ( ) also mentioned the dimensions of psychological empowerment according to thomas and velthouse ( ) , which consider that psychological empowerment has four dimensions: this is concerned with the values of the goal and tasks that are judged by the criteria or ideas of the individual, and includes giving meaning to the work comparison between the requirements of the role of work and beliefs of the individual. the degree to which an individual can perform the activities and tasks assigned to them with high skill when trying. the degree to which behaviour is perceived to make a difference in relation to the achievement of a goal or task, which in turn has the intended effect in an individual's environment. includes causal responsibility for the actions of the individual, and the opportunity to choose the tasks that are meaningful to him or her and perform in a manner that seems appropriate. from the above, we can determine the following seven dimensions of psychological service providers' empowerment: . expect psychological services effectiveness: this refers to the psychological service provider's expectation of their ability to perform their duties and responsibilities, as well as their ability to provide psychological services to the client, and their awareness that they are capable of solving the problem of the client, their self-determination and independence. the more empowered a psychological service provider is, the more effective they will be in carrying out their work and tasks. it is intended for the psychological service provider to feel that they have the authority to take personal responsibility in the psychological services process and to receive recognition and support from colleagues and clients of the psychological services, and to help them feel the achievement of the psychological services' aims. . psychological service providers' decision-making: it is intended that the ethical framework of the psychological services profession defined the right of the psychological service provider to take the decisions governing the psychological services work and move in the direction of achieving the desired aims, whether the decision to continue work with a client and professional assistance specialist, or the decision to choose the appropriate method and techniques to solve the problem of the client for which the psychological services came, or the decision to terminate the relationship with the client and refer them to another psychological service provider, because this enables the psychological service provider to take responsibility to solve the problem of the client and satisfy the psychological needs. . creative psychological service behaviour: it is intended to distinguish professional psychological services, in providing new psychological services in unusual ways, which enables them to solve the problem of the psychological service in creative ways. it collects data and analyses them in a new way and evaluates alternatives to solve them and selects the most appropriate alternative to achieve greater benefits for the psychological services. . psychological services confidence: it is intended to guide the confidence of the psychological service provider in their performance, as well as confidence between them and their colleagues in the profession, and between them and their clients so that they can perform their duties and responsibilities in a sound manner successfully and distinctly. whenever there is confidence in the guidance from the parties of the psychological services process and colleagues, they can increase creativity and excellence in their work, improve performance and job satisfaction, and increase the ability of the psychological service provider to respond to environmental and societal changes. empowering the psychological service provider in their psychological services process requires four basic skills: psychological services offer specialised help provided by a trained person to another person who needs it either to solve a problem or to develop their abilities and invest their optimal development. therefore, the psychological service provider must have problemsolving skills, but given the importance of these skills in their work, psychological service providers must receive training to increase their ability to solve the problem with sound scientific steps from the collection of information and also identify alternatives and choose the best option to solve the problem. this skill increases the confidence of the psychological service provider, and it achieves a high level of satisfaction with the performance of the client in solving their problem, which contributes to the empowerment of the professional provider and their ability to make decisions during the psychological services process and increase the level of personal satisfaction with the performance of their psychological service work. the self-awareness of the psychological service provider means understanding and accepting it in a peaceful manner, managing it efficiently and then developing its potentials and making the best use of them. the more self-awareness they have, the more the powerfully and personally they will do the job. self-awareness skills refer to those skills that help the psychological service provider to know the strengths and weaknesses of their personality. it also includes the psychological service provider's knowledge of their personal rights, professional obligations and duties towards their profession and clients, and what they want to achieve from their work and from life in general. there is no doubt that this skill, if available to the psychological service provider and covered in training to increase their professional and personal empowerment, gives them the ability to make decisions. if the psychological service provider lacks sufficient self-awareness, they behave without full consciousness, and they will miss the knowledge of the consequences of the decisions they make, and thus be exposed to many mistakes that they could have remedied if they had enough self-awareness. these are necessary skills needed by the psychological service provider during their professional practice, and attempts to solve the problem of the client; it must not rush the results of psychological services and not rush to choose between alternatives to solve the problem of the client; and the choice between methods and techniques must be carefully chosen according to the nature of the client problem and the integrated diagnosis of them and the nature of their personality. because psychological services work is hard and painstaking, the psychological service provider is in urgent need to persevere in order to achieve professional empowerment in their professional practice, and to reach the level of creative professional behaviour, not just traditional. there is nothing else that can play this role, since perseverance is the key to success and the basis of effectiveness and efficiency. communication skills are a set of skills that an individual needs in their daily dealings, through which an individual can convey his or her thoughts, attitudes, values and feelings to others either verbally or in writing or through body language and facial gestures. communication skills are essential skills in psychological services work. psychological services is a face-to-face communication process, in which specialised assistance is provided to a person with a problem. therefore, if a psychological service provider wants to do their job well and be successful, they must have communication skills and receive training in them because this makes them skilled in their work and able to perform their duties and responsibilities towards the psychological service providers. effective communication skills help the psychological service provider to achieve their planned aims, as well as strengthen the relationship between the parties of the psychological services process through increased understanding and empathy. it can be said that % of the success in the psychological services work is due to mastery of communication skills and psychological services skills, and only % of it is attributed to science and specialised knowledge. undoubtedly, the community's efforts to seek psychological ser- the statistical population of this study includes all psychological service providers. from this population, a random sample consisting of psychological service providers ( males and females) was selected, with an age range of between and years. participants were first informed about the aims and the content of the study. then, they were assured about the confidentiality of their answers. they were asked to check a box if they agreed to participate in this study. institutional review board approval was obtained, and participants' informed consent in this study was secured prior to data collection. the study applied a descriptive method to test the psychometric properties of a statistical psychological service providers' empowerment scale. participants completed the psychological service providers' empowerment scale (pspes- ). all analyses were performed with spss . (statistics package for the social sciences) and amos (v. ) by maximum likelihood method to evaluate the measurement modelling proposed by psychological service providers' empowerment and test the validity and reliability of the scale prepared in this study. the self-report psychological service providers' empowerment scale was prepared by the researcher, and consists of items distributed on seven dimensions (see table ): the first dimension is expect psychological services effectiveness, consisting of six items ( , , , , and ), the second dimension is self-stimulation, consisting of six items ( , , , , and ) , the third dimension is responsibilities and duties, consisting of three items ( , and ), the fourth dimension is psychological services work environment, consisting of three items ( , and ) , the fifth dimension is psychological service providers' decision-making, consisting of three items ( , , ), the sixth dimension is creative psychological service provider behaviour, consisting of three items ( , and ), and the seventh dimension is psychological services confidence, consisting of four items ( , , and ). the individual responds with a -point likert scale (fully agree = to not fully agree = ). the present study aimed to test the psychometric properties of a psychological service providers' empowerment scale and evaluate the proposed measurement modelling to predict psychological service providers' empowerment. the reliability of the scale was assessed on the study sample. regarding internal consistency, the correlation coefficients of the items with seven dimensions of the scale (see table ), and the correlation coefficients between the seven dimensions and the total score (see table ) were . , . , . , . , . , . , and . , respectively. the cronbach's alpha values for dimensions and for the scale as a whole (see table ) were α = . , the principal components analysis (pca) method was used to derive psychological service providers' empowerment factors. the factor was also considered if the value of the underlying root eigenvalue was correct and the expression was capped at . or higher, according to the kaiser test as a minimum for the acceptance of the factor, and the items with the lowest determinations were excluded (see figure ). in accordance with these determinants, the exploratory analysis produced seven factors that accounted for . % of the total variance of the scale. the results are shown in tables and . it is clear from the results shown in two tables and that the subcomponents of the psychological service providers' empowerment scale are saturated on seven factors, which explained . % of the total variation of psychological service providers' empowerment, so that the proposed model of psychological service providers' empowerment and the theoretical basis of the scale are fully matched. in order to find how the seven factors of empowerment relate to produce an overall measure of empowerment among psychological service providers' empowerment, a empowerment model was designed (see figure ). to confirm that the theoretical structure of the scale has goodness-of-fit and to test hypotheses about the relationship between certain variables belonging to common hypothesis factors, a confirmatory factor analysis was used by maximum likelihood method, assuming that the subcomponents saturate on only seven factors. the results of the exploratory factor analysis are as follows: . expect psychological services effectiveness factor: saturated on four measured indicators (c , c , c , c , c , c ). . self-stimulation: saturated on four measured indicators (c , c , c , c , c , c ). . responsibilities and duties: saturated on four measured indicators (c , c , c ). . psychological services work environment: saturated on four measured indicators (c , c , c ). four measured indicators (c , c , c ). . creative psychological service provider behaviour: saturated on four measured indicators (c , c , c ). . psychological services confidence: saturated on four measured indicators (c , c , c , c ). the measurement components of the model are designed to ensure the accuracy of the measurement of the latent variables of the model. in this model, as seen in figure , ellipses represent latent variables, and rectangles represent measured variables. figure illustrates we should identify the implications of these indicators on the factors to which they belong. figure shows that the indications of items range from . to . for the expect psychological services effectiveness factor, from . to . for self-stimulation, from . to . for the responsibilities and duties factor, from . to . for the psychological services work environment factor, from . to . for the psychological service providers' decision-making factor, from . to . for the creative psychological service provider behaviour, and from . to . for the psychological services confidence factor (see figure ). the present study applied sem, an advanced statistical method, to test the construct validity of the psychological service providers' empowerment scale. the exploratory factor analysis was used to demonstrate a more realistic representation of the relationship between the items and factors. the seven factors modelling the psychological service providers' empowerment scale were confirmed, which means that we can predict psychological service providers' empowerment from these seven factors. the study that was conducted by sürücü and besen ( ) showed that we can predict empowerment of type diabetic individuals from education about diabetes, high school, university, age, social support and employment status; these variables were statistically significant predictors. in addition, the study of wallach and mueller ( ) spreitzer, ; thomas & velthouse, ; zimmerman, ) . the factorial structure of the scale prepared by the researcher showed a great compatibility between the theoretical aspect of the scale and the analysis data obtained from the study sample, and this increases the confidence in the ability of the scale to measure psychological service providers' empowerment and also indicates that the scale has the implications of internal consistency. the covid- pandemic crisis and the stresses associated with quarantine and social distancing have increased the need for specialists in psychological counselling and psychotherapy and those responsible for psychological service centres to prepare and plan counselling and psychological therapy programmes via the internet for community members who suffer from symptoms of mental disorders resulting from the increasing outbreak of covid- , and provide psychological services to patients with covid- to increase their coping skills and to recover from serious physical and psychological symptoms (arnout, al-dabbagh, et al., ) . thus, the spread of the covid- pandemic increases the continuous professional burdens or stresses of psychological service providers, causing pressure that affects the quality of their performance, resulting in them requiring professional assistance to enable them to do their work. this is confirmed by barnett et al.'s ( ) findings that continued work stresses affect helping professionals' mental health and leads to burnout and other stress-related disorders. from the findings of this study, we can predict psychological service providers' empowerment from seven factors. therefore, we recommend looking at ways to increase psychological service providers' f i g u r e standard path parameters of the measurement component of the proposed model for psychological service providers' empowerment [colour figure can be viewed at wileyonlinelibrary.com] empowerment, which requires his or her skilful empowerment, that is gaining and developing their skills in psychological services work on the one hand, as well as empowering them in managing psychological services work with clients and the freedom to choose psychological services methods and techniques, planning the psychological services process and recognising that they have the ability to influence the clients, which improves job satisfaction, encouraging them to respond quickly to guide the needs of clients, solve their problems and work in positive ways, and create a climate of trust between psychological service providers and clients. we can list the benefits of empowering a psychological service provider in their work as follows: . increase creative psychological services practice. . ability to make decisions related to the psychological services process. . effective participation of the psychological service providers and the ability to influence the psychological services process and co-workers. . increase the ability to solve problems that they may face during their work. . increase job satisfaction and psychological services confidence. . raise the level of satisfaction of the beneficiaries of the psychological services provided to them. . performance excellence and take risks effectively. . the high level of psychological services provided to clients. . abandon the traditional methods of professional practice. . professional, moral and community commitment. psychological service providers' empowerment can lead to a sense of belonging, satisfaction in their profession of psychological services, perception of the importance of their work in providing assistance to clients, increase in their responsibility towards them and the direction of the profession and active participation in the development of their professional performance, as a result of their psychological, cognitive and professional empowerment at the physical, sensory or moral level. this enables them to achieve the objectives of the psychological services process and the personal aims of the clients, and even the profession of psychological services and the organisation in which they work, as a result of providing the conditions that make them able to accomplish the responsibilities of their job. in the light of this study's results, we need future studies on psychological service providers' empowerment, as there are no studies dealing with this variable by investigation and analysis. in addition, the results of this study will direct the future studies to develop programmes to increase empowerment among psychological service providers according to the seven factor model proposed, which was tested in this study. the authors would like to express their gratitude to king khalid university, saudi arabia, for providing administrative and technical support. the author of this manuscript declared that they have no conflict of interests. the author of this manuscript has complied with ethical principles in their treatment of individuals participating in the research policy described in the manuscript. all data underpin this study found in this manuscript, and there are no any additional data. boshra a. arnout https://orcid.org/ - - - religiosity, psychological resilience and mental health among breast cancer patients in kingdom of saudi arabia leader's spiritual intelligence and religiousness: skills, factors affecting, and their effects on performance (a qualitative study by grounded theory) psychological empowerment and life orientation among a sample of primary stage teachers exploring the experiences of healthcare providers who survived mers-cov in saudi arabia enjoying life and health status among young adults and elderly: a comparative study in light of the globalization effects on the human being of the st century the integrated encyclopedia of psychological services and psychotherapy a structural equation model relating unemployment stress, spiritual intelligence and mental health components: mediators of coping mechanism covid- pandemic crisis: and the new face of the world the effects of corona virus (covid- ) outbreak on the individuals' mental health and on the decision-makers: a comparative epidemiological study a structural model relating gratitude, resilience, psychological well-being and creativity among psychological counsellors a structural equation modeling analysis of marital bullying scale diagnostic criteria for post-bullying disorder (pbd): a phenomenological research design of bullying victims empowering service employees ten characteristics of empowerment-oriented social service organizations an investigation of the relationships among employee empowerment, employee perceived service quality, and employee job satisfaction in a u.s. hospitality organization an assessment of ebola-related stigma and its association with informal healthcare utilization among ebola survivors in sierra leone: a cross-sectional study. l the impact of using the strategy of empowering workers on achieving job satisfaction within the institutions recent trends in measuring psychological empowerment engaged, committed and helpful employees: the role of psychological empowerment employee empowerment: an integrative psychological approach stigma and ebola survivorship in liberia: results from a longitudinal cohort study the drivers of employee engagement psychological empowerment in the workplace: dimensions, measurement, and validation predictors of empowerment in individuals with type diabetes mellitus cognitive elements of empowerment: an "interpretive" model of intrinsic task motivation job characteristics and organizational predictors of psychological empowerment among paraprofessionals within human service organizations: an exploratory study psychological empowerment: issues and illustrations key: cord- -lx krl v authors: domínguez-salas, sara; gómez-salgado, juan; andrés-villas, montserrat; díaz-milanés, diego; romero-martín, macarena; ruiz-frutos, carlos title: psycho-emotional approach to the psychological distress related to the covid- pandemic in spain: a cross-sectional observational study date: - - journal: healthcare (basel) doi: . /healthcare sha: doc_id: cord_uid: lx krl v anxiety, depression, and stress are common and expected reactions to the coronavirus disease (covid- ) pandemic. the objective of this study is to analyze psychological distress in a sample of spanish population, identifying the predictive nature of the information received, the preventive measures taken, level of concern, beliefs, and knowledge about the infection. a cross-sectional observational study was conducted on a sample of participants. data were collected through a self-prepared questionnaire and the general health questionnaire (ghq- ). bivariate analyses and logistic regressions were performed. of the total participants, . % presented psychological distress. the study population actively sought information about coronavirus, expressed a high level of concern and knowledge, and the most frequent preventive behavior was hand washing. as predictive factors, the degree of concern for covid- was identified (odds ratio (or) = . , % confidence interval (ci) = [ . , . ]), the number of hours spent consulting information on covid- (or = . , % ci = [ . , . ]), or the need for psychological support (or = . , % ci = [ . , . ]), among others. these results could help design more effective strategies towards a psycho-emotional approach for the population when in similar health crisis situations. there is a need for interventions aimed at the psychological well-being of the population that meet the needs of their reality. the world health organization (who), on march, classified the health crisis triggered by coronavirus disease as the pandemic in the face of , reported cases and deaths in countries [ ] . in spain, the state of health alert was declared on march [ ] , most previous studies look at beliefs about the disease and protection and transmission measures by analyzing their relationship with protective behaviors [ , , , ] and, more rarely, this relationship is assessed regarding the psychological effects of an epidemic. because of all the above, when approaching the current pandemic situation by covid- , the information, knowledge, beliefs and concerns of the population should be taken into account given their influence on both the psychological and emotional impact this situation has on the population and on preventive behaviors. the objective of this study was to analyze psychological distress on a sample of the spanish population during the beginning of the contagion curve in the covid- pandemic, identifying the predictive nature that the information received, the preventive measures taken, the level of concern for transmitting the infection or being infected, the beliefs and the level of knowledge about the infection may have on psychological distress. cross-sectional observational study. this study initially included a total of participants. in order to participate, it was necessary to comply with the following conditions: (i) living in spain during the pandemic; (ii) being years of age or older; and (iii) accepting the informed consent. a strict selection criterion was adopted, eliminating all questionnaires with an answer percentage of less than % ( questionnaires), leaving questionnaires in the final sample. questionnaires were received from the spanish provinces and the small autonomous cities located in north africa. a specific questionnaire was developed for data collection, which included socio-demographic data, information received, prevention measures, beliefs, concerns, and population's knowledge about covid- . questions from similar previous studies [ ] were adapted and new ones were added to meet the objectives of the study and cover the characteristics of the population. as sociodemographic data, the variables collected were age, sex, level of studies, marital status, people with which they cohabited, and employment situation. the information received was assessed by evaluating the number of sources of information and the hours spent listening, reading, or watching news about the pandemic per day. items evaluating the accessibility, quantity, quality, and usefulness of information received through the media and official channels were included, with five categorized response options from very bad to very good. questions about the amount of information received on symptoms, prognosis, treatments, routes of transmission, and preventive measures were added. a dichotomous response question (yes/no) was included to assess whether the person contrasted the information received with official sources. prevention measures were evaluated through questions with five answer options categorized from never to always regarding how often the following behaviors were performed: covering your mouth using your elbow when coughing or sneezing; avoiding sharing utensils (e.g., fork) during meals; washing hands with soap and water; washing hands with hydro-alcoholic solution; washing hands immediately after coughing, touching your nose or sneezing; washing hands after touching potentially contaminated objects; wearing a mask regardless of the presence or absence of symptoms; leaving at least a meter and a half of separation from others. beliefs and concerns about covid- were assessed through likert-type answer questions from to , a higher score meaning higher agreement. to assess participants' knowledge, five basic questions on knowledge about covid- regarding its transmission, symptoms, and prevention measures were included with "yes", "no", and "i don't know" as answer options. the questionnaire was pre-piloted by a panel of experts formed by psychologists, occupational doctors and nurses, epidemiologists, and public health experts. subsequently, a piloting was carried out in which people from different professions, educational levels, sex, age, and geographical areas of spain participated. no comprehension issues or relevant incidents were identified. psychological adjustment was measured by the general health questionnaire (ghq- ) [ ] , a tool used to assess mental health and psychological well-being. this consists of items with four answer options; the first two are assigned a score of points, and the last two are assigned a score of point, so the total score ranges from to . the questionnaire has been adapted and validated for the spanish population, obtaining good internal consistency (cronbach's alpha coefficient of . ) and good psychometric properties [ ] . the cut-off point set for the general population was three, considering psychological distress those with scores greater than or equal to [ ] . cronbach's alpha amounted to . . data were collected through an online questionnaire, the qualtrics ® survey and storage platform. in this way, the confinement measures established during the pandemic did not interfere with the data collection process. for the sampling, the snowball method was chosen, involving professional colleges and associations, universities, and scientific societies in the process of disseminating the information, as well as through social networks and press. the questionnaires were collected between march and april. the health alert was decreed in spain thirteen days before the start of the study. the analyses were performed using the spss statistical software ( . ) (ibm, armonk, ny, usa). the presence or absence of psychological distress was assessed for each independent variable (information received, preventive measures taken, level of concern about transmitting the infection or getting infected, beliefs, and level of knowledge about the infection). subsequently, bivariate analyses were performed, including chi-squared test and student's t-test for the independent variables, depending on their type. crammer's v and cohen's d effect size indexes were also calculated with the following cut-off points: to . , negligible; . to . , small; . to . , medium; from . on, high. then, with the aim of studying the predictive ability for psychological distress of the different sets of variables, logistic regression analyses (controlled by sex and age) were carried out including variables with p value < . . finally, variables that manifested to have a predictive nature in each of the models were included in a global model (model ). odds ratios (ors) were calculated with a % confidence interval. the ethical principles set out in the helsinki declaration have been followed. the permission of the participants was obtained through an informed consent in which they expressed their voluntary desire to participate in the study. data were recorded anonymously and treated confidentially. the study was authorized by the research ethics committee of huelva, belonging to the andalusian ministry of health (pi / ). this study is integrated into a larger investigation that includes other variables on the psychological impact of the covid- pandemic on the general population and on healthcare professionals. some of the results that differ from the present study have already been published [ ] . the description of sociodemographic data is shown in table . the sample consisted of a greater number of women ( . %), most with university or higher education level ( . %), married ( . %), and a mean age of . . most of them were working away from home ( . %), . % at home via teleworking, and . % were not working. data on information received on covid- and its sources were analyzed. participants were identified as consulting a mean of . (sd = . ) different sources of information, being social networks the most widely used ( . %), followed by television ( . %), official bodies or scientific societies websites ( . %), friends or family ( . %), online or printed press ( . %), google or other search engines ( . %), radio ( . %), and official phone numbers or information apps ( . %). the results showed no statistically significant differences between this variable and the presence of psychological distress (t = . , p = . , cohen's d = . ). regarding the number of hours spent seeking information on covid- , the results were higher in the group that presented psychological distress, as compared to the group that did not present it (m = . , sd = . , and m = . , sd = . , respectively). statistically significant differences were found between both groups (t = . , p ≤ . , cohen's d = . , small effect size). taking into account the assessment made by the participants on the information provided by the media, participants with psychological distress rated the information provided by the media as more accessible (m (table ) . when analyzing the frequency of use of the recommended preventive measures (table ) , the most common ones reported by participants have been washing hands with soap and water (m = . , sd = . ), washing hands after touching potentially contaminated objects (m = . , sd = . ), leaving at least a meter and a half of separation from others (m = . , sd = . ), and avoiding sharing utensils during meals (m = . , sd = . ). the last most commonly adopted measure was "wearing a mask regardless of the presence or absence of symptoms" (m = . , sd = . ). statistically significant differences were found in terms of the use of preventive measures and the development of psychological distress. seven of the eight measures showed significant differences (p = . in all cases), with effect sizes ranging from negligible to small. in each of them, the mean score obtained was higher in the group of subjects who presented psychological distress ( table ). the only exception was in the preventive measure "leaving at least a meter and a half of separation from others", where this group of participants obtained a lower mean score (m = . , sd = . ), as compared to the group which did not present psychological distress (m = . , sd = . ). in response to concerns about covid- (table ), participants expressed that being a transmitter of the infection was their main concern (m = . , sd = . ), followed by the degree of general concern about covid- (m = . , sd = . ), and the degree of concern about becoming infected was in the last place (m = . , sd = . ). the results showed statistically significant differences between both groups of subjects for all the variables (p < . in all cases), with small effect sizes. in this regard, the group of patients with psychological distress had higher scores (m = . information on the relationship between beliefs and knowledge about covid- and the presence of psychological distress is presented in table . in view of the participants' beliefs on covid- , those who presented a higher score have been related with the need to provide a psychological support service to both the persons and families similarly, when subjects were asked whether they felt it necessary to offer psychological support to professionals and volunteers who are directly involved in the health crisis, to individuals and families affected by covid- , as well as to the general population, the group with psychological distress showed significantly higher scores (table ) . finally, most participants showed a high level of knowledge about covid- . thus, most correctly answered questions were related with the need to isolate infected people ( . %), transmission routes ( . %), the incubation period ( . %), and on the infective capacity of asymptomatic people ( . %). however, only . % correctly answered questions related to the symptoms of the virus. no statistically significant association was found between any variables on the level of knowledge about covid- and the presence of psychological distress (p > . in all cases). logistic regression models are displayed in table . degree of concern about covid- model , which is related with concerns about covid- , showed a predictive ability of %, higher than the previous models (χ = . , p < . ), correctly classifying . % of participants ( . % sensitivity and . % specificity). those subjects with a higher degree of concern about covid- were . times more likely to suffer psychological distress ( % ci = . , . ). similarly, participants with a higher degree of concern about becoming infected with the virus were . times more likely to develop psychological distress ( % ci = . , . ). with finally, model (global model), where variables that showed a predictive ability in previous models were included, presented a predictive ability of . %, correctly classifying . % of participants ( . % sensitivity and . % specificity). the variables that showed a predictive ability were sex, age, number of hours consulting information on covid- , assessment of the information provided by the media in terms of accessibility, assessment of the information available on the prognosis of the disease, washing hands with hydroalcoholic solution, degree of concern about covid- , degree of concern to become infected, belief about the likelihood of survival if infected, level of confidence in the diagnostic ability of the health system, risk of getting infected, the belief about the effectiveness of preventive measures, and the need to offer psychological support to the general population ( table ). the variables that showed a higher weight, with ors greater than , were being female (or = . , % ci = [ . , . ]), degree of concern about covid- (or = . , ci % = the results indicate that the population is actively looking for information on covid- . participants consulted several sources of information, with social media being the most common one. people with psychological distress spent more hours a day looking for information, and considered it more accessible, albeit of worse quality and usefulness. in addition, the information provided by the official channels in terms of quantity and usefulness was valued with lower scores. choosing the internet as the main source of information is consistent with the results of previous studies [ ] . the lack or inadequacy of the information has been identified as a stressor during this pandemic, which leads the population to find answers to their concerns [ ] . the internet is currently the leading source of information worldwide, and users approach it as the first means of communication and information for health-related issues [ ] . abd-alrazaq et al. analyzed the contents of the social network twitter that were related to covid- and identified the topics that most affected users: the origin of the virus; routes of transmission; impact on people and countries (death toll, stress and fear, travels, economy, and xenophobia), and risk and spread control measures [ ] . another similar analysis of the content on social networks related to covid- grouped the topics of interest into five categories: ( ) update of new cases and their impact; ( ) first-line reports on the epidemic and its prevention measures; ( ) expert opinions on the outbreaks of the infection; ( ) frontline health services; and ( ) global reach of the epidemic and identification of suspected cases [ ] . the concern and need for information of the population is reflected in the use of social networks. the study conducted by li et al. revealed that, following the outbreak of covid- , the expression of negative feelings on social media such as anxiety, depression or outrage increased significantly. users expressed greater concern for their health and that of their families, and less interest in leisure and friends [ ] . on the other hand, zhao et al. identified an evolution of the content on social networks from the beginning of the health crisis, being it from negative to neutral, and a progressive increase in the expression of positive emotions [ ] . the use of the internet as a source of health-related information also implies a risk. as cuan-baltazar et al. state, the quality of the information available on the internet on covid- does not meet the quality criteria and may lead to a worrying situation of misinformation to the non-healthcare related population who do not have criteria to discriminate [ ] . a recent critical analysis of the contents of the websites that disclosed the preventive measures before covid- revealed that, in most cases, the information was ambiguous and not in line with who recommendations. less than half of participants reported on the proper use of masks and that the most correct information was provided by official bodies' websites [ ] . regarding adherence to preventive measures, the behavior that participants stated most often was hand washing. participants with psychological distress performed preventive measures more frequently than those without distress, except for leaving a meter and a half of separation from others. the high adhesion obtained to hand washing and respiratory hygiene measures is consistent with results from previous studies [ , [ ] [ ] [ ] . these measures are in line with who recommendations [ ] and are among the most suggested ones to deal with the covid- pandemic [ , ] . the practice of preventive measures was associated with the perception of risk of coronavirus infection [ ] . the results of this study coincide with wang et al. by identifying the flattering influence of psychological distress on preventive behaviors regarding the spread of covid- [ ] . in relation to depressive symptomatology, studies show that the implementation of more precautionary behaviors and greater social distance is associated with a higher level of anxiety [ , ] . still, authors like cowling et al. found that a lower use of hygiene measures and greater social distancing have been associated with increased anxiety [ ] . it seems clear that social distancing is related to the psychological impact, leading to greater symptomatology. what does not seem to be so clear is the role of individual protective measures, which may be mediated by other variables such as the perceived risk or vulnerability of getting infected. the results of the present study indicate a high level of public concern regarding covid- , especially for those participants who presented psychological distress. these results are supported by findings from similar studies that reveal a high public concern about the covid- pandemic [ , , [ ] [ ] [ ] , calling it terrifying [ ] . the cause of most concern among participants was the possibility of being a transmitter. however, in similar studies, the main concerns were the infection of a family member [ ] or getting infected with coronavirus [ , ] . according to cori et al., an individual's risk perception is modulated by four elements: voluntariness, knowledge, visibility, and trust; regarding the latter, the unknown risks are perceived as more threatening [ ] . however, wolf et al. identified that people with less health knowledge considered themselves less likely to get infected with coronavirus [ ] . the uncertainty expressed by the population to this new disease manifests itself with situations of anxiety, depression, and sleep disorders [ ] . people in confinement, as a measure of containment in the face of the spread of the covid- epidemic, reported having low sleep quality aggravated by anxiety and stress [ ] . faced with the situation of concern and uncertainty generated by the health crisis, studies have described the level of public confidence regarding the measures put in place by their governments. some authors identified that most participants felt that the country could win the battle against coronavirus [ ] , were satisfied with the epidemic control measures taken [ ] and were motivated to follow the government's recommendations on quarantine and social distancing [ ] . on the contrary, the study of wolf et al. revealed that half of the participants did not trust their government's ability to contain the covid- outbreak, and people with less health knowledge were more likely to rely on the government's actions [ ] . mcfadden's results point to health workers as the better able to lead the covid- pandemic response strategy, according to the population's assessment [ ] . in order to face the concerns about covid- , coping strategies such as focusing on the problem and seeking alternatives, receiving emotional support and positive assessment of the situation [ ] , and doing physical exercise are recommended [ ] . participants in this study showed a high level of knowledge about covid- , except for their symptoms. these results support those obtained in previous similar studies that describe a good degree of knowledge on the part of the population, albeit disparately. on the one hand, there are authors who reported that participants were generally aware of coronavirus [ ] , its symptoms [ , ] , routes of transmission [ , ] , and preventive measures [ , ] . on the other hand, some authors identified knowledge gaps related to symptoms [ ] and preventive measures [ ] . regarding university students, a good level of knowledge about the covid- pandemic and its preventive measures has been described, especially among students attending life sciences degree courses [ ] . knowledge of the covid- pandemic has been associated with willingness towards preventive measures and less confidence in the success of the fight against the virus [ ] . abdelhafiz et al. found that older people with low education, lower income, and living in rural areas tend to have less knowledge about the covid- pandemic [ ] . however, the profile of the person with little knowledge described by zhong et al. is young women with low level of education, who are unemployed or students [ ] . in this study, sex, accessibility to information, hours spent looking for information about coronavirus, degree of concern, belief of becoming infected, washing hands with hydroalcoholic solution, and perceived need for psychological help have been identified as factors with higher predictive weight of psychological distress. these results are in line with previous studies which have identified an association between female gender, negative affect, and detachment and higher levels of depression, anxiety, and stress [ ] . quarantine as a measure of containment has negative psychosocial consequences such as symptoms of depression, anxiety, anger, stress, post-traumatic stress, social isolation, loneliness, and stigmatization [ ] . psychological support interventions are needed to approach the situation, as the absence of psychological support is associated with higher levels of anxiety and depression [ ] . bäuerle et al. proposed a self-guided tool to promote psychological well-being based on mindfulness to reduce stress in the face of the covid- crisis, to enhance coping strategies, perceive self-effectiveness, and mobilize personal resources [ ] . several community care initiatives have been described, which have been managed by mental health professionals who act as counsellors and by volunteer staff. phone calls and apps provide support, advice, and training to address the psycho-emotional impact of the pandemic [ , ] . the cross-sectional observational design of the study can be considered a limitation as it offers a photograph of what is happening at a precise time and does not allow inferring that such levels of psychological distress occur equally throughout the pandemic period. however, being able to obtain data at the time of the rise of the contagion curve is precisely what gives greater value to the study. the sample collection was not randomized and there were more women than men, factors that were compensated with a large sample and a representation of all the provinces and autonomous cities. it is difficult to compare the results between countries because confinement measures or cessation of labor activities differ greatly among them. further study is planned to check for the effects at different stages of the pandemic. this study revealed a strong psychological impact on the population as a result of the covid- pandemic. the results describe a population profile that searches for information about the coronavirus by consulting various sources of information, although social media was the most widely used. with regard to adherence to preventive measures, the behavior that participants most often reported was hand washing and respiratory hygiene. the results of our study indicate that the population has a high level of concern and knowledge in relation to covid- , and this is especially true for those who presented psychological distress. logistic regression analyses, on the other hand, have shown an adequate adjustment for the most part and an explained variance that exceeds % in the global model, being sex, degree of concern about the virus, getting infected, accessibility to information, number of hours looking for information, hand washing with hydroalcoholic solution, amount of information available on the prognosis of the disease, beliefs about the risk of infection, or need for psychological care for the population, among others, the predictors with greatest weight for psychological distress. these results could help design more effective strategies for a psycho-emotional approach of the population in similar health crisis situations. interventions aimed at the psychological well-being of the population are necessary to meet the needs of their reality. who director-general's opening remarks at the media briefing on covid- - por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el covid- (royal decree-law / , of march , declaring the state of alarm for the health crisis situation's management caused by covid- ) por el que se regula un permiso retribuido recuperable para las personas trabajadoras por cuenta ajena que no presten servicios esenciales, con el fin de reducir la movilidad de la población en el contexto de la lucha contra el covid- (royal decree-law / , of march , which regulates a recoverable paid leave for self-employed persons who do not provide essential services, in order to reduce population mobility in the fight against covid- context). available online enfermedad por coronavirus, covid- (scientific-technical information: coronavirus disease, covid- ). available online coronavirus/pdf/ _informe_cientifico_sanidad_covid- .pdf (accessed on the sars epidemic in hong kong consistent detection of novel coronavirus in saliva q&as on covid- and related health topics epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid- ) during the early outbreak period: a scoping review available online covid- and mental health: a review of the existing literature the factors affecting household transmission dynamics and community compliance with ebola control measures: a mixed-methods study in a rural village in sierra leone the experience of quarantine for individuals affected by sars in toronto avoidance behaviors and negative psychological responses in the general population in the initial stage of the h n pandemic in hong kong factors influencing compliance with quarantine in toronto during the sars outbreak ebola and healthcare worker stigma accepted monitoring or endured quarantine? ebola contacts' perceptions in senegal knowledge and risk perceptions of the ebola virus in the united states immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china association of self-perceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid- generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey a review of coronavirus disease- (covid- ) prediction for the spread of covid- in india and effectiveness of preventive measures lockdown contained the spread of novel coronavirus disease in huangshi city, china: early epidemiological findings effectiveness of the measures to flatten the epidemic curve of covid- . the case of spain the positive impact of lockdown in wuhan on containing the covid- outbreak in china adoption of preventive measures during and after the influenza a (h n ) virus pandemic peak in spain knowledge, attitudes and practices (kap) related to the pandemic (h n ) among chinese general population: a telephone survey association between knowledge of zika transmission and preventative measures among latinas of childbearing age in farm-working communities in south florida effect of knowledge and perceptions of risks on ebola-preventive behaviours in ghana community psychological and behavioral responses through the first wave of the influenza a(h n ) pandemic in hong kong public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey the validity of two versions of the ghq in the who study of mental illness in general health care propiedades psicométricas y valores normativos del general health questionnaire (ghq- ) en población general española the general health questionnaire related health factors of psychological distress during the covid- pandemic in spain the psychological impact of quarantine and how to reduce it: rapid review of the evidence misinformation of covid- on the internet: infodemiology study top concerns of tweeters during the covid- pandemic: infoveillance study chinese public's attention to the covid- epidemic on social media: observational descriptive study the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users assessment of health information about covid- prevention on the internet: infodemiological study. jmir public health surveill. , , e long-term effect of the influenza a/h n pandemic: attitudes and preventive behaviours one year after the pandemic perceptions and behaviors related to hand hygiene for the prevention of h n influenza transmission among korean university students during the peak pandemic period the influenza a (h n ) pandemic in reunion island: knowledge, perceived risk and precautionary behaviour coronavirus diseases (covid- ) current status and future perspectives: a narrative review psychological and behavioral responses in south korea during the early stages of coronavirus disease (covid- ) demographic and attitudinal determinants of protective behaviours during a pandemic: a review awareness, attitudes, and actions related to covid- among adults with chronic conditions at the onset of the u.s. outbreak: a cross-sectional survey covid- and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid- pandemic the network investigation on knowledge, attitude and practice about covid- of the residents in anhui province risk perception and covid- social capital and sleep quality in individuals who self-isolated for days during the coronavirus disease (covid- ) outbreak in january in china knowledge, attitudes, and practices towards covid- among chinese residents during the rapid rise period of the covid- outbreak: a quick online cross-sectional survey perceptions of the adult us population regarding the novel coronavirus outbreak narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the covid- pandemic ensuring mental health care during the sars-cov- epidemic in france: a narrative review use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: a cross-sectional survey on covid- understanding knowledge and behaviors related to covid- epidemic in italian undergraduate students: the epico study a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors psychosocial impact of quarantine measures during serious coronavirus outbreaks: a rapid review comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the covid- epidemic in southwestern china an e-mental health intervention to support burdened people in times of the covid- pandemic: cope it psychological crisis intervention response to the covid pandemic: a tunisian centralised protocol psychological assistance during the coronavirus disease outbreak in china this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflicts of interest. key: cord- - nisyl r authors: wang, huiyao; xia, qian; xiong, zhenzhen; li, zhixiong; xiang, weiyi; yuan, yiwen; liu, yaya; li, zhe title: the psychological distress and coping styles in the early stages of the coronavirus disease (covid- ) epidemic in the general mainland chinese population: a web-based survey date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: nisyl r as the epidemic outbreak of coronavirus disease (covid- ), general population may experience psychological distress. evidence has suggested that negative coping styles may be related to subsequent mental illness. therefore, we investigate the general population’s psychological distress and coping styles in the early stages of the covid- outbreak. a cross-sectional battery of surveys was conducted from february – , . the kessler psychological distress scale, the simplified coping style questionnaire and a general information questionnaire were administered on-line to a convenience sample of in china. a multiple linear regression analysis was performed to identify the influence factors of psychological distress. general population’s psychological distress were significant differences based on age, marriage, epidemic contact characteristics, concern with media reports, and perceived impacts of the epidemic outbreak (all p < . ) except gender (p = . ). the population with younger age (f = . ), unmarried (t = . ), with history of visiting wuhan in the past month (t = - . ), with history of epidemics occurring in the community (t = - . ), more concern with media reports (f = . ), perceived more impacts of the epidemic outbreak (changes over living situations, f = . ; emotional control, f = . ; epidemic-related dreams, f = . ) and negative coping style (t = . ) had higher level of psychological distress. multivariate analysis found that marriage, epidemic contact characteristics, perceived impacts of the epidemic and coping style were the influence factors of psychological distress (all p < . ). epidemic of covid- caused high level of psychological distress. the general mainland chinese population with unmarried, history of visiting wuhan in the past month, perceived more impacts of the epidemic and negative coping style had higher level of psychological distress in the early stages of covid- epidemic. psychological interventions should be implemented early, especially for those general population with such characteristics. a a a a a the epidemic of the coronavirus disease has aroused widespread concern throughout society in china. because the virus can be transmitted through droplets, contact, etc. [ ] , cities in many regions of china have closed non-essential public places, restricted mass gathering activities, and enacted other control measures to effectively control the spread of the virus [ ] . the epidemic has had a strong impact on general population's daily life. at the same time, as the epidemic continues, general population gradually experience different levels of psychological distress, such as nervousness, fear of infection, anxiety, depression, sleep problems, and inattention [ , ] . previous studies have reported that some psychological problems often occur during similar epidemic [ , ] or other traumatic stress events, such as natural disasters [ , ] , disease [ ] , or long-term employment in high stress occupations [ ] [ ] [ ] , and may last for a long time [ , ] . when faced with stress or traumatic experiences, general population often responds differently, with some responding positively and others responding negatively. evidence has suggested that coping styles in the face of stress have an impact on the quality of general population's life [ , ] , and negative coping styles may be related to psychological distress or mental illness such as post-traumatic stress disorder (ptsd), anxiety, and depression [ , , ] . for this reason, we conducted this study in the early stages of this epidemic to investigate the general population's psychological distress and coping style related to the epidemic of covid- so that those who have high levels of psychological distress and/or respond negatively can be detected early and undergo timely intervention. this study was conducted through an online survey, starting at : on february , and ending at : on february , and the survey was approved by the ethical review board of the west china hospital of sichuan university. the snowball sampling method was used to invite subjects. all invitees completed the questionnaire online via questionnaire star (https://www. wjx.cn). an initial set of invitees ( participants) was chosen to ensure broad representation of age, gender, occupation, education level, and city. this set of invitees then forwarded the questionnaire to companions whom they considered suitable for the survey, and this second set forwarded the questionnaire in the same way. the study included a general population aged years or older who volunteered to participate in the study. the participants received a complete description of this survey and were asked to sign an online informed consent prior to data collection. respondents were excluded if they reported a history of mental illness and/ or could not complete the online survey independently. a self-made questionnaire was used to collect demographic and epidemiological information of participants, including gender, age, marriage, epidemic contact and concern characteristics, and perceived epidemic impacts of the epidemic of covid- . the kessler psychological distress scale (k ) was used to assess the psychological distress of participants; this scale has been proven to have cross-cultural reliability and validity [ ] . it contains six questions that ask participants to rate how often they have felt 'nervous', 'hopeless', 'restless or fidgety', 'so depressed that nothing could cheer you up', 'that everything was an effort', and 'worthless' during the past days. the simplified coping style questionnaire (scsq) was used to assess the participants' coping styles during the covid- epidemic; this questionnaire has been proven to have good reliability and validity in chinese [ ] . the scsq contains twenty items, with each item using a four-point score ( = never, = seldom, = often, = always), and two subscales: positive coping ( items) and negative coping ( items) . according to the average and standard deviation of the positive coping style and the negative coping style scores, a z conversion is used to calculate their respective standard scores, and then, the negative coping standard scores are subtracted from the positive coping style standard scores to calculate the tendency value of coping style. a result greater than was defined as a participant adopting a positive coping style when faced with stress, and a result less than was defined as a participant adopting a negative coping style [ ] . differences in psychological distress (k score) among categorical variables were tested by ttests or one-way analysis of variance. a stepwise multiple linear regression analysis was performed to identify the influence factors of psychological distress. all statistical analyses were conducted in spss version . (ibm, chicago, il, usa), and p< . was considered to be statistically significant. the same ip address could be used only once to complete the questionnaire, which did not collect any personal information such as names, thereby ensuring anonymity and honest responses. the time spent on each questionnaire was monitored automatically, and the whole questionnaires completed in fewer than seconds were rejected as invalid. there were individuals from regions of china who completed this survey, and ( . %) were included in the analysis participants. among all participants, ( . %) were female, ( . %) were male; ages ranged from to years old (mean . ± . years); ( . %) were married, were unmarried ( . %); ( . %) had a history of visiting wuhan; and ( . %) had a history of epidemics occurring in their community; ( . %) concern with media reports related to the epidemic; ( . %) feel nervous, ( . %) feel difficult to control emotion and ( . %) have epidemic-related dreams in perceived impacts of the epidemic; ( . %) respond with negative coping styles (table ) . the results revealed significant differences in the participants' psychological distress based on age (f = . ), marriage (t = . ), history of visiting wuhan or not (t = - . ), history of epidemics occurring in the community or not (t = - . ), concern with media reports related to the epidemic (f = . ), and changes over living situations (f = . ), emotional control (f = . ), and epidemic-related dreams (f = . ) in perceived impacts of the epidemic (all p < . ); there were no significant differences based on gender (t = - . , p = . ). as age increases and marital status changes, k scores have a downward trend. those with a history of visiting wuhan and a history of epidemics occurring in the community have higher level of psychological distress than those without such experiences. the psychological distress tended to increase with concern with media reports related to the epidemic and perceived impacts of the epidemic. at the same time, the results also show that those with negative coping style have higher level of psychological distress than those with positive coping style (t = . , p < . ) ( table ). age, marriage, epidemic contact characteristics, perceived impacts of the epidemic and coping style were included in the multivariate analysis. factors' values were listed in (table ). unmarried, history of visiting wuhan, more serious changes over living situations, more difficult of emotional control, higher frequency of epidemic-related dreams, and negative coping style in the general population showed higher level of psychological distress. the results of the present study suggest that the general population in china mainland reported higher level of psychological distress in the early stages of covid- than those in non-epidemic period [ ] . the present study was conducted during the first two weeks of the covid- outbreak, so it indicated that the general population have already presented psychological distress in the early stages of epidemic. this finding is consistent with the previous studies. the traumatic stress experiences during the occurrence of emergency events, such as major public events or natural disasters, were often related to the general population's early psychological distress and subsequent mental illness [ , , ] . the psychological distress could cause the impairment of individual's normal daily activities and was associated with worse social functioning [ ] . so, our result suggested that the psychological intervention for the general population should be provided urgently after the outbreak of covid- epidemic. the multivariate analysis showed that marriage was the influence factor of psychological distress in general population. the population with unmarried showed higher level of psychological distress. unmarried status, lack of a major social support system, was found to be related to psychological distress [ ] . the other study also found single mothers without additional personal support showed higher values of psychological distress [ ] . these might imply the importance of the basic social support of marriage when an individual faced the covid- epidemic and suggest that mental health workers should pay increased attention to unmarried population. our results also found that the history of visiting wuhan in the past month was the influence factor of psychological distress. the population with history of visiting wuhan showed higher level of psychological distress. mandatory contact tracing and days quarantine, which form part of the public health responses to the covid- outbreak when having the history of visiting wuhan in the past month. the quarantine may perpetuate the sense of danger and uncertainty and increase individuals' psychological distress about the effects of contagion, infection, and stigma on their families and friends [ ] . it indicated that the general population who have the history of visiting wuhan should be paid more attention in the early stages of covid- epidemic. perceived impacts on changes over living situations, emotional control, and epidemicrelated dreams were found to be the influence factors of psychological distress. the population with more serious changes over living situations, more difficult of emotional control, and higher frequency of epidemic-related dreams showed higher level of psychological distress. previous investigations on ebola virus and severe acute respiratory syndrome (sars) have found the similar phenomena that individuals might perceive the infectious diseases as a type of life-threatening life event which could cause various negative emotions, such as anxiety, depression, fear, and a series of sleep problems [ , [ ] [ ] [ ] [ ] . in addition, these symptoms may be risk factors for individuals suffering from mental illness in the future and affect individual's attitudes and behaviors towards the epidemic prevention [ ] . as of jan , , chinese provinces, municipalities, and autonomous regions have initiated first-level responses to major public health emergencies [ ] . a range of measures has been urgently adopted, including closed non-essential public places, restricted mass gathering activities, delineating control areas, contact tracing and monitoring to effectively control the spread of the virus, which may bring public uncertainty and a sense of crisis [ , ] . so, the sudden changes over living situations may increase individual's anxiety and nervous. the sleep problems, especial recurrent distressing dreams in which the content are related to the traumatic event are the core symptoms in patients with ptsd [ ] . so, this indicated that the general population may present the symptoms of ptsd in the early stages of covid- epidemic. difficult to control the emotion and emotional instability could lead to worsening psychological problems which have been reported in the outbreak of sars [ ] . taken these results together, suggested that the psychological intervention should be implemented urgently for the general population who perceived more impacts on changes over living situations, emotional control, and epidemicrelated dreams to prevent suffering from ptsd in the later time. the multivariate analysis also showed that the coping style was the influence factor of psychological distress. the population with negative coping style showed higher level of psychological distress. the previous study related to traumatic stress events has reported that those in the general population with traumatic stress experiences were more likely to adopt a negative coping style [ ] . many previous studies have shown that different coping styles, especially negative coping styles, for trauma stress events are also related to subsequent mental illness [ , , ] . in contrast, a positive coping style may promote emotional well-being [ ] . therefore, the general population with negative coping styles should be given attention and the appropriate psychological interventions should be considered urgently. there are several limitations in our study. firstly, the survey method is based on network invitation rather than face-to-face random sampling, and participants need to be able to use network tools. as a result, the status of the general population who cannot use network tools is unclear. secondly, we did not assess whether and how respondents were engaging in prevention. finally, our study design is cross-sectional and thus cannot capture changes in psychological distress and its predictors over the course of the covid- . our study revealed that the epidemic of covid- caused high level of psychological distress in the general population. the general mainland chinese population with unmarried, history of visiting wuhan in the past month, perceived more impacts of the epidemic and negative coping style showed higher level of psychological distress in the early stages of covid- epidemic. psychological interventions should be implemented urgently, especially for those in the general population with such characteristics. facts about the novel coronavirus: transmission. chinadaily hubei province steps up epidemic prevention, control efforts. chinadaily timely mental health care for the novel coronavirus outbreak is urgently needed. the lancet psychiatry the mental health of medical workers in wuhan, china dealing with the novel coronavirus. the lancet psychiatry mental distress among liberian medical staff working at the china ebola treatment unit: a cross sectional study. health and quality of life outcomes monitoring of perceptions, anticipated behavioral, and psychological responses related to h n influenza symptoms and coping in sri lanka - months after the tsunami post-traumatic stress disorder status in a rescue group after the wenchuan earthquake relief at risk" of suffering from persistent complaints after mild traumatic brain injury: the role of coping, mood disorders, and post-traumatic stress psychological endurance, anxiety, and coping style among journalists engaged in emergency events: evidence from china. iranian journal of public health direct and interactive effects of occupational stress and coping on ulcer-like symptoms among chinese male off-shore oil workers is humor the best medicine? the buffering effect of coping humor on traumatic stressors in firefighters factors influencing psychological distress during a disease epidemic: data from australia's first outbreak of equine influenza coping and psychological distress in children involved in road traffic accidents brain functional connectivity correlates of coping styles. cognitive, affective & behavioral neuroscience coping style and quality of life in patients with epilepsy: a cross-sectional study screening for serious mental illness in the general population with the k screening scale: results from the who world mental health (wmh) survey initiative reliability and validity of the simplified coping style questionnaire the simplified coping style questionnaire. beijing: people's military medical press comparative study of the kessler and kessler scales on chinese university students' mental health. sciencepaper online psychological distress and social functioning in elderly spanish people: a gender analysis associated risk factors for psychological distress in patients with gastric epithelial neoplasm undergoing endoscopic submucosal dissection psychological distress and socioeconomic status in single mothers and their children in a german city an evaluation of psychological distress and social support of survivors and contacts of ebola virus disease infection and their relatives in lagos, nigeria: a cross sectional study- the impact of community psychological responses on outbreak control for severe acute respiratory syndrome in hong kong a novel coronavirus outbreak of global health concern the continuing -ncov epidemic threat of novel coronaviruses to global health-the latest novel coronavirus outbreak in wuhan, china diagnostic and statistical manual of mental disorders, th edition, and clinical utility the immediate psychological and occupational impact of the sars outbreak in a teaching hospita the mediating effects of coping strategies in the relationship between automatic negative thoughts and depression in a clinical sample of diabetes patients positive emotions trigger upward spirals toward emotional well-being we thank the general population who participated in this survey and bravely resisted the covid- epidemic, and thank the questionnaire star (https://www.wjx.cn) for providing us with a data survey platform. key: cord- -vbzceozs authors: hu, zhi-hua; sheu, jiuh-biing; xiao, ling title: post-disaster evacuation and temporary resettlement considering panic and panic spread date: - - journal: transportation research part b: methodological doi: . /j.trb. . . sha: doc_id: cord_uid: vbzceozs abstract after a disaster, a huge number of homeless victims should be evacuated to temporary resettlement sites. however, because the number of temporary shelters is insufficient, as are shelter building capabilities, victims must be evacuated and resettled in batches. the perceived psychological penalty to victims may increase due to heightened panic when waiting for evacuation and resettlement, whereas psychological interventions can decrease the magnitude of this panic. based on the susceptible–infective-removal model, panic spread among homeless victims and other disaster-affected people is modeled, while considering the effects of psychological interventions on panic spread. a function is derived to compute the increase in the number of victims to be evacuated due to panic spread. a novel mixed-integer linear program is constructed for multi-step evacuation and temporary resettlement under minimization of panic-induced psychological penalty cost, psychological intervention cost, and costs associated with transportation and building shelters. the model is solved by aggregating objectives into a single objective by assigning weights to these objectives. with wenchuan county as the test case, the epicenter of the sichuan earthquake, the influence and the sensitivity of parameters, tradeoff among costs, and the effects of various functions of panic strength on psychological penalty and monetary costs are assessed using six experimental scenarios. analytical results reveal the complexity and managerial insights gained by applying the proposed method to post-disaster evacuation and temporary resettlement. worldwide. over the last decade, china, the united states, the philippines, india and indonesia, are the top five countries most frequently targeted by natural disasters (guha-sapir and below, ) . earthquakes, hurricanes, droughts, and floods are global challenges due to their unpredictability and potential scale of impact in terms of social, environmental, and economic costs. many natural disasters displace people. furthermore, natural disasters can cause psychological suffering, altering people's behaviors and decision-making, increasing rescue and relocation difficulties, and decreasing social stability and security (hu and sheu, ; rennemo et al., ) . although few direct evidences of the effects of panic and its spread on post-disaster evacuation and resettlement have been recorded in literature, the synthetic effects of psychological damage on victims have been identified. this study addresses the effects of panic and its spread on evacuation and temporary resettlement. evacuation is the allocation and transport of disaster victims from disaster sites to sites with temporary shelters, whereas temporary resettlement refers to the resettlement of disaster victims during the period from the moment a disaster occurs to their allocation to transitional or permanent houses (el-anwar and chen, ) . more than million people were evacuated to temporary shelters after the sichuan earthquake. about . million tents and tarpaulin shelters were produced and transported to the affected areas within three months after the disaster (lian, ) . many farmers and urban residents were persuaded to engage in reconstruction by subsuming their grief. about . % of the victims who were evacuated and temporarily resettled returned to their houses and reconstructed their lives and buildings (lian, ) . because panic was widespread, many people refused to return to their houses even through their houses were deemed safe and no aftershocks were observed. panic spread had affected those people in sichuan province. the psychological effects of panic on demand for evacuation and resettlement are examined in this study. shadow evacuation is representative of these effects. shadow evacuation, which is the evacuation of people outside the disaster area who ''shadow'' the evacuation of those within the target area, is considered in a group of studies on evidences of the psychological effects of evacuation, especially that of those experiencing panic and other emotions. in some areas, over-evacuation of people not threatened directly by a hazard can add to traffic and congestion within a network and hinder the transportation of evacuees who are directly threatened. lamb et al. ( ) identified the factors influencing shadow evacuation. dependent measures were used to assess the likelihood of a shadow evacuation and identify messages and presenter characteristics. despite a -year experience with shadow evacuations, its causes are not sufficiently understood. dash and gladwin ( ) argued that studies should examine the role of perceived risk of shadow evacuation. they examined evacuation as a social process that is affected by the complex relationship between compliance with an evacuation message and an individual's perception of their risk exposure. panic is a source of risk perceived by disaster victims, and panic spread is through typical social relations among victims. shadow evacuations also provide clues as to the number of people affected by psychological emotions, as typical negative effects on hurricane-induced evacuation operations. following hurricane andrew in , gladwin and peacock ( ) noted that % of residents outside the evacuation zone also evacuated, placing considerable additional stress on transportation networks. lindell and prater ( ) also observed shadow evacuations associated with hurricane events, often occurring from inland areas deemed safe. shadow evacuation overloaded the capacity of the transportation networks. dueñas-osorio et al. ( ) estimated risks of hurricane hazards and then compared them with risk perceptions of residents after hurricane ike's landfall in . comparison results show that shadow evacuation is partly attributable to risk overestimation. overestimation of damage risk from wind or water surges resulted in , shadow evacuees. in this work, those in a shadow evacuation are motivated by panic and panic spread. although homeless people are in urgent need of evacuation, the number of temporary shelters is often limited immediately after a disaster. additionally, temporary shelters (mainly tents and tarpaulin rooms) generally take three days to erect, and are costly and difficult to recycle when abandoned. therefore, how to evacuate and resettle victims effectively with a limited number of temporary shelters is a significant problem. uncertainty associated with a disaster and the possibility of secondary disasters typically causes panic as victims wait for evacuation and resettlement. when panic spreads among disaster-affected people, many people who should not be evacuated will request evacuation. panic and its spread among victims are practical problems which complicate post-disaster evacuation and resettlement processes. panic is the primary risk when a disaster occurs (fritz and marks, ; mawson, ) . the typical response to various threats and disasters is not to flee but to seek familiar persons and places; moreover, separation from what is familiar creates more stress than physical danger (mawson, ) . mawson also asserted that waiting for evacuation can induce panic among victims because those waiting often see others leaving for resettlement sites. although post-disaster panic is reported frequently, quantitative studies are few. people are prone to panic and it spreads easily after disasters, namely, panic is infectious. that panic can induce a series of non-adaptive crowd behaviors during evacuation, such as pushing and trampling, and trying to jump in the line of those to be evacuated first. these actions are responsible for many disaster-related injuries and deaths. price-smith et al. ( ) determined that, with severe acute respiratory syndrome (sars), which originated in guangdong, china, in , both infected and non-infected people panicked, and this panic had negative impacts (e.g., people fleeing, tourism declining, and trade slowing) on societies and their economies. this study characterized qualitatively the impact of panic spread, but did not consider the socio-psychological mechanism of panic a contagion. based on diffusion theory of general diseases and public opinion, the effects of panic and its spread on temporary resettlement are considered in this study. the panic degree while waiting for resettlement is quantified by this work, and panic spread typically increases the number of people who request resettlement and evacuation. to relieve panic and avoid mass incidents, governments organize mental health workers, including general mental health workers and mental health professionals (daly et al., ) , for post-disaster psychological treatment. mental health workers have become a part teams working with the disaster-affected populations worldwide. in this study, mental health workers are the main vehicle for psychological intervention. the effects of shelter preparation, psychological intervention, and logistics on evacuation and resettlement solutions are also examined. compared to studies of emergency management and decision, post-disaster resettlement, evacuation, psychological intervention, and the many other issues related to post-disaster relief and recovery, this study contributes to literature in the following ways. first, the evacuation and temporary resettlement are jointly considered as a multi-step decision problem. a novel post-disaster resettlement flow with five stages is applied to identify the stages of evacuation and temporary resettlement. second, the effects of panic and panic spread among victims on evacuation and temporary resettlement are considered. osuna ( ) showed that the psychological stress that accumulates while waiting is a marginally increasing function of wait times. therefore, this study formulates panic degree as a function of wait times for evacuation. further, panic spread is formulated using the susceptible-infective-removal (sir) model (anderson, ) . in this model, psychological intervention can reduce the degree of panic and panic spread. based on these formulations, the number of victims to be evacuated due to panic spread is derived. third, psychological penalty cost perceived by victims due to wait for evacuation, psychological intervention cost, cost of transporting victims from disaster sites to resettlement sites, and cost of building resettlement shelters are minimized in this formulation. these four costs are utilized to assess the efficacy of evacuation and resettlement solutions. the proposed models and formulated effects of panic and panic spread are characterized and analyzed based on estimated data from wenchuan county after the sichuan earthquake. via parameter sensitivity analysis and pareto analysis of the relationship between psychological penalty cost and monetary cost, the features of the proposed method are elucidated. the remainder of this paper is organized as follows. section briefly reviews relevant literature on temporary resettlement, psychological panic and resource allocation in disasters caused by infectious diseases. section introduces the problem of temporary resettlement impacted by panic-induced psychological panic and panic spread. section formulates a multi-objective optimization model for this problem. section lists the tasks required for acquiring data, and estimating parameter values. section gives numerical results for test scenarios, and findings based on these numerical results are summarized and discussed. section demonstrates the potential advantages and efficacy of the proposed method. this section has several parts. first, after introducing the behavioral and social features of evacuation, shadow evacuations are examined to explain the effects of panic and panic spread on demands for temporary shelters. second, psychological panic is further examined rationally by considering panic in post-disaster evacuation and resettlement processes. third, the principles of panic spread and base models are analyzed and applied to dynamic evacuation and resettlement. ( ) shadow evacuation evacuation research can be grouped into two main categories: behavioral and social science; and modeling and operations (tayfur and taaffe, ) . a fairly large body of research has focused on evacuation planning within behavioral and social science. in modeling and operations literature, researchers have focused mostly on the general population and used roadway infrastructure to move people away from a hazard. many of these researchers proposed operational policies for mass evacuations (daganzo and so, ; guo et al., ) , and studied routing and traffic problems during evacuation, whereas this study treats evacuation as a relief valve for psychological panic as perceived by disaster victims by considering the behavioral and social aspects of evacuation. as mentioned, shadow evacuation is the movement of evacuees who are not required to evacuate. numerous issues associated with shadow evacuation can affect the evacuation process. the shadow evacuation was a planning concern in the houston metropolitan region, which greatly restricted the movement of evacuees from high-risk areas (lamb et al., ) . in fact, this particular problem was underscored by conditions during and after hurricane rita. many shadow evacuees perceived that they were at high risk if they remained. although shadow evacuation has been examined to some degree as a part of the evacuation process, few studies have investigated shadow evacuation as a phenomenon separate from necessary evacuation. modeling techniques are similar to those outlined above. lamb et al. ( ) asserted that evacuation efficiency can be achieved in a variety of ways: minimizing the shadow evacuation and background traffic; sheltering victim in place; and phased (staged or sequenced) evacuation. reducing the magnitude of a shadow evacuation is likely best accomplished through clear communication and education. evacuation decisions are largely products of government bodies feeling that a particular population is at risk of harm. reducing background traffic also involves communication, typically urging people who do not need travel to cancel their trips. because evacuation demand considerations are not directly controlled by transportation agencies, they are seldom explored in transportation literature. this study considered dynamic evacuation demands that are affected by victims' psychology. as temporary shelters are for evacuated victims, shadow evacuations increase demands for shelters. this study makes a connection between post-disaster evacuation and temporary resettlement. temporary resettlement is a time-sensitive service that should be provided for evacuees. the temporary resettlement capacity and replenishment capability should be carefully considered when making post-disaster evacuation decisions. these considerations are based on the observation that a shadow evacuation may be induced by panic and panic spread. ( ) temporary resettlement the temporary resettlement period plays an important role in the economic and psychological recovery of a disasteraffected society (el-anwar and chen, ). the primary goal of emergency response efforts is to provide shelter and assistance to disaster victims as soon as possible (rawls and turnquist, ) . to restore normalcy and complete post-disaster reconstruction, temporary resettlement should proceed quickly. kellett ( ) argued that temporary resettlement not only provides shelters for victims, but also satisfies the functional and social demands of victims. however, temporary shelters have strong negative effects on homeless victims when they are forced to live in temporary shelters for prolonged periods, and often lead to significant social problems such as high unemployment rates, decreased quality of life, and increased crime rates (johnson, ) . therefore, those living in temporary resettlement sites should be transferred to transition resettlement houses and then resettled in permanent structures. el-anwar et al. ( ) proposed a multi-objective optimization model for assignments of large numbers of victims to temporary housing that minimizes social and economic disruption, temporary housing vulnerabilities, and adverse environmental impacts and public expenditures after a disaster. furthermore, el-anwar and chen ( ) determined the computational efficiency of the current socioeconomic model of the temporary resettlement problem, which is formulated as an integer linear programming model. moreover, to solve the model, an algorithm was developed based on the hungarian algorithm. johnson ( ) determined that erecting prefabricated temporary houses can minimize the negative effects associated with resettlement on disaster victims. although post-disaster housing and recovery have been well studied in literature, few researchers have formulated housing demands that are affected by shadow evacuation and the victims' psychology. although victim panic after a disaster is difficult to quantify, its effects on operations and management have been identified. although psychology literature is vast, for example, decision making under time pressure and safety concerns (see adam et al., ,dombroski et al., , few studies are related to evacuations. this may be due in part to that fact that it is often a non-quantitative topic. keating ( ) considered panic as a unique collective phenomenon when fear is the dominant psychological entity of a group. neria et al. ( ) argued that when first learning of an impending natural disaster, people will have negative psychological reactions, such as insecurity, anxiety, and/or fear. armfield ( ) argued that the danger levels associated with a disaster have a major impact on the severity and distribution of panic. some researchers have found indirect evidence of panic, even in the evacuation processes. first, once danger is recognized and people start responding, their information-processing and decision-making capabilities may be confounded by the mentally demanding circumstances, and those pressures are related to the perception of time pressure (adam et al., ) . second, egocentric behavior, a panic-related behavior, has been shown to be quite uncommon during an emergency (bohannon, ) . third, supported by a substantial number of empirical studies (e.g., dash and gladwin, ) , disaster victims do not automatically follow advice and orders from public officials, and tend to seek information, assess personal risk, and make their own evacuation decisions. according to adam et al. ( ) shadow evacuation is primarily motivated by people's perception of being at risk, and shadow evacuation may most commonly occur during mass evacuations, increasing pressure on infrastructure and hindering those who need to evacuate. on the other hand, the response rate for evacuation has a marked non-linear impact on evacuation traffic conditions and arrival patterns, and a higher response rate leads to more traffic on roads, results in traffic congestion. the socio-psychological and circumstantial factors markedly affect individuals' evacuation decisions. ( ) panic spread panic affects victims' evacuation decisions. panic-related emotions can be minimized or spread to others in a social network. one factor influencing evacuation decisions is the strength of a person's social network. based on the assumption that social cues are a causal factor, hasan and ukkusuri ( ) created a social contagion model to investigate the conditions for a cascade through a network of the decision to evacuate. they also considered the effects of social community mixing patterns, the first person to decide to evacuate, and the decisions neighbors made in previous time steps. their model used a mathematical approach and simulation to investigate these factors that bring about the desired behavior of evacuating people in an area based on social relationships. wang et al. ( ) created a qualitative simulation model of a large evacuation system while considering panic spread, and analyzed uncertainty factors that can affect panic spread during the evacuation process. a threshold model of social contagion was developed by hasan and ukkusuri ( ) . this model characterized social influence in decision about evacuation. based on these studies, this study considers the effects of panic spread among disaster victims on temporary resettlement. bi and ma ( ) and zhang et al. ( ) investigated panic psychology during resettlement of disaster victims. bi and ma assessed the effects of two resettlement modes, centralized and non-centralized resettlements, on psychological health, and noted that centralized resettlement mode improved mental health better than decentralized resettlement. zhang et al., who applied statistical methods to analyze factors affecting post-flood anxiety and psychological wellness, determined that timely and effective psychological intervention can minimize anxiety following a disaster. these two studies primarily analyzed the effects of resettlement modes, especially centralized resettlement, on the psychological health of victims; the effect of their psychology on the resettlement process did not get sufficient attention. this study differs from those by bi and ma, and zhang et al. in the following ways. first, they analyzed the effects of resettlement modes on panic and panic spread among victims, whereas this study considered the effects of panic and panic spread on evacuation and temporary resettlement decisions; multi-period evacuation and resettlement decisions are the main focus. second, they quantified the effects by questionnaire-based methods, which contributed to psychological research, whereas this study minimized psychological penalty or cost perceived by victims and three monetary costs by considering the effects of panic and panic spread. another stream of research involves resource allocation problems associated with the rapid spread of infectious diseases (brandeau et al., ; pietz et al., ; ren et al., ; mamani et al., ) . based on these studies, our study considers the following features. the resettlement problem while considering panic spread is formulated as a multi-step evacuation and resettlement problem. next, the time-varying strength of panic, and the time-varying costs and limits of shelters and mental health workers are modeled to study the effects of wait times on evacuation and resettlement solutions. finally, the panic spread in this study is affected by wait times and mental health workers. prevention, preparedness, response, and recovery are the four phases comprising the disaster management lifecycle (quarantelli, ) . quarantelli further divided the recovery period into four stages: instant settlement (within a couple of hours after a disaster); emergency settlement (within one or two days after a disaster); temporary resettlement (within a couple of weeks after a disaster); and permanent resettlement (within a couple of years after a disaster). according to practices in china (lian, ) , before permanent resettlement, a period of transitional resettlement is considered within a couple of months to years after a disaster based on the time needed to construct permanent houses. therefore, this study uses five-stage post-disaster resettlement processes ( fig. ) . after a disaster, emergency rescue resources are distributed and instant settlement sites are chosen and built immediately. shortly after rescue resources arrive, emergency settlement sites and facilities are usually built in safe spaces close to disaster sites. during this stage, young or healthy people take part in rescue operations at disaster sites, and some begin repairing their houses. for issues of water safety, sanitation, water and electricity supply, and other management-related factors, most homeless and injured victims should be evacuated to temporary resettlement sites gradually within about - days after the disaster. during these processes, panic and panic spread markedly affect victim psychology and demands for evacuation. to achieve efficient management of order and evacuation, demands of disaster-affected people should be met as soon as possible. as an indirect evidence of panic spread, some people will return to their homes and repair their houses after living in temporary resettlement shelters for a few days, partially because they were evacuated due to ''shadow evacuation''. this study focuses on the evacuation and temporary resettlement processes, which are enclosed by the grey box in fig. . shelters in the first three stages are typically tents and tarpaulin rooms, which cannot be deployed for extended periods due to issues related to safety and comfort. victims in temporary shelters wait for transition resettlement houses that they can live in for several years. shelters and/or houses for temporary, transitional and permanent resettlement are generally built in successive stages because of shortages in resources and capabilities. therefore, evacuation from one stage to the next stage is dynamic, and conducted step by step. after a disaster, a large number of victims must be evacuated in the temporary resettlement stage from disaster sites (including instant and emergency settlement sites) (denoted as set s that has jsj sites, and are indexed by s) to resettlement sites (denoted as d that has jdj sites, and are indexed by d). however, because resources are limited and lead times for producing and building shelters are long, not all homeless or injured victims can be evacuated immediately to temporary resettlement sites. due to these wait times for evacuation, the strengths of panic and panic spread among victims will rapidly increase. as a result, the number of panicked victims increases, as does the number of those who request evacuation and some young victims and those whose houses can be lived in victims evacuated from disasteraffected or emergency settlement sites to temporary resettlement sites that are relatively far from the disaster-affected sites affected by panic and panic spread, and focused on by this study fig. . five post-disaster settlement and resettlement stages. resettlement. indeed, some victims can remain at the emergency settlement sites close to disaster sites, support rescue processes, and repair their houses ( fig. ) . to examine the dynamic evacuation and resettlement processes, and the effects of wait times on the strengths of panic and panic spread, the temporary resettlement stage is divided into a set of discrete time steps (denoted as t that has jtj time steps, and are indexed by t). the spread of collective panic has a lifecycle comprised of initialization, development, outbreaks, and decline (she and sheng, ) , resembling that of infectious diseases. according to the sir model (anderson, ) , people are divided into three groups: infective, susceptible, and removed people. fig. shows relations among these three groups based on the sir model. initially, homeless victims whose houses have collapsed or are heavily damaged should be evacuated to temporary resettlement sites. however, temporary shelters are scarce and supplied gradually, such that victims are evacuated and gradually resettled at resettlement sites. because of the fear of secondary disasters, panic, especially that among the homeless, which are affected most by the disaster, will aggregate overtime. panic spreads from homeless victims to those that do not need to be evacuated. to keep the order in disaster areas and protect victims, most people affected by panic should be evacuated. ( ) ''infective people'' are victims who must be evacuated to resettlement sites at time t, denoted by x i t;s ; p i ;s denotes the initial number of homeless victims who must be evacuated and resettled. over time, x i t;s is increased by panic spread and decreased by evacuation. ( ) ''susceptible people'' are those who remain at a disaster site s at time, denoted by x s t;s . generally, the houses of susceptible people can still be used because these houses are not unsafe, or these people are healthy and young and can contribute to disaster relief. the initial number of these people is denoted by p s ;s . however, as disaster victims, their psychology is sensitive to the disaster and the willingness to be evacuated from disaster sites. some people in may be transferred to members in x i t;s . ( ) ''removed people'' are the victims evacuated from disaster site s to resettlement site d at time t, denoted as x r t;s;d . these three groups change dynamically as panic spreads (fig. ) . susceptible people become infective people when they are affected by infective people. the number of susceptible people who become infective people is the number of increase of people (nip) due to panic and panic spread at time t, denoted as x nip t;s . the infective people become removed people when they are evacuated to resettlement sites. notably, the nip value, or the transformation of susceptive people to infective people would be controlled by considering some eligibility criteria during on-the-spot operations. selection of these criteria affects the ratio of the nip to the entire group of susceptible people. as the number of infective people x i t;s increases, the probability of susceptible people x s t;s being ''infected'' increases, which increases x i t;s by x nip t;s . thus, x nip t;s is a function of the current number of infective people and susceptible people, denoted as , where x nip t;s is the nip added to infective people at the next time step x i tþ ;s . as b t,s represents panic spread strength, x nip t;s is proportional to b t;s , x i t;s , and x s t;s . based on the sir model, x nip t;s is then computed by eq. ( ). the panic spread strength (speed) is affected by internal and external factors. one internal factor is the panic degree of infective people. the panic degree directly affects the speed of panic spread. the speed of panic spread increases as panic degree increases. the panic degree at time t is denoted by a t . government intervention is an external factor. to maintain social stability, a government can provide psychological assistance for victims by dispatching mental health workers to the disaster areas. these workers can reduce the panic degree and slow panic spread. government intervention degree at disaster site s at time t is denoted by g t,s ; the number of mental health workers dispatched to site s at time t is denoted infective people (to be resettled) by e t,s ; and each mental health worker can provide psychological assistance to r disaster victims during one time step. obviously, g t,s is positively related to e t,s and r and negatively related to the total number of disaster victims, as in eq. ( ). panic spread strength (b t,s ) is a function of panic degree (a t ) and government intervention degree (g t,s ), as in eq. ( ). generally, b t,s is positively related to a t and negatively related to g t,s . the forms of b t,s (Á,Á) are examined in section . further, panic degree of infective people (a t ) is primarily affected by wait times for resettlement. thus, a t is a function of wait times for resettlement (osuna, ) . initially, panic degree of infective people is a constant. as wait times increase, panic degree increases, indicating that wait times and panic strength are positively correlated. moreover, when victims wait for excessively long times, psychological collapse may ensue. thus, panic degree (a t ) is computed by a function of wait times in the numerical studies (section ). the function (a t ) is defined in the data estimation section (section ). when one considers panic and panic spread among disaster victims, two factors that markedly affect temporary resettlement decisions are the nip, and the speed at which temporary shelters are erected at resettlement sites. the number of temporary shelters that can be erected at time t is denoted by z inc t;d . the number of erected temporary shelters directly determines the resettlement capacity, which is denoted by z a t;d . the initial resettlement capacity at site d is denoted by p a ;d . thus, to assess the efficacy of evacuation and resettlement solutions, the following costs are considered. panic-induced psychological penalty perceived by victims when waiting for evacuation is determined by panic degree (a t ) and number is a function of time and sensitive to time. to minimize panic of victims and maintain stability in disaster areas, local governments typically dispatch mental health workers to these areas. these psychological relief actions have allocation and training costs and emergency-related worker pay. the entire cost of one mental health worker serving for one time step at time t is denoted as c p t . three sets, a set of disaster sites, a set of resettlement sites, and a set of time steps, are involved, which are denoted by s, d and t, and indexed by s, d and t, respectively. two groups of known data for disaster site s at the initial time step are the initial number of infective people that should be evacuated to resettlement sites, p i ;s , and the initial number of susceptible people, p s ;s . the unit cost of building a shelter at time t is c inc t . transportation cost for one person from a disaster site s to a resettlement site d, is c t s;d Á p tc , where c t s;d is the distance from s to d, and p tc is the cost for a unit of distance (km). additionally, the cost of a mental health worker serving for a time step at time t is c p t , and the strength of panic spread at time t is denoted by a t . the first group of constraints characterizes the conditions at the initial and end time steps. at the initial time step, the number of infective people x i ;s À x nip ;s and the number of people who are evacuated from disaster areas to resettlement sites x r ;s equal the initial number of homeless disaster victims p i ;s , as defined by eq. ( ) . second, the number of people who should remain at the disaster site x s ;s þ x nip ;s equals the number of susceptible people at the initial time step p s ;s , as defined by eq. ( ) . third, the number of people who are evacuated to resettlement site d at time t is , as is defined by eq. ( ) . fourth, eq. ( ) sets the initial capacity of resettlement site d to p a ;d . the pre-establishment of an adequate capacity and amount of resources enables efficient response to a disaster (salmerón and apte, ). at the last time step (t = jtj), all homeless victims should be evacuated to resettlement sites, meaning that x i t;s and x nip t;s are both , namely, x i t;s þ x nip t;s ¼ for all t = jtj and s. further, by eq. ( ), when x i t;s is , x nip t;s is . therefore, as in eq. ( ), the number of infective people at the last time step (t = n t ) for each disaster site s must be . the second group of constraints comprises flow constraints. first, eqs. ( ) and ( ) the third group of constraints defines x r t;s (eq. ( )) and x r t;d (eq. ( )), and limits the number of the resettled people to the resettlement capacity (eq. ( ) ). furthermore, as a complementary constraint for eqs. ( ) and ( ) restricts the number of people served by mental health workers to the number of disaster-affected people. the fourth group of constraints handles the boundaries and integrities of decision variables. by eqs. ( ) and ( ), the boundaries of the shelter supply and the supply of mental health workers are set. additionally, by eq. ( ), the upper boundaries of the capacity of temporary resettlement sites are constrained. capacity should exceed the number of disaster victims. eq. ( ) indicates that homeless victims must be evacuated and resettled. all variables are non-negative numbers, as denoted by eq. ( ) s:t: eqs: ð Þ-ð Þ; ð Þ-ð Þ the earthquake that hit sichuan, china, on may , , caused numerous casualties and considerable property losses; that is, the earthquake killed , people, injured , , left , people missing, damaged , , houses, and toppled , , more (lian, ) . after the earthquake, about , , people had been relocated. more than , , tents or tarpaulin rooms were dispatched to the disaster sites. the earthquake's epicenter was in wenchuan county, which has a population of , , of which , ( . %) were killed (lian, ). the earthquake also brought psychological harm to residents. according to estimates by the psychology institute of chinese academy of science, more than , people suffered psychological problems. within five days after this earthquake, , people in wenchuan county were evacuated to temporary resettlement sites. after that, many victims were evacuated and resettled. the number of tents or tarpaulin rooms was not revealed in news reports on wenchuan county; neighboring guangdong province had built , movable houses within roughly one month after the disaster (kong, ) . because approximately % rural peasants would return to repair or rebuild their houses after staying at temporary shelters for a couple of weeks, we estimate that about , ( , Á /( À %)) victims, where a house can accommodate on average two victims, were evacuated to temporary resettlement sites after the earthquake. the number of evacuated people exceeds the number of damaged houses. panic and panic spread may account for this difference between number of damaged houses and number of evacuated people (lian, ). ( ) estimate the number of initial infective people p i ;s and susceptible people p s ;s the villages and towns in wenchuan county were disaster sites (with instant and emergency resettlement sites). based on the populations and geographic locations of these sites (fig. ) , two temporary resettlement sites were established in weizhou and yingxiu. according to data published by wenchuan government (http://www.wenchuan.gov.cn), the total number of people before the earthquake and the number of people killed by disaster at each village were summarized by statistical data. the total population at village after the disaster is denoted by p s . then, by using the data from lian ( ) , the ratio of damaged houses in village to the houses before the disaster is estimated, and denoted by. when reported data about the damage ratio differ, the average value is used as the estimation. the values of p i ;s and p s ;s can thus be estimated by p i ;s ¼ l s p s , and p s ;s ¼ p s À l s p s . table presents the statistical and estimated results (see fig. ). ( ) estimate transportation cost c t s;d the distance between a disaster site s and a resettlement site d c t s;d is estimated using the geographic information system (gis) ( table ). the unit transportation cost for one person for a kilometer (p tc ) is set to yuan. ( ) efficiency of a mental health worker (r) one psychological intervention group with one to three workers can serve for about victims per day (wo, ) . this study presumes that one mental health worker can serve roughly victims per day, r = . due to urgent demands for mental health workers and temporary shelters, and the marginally increasing degree of panic perceived by victims while waiting for evacuation and resettlement, three parameters (c p t ; c inc t and a t ) are defined as functions of wait times. reducing the time needed to dispatch mental health workers increases dispatching cost, subsidies, and training costs. the total cost of these types of costs for each worker is represented by c p t at time t. here, c p t is a linear decreasing function of time, and the highest cost is set to yuan, as in eq. ( ), where e p (t) is a monotone increasing function of time t. similarly, c inc t (the cost of increasing a unit of settlement capacity at time t) decreases as a function of time, as in eq. ( ), where e p (t) is also a monotone increasing function of time t. the space in a temporary resettlement shelter for each victim is set to five square meters; thus, resettlement cost per person is set to about yuan and the reference cost at safe times is set to yuan, as shown in eq. ( ). notably, for transition and permanent resettlement, the space allocated for each victim is larger than five square meters. the panic degree a t increases with wait times, and the initial and maximum degrees of panic are set to and , respectively, as in eq. ( ), where e a (t) is a monotone increasing function of time t. a t ¼ minf : Á e a ðtÞ; g to decide e p (t), e inc (t) and e a (t), three governmental officials, three scholars, and three disaster victims, which are all affected by the sichuan earthquake, are interviewed. three base forms, t, t , and e t are used and their figures with descriptions are shown to the interviewees. empirical results indicate that the answers are consistent and the analytical results are used to set the parameters: e t is extreme and too severe; the variances of c p t and c inc t can be described by linear relations (e.g., t), whereas e a (t) is more complex than both; and the forms based on t are used to describe the effects of panic on evacuation and resettlement solutions. a second interview was then conducted by using a curve figure (fig. ) in the questionnaire forms to determine e a (t). no distinct consistent answer was achieved for the question of choosing a property curve for e a (t). the interviewees thought the function values depended on many conditions. however, they believed that the degree affected by panic due to wait times was severe and generally managed well by the communities and local governments. therefore, very serious situations due to panic were rare. according to interviews and investigation results for the disaster areas, reference data for a t ; c p t and c inc t (table ) are basically linearly related to passed time. ( ) time-varying capacities for resettlement and mental health workers temporary resettlement capacities vary with time p zu t and are estimated by news reports (lian, ) . the values are determined by stocks of reserved disaster relief resources, and the capabilities of contracted manufacturers and suppliers. within several weeks after a disaster, many mental health workers p pu t dispatched are not specialized, coming from general hospitals, nearby schools and universities, and governmental and non-governmental organizations (ngos). these people are generally trained and can reach the disaster sites. however, because of the urgency and traveling costs, the number of people is limited. some reference data are set for p zu t and p pu t (table ) . ( ) strength of panic spread as defined in eq. ( ), panic spread strength (b t,s ) is a function of panic degree (a t ) and governmental intervention degree (g t,s ). generally, b t,s is positively related to g t;s and negatively related to g t,s . three typical forms of b t,s (a t ,g t,s ) for a given s are given in eqs. ( ) notably, g t,s = . t is used as the typical function representing governmental psychological intervention degrees that vary over time (fig. ) . however, set a t ¼ t (fig. (a) ), and set a t ¼ t (fig. (b) ). notably, a t Á ( À g t,s ) and a t /( + g t,s ) almost overlap, except for the first point (t = ) ( fig. (a) ). the differences between these two functions shown in fig. (b) are more apparent than those in fig. (a) in their slopes. the curves of a t /g t,s in fig. (a) are not representative. when interviewers are invited to select representative functions, a t Á ( À g t,s ) is comparably better than others when a t = t and a t = t . ( ) initial capacities of resettlement sites by default, p a ;d is set to . by these seven groups of estimates and analyses, the data of h in p (eq. ( )) are determined. for ease of reference, p represents the default settings for the parameters (eq. ( )). this section presents numerical studies, demonstrating the efficacy of the models whose primary known data are given in section . lingo (www.lindo.com) software was used to solve [m ] and [m ] . the purpose of the numerical experiments is to demonstrate application of the proposed methods for evacuation and temporary resettlement of people in wenchuan county after the sichuan earthquake. table summarizes the six experimental scenarios, corresponding purposes, and experimental steps. via these experiments, the proposed models are demonstrated; the effects of parameters on solutions and their sensitivities are analyzed; the consistencies of or conflicts between various costs are quantitatively studied. the analytical results can be used for decision-makings for post-disaster evacuation and temporary resettlement. performance of [m ] or [m ] is examined in each scenario. (fig. ) ( ) demonstrate the effects on f psych , f gint , f trans and f build , and the effects on f p and f c when they have equal weights ( ) use p as the base setting of parameters; ( ) set the weights in w to . ( ) use [m ] and use p as the base settings of parameters ( ) adjust weights (w p = , . , Á Á Á , , and w c = À w p ) to generate test cases and solve each [m ] ( ) draw and analyze the pareto fronts between f p and f c (fig. ) ( ) analyze the effects of the strength of psychological penalty on the solutions by altering e a (t) ( ) use [m ] and use p as the base settings of parameters ( ) set e a (t) to t,t / ,t / , t / and sequentially in the following experiments ( ) set w p = w c = . , and solve [m ] ( ) compare the experimental results of the five functions of (fig. ) based on the results (tables and ; figs. - ) for the six experiments (table ) , experimental results are summarized as follows. ( ) because their values will be changed when the parameters change. table presents values of min(f ⁄ ) and max (f ⁄ ) for the first and second experimental scenarios. ( ) experimental results by minimizing only f psych , f gint , f trans , f build or f c (fig. ) . ( ) by minimizing f psych , the evacuation and resettlement can be completed within the first days. the psychological penalty cost reaches its lowest ( ) after six days, and building cost remains high from day to day . the psychological intervention cost also reaches the allowed maximum within the first days. minimization of psychological penalty cost increases the costs of building shelters and psychological intervention. ( ) the minimum of f gint reaches while psychological penalty cost increases gradually during the first days. minimization of psychological intervention delays building shelters and victim evacuation. therefore, minimizing psychological intervention cost lowers psychological penalty costs and ignores the importance of evacuation and resettlement. ( ) minimizing f trans reduces the nip and the number of infective people who attempt to evacuate. therefore, the number of temporary shelters will also be minimized. psychological penalty cost also reaches its minimum on the sixth day. psychological intervention cost gradually increases during the first days and then declines to the following days. however, the reduction in this value does not minimize building cost. generally, the minimization of transportation cost is paid by the psychological intervention cost and building cost. ( ) the minimization of f build postpones building temporary shelters. before construction of many temporary shelters, psychological penalty cost and psychological intervention cost increase gradually. this increase in monetary costs is also reflected by the increase to the nip and number of mental health workers needed. ( ) minimizing psychological intervention cost has effect similar to those effects of minimizing f build . psychological penalty cost gradually increases over the first days. as building cost increases, psychological penalty cost decreases because more victims can be evacuated to temporary shelters. ( ) when weights of the costs returned by solving [m ] and [m ] are equal, the resulting solutions indicate that building costs have almost the same tendency during the first days, whereas the other three costs (psychological penalty cost, psychological intervention cost, and transportation cost) are distributed differently (fig. ) . when the four costs are equally weighted, psychological penalty cost is high while psychological intervention cost is minimized (fig. ( a) ). the curves of the four costs are explicitly distributed (fig. ( a) ). as indicated by the curves (fig. ( b) and ( b)), many mental health workers are needed during the period from day to day in the results of solving [m ] . when the sum of monetary costs (psychological penalty cost, psychological intervention cost, and transportation cost) is a single objective, the significance of psychological intervention is reflected by the fact that many mental health workers are deployed. however, when the four costs are weighted equally, building cost remains high while psychological penalty cost is also high. ( ) table presents sensitivity test results for eight groups of parameters (p i ;s ; p s ;s ; a; c p ( ) although psychological intervention cost is directly affected by c p t , it has no effect on other costs. ( ) notably, p pu t affects psychological intervention cost mostly, followed by psychological penalty cost. rationally, because the number of mental health workers is limited, sufficient workers in the early stages would be recruited when the recruit cost is high. when p pu t is increased markedly, the psychological intervention method will be used excessively, which can be seen with the large increase in psychological intervention cost, while its effects on other costs are minimal. ( ) decreasing p zu t affects the four costs significantly, especially psychological intervention cost. by decreasing p zu t , decision-makers will use the capacities as many as possible, such that capacities in the early days after a disaster with high building costs may be fully utilized. when p zu t is increased to the extent that resettlement sites can accommodate all disaster infective victims soon after the disaster, no worker is needed to treat the victims at the disaster sites. ( ) although c inc t directly affects building cost, it affects psychological intervention cost more, and affects psychological penalty cost consistently. the effect of c inc t on transportation cost is minor. ( ) transportation cost is markedly affected by c t s;d and also slightly affects psychological intervention cost; however, it does not affect the psychological penalty cost and building cost. ( ) fig. shows the effects of varying the initial stock of shelters at resettlement sites p a ;d on the four costs. notably, this study does not consider the cost for reserving the initial stock of shelters. with the increase in stock, the building cost decreases linearly; psychological intervention cost drops to almost when the stock increases to at each resettlement site; psychological penalty cost drops rapidly when stock reaches and then declines slowly; the varying curve of transportation cost reaches the minimum and then increases very slowly. ( ) by solving the [m ] with different weights for psychological penalty and monetary costs, pairs of the two costs are obtained. fig. shows the distribution of solutions and their pareto font. a decrease of % to psychological penalty cost can be achieved by increasing monetary cost by . %. ( ) fig. shows the effects of different psychological penalty costs associated with wait times on the solutions. here, a linear function (t) and four functions with different coefficients ( / , / , / and ) for squared wait times (t ) are considered and computational results for the four costs are compared. psychological intervention cost, transportation cost, and building cost increase almost linearly when e a (t) is formulated as t, t / , t / , t / and t . however, the increase in psychological intervention cost is fastest. psychological penalty cost increases nonlinearly when e a (t) is sequentially formulated as t, t / , t / , t / and t . when e a (t) is formulated as t / and t , the cost increases rapidly. the discussion of experimental results is generalized as follows. ( ) the costs of psychological penalty, psychological intervention, and transportation and building shelters may be correlated or conflict. first, minimizing psychological penalty cost is consistent the increased costs for building shelters and psychological intervention. second, when psychological intervention is excessively emphasized, the evacuation and resettlement process is delayed. third, although transportation cost is minor when compared to total monetary cost, it is representative of the number of victims affected by panic spread because it is computed based on the number of evacuated victims. fourth, building cost conflicts with psychological intervention cost and psychological penalty cost. further, psychological intervention cost and psychological penalty cost also conflict. fifth, minimization of transportation cost indicates that the number of victims influenced by panic spread is reduced, which in turn increases psychological intervention cost. finally, when psychological penalty cost and the entire monetary cost are considered separately, psychological intervention cost can be used to balance psychological penalty and psychological intervention costs. ( ) of all eight groups of parameters, p i ;s affects solutions most. all costs are related to the number of infective people and the increase in number of infective people. when the value of p i ;s is increased and resources are limited, the costs of psychological intervention and psychological penalty will increase markedly. the initial number of infective people and susceptible people affect the four costs greatly. therefore, these numbers should be reduced as much as possible. although the number of infective people cannot be reduced, some susceptible people can be persuaded to take part in the rescue processes. therefore, mental health workers can focus on infective people. the psychological pressure due to wait times (a) imposes great effects on costs related to victim psychology. ( ) psychological intervention may be overused when the number of available mental health workers is adequate. this overuse does not reduce psychological penalty cost significantly, and it also does not affect building and transportation costs significantly. ( ) expanding the limits of resources (e.g., mental health workers, reserved resettlement resources and replenishment capability for resettlements) can affect psychological intervention cost and psychological penalty cost considerably. and the expansion itself may have a high cost because the probability of disaster occurrences is in fact low. therefore, the increase in replenishment capability is practical for critical relief resources. ( ) although the unit cost of building a shelter affects building cost directly, it affects psychological intervention cost more, and also affects psychological penalty cost. therefore, controlling unit building cost for temporary shelters contributes markedly to cost reductions related to victim psychology. increasing the supply of shelters by emergency supply chain management and logistics is important to post-disaster psychological relief. ( ) in comparing to psychological intervention cost and building cost, the ratio of transportation cost to the overall monetary cost is small. although the ratios affect solutions, they can be neglected. however, when disasters such as earthquakes and landslides occur, road damage may increase transportation costs and evacuation difficulties. ( ) psychological intervention cost is the cost affected most by the initial resettlement capacity because infective people can be accommodated quickly after a disaster. then, the psychological penalty cost and building cost can be markedly reduced. therefore, improving the stock of temporary shelters or providing alternatives can reduce psychological and monetary costs significantly. ( ) by the pareto analytical tool, the tradeoffs between psychological penalty cost and monetary cost can be examined. in the experiments, a small increase to monetary cost ( . %) can cause psychological penalty cost to decrease significantly ( %). therefore, when the budget allows, psychological penalty perceived by victims can be minimized. by extending the proposed methods, the tradeoffs among four costs are revealed. ( ) the magnitude of psychological penalty cost induced by wait times directly affects total psychological penalty cost. however, this magnitude cannot be determined directly according to disaster type or other simple quantification methods. it is affected by the extent of damage, disaster severity, and post-disaster natural and social environments. therefore, minimizing the strength of panic and panic spread is important for evacuation and resettlement, and the recovery of disaster areas. psychological intervention and timely rescue are general ways to reduce the strength of panic and panic spread. this study addressed the post-disaster evacuation and temporary resettlement problem for victims affected by psychological penalty induced by panic and panic spread. psychological penalty due to panic is strengthened by wait times. victim panic and panic spread among victims may increase the number of people to be evacuated to temporary resettlement sites. this problem is formulated with following features. first, the considered period of evacuation and temporary resettlement is divided into time steps. second, panic degree is quantified as a function of wait time, and degree of governmental psychological intervention is determined by the number of dispatched mental health workers, infective people and susceptible people. third, based on the sir model of infectious disease spread, the increase in the number of people who are panicked and need to be evacuated to temporary resettlement sites in each time step is quantified. then, a multiobjective optimization model for evacuation and temporary resettlement was developed with the objectives of minimizing panic-induced psychological penalty, psychological intervention cost, transportation cost, and shelter building cost during evacuation and temporary resettlement. the model is solved by aggregating the objectives into a single objective by weights. the allocation of mental health workers to disaster sites, the shelter building and evacuation solutions are researched by solving the model and considering parameter sensitivities and tradeoffs among the four costs. the following experimental results are obtained. the costs of psychological penalty, psychological intervention, and transportation and building shelters may be affected by the number of victims that evolve from susceptible people to infective people, the number of dispatched mental health workers, timely evacuation, and building shelters. these factors also influence each other. indeed, among all parameters and factors, the initial number of homeless infective people imposes great effects on costs and solutions. psychological intervention apparently prevents the evolution of susceptible people to infective people. however, overuse of psychological intervention yields a big increase in monetary costs and a minor decrease in psychological penalty cost. therefore, timely and efficient evacuation and resettlement are very important. generally, psychological penalty and monetary costs conflict, and can be analyzed by the pareto analytical tool. experimentally, a small increase to monetary cost ( . %) can cause psychological penalty cost to decrease markedly ( %). this study used various functions to represent the strength of psychological penalty cost affected by wait times. the functions should be based on various conditions, such as extent of damage, disaster severity, and post-disaster natural and social environments. psychological intervention and timely rescue are general ways to reducing the strength of panic and panic spread. due to a lack of quantitative research on panic and panic spread during post-disaster relief and recovery, this study proposed a framework that considers the effects of panic and panic spread on post-disaster evacuation and temporary resettlement. therefore, quantification methods could be further researched and incorporate the new developments with practical evidence and theoretical research results in disaster psychology. next, this study formulated evacuation and temporary resettlement as a multi-step optimization model, where parameter uncertainties and conditions are assessed by sensitivity analysis. bell et al. ( ) asserted that the post-disaster transportation network may degrade due to disasters. in post-disaster scenarios, due to secondary disasters and disruptions, robust solutions for evacuation and resettlement should be researched. the evacuation routing problem is complex when one considers the roads adversely affected by disaster. third, this study focused on the temporary resettlement period and does not consider dependencies on other stages. moreover, pre-determined resettlement sites may affect the evacuation and resettlement solutions (rawls and turnquist, ) . incorporating the analytical results of this study, the entire post-disaster relief and recovery processes deserve further research under the consideration of psychological penalty as perceived by victims and rescuers. ( ) set s a set of n s disaster sites, denoted by s = { , , Á Á Á ,jsj} and indexed by s. d a set of n d resettlement sites, denoted by d = { , , Á Á Á ,jdj} and indexed by d. t a set of n t time steps, denoted by t = { , , Á Á Á , jtj} and indexed by t. ( ( ) other notations b t,s panic spread strength representing the speed of panic spread, which affects the nip x nip a review on travel behaviour modelling in dynamic traffic simulation models for evacuations discussion: the kermack-mckendrick epidemic threshold theorem cognitive vulnerability: a model of the etiology of fear depot location in degradable transport networks moderating effects of the community scenario on people's mental health after severe natural disaster: a contrastive analysis of two settlement models during the transition period of the wenchuan earthquake (in chinese) directing the herd: crowds and the science of evacuation resource allocation for control of infectious diseases in multiple independent populations: beyond costeffectiveness analysis managing evacuation networks disaster mental health workers responding to ground zero: one year later evacuation decision making and behavioral responses: individual and household predicting emergency evacuation and sheltering behavior: a structured analytical approach engineering-based hurricane risk estimates and comparison to perceived risks in storm-prone areas computing a displacement distance equivalent to optimize plans for post-disaster temporary housing projects maximizing the computational efficiency of temporary housing decision support following disasters optimizing large-scale temporary housing arrangements after natural disasters the norc studies of human behavior in disaster hurricane andrew: gender, ethnicity and the sociology of disasters route choice in pedestrian evacuation under conditions of good and zero visibility: experimental and simulation results a threshold model of social contagion process for evacuation decision making post-disaster debris reverses logistics management under psychological cost minimization impacts of prefabricated temporary housing after disasters: earthquakes in turkey the myth of panic residential mobility and consolidation processes in spontaneous settlements: the case of santa marta temporary housing construction supported by guangdong province was started at wenchuan county (in chinese) effect of authoritative information and message characteristics on evacuation and shadow evacuation in a simulated flood event wenchuan earthquake cases: emergency part (in chinese) critical behavioral assumptions in evacuation time estimate analysis for private vehicles: examples from hurricane research and planning a game-theoretic model of international influenza vaccination coordination understanding mass panic and other collective responses to threat and disaster post-traumatic stress disorder following disasters: a systematic review the psychological cost of waiting modeling and optimizing the public-health infrastructure for emergency response epidemic of fear: sars and the political economy of contagion in the pacific rim (chapter ) patterns of sheltering and housing in us disasters pre-positioning of emergency supplies for disaster response optimal resource allocation response to a smallpox outbreak a three-stage stochastic facility routing model for disaster response planning the sir epidemic mode-based analysis on the group behaviour under the situation of unconventional accident a model for allocating resources during hospital evacuations qualitative simulation of the panic spread in large-scale evacuation post-disaster psychological crisis research: a survey of the psychological crisis intervention after the sichuan earthquake anxiety and influencing factors of flood victims on pending arrange period the authors would like to thank the national science council of the republic of china, taiwan, for financially supporting this research under contracts nsc - -h- - -my and nsc - -h- - -my . moreover, this study is partially supported by the program for professor of special appointment (eastern scholar) at shanghai institutions of higher learning, shanghai recruitment program of global experts, the national nature science of china ( , , , ), the science foundation of ministry of education of china and shanghai ( , yz , , sg ), and the science and technology commission of shanghai ( zr , ). ( ) notably, p i ;s markedly affects solutions, especially when the values are increased. moreover, among the four costs, psychological intervention cost is affected most. when p i ;s increases by %, psychological intervention cost increases by roughly times. in addition to the psychological intervention cost, psychological penalty cost is affected considerably, especially when p i ;s decreases.( ) although p s ;s affects all four costs, the percentages of all variances for costs, expect for psychological intervention cost, are less than %. comparatively, the psychological intervention cost is affected by p s ;s more than the other costs. when p s ;s decreases by %, the psychological intervention cost will decrease by %.( ) psychological penalty cost and psychological intervention cost are markedly affected by a. the values of a also affect slightly the other two costs (transportation and shelter building costs). the values of a in this study are linearly related to time. sum of the weighted cost of f p and f c , or f psych , f gint , f trans and f build . e p (t) a function of time t, which determines the cost of a mental health worker at time t c p t . e c (t) a function of time t, which determines the cost of increasing a unit of resettlement capacity at time t c inc t . e a (t) a function of wait time, which determines panic degree at time t (a t ). key: cord- -ertcvh x authors: madani, azzeddine; boutebal, saad eddine; bryant, christopher robin title: the psychological impact of confinement linked to the coronavirus epidemic covid- in algeria date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ertcvh x the covid- pandemic continues to spread in countries around the world. the impact of this virus is very great on populations following the application of total and partial containment measures. our study aims to study the psychological impact of total and partial containment applied in algeria, on march , following the spread of the virus covid- and also studied the habits and behaviors of the algerian population during this new way of life and this through a cross-sectional survey launched after three days from the start of confinement to quickly assess the impacts over the period from march to april , by an online questionnaire which allowed us to obtain responses from internet users, who live in confinement in algeria. according to the gender variable, our sample includes men, or . %, and women, representing . %. the results of the statistical analysis carried out using spss version . software showed that . % of the respondents were in an anxious situation during these first three weeks of confinement. in addition, . % feels stressed, . % of the respondents confirmed to be feeling in a bad mood, and . % do not stop thinking throughout the day about this epidemic and how to protect themselves. in addition, the study shows that . % of the respondents in algeria found it difficult to follow the confinement instructions. a significant change in the habits of the population was noted especially for the time of going to bed, the time of waking up, and the use of the internet as well as the hours devoted to daily reading. the coronavirus pandemic covid- has continued to spread to countries around the world since its first appearance in wuhan, china, on december [ ] and the declaration of the world health organization (who), on january , on the high risk of the epidemic in china and worldwide [ ] . the number of people tested positive continues to increase, and for april , it had reached , , in several countries, which also recorded , deaths [ ] . the daily increase in deaths and confirmed cases has prompted countries to take social distancing measures and other actions related to general and partial containment that are difficult for some countries to enforce. in china, covid- has spread rapidly since its first appearance in wuhan and has proven to be very dangerous since some affected patients do not have fever and other symptoms which complicate the diagnosis [ ] . the report of the national health commission of china indicated on january that people carrying the virus can infect others by respiratory droplets as well as by direct contact [ ] . the severity of the disease is summed up in the ability of the virus to spread and the difficulties in identifying those affected to care for them and preventing them from infecting other people [ ] . based on these conclusions, the chinese government reacted quickly by quarantining a population estimated at question of studying the relationship between socio-demographic variables and the psychological impact of containment during the covid- epidemic in algeria. this study will allow algerian health authorities and possibly elsewhere in the countries of the world to better understand the situation, and this in order to take the necessary measures to assist the population during this period of containment which is likely to lengthen as well after this epidemic. it is signified by containment during coronavirus covid- that the containment procedures were approved by the algerian state from march to deal with this epidemic. the psychological impact signifies the various psychological effects of containment in algeria on the individual, measured in the current study by the sum of the responses to the questionnaire applied in the current study to a sample of respondents. daily habits represent the totality of practices and behaviors that the individual frequently embodies in his or her daily life such as: washing hands, going to bed and waking up, watching television, and using the internet. the present study is limited by its subject which studied the psychological impact of containment during the coronavirus covid- in algeria, by applying for this purpose a questionnaire to measure specific psychological factors; moreover, this study is limited by the number of respondents to the questionnaire, and the short duration of the study from march to april , imposed by the exceptional nature of this confinement and this epidemic. march march april april april april april april april april april april april source: the authors based on the data [ ]. in the current study, we used the design of the descriptive survey by an online questionnaire, with the snowball sample due to the conditions of the home confinement accompanying the spread of the coronavirus pandemic; thus, the electronic questionnaire includes items with meanings about the psychological effects of the coronavirus, and, after data collection, these were statistically analyzed by the spss program version (spss inc., chicago, il, usa). then, the stage of scientific description came, which is related to the significance of the indicators of the questionnaire items. therefore, the data were collected using an online questionnaire from different regions of algeria. knowing that it was not based on random selection and the study population did not reflect the reality of the general population, we used the statistical approach to describe the results and their analysis was linked through the qualitative indicators that came along with the meanings of the questionnaire items. we adopted a cross-sectional survey to assess the immediate psychological impact on the public during the covid- epidemic using an online questionnaire. with a wide dissemination of the questionnaire with the help of university students, our sampling strategy based on the snowball method is suitable in exceptional cases where it is difficult to communicate with the population to study an urgent health problem related to containment. this method allowed us to obtain responses from internet users, who are living through this first confinement of the coronavirus epidemic covid- in algeria. according to the gender variable, our sample includes men, or . %, and women, representing . % of the total sample. for the age variable, of the respondents were aged between and years old or . %, of the respondents were aged between and years old and . %, and of the respondents were aged between and years old or . % of the total number of respondents in the sample. therefore, we see in the composition of this sample the representation of practically all the age groups of the society concerned by this research issue. the psychological impact of covid- was measured using a global questionnaire measuring the impact of confinement during covid- coronavirus. this questionnaire of items is composed of three subscales: social impact, psychological impact, and impact on mobility. the impact scale of the coronavirus covid- in algeria was designed on the standards of the likert scale which includes five response options. this means that the average score for the questionnaire items is , so a total score greater than three indicates a negative impact on this variable, and when it is less than , this means that there is no negative impact within the meaning of this element. the questionnaire includes in its entirety questions which are concerned with the following sections: impacts on mobility q - in this study, we focused on the psychological impacts as the only component (psychological impacts subscale). the questionnaire was designed online to facilitate its dissemination and to obtain respondents' answers immediately. we focused on the current study on psychological effects and daily habits only, and therefore we clarify the two concepts in that psychological effects designate the emotional changes occurring in the behavior of the individual during interaction with those around him, as measured by individual self-assessment through the items of the questionnaire according to the measurement scale, where this indicates, in quantitative terms, the total score obtained by the respondent to the questionnaire in the dimension related to psychological effects. the daily social habits are the behaviors which are linked to the process of the daily interactions of the individual in various social situations. this means in our study that the habits linked to the interaction with the coronavirus, such as sleep patterns and hand washing, were measured with direct questions. the psychological impact section contains items; this means that the total score varies from to with a theoretical average of , and it also means that the score which exceeds reflects a negative effect of the psychological factor, and a lower score in relation to expresses the absence of a negative effect of this factor. we used the alpha-cronbach coefficient to calculate the reliability on answers, and the results gave a coefficient of . for the questions related to social impacts, so it is a value which indicates the reliability in the tool of this study. the statistical results also show that the alpha-cronbach coefficient, in the questions on psychological impacts, is equal to . , which indicates the reliability of the study tool. for the six questions concerning the impacts on the mobility of the population during this period of total and partial confinement, the statistical results show that the coefficient alpha-cronbach is equal to . , a value indicating the reliability of the tool of study. for the entire questionnaire, with its questions on the impacts during the first total and partial containment of the coronavirus epidemic covid- , the statistical results show that the alpha-cronbach coefficient is equal to . ; this value indicates the reliability of the tool used. the signified validity of the capacity of the questionnaire to measure what was ready to be actually measured involved the social, psychological, and mobility effects of total and partial confinement on citizens in algeria. for this, we used the internal validity method of the questionnaire (for individuals), which indicates the correlation between the items of the questionnaire and its overall score. the results are presented in table . from this table, it is clear that all the pearson correlation coefficients between the items and the total score of the questionnaire are positive and statistically significant at the level of . and . . this result means that the questionnaire has a considerable degree of internal validity. a statistical analysis was performed using spss version . software. therefore, descriptive statistics were calculated for socio-demographic variables and psychological impact factors. the pearson correlation coefficient was also used to measure the correlation between various socio-demographic variables and the psychological impact of coronavirus containment covid- . in addition, the multiple regression analysis method was used to measure the effect of socio-demographic variables on the psychological effects of confinement, and the t-test was also used to study differences in the psychological impact of coronavirus confinement between men and women. the results obtained show the impacts of confinement during the first total and partial confinement operations of the coronavirus epidemic covid- in algeria on certain habits of the daily life of citizens, where we note a high rate of hand washing during the day, since . % of the study sample reported washing their hands up to times a day, and . % of the population washed their hands between and times a day. on the other hand, the rest of the sample . % paid special and somewhat exaggerated attention to hand washing between and times a day (see table ). we also note that . % of those questioned confirm that they sleep late between midnight and : a.m., and that . % of people go to bed in the regular period between : p.m. and : p.m., while the remaining . % would sleep between : a.m. and : a.m. the next day. thus, we can deduce the considerable impact of the first period of total and partial confinement following the coronavirus epidemic covid- , on the hour of going to sleep, considered to be very late. regarding waking up time, the survey results show that . % of the study sample confirmed that they woke up between : a.m. and : p.m., and that . % said they woke up between : a.m. and : a.m., while . % of the respondents woke up between : p.m. and : p.m. for the time spent watching tv, the survey results showed that . % of respondents spend up to h watching tv every day, and . % of citizens confirmed that they watch tv for about h every day. on the other hand, we find that . % of the respondents watch television programs daily for around h. knowing that television is an important means of passing time during the period of the coronavirus pandemic covid- through the many programs and tv channels, the survey results shown in table also show that . % of respondents, during this period of total and partial containment linked to the covid- pandemic, say that they do not read books, and . % devote one hour a day to reading books, and . % of the respondents read books for h a day. on the other hand, . % of the population prefer to read between and more than h. what is noticed here is poor reading, but perhaps reading books is compensated by electronic reading on smart-phones and computers, and this is shown later. the respondents confirmed that they use the internet for several hours a day, so . % of them spend between and h a day, and . % spend between and h maximum a day surfing the internet. as for the remaining proportion, it uses less internet, to h a day. indeed, there is a strong dependence on the internet and related devices that allow time to pass during the period of the pandemic. finally, we find that . % of respondents are interested in the content of social networks (facebook and twitter), and that of youtube, while . % prefer reading including scientific research by electronic means. in addition, . % of respondents prefer to follow new local and international news related to covid- and other areas on the internet (see table ). the table above shows the correlation matrix between certain study variables; we note the presence of a statistically significant negative correlation between the variables age and waking time, which means that young people get up later by comparison with the people in the older age categories (r = − . **); as shown in the table, there is a statistically significant positive correlation between the variable psychological impacts and waking time (r = . ** ), which means that the increase in sleep time and the delay in getting up are linked to the increase in the level of psychological effects during the first confinement of the coronavirus epidemic covid- . the results in table above show the relative levels and weights of the psychological impact factors of the coronavirus covid- in algeria during the first total and partial confinement, knowing that the value signifies the theoretical average. according to the respondents, we find that the item related to the difficulty of voluntary engagement in home confinement is ranked first in the psychological factors, with a mean of . , and this signifies a lack of social consciousness and previous experiences in behavior during an epidemic. the rapid spread of the epidemic may not have left the time necessary for better awareness among citizens of the seriousness of the coronavirus covid- and the usefulness of home confinement as the sole means of current prevention. in second position for the psychological factors, we find anxiety with a mean of . where the respondents confirmed their feelings of anxiety during the confinement period, perhaps because there are difficulties in accepting confinement itself, or difficulty organizing family life inside the house. in addition, anxiety is strongly present in the event of an epidemic among fragile personalities and contributes to the deterioration of the psychological state of the individual, which affects his or her daily interactions and even his or her physical functions. the state of psychological stress is the third psychological factor affecting individuals during the coronavirus pandemic covid- in algeria during this period from march to april , and this is confirmed by the respondents with a mean of . . admittedly, the spread of the epidemic and the obligation of confinement at home on the one hand, and the difficulty of coping with it, on the other hand, put the individual in a state of psychological stress, especially with the transformation of daily life into a boring daily routine. the fourth psychological factor (see table ) affecting individuals during confinement is a mood fluctuation with a mean of . , which reflects the entry of the individual into a state of being emotionally unstable, and which negatively affects him or her and the family environment, not only because of the feeling of limited living space, but also because of a feeling of fear of the pandemic and its various repercussions. the fifth psychological factor represents dependence on thinking throughout the day about the subject of the epidemic, and this is confirmed by the respondents with a mean of . . this indicates an addiction of thinking about the coronavirus covid- , its dangers, and its consequences in an exaggerated way, which leads to psychological, moral, and physical fatigue, and especially in relation to the monitoring of new information which is sometimes incorrect about coronavirus covid- . regarding the rest of the items and psychological factors, the current study did not show any negative effect on the sample of our research, since its arithmetic mean is lower than the theoretical mean . according to table , in the multiple regression analysis, it is shown that the variables of sex, age, and family situation were significantly associated (ar = . ) with the scores of the psychological impact subscale. through this table, we find that gender was significantly associated with psychology impact scores (b = . , % ci). in addition, age was significantly associated with lower psychology impact scores (b = − . , % ci). in addition, the family situation was significantly associated with psychology impact scores (b = . , % ci). table below presents the study of the differences in psychological impact between men and women during the first confinement of the coronavirus epidemic covid- in algeria; the results show the existence of statistically significant differences in favor of women (m = . ) compared to men (m = . ) in the psychological impact scale. this result means that the female population is more affected by coronavirus covid- than men, and, to determine the details, we return to the differences in the statistically significant items. indeed, women were more delusional than men, more eager to wash their hands too much, presenting more emotional stress, fear and an unstable mood, and they were more unreal optimists that they would never be infected by the coronavirus covid- . the results were discussed according to the structure of presenting the data by linking them to previous studies according to what we had, especially since the problem is recent. the results obtained to see the changes in behavior and habits as well as the psychological impacts on the algerian population during the first three weeks (from march to april ) of the total and partial confinement applied by the algerian government show that the difficulty of voluntary engagement in home confinement is ranked first in terms of psychological factors, especially since . % of the respondents have difficulty applying the confinement instructions. our field observations confirm that some people often leave their homes and do not follow or have difficulty applying the instructions for containment. the lack of awareness through the dissemination of specialized information affects the population, which remains worried in the absence of reliable information, while previous research has revealed the presence of a wide range of psychosocial impacts on people at the individual, community, and international levels during the spread of the epidemic [ ] . it is also possible that the rapid spread of the epidemic has not left the time necessary for better awareness among citizens of the usefulness of levels of home confinement as the only means of prevention. among other things, . % of respondents indicated that they are in an anxious situation for various reasons related to a new organization of daily life, in addition to the measure of confinement or quarantine that shows that the authorities consider the serious situation and its risk of worsening [ ] , and this worries the population; and the rapid increase in anxiety in people is linked to the lack of information on the disease and the preventive measures that produce a blockage in daily life [ ] . it is also found that . % of respondents experience stress during the period of total and partial containment, and certainly people are well informed that covid- threatens the lives of people and that there is no treatment in this current period, which has triggered a wide variety of psychological problems [ ] in the population. in addition, there is the transformation of everyday life into very limited actions which in time becomes very boring. in addition, . % of the surveyed population confirmed feeling in a bad mood during this first period of confinement, which means that the individual is in an unstable emotional state which negatively affects him or her as well as the family environment. in addition, . % of respondents continue to reflect throughout the day on this epidemic and on the ways to protect themselves, and this dependence in an exaggerated way leads to psychological, moral, and physical fatigue. the chinese government has improved public awareness of prevention measures, and psychologists and psychiatrists use the internet and social media to share strategies for managing psychological stress [ ] . the results of this survey showed that women are the most affected compared to men by the impacts of confinement linked to covid- . therefore, women prefer to wash their hands several times, are more stressed and manifest more fear and instability of mood while they are also more unreal optimists that they would never be infected by the coronavirus covid- . the change in population behavior during confinement also affects psychological and physical health, so, during this -week period . % of respondents indicated that they wash their hands up to times a day, and . % do it between and times a day. on the other hand, . % of the respondents exaggerate in terms of hand washing and do it between and times a day; this category of people either move frequently outside, in regions of partial containment and know perfectly the hygienic rules which pushes them to react like this. either he or she lives in the region where the confinement is total which forces them, for fear, to wash his or her hands regularly even at home. note that . % of those questioned sleep late between midnight and : a.m. and that only . % go to bed in normal h between : p.m. and : p.m. on the other hand, . % of respondents say that they will go to bed between : a.m. and : a.m., which shows that confinement has changed their habits, since schools are closed, and life is slowing down. in this same context, . % of respondents woke up in the morning between : a.m. and noon and . % indicated that they woke up between : a.m. and : a.m. . % of respondents wake up between : p.m. and : p.m.; this category represents that of young people who stay connected to the internet for a long time. these changes in the time to go to bed and wake up are a sign of an increase in the level of psychological effects during this first confinement. in addition, there are many hours spent watching television since . % of respondents say they spend to h watching television programs daily, and . % spend between to h watching television daily. the population is also trying to follow the information associated with the epidemic covid- on the various international tv channels since the gravity of the epidemic has not been widely broadcast or recognized, which has delayed protection measures and also containment [ ] , which pushes citizens to search for information themselves. we also find that . % stay up to h in front of the television, which becomes an essential means to follow the new information on the epidemic and the measures taken by many countries which continue to make efforts to minimize the contacts between humans and guarantee good protection for the population [ ] , especially since it is always difficult to fight against covid- of unknown origin and mysterious biological characteristics with a long period of incubation [ ] . reading books, during the period of total and partial confinement in algeria, does not interest . % of respondents, while . % devote one hour per day to reading and . % of the surveyed population prefer to read books for between h and more than h a day. confined people do not pay much attention to reading since it is certainly linked to reading on digital media via the internet for many hours. thus, . % of respondents say that they devote to the internet between and h per day, and . % remain connected to the internet between and h per day, which constitutes a strong dependence on the internet and its services during the containment period. social networks (facebook, twitter, and youtube) attract the attention of . % of respondents. on the other hand, . % prefer reading and scientific research on the internet; . % of the surveyed population opt to follow new local, national and international information related to covid- and other subjects, since it would not be surprising that one day, in the near future, broader containment measures will be required to protect against this pandemic [ ] . for this purpose, it is necessary to use the different means of information and communication so that psychologists increasingly approach the confined population in need of psychological help. the dissemination of information related to covid- must be carried out with complete transparency and by specialized scientific journalists capable of disseminating most of the information with great precision. identifying confined people through a platform and remote assistance will make it possible to quickly get closer to people in urgent need of psychological support. the covid- pandemic continues to spread in countries all over the world. the number of people affected and deaths is increasing every day. the impacts of this are very big on the populations following the application of total and partial containment measures. our study evaluated the psychological impact of total and partial confinement applied in algeria, on march , following the spread of the virus covid- and we also studied the habits and behaviors of the algerian population during this new mode of life, and this through an investigation launched after three days of the start of confinement to quickly assess the impacts over the period from march to april , by an online questionnaire. the results showed that . % of respondents were in an anxious state during these first three weeks of confinement. in addition, . % feel stressed, . % of the respondents confirmed feeling in a bad mood, and . % do not stop thinking throughout the day about this epidemic and how to protect themselves. in addition, the study shows that . % of respondents in algeria found it difficult to follow the instructions for full and partial containment. a significant change in the habits of the confined population, especially about going to bed and waking up time, is observed, which shows the increase in the level of psychological effects. note also that changes in internet use and daily reading are seen in the results of this study. among others, the limitations of this study are linked to the sampling strategy, the number of respondents, and the short duration of the study. thus, this will not make it possible to generalize these results over the entire population. however, these results can help the health authorities and other services concerned by the epidemic covid- in the procedures for taking charge of the population during this period of confinement, which is likely to lengthen further, knowing that the psychological aspect, which influences behavior, is very important to fight against the coronavirus. it is also necessary to regularly monitor the change in daily habits since it indicates the level of awareness of citizens about health protection. in this type of situation, psychological support must be provided remotely to families and individuals to alleviate their suffering and encourage them to stay at home during the confinement period and to respect the habits of prevention against the coronavirus. the current study can be developed to study the effect of confinement on personality characteristics, quality of life, and link them to behavioral habits to be more preventive. prediction of epidemic spread of the novel coronavirus driven by spring festival transportation in china: a population-based study clinical characteristics of coronavirus disease in china a novel coronavirus emerging in china-key questions for impact assessment immediate psychological responses and associated factors during the initial stage of the coronavirus disease covid- epidemic among the general population in china world health organization declares global emergency: a review of the novel coronavirus covid- the psychological effects of quarantining a city vitesse de propagation du covid- , l'algérie sera-t-elle comme les pays les plus touchés de l'europe? available online suivi quotidien du coronavirus covid- lundi avril covid- chroniques d'un géographe de la santé covid- -navigating the uncharted psychosocial effects of an ebola outbreak at individual, community and international levels psychological effects of the coronavirus disease- pandemic a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations -ncov epidemic: address mental health care to empower society covid- : a promising cure for the global panic insight into novel coronavirus-an updated interim review and lessons from sars-cov and mers-cov what further should be done to control covid- outbreaks in addition to cases of isolation and contact tracing measures the authors declare no conflict of interest. key: cord- -hi u w q authors: xu, xinglong; zhou, lulin; asante-antwi, henry; boafo-arthur, ama; mustafa, tehzeeb title: reconstructing family doctors’ psychological well-being and motivation for effective performance in china: the intervening role of psychological capital date: - - journal: bmc fam pract doi: . /s - - - sha: doc_id: cord_uid: hi u w q background: family practice and family doctors are critical part of china’s primary healthcare delivery in a constantly evolving society. as the first point of contact with the medical system, family practices require physically and psychologically sound and a well-motivated family doctors at all times. this is because an error can lead to loss of lives as gatekeepers of the medical system. our study explored the extent to which positive psychological capital promotes higher performance among family doctors. methods: a questionnaire was used to collect data from family doctors in shanghai, nanjing, and beijing. we applied a structural equation analysis to analyze the causal relationship among the variables. results: we found out that psychological well-being and job involvement significantly influences the performance of family doctors in china. the study also noted that psychological capital moderates the relationship between psychological well-being attainment, job involvement, and performance. conclusions: studies have shown that these pressures affect their well-being considerably. for this reason, a healthcare professional who experiences positive emotions affects the total behavior which culminates into performance. healthcare services to both individuals and families within the community as the first line of contact with the overall national health system [ ] . this role requires fundamental requires continuous fundamental reform to strengthen its capacity to provide a vast network of primary care, especially to the majority of its population that lives in rural areas [ ] . the current primary healthcare system in china is organized into three tiers and the intensity of care increases with a higher tier. it starts with primary care facilities in the villages and towns. then second tier comprises of the county hospitals while the third tier includes the tertiary hospitals located in the major cities but each tier has its own challenges [ ] . the first challenge relates to the number of patients. two decades ago, the outpatients' medical doctor in a normal hospital treated around - patients in a single day. this number has doubled in and nearly patients visit a single medical doctor's consulting room in urumqi, zhenjiang, xian, hefei, nanning, kunming, nanchang, etc. every day. the situation is worse in major cities such as shanghai, beijing, nanjing, guangzhou, shenzhen, hangzhou, suzhou, etc. and these can have a significant effect on the mental and psychological wellbeing of the primary care doctor. there are other challenges that face primary health doctors in china [ ] . generally, the healthcare industry has little room for errors but the constraints of working as a family practitioner makes doctors susceptible to errors. if these results in the loss of lives and other fatal injuries, they can significant impact on the family doctors mental and psychological well-being [ ] . gallagher [ ] , recommends that each primary health system must put in place appropriate coping strategies to help medical professionals to deal with the emotional, mental and psychological impacts on of their work on their wellbeing. thus the psychological and mental well-being of the primary health doctor and nurse is the catalyst for their happiness, satisfaction, creative thinking, pro-social behaviour, good physical health, sense of purpose and meaning to life needed to thrive professionally despite the ups and downs of primary healthcare in china [ ] . another source of vulnerabilities of mental and psychological health faced by family care practitioners in china is that they have a very low social status, receives low salary. compared with specialist clinicians in hospitals, family practitioners receive limited recognition for their work and this occurs in both urban and rural areas in china [ ] . these conditions do not befit the status of family doctors as a special gateway to health services for families before referral to advanced medical facilities. this duty entails managing risk and uncertainty, caring for individuals in the context of their families and communities, and addressing the totality of the patient. yuan [ ] explains that a vibrant family practice system potentially lessens the burden of work provided by specialist physicians, nurses, and other public health workers in the community health clinics in the urban areas. through effective planning and provision of comprehensive primary health care, regardless of age or sex, continuingly, family doctors support public health services by offering health management, disease prevention, disease control, health assessment to patients. china's initial attempt to revamp the family doctor system after the sars virus did epidemic in did not achieve much success hence the effort to resuscitate the system in . four years on, the hope that family doctor contract services will mature and become an integral part of the primary healthcare system in china is still far from being attained. a study conducted by xu et al. [ ] suggests that an average proportion of . % of china's family doctors intend to quit direct patient contact in the next years if the current system continues. in most instances, work-related mental and psychological health issues underscore the decision to opt for other related practices. selvaggio [ ] appropriately captures thus when they allude to the fact that a more pathogenic work environment appears to be developing for a population already known to be at risk of mental and psychological ill-health including burnout, depression, and addiction. prior studies that support this situation among china's family doctors argue that this category of workers must abide by several rules and regulations that affect their rate of pay. most family doctors consider the strict official guidelines given to them to follow as unpleasant interference and manipulation by people of inferior social status. in addition, family doctors in china believe that a lot of the paperwork they fill is unnecessary and tortuous. they are subject to strict, unfriendly monitoring and evaluation requirements that are deemed unsuitable to the healthcare industry. for this reason family, doctor practice has become an unattractive field of specialization relative to medical specializations. the persistence of these challenges significantly increases the potential for mental and psychological decay among family doctors which can affect their performance. ryff, [ ] explains that psychological well-being is affected by several factors which consist of motivation, job satisfaction, self-efficacy, achievement, de-individuation, physical and psychological fatigue, environment and organization identification psychological fatigue, environment, and organization identification [ , ] . doctors with negative mental and psychological wellbeing will exhibit poor mental and emotional health. this can potentially create psychological, mental, and emotional disorders that can interfere with their ability to enjoy life as primary care providers and participate as active members of the society in general. thus psychological and mental wellbeing is the precursor to a desirable or positive work outcome which includes the sustainable performance of family doctors in china. however, robertson & cooper [ ] assert that psychological wellbeing alone is not enough to achieve the sustainable performance of family doctors. a strand of contemporary literature in human resources for health is revisiting the concept of psychological capital and its influence on family doctor motivation particularly in the case of china. according to robertson & cooper [ ] , positive psychology builds the human resources to be dedicated and engaged to create and guarantee the competitiveness that organizations so much desire. this position is attested in the extant literature in other. for example, pan, mao, zhang, wang, and su [ ] investigated the mediation role of psychological capital on the association between nurses' practice environment and work engagement among chinese male nurses and noted that creating a supportive nursing practice environment could increase male nurses' work engagement by developing their psychological capital. they suggested that nurse managers can then provide reasonable workload and pathways for male nurses to achieve goals, thereby fostering their hope. this research on "psychological capital-work engagement-job performance" mostly focused on employees' individual dimensions leaving the organizational dimensions. the work of tien-ming cheng, hong, and yang [ ] examined the moderating effects of service climate on psychological capital, work engagement, and service behavior. the study noted that attendants who showed high psychological capital tended to show more work engagement and better service behavior. the study further indicated that work engagement is the mediator between psychological capital and service behavior. comparatively, studies have shown that there is much difference in the impact of psychological capital on government and private employees. comparing the impact of psychological capital dimensions on the level of happiness of private and government employees, singh and khan [ ] found that private-sector employees had higher happiness based on higher forms of the various dimensions. the government workers had a lower level of happiness as a result of lower forms of psychological capital development; an indication that an enhanced psychological capital significantly influences employees' level of happiness which subsequently impact their well-being. the current crisis in family doctor motivation in china offers an opportunity to explore the intermediating role of psychological capital in the relationship between psychological wellbeing and job involvement on one hand and sustainable performance of family doctors. this is because, in the traditional human resource strategy literature, psychological well-being is conceptualized to mean the experience of positive emotions that is global than negative emotions. although most studies continue to concentrate on the negative emotions, lazarus [ ] new findings emanating from the proponents of positive psychology point to the need to advance argument on how positive emotions influence the total functioning of the individual, [ ] . in this paper, we apply a novel structural equation model to explore effect of interplay between psychological wellbeing, psychological capital and job involvement on family doctor motivation in shanghai, nanjing and beijing in china. first we explain the methods used in the study and present our analytical procedure and results. next we discuss the findings and make our conclusions. figure shows the final conceptual model for the current study. a quantitative research study was designed to explore the direct influence of the psychological wellbeing of family doctors and job involvement (independent variables) on family doctor's performance (dependent variable). secondly the study also explored the moderating effect of psychological capital (hope, the self-efficacy, the optimism, the resilience) on the two direct relationships. this crosssectional study was conducted among practicing family doctors, potential family doctors and past family doctors selected in shanghai, beijing, and nanjing cities between july and december . these cities were chosen because family doctor contract services are relatively developed in chinese megacities than in other parts of china. an initial number of questionnaires were designed and sent to family doctors who were randomly selected by cluster sampling to accommodate the three different groups of targeted doctors. the number of years of work experience of the doctors was a major factor in deciding a qualified participant. a target least years post-qualification experience was deemed sufficient. a similar effort was put into recruiting both male and female participants to compare responses were necessary. a selfadministered questionnaire was directly administered to them after obtaining their written consent. a questionnaire was given to each worker that contained a declaration of anonymity, information secrecy, voluntary participation, and voluntary withdrawal. the co-investigators directly distributed, retrieved, codded, and managed the questionnaires, and where possible respondents were provided with an explanation without inducement for any unclear questionnaire items. items in the questionnaire were based on appropriate items in pre-existing measurement scales and respondents needed between and min to complete a full questionnaire. at the end of the research period, questionnaires were not returned and questionnaires with missing data were regarded invalid. thus effective response was made up of respondents which represent a response rate of approximately %. the study was approved by the ethics committee of centre for health and public policy research and validated by the human experimentation of jiangsu university in china. psychological wellbeing was measured using the shortened version of the psychological wellbeing (pwb) scale developed by ryff [ ] . this model measures six aspects of psychological wellbeing and happiness namely; autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance (ryff et al., [ ] ; adapted from [ ] ). the item version is configured with a point likert scale where ( = strongly agree; = strongly disagree). response to the individual questions is composed of six subscales and a composite value of the subscales is used as a proxy score of psychological wellbeing of each doctor. the psychological capital questionnaire (pcq) was used in measuring psychological capital (psycap). it is the most widely used standard scale and has been validated in a different research context. this questionnaire was developed by [ ] and consists of items composed into four subscales namely hope, optimism, resilience, and self-efficacy. the scale is configured on a sixpoint likert scale measure ranging from ('strongly disagree') to ('strongly agree'). kanungo's [ ] job involvement scale was used to measure the concept of job involvement. the model is a item job involvement questionnaire. this questionnaire was adopted due to its high internal consistency and wide applicability in a different research context. the response scale to this questionnaire is on a -point likert scale ranging between "do not agree/not applicable to me" to "fully agree/fully applicable. performance sustenance, on the other hand, was measured based on four constructs which include frequency of patients' visits [ ] , frequency of patients complain [ ] , intention to stay or re-enrol in family practice [ ] , doctors days worked [ ] . the response scale for items measured was ( = strongly agree to = strongly disagree). the composite value was determined and used as a proxy for performance sustenance. firstly descriptive statistics were computed using spss and inferential statistics was conducted using amos version . the pearson moment correlation coefficient was conducted to determine the significance and possible multicolinearity in the relationship between the variables. subsequently, a mixed structural equation model was modelled to establish the direct effect of family doctors' psychological wellbeing and involvement on performance sustenance. similar model was done to determine the moderating effect of psychological capital on the direct relationships. a structural equation model is a better analytical model for this research because it produces more robust inferences compared to the traditional regression model. a structural equation helps to analyse the influence of predictor variables on different dependent variables simultaneously. the specific model used in our study is expressed in a matrix form as follows: where for each of the causal parameters (psychological wellbeing and job involvement), the γ's and the β's, the subscripts follow the same pattern. in the matrix, the p by p b matrix holds the coefficient of regression of the y variables whereas the other y variable with 's on the diagonal indicates that a variable cannot cause itself. the model also contains the p by q Γmatrix which contains the coefficients of the y's on the x's. the error vector (errors-in-equations or specification errors) ζ, is p by . for example, we assumed that e(y) = and e(x) = and these have absolutely no impact on both the variance and the covariances of the variables if we assume the independence of x and ζ. finally, we adopted a secondorder factor model that assumes that the factors can form higher-order factors. we ensured that the correlation among the factors has the correct structure as a result of the latent variables. this leads to the following path diagram indicated below; (adopted from bediako et al., [ ] ) in this model each η has a unique factor and a known variable while ξ represents the higher-order factor. generally, we write the second-order factor analysis of the mixed structural equation as follows; this special case of an sem with latent variables can be rewritten more compactly as in this model, it is assumed that cov(ε, ζ) = , cov(ζ, ζ) = , v(ε) = Θε, v(ζ) = Ψ and v(ζ) = Φ. in this model also, the variance of y, Σ, assumes a unique aesthetic form mathematically expressed as follows; where [ΓΦΓ ' + Ψ] represents v(η). ( ) next, we used summed indicators to "specify" the latent variables (psychological wellbeing and job involvement) and the regression model for the structural equation used the "no origin" option. consistent with prior works of rabenu et al. [ ] , we set a strict level of significance for the regression coefficients ( % confidence interval) for each latent variable. we accordingly evaluated the reliability, validity and internal consistency of each latent variable using appropriate respected techniques and each latent variable met the criteria based on pallant et al's [ ] minimum threshold. next, the single-construct measurement model (mm) for each latent variable was evaluated to ensure it fitted the data. the reliability, validity, and internal consistency of the latent variables were evaluated and subsequently averaged to obtain the error attenuated covariance matrix (cn). using the procedure set out in ping [ ] , the resultant matrix was adjusted to obtain the measurement errors. the resulting error-adjusted (err-adj) cm was used to estimate eqs. and without omitting the variables. this approach is much superior to existing approaches because a measurement error is determined by measuring model loadings and measurement error variances from the "no dummies". in this instance using the measurement model loadings and measurement error variances from the "no dummies" for eq. was applied. related studies that have used this approach include; anderson et al., [ ] ; asante-antwi, zhangxiao tian et al. [ ] , kong, akomeah et al. [ ] . next, the err-adj cm was used as inputs into the least square structural regression model. again ping [ ] as cited in kong, akomeah et al. [ ] judges this approach to be a much superior method of validating the integrity of a data relative to other traditional options since it produces fairly accurate and consistent structural coefficients in a model. finally, we inputted the parameter estimates obtained from the no dummies mm into the latent variable regression excel spreadsheet to produce the err-adj cm matrix based on the following computations; cov where var(ξ x ) represents the expected error-adjusted variance of the regression inputs x, var(x) represents the error attenuated variance of x. Λ x represents the average λ x + λ x + λ x … λ xn ), where avg (θ x ) = var(ε x ) + var(ε x ) + var(ε x ) … + var(ε xn ), in which case the ε x 's and the λ's represent the measurement error and the measurement model respectively. the cov(ξ x ξ z ) represents the desirable level of erroradjusted covariance of x and z, and cov (x, z) represents the error attenuated covariance of x and z, finally, we inputted the err-adj cn into the regression function based on the "regression-through-the-origin" option. as recommended in warren, white et al. as cited in bediako et al. [ ] , we corrected the coefficient standard error (ses) i.e. the ses of β , β , … ... in eq. ( ) produced by the err-adj for measurement error by adjusting the se from regression using the root mean square error (rmse) as expressed as follows; where y i represents the observed andŷ i represents the predicted values based on the err-adj cm [ , ] . this implies that the correct standard errors for the err-adj cm structural coefficients involve the standard error from the regression based on the err-unadj cm. this leads to the formulation of the ratio of the standard error (se) from err-unadj cm regression and the standard error (se) from err-adj cm regression which is formulated as; in which case se a a is the err-adj cm regression standard error, se u is the standard error obtained from the err-unadj cm regression, rmse u is the standard error obtained from the err-unadj cm regression, and rmse a is the standard error obtained from the err-unadj cm regression. descriptive statistics table shows the inter-correlation matrix between the latent variables as well as the relationship between the latent variables and the moderator and dependent variables. the results indicates that psychological well-being was positively and significantly correlated with psychological capital (r = . ) and performance (r = . ) but not job involvement. this means that an increase in the psychological wellbeing of a family doctor is positively associated with their performance and their psychological capital. this also supports the absence of multicolinearity among the independent variables (psychological wellbeing and job involvement). similarly, a higher job involvement is positively associated with psychological capital (r = . ) and performance (r = . ). finally, the analysis also shows that psychological capital is positively associated with performance (r = . ) and this is statistically significant at a % confidence interval. confirmatory factor analysis (cfa) was adopted to assess the adequacy of the measurement components. reliability and validity of the constructs was also assessed and showed that the item-to total correlations were stronger. some scholars have argued that factor loadings from . should be an acceptable loading. for this reason, the constructs that reported standardized factor loadings above the . criteria were accepted as recommended by hair et al. [ ] . based on this threshold, all, the measures of the study were considered as showing satisfactory reliability. again all the constructs showed high average variance extracted (ave) and that further strengthens the evidence of strong evidence of convergent validity. the results of cfa, reliability, and convergent validity are shown in table confirmatory factor analysis confirmatory factor analysis (cfa) is an important statistical tool for probing the nature of relationships among latent constructs. it is important because it helps to measure the construct validity, identify method effects, and helps in evaluating the factor invariance through time and groups. the use of confirmatory factor analysis (cfa) continues to gain ground in the psychological literature as a result of the belief researchers have in the structural equation model as a robust model specifically. given the key impact cfa makes in the measure development and due to the understanding that having a tool that manages the measurement of variables effectively, it can be presumed to be paramount quantitatively simply because its role is crucial to the results a researcher reports we sought to find out the relationship between the latent variables using amos version . the model consisted of the latent variables psychological wellbeing, job involvement, the moderating variable (psychological capital and its constructs i.e. optimism, self-efficacy, resilience, hope) and the dependent variable (performance sustenance) among family doctors in china. the items in the observed variables with low factor loadings were eliminated leaving the strong ones to be included. for instance, on hope, h , h were eliminated, psychological well-being pwb , pwb , pwb pwb were also eliminated. performance sustenance jp and jp which showed low loadings were also eliminated. figure shows the second-order confirmatory factor analysis of psychological capital and well-being, involvement, and performance. the fit indices for the model were, (χ = . , df = , χ /df = . tli = . , cfi = . , nfi = . , ifi = . , rfi = . rmsea = . . we tested the significance of psychological capital as a moderator between psychological well-being and job involvement. the model showed adequacy as an indication of a good fit for the data. the fit indices of the final measurement model were, χ = . , df = χ /df = . , cfi = . , tli = . , rfi = . , ifi = . , and rmsea = . . the model confirmed h a: that psychological wellbeing and job involvement directly influence performance sustenance of family doctors with pwb . (p > . ), job involvement . (p > . ) and h b: was confirmed . (p > . ) that psychological capital moderates significantly between job satisfaction and performance sustenance. psychological capital interacts with both psychological well-being and job involvement to predict the performance sustenance of family doctors. figure shows the final path analysis of the moderated model of psychological wellbeing, job involvement, psychological capital and performance sustenance. we did a bootstrap of the sample to find out the indirect effect of the interaction, details are presented in table table shows the results of the path coefficient analysis of the structural equation model. a unit change in a family doctors' psychological wellbeing influences performance positively by . and is statistically significant at a % confidence interval. similarly, a change in job involvement causes a positive change in the performance of family doctors in the selected cities. the coefficient value of . and a p-value of . statistically justify this claim. the moderating effect of psychological capital on the relationship between family doctor's psychological wellbeing and their performance is also positive. the coefficient is statistically significant at a % confidence interval. this is also the case with the moderating effect of psychological capital on the relationship between job involvement and performance. these cases support the assumption that psychological capital is a significant factor in stimulating positive mental, psychological and emotional behavioural outcomes among family doctors in china china's healthy china initiative has changed the view of the family practice profession from a mere gatekeeping practice to the pivot of overall primary healthcare delivery in china. family doctors have assumed extended responsibility to manage risks and uncertainties, care for individuals in the context of their families and communities, and address the totality of patients. this underscores the ambition of china to train , more gps in the next decade to consolidate its primary health gains. however, the results of this study suggest that endemic psychological and mental wellbeing concerns among family doctors may erode the gains already achieved. traditionally, family doctors in china have considered themselves "people's doctors" yet, a stressful workday, endless rules and regulations, poor wages and salaries are perceived dehumanizing routines attenuating the growth of family doctors and the primary healthcare system in china [ , ] . these and many other hindrances have taken away a strong sense of the mutually beneficial long-term therapeutic relationship between family doctors and patients which is the central psychological factor for doctors' willingness to accept family doctor jobs. the result of these challenges is that young doctors, in particular, see family doctor services as less prestigious and an unfulfilling arena to build a noble career [ ] . the results of this study show that when psychological capital can interact with other job-related attitudes to generates positive and significant results thereby sustaining the performance of family doctors. consequently, enhancing the well-being of health professionals such as the family doctor system, for instance, is a sure way of bettering the lives of the larger society. similarly, a health employee who feels satisfied with the level of responsibilities and a positive work environment identifies with the organization by way of job involvement. in countries such as uk (where the family doctor system is well established), fig. second order confirmatory factor analysis of psychological capital and well-being, involvement, and performance it contributes to solving nearly % of health-related problems and only rare or complex conditions are referred to specialists in secondary or tertiary hospitals. to ensure china reaps the benefits of the family doctor system and guarantee its sustainability, a strong and well-motivated family doctor workforce must be pursued. the results of this study support the need to build and develop family doctors that are mentally, psychologically and emotionally healthy. to achieve the target of training and retaining , more gps human resource managers in china's health sector must focus on helping doctors overcome the challenges that negatively affect psychological and mental well-being. some of these include high workload, avoidable bureaucratic requirements, and problems of low salary and limited recognition of their competency by the public, compared with hospital specialists. being able to satisfy family doctors' psychological needs can offer them the belief that they are masters of their own decisions, which when enabled, reflects in various jobrelated attitudes of satisfaction, peak performance, and increase in commitment levels, job involvement, and ultimately psychological well-being. theoretically, this study confirms the self-determination theory and further contributes to the theoretical outcomes of the development of self-determination theory and its application to supporting human resources for healthcare from an emerging country perspective. precisely because this study extends the theory in practice by providing an additional outcome of sustained positive performance to the self-determination theory (sdt) aside from what the theorist propounded. this is particularly relevant to the expansion of the self-determination theory discourse because the essence of developing individuals to be self-reliant and selfmotivated in an organization or field of specialization is to ensure their commitment to the said organization based on strong mental, emotional and psychological wellbeing. in this regard, when employees are emotionally glued to an organization, it guarantees high-level performance because they begin to appreciate the fact that they can balance their personal goals and that of the organization. a condition that ensures a win-win situation enables employees to give off their best in the execution of tasks assigned to them. most importantly, when employees such as family doctors are emotionally committed to an organization, they become intrinsically motivated. intrinsic motivation is the foundation of the self-determination theory. an intrinsically motivated family doctor who has developed a more emotional attachment to the job will place the clients or patients ahead of any challenges faced in the line of duty. this provides additional validity of the confirmation of the self-determination theory especially among the healthcare professionals in china. additionally, family doctors and other health employees who develop affective commitment dedicate and consign themselves to making the work environment a better place. an effectively committed employee takes on additional responsibilities to enhance individual and organizational performance and becomes autonomous in motivating himself and others. importantly, when a healthcare employee develops affective commitment, it makes an individual a team player in the task execution of the institution. in terms of the setting, our extension of the theory is relevant because we conducted our study in a different environment outside the areas the theory was conducted. this study intended to examine the relationship between job involvement, psychological well-being, and performance among family doctors in china. it again considered the influence of the interaction effect of psychological capital on psychological well-being, job involvement leading to performance sustenance on the family doctor system. the study confirmed all the hypotheses that job involvement correlates positively and significantly with performance sustenance while psychological well-being significantly correlates with performance sustenance,. secondly, the interaction effect of psychological capital significantly affects the performance sustenance of healthcare employees positively. health professionals such as family doctors experience a lot of pressure that weighs heavily on their psychological and emotional wellbeing. for this reason, a healthcare professional who experiences positive emotions affects the total behaviour which culminates in a performance. the results lay credence to preceding studies that observed that healthcare professionals who demonstrated subjective happy feelings brought on by the pleasure in the profession and work environment they appreciate shows in their performance. additionally, health professionals who experience sentiments or emotions that give the impression of having purpose and meaning in the life they live translate it the task performance family doctors who experience a sense of drive, happiness, and satisfaction identifies with the organization in terms of task execution, relationship with co-workers, and forming an identity with the organization they serve.. again the higherorder construct of psychological capital relate significantly with job involvement to sustained performance. psychological capital which consists of constructs such as hope, resilience, optimism, and self-efficacy reflects significantly on performance. this suggests that an upsurge in psychological capital equally leads to an improvement in psychological well-being. similarly, an increase in the level of psychological capital leads to the job involvement of employees. the data for this research is held by the authors and will be made available upon reasonable request. ethics approval and consent to participate ethical approval was granted by the ethics committee of the center for health and public policy research of jiangsu university china and confirmed by the jiangsu university. this was approved by the zhenjiang administration bureau for scientific and industrial research. written consent to participate was obtained from the study participants. the questionnaire included an opening statement explaining the ethical responsibilities of confidentiality of data, the anonymity of respondents, and participants responsibility to opt-out of the study at any time. respondent's decision to fill the questionnaire constituted their consent to participate in the research-informed. consent for publication "not applicable" the author declares that there is no conflict of interest amongst them. author details job displacement and the duration of joblessness: the role of spatial mismatch china's "left behind children" and the consequences of distributive injustice: a systematic review protection of migrant workers under new chinese labour law: a critical review immigrant generational status and developmental problems among prematurely born children job satisfaction in health-care organizations the emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability sarcopenia in asia: consensus report of the asian working group for sarcopenia examining the moderating effects of service climate on psychological capital, work engagement, and service behavior among flight attendants i know you are suffering from burnout: the moderated mediation effects of "leisure benefits" and" leisure coping" on the burnout model of flight attendants the role of positive emotions in positive psychology: the broaden-and-build theory of positive emotions supporting health care workers after medical error: considerations for health care leaders partial least squares structural equation modeling: rigorous applications, better results and higher acceptance. long range plan measurement of job and work involvement the relationship between organizational commitment and work performance: a case of industrial enterprises evaluation of the robusticity of mutual fund performance in ghana using enhanced resilient backpropagation neural network (erbpnn) and fast adaptive neural network classifier (fannc) author's response: the lazarus manifesto for positive psychology and psychology in general utilitarian orientation, long-term orientation, and performance: evidence from chinese millennial-generation employees employee perceptions of psychological capital and learning organization dimensions in a community medical center the effect of herd formation among healthcare investors on health sector growth in china human, social, and now positive psychological capital management: investing in people for competitive advantage an introduction to the rasch measurement model: an example using the hospital anxiety and depression scale (hads) psychological capital mediates the association between nurses' practice environment and work engagement among chinese male nurses the influence of significant screen time on mental health among adolescents an integrative literature review estimating la tent variable interactions and quadratics: the state of this art latent variable interaction and quadratic effect estimation: a twostep technique using structural equation analysis adapting to the new era: necessary steps for advancing a robust science full engagement: the integration of employee engagement and psychological well-being well-being, satisfaction and commitment: the substitutable nature of resources for maternity hospital nurses national survey of midlife development in the united states happiness is everything, or is it? explorations on the meaning of psychological well-being psychological well-being revisited: advances in the science and practice of eudaimonia improving stress management of a nursing staff in a postanesthesia care unit psychological capital and happiness among government and private bank employees-a comparative investigation c- neuropsychological sequelae of hypernatraemic dehydration in neonates-working towards the nhs england five year forward view epidemiology of multimorbidity in china and implications for the healthcare system: cross-sectional survey among , community household residents in southern china health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in zhejiang province, eastern china healthcare data analysis system for regional medical union in smart city healthcare data analytics: using a metadata annotation approach for integrating electronic hospital records socialized healthcare service recommendation using deep learning publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the support of colleagues and staff at the department of public management of the school of management and the center for health and public policy research and the overseas education college of jiangsu university is deeply appreciated. we are also grateful to the zhenjiang administration bureau for scientific and industrial research for their support. received: january accepted: june authors' contributions xx: conceived the idea, collected the data, and revised the manuscript in line with the objectives. lz: is the supervisor of the project and sequentially aligned the parts of the research paper, haa: conducted the analysis of the data and drafted manuscript. ab: collected data and analyzed the data. tm: collected the data, conducted the analysis. all authors read and approved the final manuscript. the national natural science foundation of china ( ), the social science application research project of jiangsu province ( syb- ) and the universities' philosophy and social science researches in jiangsu province ( sja ) provided assistance for pre-study, data collection and other administrative expenses incurred for the study as part of a larger project to key: cord- -r lnjsvl authors: rodriguez, lindsey m.; litt, dana m.; stewart, sherry h. title: drinking to cope with the pandemic: the unique associations of covid- -related perceived threat and psychological distress to drinking behaviors in american men and women date: - - journal: addict behav doi: . /j.addbeh. . sha: doc_id: cord_uid: r lnjsvl the coronavirus pandemic has brought about significant and unprecedented changes to the modern world, including stay-at-home orders, high rates of unemployment, and more than a hundred thousand deaths across the united states. derived from the self-medication hypothesis, this research explored how perceived threat and psychological distress related to the covid- pandemic are associated with drinking behavior among an american sample of adults. we also evaluated whether links between covid- -related perceived threat and psychological distress with drinking behavior are different for men and women. participants (n= ; % women) completed an online qualtrics panels study between april (th) and (rd), . results suggested that psychological distress related to the covid- pandemic was consistently related to alcohol use indices, and moderation results indicated this pattern was significant only among women for number of drinks consumed during the recent heaviest drinking occasion and number of drinks consumed on a typical evening. covid-related distress’ link to frequency of drinking and heavy drinking episodes was not different for men and women. our results suggest that continued monitoring, particularly among women, should be conducted as this pandemic continues to evolve to identify the long-term public health impacts of drinking to cope with covid- distress. towards the end of , a previously unidentified coronavirus -severe acute respiratory syndrome coronavirus (sars-cov- ) -was identified in wuhan, hubei province, china (sangeeta & deepjyoti, ) . the disease associated with this novel coronavirus strain eventually became ubiquitously known as the coronavirus disease (nih, ) . covid- quickly spread globally, sparking widespread international public health concerns, and ultimately was deemed a pandemic (world health organization, ) . in attempts to control the pandemic, governments across the world, including the united states (u.s.), implemented social distancing and stay-at-home measures which have resulted in millions of people being isolated at home. these ongoing disease containment strategies are unprecedented in the modern world, and very little is known of their effects on the health and well-being of adults in the u.s. over the past three decades, studies have shown that survivors of other types of community-wide disasters (including both natural disasters and acts of terrorism) suffer from both mental health problems and substance misuse. specifically, research indicates that such community-wide disasters are prospectively linked to numerous behavioral health outcomes, including increased mental health concerns (boscarino et al., ; breslau et al., ; nandi et al., ; rohrbach et al., ; vetter et al., ; walsh et al., ) and escalations in use of alcohol (flory et al., ; north et al., ) . many scientists have predicted that the social distancing, stay-at-home orders, and quarantine measures society has undertaken as public health strategies for disease containment during this current pandemic will inadvertently lead to worsened mental health and increased substance misuse (holmes et al., ) the lancet similarly suggested that alcohol use during this pandemic may be a major public health concern (clay & parker, ) . indeed, data from prior pandemics as well as emerging data from the current covid- crisis support these predictions. a recent rapid review (brooks et al., ) identified studies of the psychological impact of pandemic-related quarantine. high rates of psychological difficulties were observed including fear, nervousness, stress, depression, and irritability. they concluded that quarantine has negative psychological effects that can be severe and persistent for some (brooks et al., ) . sprang and silman ( ) studied psychological reactions to a pandemic disaster among those with exposure to varying disease containment strategies. posttraumatic stress, a particularly severe form of psychological distress, was higher in those who had been quarantined with % meeting diagnostic criteria for posttraumatic stress disorder (sprang & silman, ) . studies emerging on psychological reactions to covid- suggest that the pandemic is severely affecting mental health worldwide. for example, a general population study of psychological reactions to covid- in italy showed that ~ % experienced mild psychological distress with another ~ % showing moderate-to-severe distress from the pandemic (moccia et al., in press) . zhu et al. ( ) found that covid- quarantine in china was much more likely to lead to psychological distress among those for whom the quarantine had the greatest impact on daily life. research is also emerging that pandemics can have important impacts on drinking and substance use behavior. in march , during the covid- pandemic and while many americans were under a stay-at-home order, market research by nielsen showed that alcohol sales increased by % relative to the same time last year (bremner, ) . a recent nanos poll similarly showed that canadians are drinking more alcohol during the covid- pandemicrelated quarantine (canadian centre on substance use and addiction, ). the largest increases were observed in - -year-olds, where % acknowledged that they had increased their alcohol use during the pandemic, with % attributing this change to stress (canadian centre on substance use and addiction, ). longitudinal research in china during sars concerningly indicated that some respondents who began abusing substances during the pandemic showed persistent substance abuse that lasted well beyond the pandemic (wu et al., ). there are several explanations for why alcohol use might increase during a pandemic and the associated restrictive disease-containment strategies (e.g., boredom, disruption to routines, distress). the self-medication hypothesis posits that the use of certain substances, like alcohol, acutely relieves psychological suffering (khantzian, ) . thus, many adults may use substances such as alcohol to cope with the perceived threat and/or psychological distress (boschi et al., ; stewart, ) associated with the covid- pandemic. while potentially effective in the shorter-term, self-medication is typically seen as an avoidance coping strategy, which may paradoxically maintain or even increase distress in the longer term (see stewart et al., , for review) . this type of coping-related drinking is also associated with risk for development of alcohol-related problems (cooper et al., ) . given that during covid- related social distancing, individuals may be faced with increased stress and uncertainty (taylor, ) as well as anxiety and depressive symptoms (brooks et al., ) , those who experience more perceived threat and/or psychological distress may be those most likely to use alcohol to cope. outside of the context of a global pandemic, alcohol misuse is one of the leading causes of preventable death, contributing annually to ~three million deaths worldwide (niaaa, ). in the u.s., nearly one in six adults engages in heavy episodic drinking (hed; i.e., consuming at least five drinks for men or four drinks for women in the span of two hours) (samhsa, ) four times per month, where they consume, on average, drinks per episode (kanny et al., ) . while hed is most common in younger adults age - , more than half of the total drinks consumed are by those age and older (kanny et al., ) . aside from acute consequences of heavy alcohol use such as alcohol poisoning and blackouts (white et al., ) , there is the potential that for some, longer-term alcohol misuse might escalate into a full-blown alcohol use disorder. there are some important gender differences relevant to the self-medication hypothesis in the context of the covid- pandemic. first, women are more likely than men to experience comorbid emotional (i.e., anxiety, depression, and ptsd) and alcohol use disorders (see stewart et al., , for a review). second, some research suggests that women are more vulnerable to experiencing psychological distress from the pandemic (see reviews by brooks et al., ; taylor, ) , suggesting women may be more motivated than men to drink to cope with pandemic-related distress. indeed, the consensus from both human and animal studies is that women are more likely than men to drink in response to stress (e.g., becker & koob, ; koob & white, ; peltier et al., ) . for example, the largest drinking motives study to date suggests that coping motives are more important for women's than men's drinking (kuntsche et al., ) . the current study built upon emerging research demonstrating the covid- pandemic is impacting both psychological distress and drinking behavior, by testing predictions derived from the self-medication hypothesis. a secondary goal was to determine whether such associations are stronger in women compared to men. given that psychological distress and mental health concerns are prominent risk factors for the onset and maintenance of alcohol misuse and the fact that the potential public health effects of long-term social isolation on alcohol use and misuse are unknown, understanding the links of perceived threat/psychological distress with alcohol use patterns during covid- is warranted. the present study had the following primary hypotheses: ( ) covid- -related perceived threat and psychological distress would be associated with alcohol consumption such that individuals who report more covid- -related perceived threat and psychological distress would also report higher levels of drinking behaviors during the past month; and ( ) these associations would be moderated by gender such that the association between covid- -related perceived threat/psychological distress with alcohol consumption would be stronger among women compared to men. participants included individuals ( % [n= ] women; % [n= men ]) in the u.s. who were on average . years of age (sd= . ). most ( . %) were married, with another . % in an exclusive relationship/with a life partner, and . % engaged. on average, participants had been romantically involved with their partner for . (sd= . ) years. most participants ( . %) were white, with . % black, . % asian, . % native american/ american indian, . % native hawaiian/pacific islander, . % multiracial, and . % other. ten percent ( . %) reported hispanic ethnicity. most participants ( . %) identified as heterosexual, with another . % bisexual, . % homosexual, and . % pansexual/other. approximately two-thirds ( . %) reported having children living at home with them at the time of the survey . qualtrics panels is a survey management service wherein participants are recruited from a large pool of potential subjects based on criteria specified by the researcher. qualtrics respondents completed the online survey through qualtrics panels between april and april , . participants provided informed consent and were screened for eligibility. eligible panel respondents met the following criteria: (a) at least years of age; (b) consumed at least alcoholic beverages in the last months; (c) worked at least hours per week; (d) romantically involved with their current romantic partner for at least six months; and (e) cohabiting with that romantic partner. the panel was also split evenly by gender with % men and % women. participants who met eligibility criteria (n= , ) began the survey and were asked a series of questions about their demographics, alcohol use, and thoughts and feelings about the current covid- pandemic. two filter questions were included where participants were asked to select a specific answer (e.g., "disagree a little") to determine if they were paying attention and thus assess survey validity (oppenheimer et al., ) . there was also one speeder check performed by qualtrics. participants who failed the filter questions or speeder check (n= ) were immediately screened out and not included in analyses. thus, results are presented only for the participants (n= ) who passed the attention filters. participants were compensated via qualtrics according to their guidelines. qualtrics was paid by the researchers at a rate of $ usd per subject, but the actual payment amount from qualtrics to respondents was between $ and $ . study procedures were approved by the university irb. the timeframe for data collection (which asked about past month drinking, assessed between april - , ) largely overlapped with covid- closures of schools and implementation of "stay-at-home" orders issued by governors requiring individuals to stay home except for essential activities. for example, on march , , school closures began in states and the centers for disease control and prevention released guidelines recommending that for the next weeks, "organizers (whether groups or individuals) cancel or postpone in-person events that consist of people or more throughout the united states." beginning with california on march th and through april th with south carolina, states had issued stay-athome orders (kates et al., ) . perceived threat related to covid- was assessed with the perceived coronavirus threat questionnaire -short version (conway et al., ) . this measure included three items: "thinking about the coronavirus (covid- ) makes me feel threatened," "i am afraid of the coronavirus (covid- )," and "i am stressed around other people because i worry i'll catch the coronavirus (covid- )" (α=. ). psychological distress related to covid- was assessed with the psychological subscale of the coronavirus impacts questionnaire -short version (conway et al., ) . this included two items: "i have become depressed because of the coronavirus (covid- )" and "the coronavirus (covid- ) outbreak has impacted my psychological health negatively" (α=. ). we ran an exploratory principal components analysis on these five covid- stress items in our total sample (n= ). a two-factor solution explained . % of the variability in item scores. examining the factor pattern . . alcohol use. to capture alcohol use during the pandemic, all alcohol questions asked about past month drinking. the quantity/frequency/peak alcohol use index (qf; dimeff, ) was used to assess peak and typical drinks and drinking frequency. number of drinks drinks on the heaviest occasion was measured by asking how many drinks individuals consumed on the occasion they drank the most in the past month. responses ranged from to + (coded as ). number of drinks on a typical occasion was measured by asking how many drinks respondents drank on a typical evening in the past month. responses ranged from to + (coded as ). drinking frequency was assessed by asking how many days of the week respondents drank in the past month ( =i did not drink at all, . =<once/month, =once/month, =two times/month, =three times/month, =once/week, =twice/week, =three times/week, =four times/week, =five times/week, =six times/week, and =every day). we also assessed the frequency of heavy drinking episodes by asking how many times in the past month participants had consumed more than drinks (if a woman) or drinks (if a man) within ~ hours. all questions referenced alcohol use during the past month, which would have overlapped completely with covid- . given the non-normal (count) distribution of the drinking outcome variables, negative binomial regression models were used in all analyses (hilbe, ) . covariates were selected based on their previously established associations with drinking behavior (i.e., age (moore et al., ) , gender (erol & karpyak, ; coded = woman, = man), and presence of children in matrix following oblique (oblimin) rotation indicated that the three covid- perceived threat items showed strong salient loadings on the first factor (loadings ranging from . -. ) and negligible loadings on the second factor (loadings ranging from -. -. ); the two covid- psychological distress items showed strong salient loadings on the second factor (loadings ranging from . -. ) and negligible loadings on the first factor (loadings ranging from -. -. ). the two factors were moderately intercorrelated (r = . ). these results show that perceived threat and psychological distress due to covid- are indeed distinct constructs. the home (bowden et al., ; coded = no child at home, = one or more children at home). as well as whether or not participants reported there was a 'stay-at-home' order in place in their location when the survey was taken ( = no order in effect, = order in effect). main effects were included in a first step and interactions were included in a second step. moderation models evaluated whether the covid- -related predictors (perceived threat and psychological distress) were differentially related to drinking for men and women by examining the gender × covid- -related predictor interaction terms. significant interactions were decomposed by examining simple slopes of the covid- predictors for men and women separately. simple slopes in negative binomial regression models are represented by rate ratios because log-linked coefficients are exponentiated for interpretation. rate ratios represent the proportion of change in the dependent variable for each unit increase in the predictor. for example, a rate ratio of . represents a % increase in the alcohol-related outcome, whereas a rate ratio of . represents a % decrease in the alcohol-related outcome, for each one-unit increase in the predictor. while we report significance at traditional levels (i.e. p-value < . ), we also report whether effects are maintained after a bonferroni correction (i.e., tests: critical pvalue = . ) to enhance confidence in the findings. descriptive statistics and bivariate correlations for all study variables are presented in table . participants consumed, on average, almost six drinks on their heaviest drinking occasion in the past month (sd = . ). they reported drinking almost four drinks on a typical occasion (sd = . ), on average, and drinking on a mean of approximately days in the last month (sd = . ). participants reported approximately . heavy drinking episodes in the past month, on average (sd = . ). both covid- -related perceived threat and psychological distress showed significant bivariate associations with all four drinking indices. men and women did not differ in their covid- -related perceived threat or psychological distress (ps > . ); however, men reported greater drinking on all four indices (ps < . ). the psychological distress associated with covid- -and not perceived threat of , z= . , p=. , threat rr= . , z= . , p<. ) . the presence of children at home was also related to a higher number of drinks on a typical occasion, rr= . , z= . , p=. , as well as a greater number of heavy drinking episodes, rr= . , z= . , p<. . all main effects except for children on typical drinking quantity continued to be significant after the bonferroni correction. the association between covid- psychological distress and both peak number of drinks and typical number of drinks per occasion were moderated by gender. these interactions were maintained after the bonferroni correction. covid- psychological distress was not differentially linked to drinking frequency and heavy drinking episodes among men and women. in the case of significant interactions, the same pattern emerged (see figures and ) . covid- psychological distress was only associated with greater drinking for women (peak drinks rr= . , z= . , p<. ; typical drinks rr= . , z= . , p<. ) , whereas covid- psychological distress was unrelated to drinking for men (peak drinks rr= . , z=. , p=. ; typical drinks rr= . , z=. , p=. ) . thus, every one-unit increase in covid- -related psychological distress was associated with a % increase in women's number of drinks consumed during their heaviest drinking occasion and a % increase in women's number of drinks on a typical occasion in the past month. our results provide preliminary evidence that indices of covid- -related stress, particularly psychological distress, are associated with drinking behavior. further, two of these associations are more pronounced for women than men, consistent with previous literature suggesting that the use of alcohol to cope with distress is more relevant to women's than men's drinking (kuntsche et al., ) . in both interactions, at low levels of covid-related psychological distress, men display the usual pattern of drinking more than women (stewart et al., ). however, as distress related to covid- increases, women's drinking "catches up" with or converges with that of the men (see figures) . gender convergence refers to the observation that women's drinking has been, over recent decades, catching up with men's drinking as women face the stressors that were historically the domain of men (e.g., career stressors) (see stewart et al., ) . our results suggest that exposure to a widespread situational stressor (i.e., covid- psychological reactions) is having a similar effect of leading women to catch up to men in terms of their drinking behavior across several different indices. this gender convergence in heavy drinking at high levels of covid- -related distress is very concerning given that similar quantities of alcohol in women and men result in greater adverse effects for women (e.g., liver and heart disease) (stewart et al., ) . interestingly, psychological distress related to covid- was similarly related to increased drinking frequency and heavy drinking among men and women, suggesting that while women may drink more on a typical and heavy drinking occasion (peak and typical quantity), both men and women drink more often (in general and heavy drinking) in response to experiencing pandemic-related stress. we need to monitor the drinking quantity particularly in response to pandemic-related distress among women and the drinking frequency and heavy drinking frequency of those experiencing pandemic-related distress regardless of their gender. while not a primary hypothesis, results also suggest that the presence of children in the home during the pandemic is related to increased drinking behavior among american adults. although contrary to pre-pandemic research indicating that parents are less likely than nonparents to exceed guidelines for both lifetime and short-term alcohol risk (bowden et al., ) , our finding is particularly interesting given the increased burden that many parents are feeling as they navigate their own job as well as home-schooling their children. it is possible that having children in the home to care for and educate during the pandemic increases role overload, which has been linked previously with heavier alcohol use (abbey et al., ) . indeed, prior research suggests that having children at home during the pandemic increases psychological distress (kisely et al., ; shevlin et al., ) , which our results link to more frequent and heavier drinking. despite making important contributions to the field, this study is not without limitations. first, our cross-sectional design precludes making assumptions about temporality or causality of the association between covid- -related stressors and drinking. further, given this data was collected close to the start of social distancing measures in the u.s., we may not have captured routine behavior established once people have settled into the new reality of the pandemic and social distancing. future research should continue to look at alcohol use trends across time as the pandemic continues to affect daily life. further, a more comprehensive assessment of covidrelated threat and psychological distress would provide a more nuanced evaluation of what specific aspects of the pandemic experience are most strongly related to drinking behavior. additionally, this sample comprised american adults cohabiting with a romantic partner, who were already regular drinkers, and who worked at least hours per week, which may limit generalizability of the results. moreover, we cannot rule out that the greater reactivity of women's drinking to the covid- stressors was secondary to greater "room to move" in the women's drinking data; however, this seems unlikely given that the men's average values on the four drinking indices were nowhere close to ceiling (see table for means). finally, while the pattern of findings is consistent with predictions emerging from the self-medication hypothesis (khantzian, ) , we did not assess drinking motives during the pandemic period; future studies should directly assess the relations of covid- -related psychological distress with copingmotivated drinking (cooper et al., ) . in support of previous literature, including a recent correspondence published in the lancet suggesting that alcohol use during this pandemic may be a major public health concern (clay & parker, ), our results validate that mental health and associated alcohol use during the pandemic are of worthy of attention. as the pandemic continues to evolve, continued monitoring should be conducted, particularly among women. ongoing monitoring will help determine the long-term mental health and alcohol-related public health impacts of the covid- pandemic among adults, particularly in light of previous findings from sars that increases in substance use to cope with the pandemic may persist beyond the pandemic (wu et al., ).  examined how covid- psychological stressors are linked with drinking behavior.  also evaluated whether these links are different for men and women.  covid- psychological distress was consistently related to alcohol use indices.  this pattern was significant only among women for quantity.  this pattern was not different for men and women for drinking frequency. the relationship between reasons for drinking alcohol and alcohol consumption: an interactional approach sex differences in animal models: focus on addiction ptsd and alcohol use after the world trade center attacks: a longitudinal study coping with psychotic symptoms in the early phases of schizophrenia parental drinking in australia: does the age of children in the home matter? u.s. alcohol sales increase percent in one week amid coronavirus pandemic posttraumatic stress disorder and the incidence of nicotine, alcohol, and drug disorders in persons who have experienced trauma the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid- and increased alcohol consumptions: nanos poll summary report alcohol use and misuse during the covid- pandemic: a potential public health crisis? the lancet public health social psychological measurements of covid- : coronavirus perceived threat, government response, impacts, and experiences questionnaires motivational models of substance use: a review of theory and research on motives for using alcohol, marijuana, and tobacco brief alcohol screening and intervention for college students (basics): a harm reduction approach sex and gender-related differences in alcohol use and its consequences: contemporary knowledge and future research considerations. drug and alcohol dependence alcohol and cigarette use and misuse among hurricane katrina survivors: psychosocial risk and protective factors negative binomal regression multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science annual total binge drinks consumed by when state stay-at-home orders due to coronavirus went into effect. kaiser family foundation the self-medication hypothesis of substance use disorders: a reconsideration and recent applications occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis alcohol and the female brain national conference on alcohol and opioid use in women & girls: advances in prevention, treatment, and recovery research drinking motives mediate cultural differences but not gender differences in adolescent alcohol use affective temperament, attachment style, and the psychological impact of the covid- outbreak: an early report on the italian general population. brain, behavior, and immunity longitudinal patterns and predictors of alcohol consumption in the united states probable cigarette dependence, ptsd, and depression after an urban disaster: results from a population survey of new york city residents months after alcohol facts and statistics covid- , mers & sars. national institute of allergy and infectious diseases postdisaster course of alcohol use disorders in systematically studied survivors of disasters instructional manipulation checks: detecting satisficing to increase statistical power sex differences in stress-related alcohol use impact of hurricane rita on adolescent substance use key substance use and mental health indicators in the united states: results from the national survey on drug use and health. substance abuse and mental health services administration wuhan coronavirus: a fast-emerging global threat anxiety, depression, traumatic stress, and covid- related anxiety in the uk general population during the covid- pandemic posttraumatic stress disorder in parents and youth after healthrelated disasters alcohol abuse in individuals exposed to trauma: a critical review women, girls, and alcohol comorbidity of anxiety and depression with substance use disorders in the psychology of pandemics: preparing for the next global outbreak of infectious disease exposure to the tsunami disaster, ptsd symptoms and increased substance use: an internet based survey of male and female residents of switzerland trauma exposure, posttraumatic stress disorder and risk for alcohol, nicotine, and marijuana dependence in israel binge drinking: predictors, patterns, and consequences coronavirus disease (covid- ): situation report, the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk the immediate mental health impacts of the covid- pandemic among people with or without quarantine managements author agreement: none of the original material contained in the manuscript has been published or submitted for publication elsewhere. all authors have approved the manuscript for submission, made substantial contributions to the conception, design, gathering, and/or interpretation of the data, and to the writing and intellectual content of the article. the authors have no conflicts of interest with respect to the research, authorship, and/or publication of this article. this research was funded by the university of south florida.