Mental health and insomnia problems in healthcare workers after the COVID-19 pandemic: A multicenter cross-sectional study

Abstract

BACKGROUND

Healthcare workers (HCWs) are at increased risk of contracting coronavirus disease 2019 (COVID-19) as well as worsening mental health problems and insomnia. These problems can persist for a long period, even after the pandemic. However, less is known about this topic.

AIM

To analyze mental health, insomnia problems, and their influencing factors in HCWs after the COVID-19 pandemic.

METHODS

This multicenter cross-sectional, hospital-based study was conducted from June 1, 2023 to June 30, 2023, which was a half-year after the end of the COVID-19 emergency. Region-stratified population-based cluster sampling was applied at the provincial level for Chinese HCWs. Symptoms such as anxiety, depression, and insomnia were evaluated by the Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and Insomnia Severity Index. Factors influencing the symptoms were identified by multivariable logistic regression.

RESULTS

A total of 2000 participants were invited, for a response rate of 70.6%. A total of 1412 HCWs [618 (43.8%) doctors, 583 (41.3%) nurses and 211 (14.9%) nonfrontline], 254 (18.0%), 231 (16.4%), and 289 (20.5%) had symptoms of anxiety, depression, and insomnia, respectively; severe symptoms were found in 58 (4.1%), 49 (3.5%), and 111 (7.9%) of the participants. Nurses, female sex, and hospitalization for COVID-19 were risk factors for anxiety, depression, and insomnia symptoms; moreover, death from family or friends was a risk factor for insomnia symptoms. During the COVID-19 outbreak, most [1086 (76.9%)] of the participating HCWs received psychological interventions, while nearly all [994 (70.4%)] of them had received public psychological education. Only 102 (7.2%) of the HCWs received individual counseling from COVID-19.

CONCLUSION

Although the mental health and sleep problems of HCWs were relieved after the COVID-19 pandemic, they still faced challenges and greater risks than did the general population. Identifying risk factors would help in providing targeted interventions. In addition, although a major proportion of HCWs have received public psychological education, individual interventions are still insufficient.

Key Words: COVID-19; Mental health; Psychological symptoms; Insomnia; Sleep disorders; Cross-sectional study; Epidemiological study

Core Tip: Limited information is known about mental health and insomnia problems among healthcare workers after the coronavirus disease 2019 (COVID-19) pandemic. This multicenter cross-sectional study revealed that 16.4%-20.5% (289) of healthcare workers overall had anxiety, depression, or insomnia symptoms; identified that those who were nurses, were female, had been hospitalized for COVID-19, or died in families or friends were at high risk of symptoms. Although a major proportion of healthcare workers have received public psychological education, individual interventions are still not sufficient.

INTRODUCTION

Since the end of December 2019, the infectious disease coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)[1], has rapidly spread and become a worldwide sudden pandemic threatening global health and leading to societal instability[2]. Apart from various respiratory and associated symptoms of COVID-19[3], population mental health problems are also of increasing global concern[4]. During the COVID-19 epidemic, the worries and uncertainty of infections, physical distancing and decreased outside activities caused by associated lockdowns[5,6] could negatively affect mental health and cause psychological symptoms such as anxiety, depression, insomnia, and others[6,7]. Healthcare workers (HCWs), who play key roles in the prevention, diagnosis, treatment, and care of patients and the public, are at increased risk of contracting COVID-19 and developing psychological distress, sleep problems, and other mental health symptoms[8-11]. Previous studies revealed that nearly half of HCWs reported experiencing psychological symptoms during the COVID-19 pandemic[9,12].

China is one of the countries most strongly affected by COVID-19[3]. After approximately three years of control of the disease and the advance of COVID-19 vaccines[13], the Chinese government announced the end of the COVID-19 emergency and eased pandemic control in December 2022[14]. However, the impact of psychological symptoms can even last for a long period, even after the pandemic[15]. Previous experience with severe acute respiratory syndrome (SARS) survivors revealed that the psychological implications of infectious diseases could include chronic effects[16,17]. For HCWs, the increased risk and severity of psychological symptoms and sleep disturbances could persist for a long time, which could not only be harmful to their mental health[18] but also influence their clinical practice[8]. However, limited studies have been conducted in this field, which is a research gap. Thus, we conducted this multicenter cross-sectional study of mental health problems, insomnia problems, and their influencing factors in HCWs after the COVID-19 pandemic. This study can be helpful for exploring the prevalence of these problems in the post-COVID-19 era and identifying potential HCWs at increased risk for targeted interventions to promote universal mental health.

MATERIALS AND METHODS

Study design and sampling process

This study was conducted following the STROBE statement[19] and was reviewed and approved by the local ethics committee (No. 2023226). Informed consent was provided by all participants prior to enrollment by clicking the “agree to the consent” button online on the guiding page of the electronic questionnaire. This study followed the Declaration of Helsinki, and all the surveys were anonymous and provided assurance of confidentiality.

This was a multicenter cross-sectional, hospital-based study from June 1, 2023 to June 30, 2023; this was a half-year after the Chinese government announced the end of the COVID-19 emergency and eased pandemic control (December 2022)[14]. The aim of this study was to evaluate mental health and insomnia problems in HCWs after the COVID-19 pandemic and to identify the potential influencing factors. The sampling was conducted in Shandong Province, which is located in eastern China and has 101.6 million residents and 1.8 million local HCWs in 2022[20]; this region serves as a sufficient representative area with nearly one-fourteenth of the Chinese population. Generally, we applied region-stratified population-based cluster sampling based on our profound previous experience[6,21,22] as follows: (1) First, the sampling site was geographically stratified as western, middle, or eastern regions[21] with one coordinating center in each region; (2) second, the research team determined the required number of participants with different characteristics (populations of regions, healthcare positions, technical titles, places of residence, and hospital levels) based on proportions of local groups for representativeness; (3) third, one frontline (e.g., doctors and nurses) department and one nonfrontline (e.g., pharmacist and laboratorian) department were randomly sampled from each selected hospital, and all of their affiliated HCWs were asked to participate in this study; and (4) finally, the HCWs from 29 hospitals (level III n = 4, level II n = 5, 1 level I n = 7, and community n = 13; classified according to the National Health Commission) were enrolled and summarized in a unified anonymous database for analysis.

Study population and eligibility criteria

The target sample size was calculated with PASS software (NCSS LLC., Kaysville, Utah; version 21) to determine the odds ratio (OR) via logistic regression. The statistical power was set at 90%, and the alpha coefficient was 0.05 according to the two-sided Wald test[23]. At least 1211 valid questionnaires were needed. After eliminating a potential 30% dropout rate, the dropout-inflated expected invited number of participating HCWs should be no less than 1730. Considering the regional allocation proportions, a total of 2000 surveys were sent (western, n = 650; central, n = 700; and eastern, n = 650).

The inclusion criteria for HCWs were as follows: (1) Resided and served as HCWs in Shandong Province during and after the COVID-19 pandemic; (2) were defined as workers who had direct or indirect exposure to patients and were involved in patient care; (3) were aged no less than 18 years; and (4) provided informed consent. Questionnaires with: (1) Abnormal response times (< 1 min or > 1 h); (2) no trust questions; or (3) incomplete responses were regarded as invalid surveys.

Questionnaire and assessments

The questionnaire included 4 parts. The first part was a guiding page to introduce the purpose, design, and informed consent of this study. In the second part, the questionnaire collected technical profiles, demographic characteristics, and experience related to COVID-19. The technical profile consisted of healthcare position, technical title, place of residence (urban or rural), hospital served (classified into level III, level II, level I, or community), demographic characteristics (classified into western, middle, or eastern), sex, age (classified into 18-34, 35-49, or ≥ 50 years to consist of studies on Chinese mental health during the normal[24] and COVID-19 periods[6,21,22] for comparison), education level, marital status, and experience related to COVID-19-related clinical practices during the COVID-19 pandemic, experiences of COVID-19, experiences of families/friends during the COVID-19 pandemic, and psychological intervention during the COVID-19 pandemic. The third part included standard mental health measurement tools [the Generalized Anxiety Disorder-7 scale (GAD-7) for evaluating anxiety symptoms and the Patient Health Questionnaire-9 (PHQ-9) for evaluating depression symptoms] and insomnia problems [the Insomnia Severity Index (ISI) for assessing insomnia symptoms]. Participants were required to answer questions mainly about their feelings about the past 2 wk. The final part consisted of 2 trust questions, “I answered truthfully (yes or no)” and “What is ten plus ten?”.

All the assessment tools used were validated Chinese versions of self-reported screening scales, with Cronbach’s α values of 0.93, 0.86, and 0.85 for the GAD-7[25], PHQ-9[26], and ISI[27], respectively. A higher score on these scales indicated a greater likelihood of having more severe symptoms (maximum scores of 21, 27, and 28 on the GAD-7, PHQ-9, and ISI, respectively). A GAD-7 score, PHQ-9 score, and ISI ≥ 10, ≥ 10, and ≥ 15 indicate symptoms of anxiety, depression, and insomnia, respectively, while scores ≥ 15, ≥ 15, and ≥ 22 indicate severe symptoms. These cutoff scores for detecting symptoms were determined according to Chinese norms and the consensus of neuropsychologists and are widely recognized in psychological studies of the Chinese population[6,10,21,22,28].

Statistical analysis

The Kolmogorov-Smirnov test was used to explore the distributions of continuous data. After all the tested variables were normally distributed, correlation analysis was performed to explore the relationships among the scores of the different scales by Pearson's correlation. To explore the potential influencing factors (technical profiles, demographic characteristics, and experiences related to COVID-19) of anxiety, depression and insomnia symptoms, multivariable logistic regression was conducted. Variables with a P value less than 0.10 in the univariate logistic regression were subsequently entered into a multivariate logistic analysis for adjustment (in a backward fashion), and ORs with 95%CI: are presented. All significance levels were set at α = 0.05, and all tests were 2-tailed. All the statistical analyses were performed using SPSS statistics software (IBM, Armonk, NY, United States; version 27).

RESULTS

Demographic characteristics of the participants

Generally, 2000 participants were invited to complete 1503 surveys. After excluding 91 invalid questionnaires (abnormal response time, n = 32; failure to answer any trust questions, n = 19; and incomplete questions, n = 40), a total of 1412 HCWs were ultimately enrolled. The final included questionnaires met the minimum sample size requirement, which was calculated previously. The overall response rate was 70.6%.

The technical profiles, demographic characteristics, and experiences related to COVID-19 of all included participants are shown in Table 1. A total of 1412 HCWs [618 (43.8%) doctors, 583 (41.3%) nurses, and 211 (14.9%) nonfrontline], 855 (60.6%), 432 (30.6%), and 125 (8.9%) participants had junior, intermediate, and senior technical titles, respectively. The majority of them (1319 (93.4%)] were residents of urban areas. A total of 829 (58.7%), 423 (30.0%), 109 (7.7%), and 51 (3.6%) HCWs served in level III, level II, level I, and community hospitals, respectively. Regarding demographic characteristics, 441 (31.2%), 502 (35.6%), and 469 (33.2%) of the participants worked in the western, middle, and eastern regions of Shandong, respectively. Most participants were women [803 (56.9%)], aged 18 to 34 years [691 (48.9%)], had an educational level of undergraduate or lower [980 (69.4%)], and were married [955 (67.6%)]. The technical and demographic data of the included participants were comparable to those of the local HCW population[20], suggesting sufficient representativeness.

Table 1 Technical profiles, demographic characteristics, and experiences related to COVID-19 of all included healthcare workers (n = 1412).

Variable	n	%
Technical profile
Healthcare position
Doctors	618	43.8
Nurses	583	41.3
Nonfrontline1	211	14.9
Technical title
Junior	855	60.6
Intermediate	432	30.6
Senior	125	8.9
Place of residence
Urban	1319	93.4
Rural	93	6.6
Served hospital level
Level III	829	58.7
Level II	423	30.0
Level I	109	7.7
Community	51	3.6
Demographic characteristics
Region
Western	441	31.2
Middle	502	35.6
Eastern	469	33.2
Sex
Male	609	43.1
Female	803	56.9
Age, yr
18-34	691	48.9
35-49	443	31.4
≥ 50	278	19.7
Education level
≤ Undergraduate	980	69.4
≥ Postgraduate	432	30.6
Marriage status
Unmarried	425	30.1
Married	955	67.6
Divorced/widowed	32	2.3
Experience related to COVID-19
Clinical practice during COVID-19
Isolated care of COVID-19 contacts	574	40.7
Hospitalized care of infections	445	31.5
None	393	27.8
Experience of COVID-19
Infected without hospitalization	1145	81.1
Hospitalization related to COVID-19	253	17.9
Did not infected	14	1.0
Experience of families/friends
Hospitalization related to COVID-19	601	42.6
Death related to COVID-19	387	27.4
None	424	3
Psychological intervention from COVID-19
Yes	1086	76.9
Public psychological education	994	70.4
Individual counseling	102	7.2
None	326	23.1

¹Pharmacist, laboratorian, and other healthcare workers who indirectly exposed patients but also served in healthcare settings.

HCWs: Healthcare workers; COVID-19: Coronavirus disease 2019.

With regard to COVID-19-related experiences, 574 (40.7%) and 445 (31.5%) HCWs provided isolated care for COVID-19 patients and hospitalized care for infections during the COVID-19 epidemic, respectively. Among the HCWs, the majority [1145 (81.1%)] were infected with COVID-19 without hospitalization, while 17.9% (253) of them experienced hospitalization related to COVID-19. In addition, 601 (42.6%) and 387 (27.4%) HCWs were hospitalized and died, respectively, from their families or friends related to COVID-19. During the COVID-19 outbreak, most [1086 (76.9%)] of the participating HCWs received psychological interventions, while nearly all [994 (70.4%)] of them had received public psychological education. Only 7.2% (102) of the HCWs received individual counseling from COVID-19.

Mental health, insomnia problems, and correlations

Table 2 shows the mental health, insomnia problems, and correlations of all the included HCWs. Among those assessed by the GAD-7, PHQ-9, and ISI, 18.0% (254), 16.4% (231), and 20.5% (289) of the included HCWs had symptoms of anxiety, depression, and insomnia, respectively. Severe anxiety, depression, and insomnia symptoms were found in 4.1% (58), 3.5% (49), and 7.9% (111) of the participants, respectively.

Table 2 Mental health, insomnia problems, and their correlations of all included healthcare workers (n = 1412).

Mental health and insomnia problems	n	%
Scale/symptom
GAD-7
Anxiety symptoms	254	18.0
Severe anxiety symptoms	58	4.1
PHQ-9
Depression symptoms	231	16.4
Severe depression symptoms	49	3.5
ISI
Insomnia symptoms	289	20.5
Severe insomnia symptoms	111	7.9
Correlation	r	P
GAD-7 with PHQ-9	0.494	0.09
GAD-7 with ISI	0.719	< 0.001a
PHQ-9 with ISI	0.684	< 0.001a

^aP < 0.01.

HCWs: Healthcare workers; GAD-7: Generalized Anxiety Disorder-7 Scale; PHQ-9: Patient Health Questionnaire-9; ISI: Insomnia Severity Index.

Analysis of the potential correlations among the scores on these scales revealed that the GAD-7 and ISI scores (r = 0.494, P < 0.001) as well as the PHQ-9 and ISI scores (r = 0.684, P < 0.001) were both significantly positively correlated. However, the correlation between the GAD-7 score and the PHQ-9 score did not reach statistical significance (r = 0.494, P = 0.09).

Influential factors and high-risk populations

To identify the factors influencing mental health and insomnia problems and explore potential populations at high risk of symptoms, multivariable logistic regressions were conducted.

For anxiety symptoms, healthcare position, sex, clinical practice during the COVID-19 pandemic, and experience with family or friends were entered into the multivariable analysis. After multivariable adjustment, age (OR = 1.114, 95%CI: 1.054-1.178, P = 0.001), female sex (OR = 1.052, 95%CI: 1.003-1.105, P = 0.04), and hospitalization for COVID-19 infection (OR = 2.047, 95%CI: 1.003-1.105, P = 0.04) were found to be independent risk factors for anxiety symptoms (Table 3).

Table 3 Factors associated with anxiety symptoms (Generalized Anxiety Disorder-7 Scale) of all included healthcare workers (n = 1412) by multivariate logistic regression.

Variable	OR	95%CI	P value
Healthcare position
Doctors	Contract	-	-
Nurses	1.114	1.054-1.178	0.001b
Nonfrontline	0.978	0.919-1.039	0.57
Sex
Male	Contract	-	-
Female	1.052	1.003-1.105	0.04a
Clinical practice during COVID-19
Isolated care of COVID-19 contacts	Contract	-	-
Hospitalized care of infections	2.047	1.675-2.236	< 0.001b
None	0.941	0.872-1.016	0.14
Experience of families/friends
Hospitalization related to COVID-19	Contract	-	-
Death related to COVID-19	1.048	0.982-1.120	0.17
None	0.870	0.817-1.126	0.32

^aP < 0.05.

^bP < 0.01.

HCWs: Healthcare workers; GAD-7: Generalized Anxiety Disorder-7 Scale; COVID-19: Coronavirus disease 2019; OR: Odds ratio.

The symptoms of depression, healthcare position, sex, clinical practice during the COVID-19 pandemic, and experience with family or friends were entered into the multivariable analysis. After multivariable adjustment, age (OR = 1.092, 95%CI: 1.029-1.160, P = 0.014), female sex (OR = 1.148, 95%CI: 1.085-1.214, P < 0.001), and hospitalization for COVID-19 infection (OR = 1.662, 95%CI: 1.476-1.855, P < 0.001) were found to be independent risk factors for depression symptoms (Table 4).

Table 4 Factors associated with depression symptoms (Patient Health Questionnaire-9) of all included healthcare workers (n = 1412) by multivariate logistic regression.

Variable	OR	95%CI	P value
Healthcare position
Doctors	Contract	-	-
Nurses	1.092	1.029-1.160	0.014a
Nonfrontline	0.958	0.898-1.021	0.244
Gender
Male	Contract	-	-
Female	1.148	1.085-1.214	< 0.001b
Clinical practice during COVID-19
Isolated care of COVID-19 contacts	Contract	-	-
Hospitalized care of infections	1.662	1.476-1.855	< 0.001b
None	0.924	0.752-1.136	0.48
Experience of families/friends
Hospitalization related to COVID-19	Contract	-	-
Death related to COVID-19	1.077	0.991-1.170	0.09
None	0.970	0.893-1.052	0.48

^aP < 0.05.

^bP < 0.01.

HCWs: Healthcare workers; PHQ-9: Patient Health Questionnaire-9; COVID-19: Coronavirus disease 2019; OR: Odds ratio.

The presence of insomnia problems was also analyzed, and healthcare position, sex, clinical practice during the COVID-19 pandemic, and experience with family or friends were significantly different (P < 0.10) according to univariate analysis. After multivariable adjustment, nurse sex (OR = 1.126, 95%CI: 1.057-1.199, P < 0.001), female sex (OR = 1.074, 95%CI: 1.019-1.131, P = 0.009), hospitalization for COVID-19 infection (OR = 1.085, 95%CI: 1.016-1.159, P = 0.01), and experience of death in families or friends (OR = 2.082, 95%CI: 1.765-2.510, P < 0.001) were found to be independent risk factors for insomnia symptoms (Table 5).

Table 5 Factors associated with insomnia symptoms (Insomnia Severity Index) of all included healthcare workers (n = 1412) by multivariate logistic regression.

Variable	OR	95%CI	P value
Healthcare position
Doctors	Contract	-	-
Nurses	1.126	1.057-1.199	< 0.001b
Nonfrontline	0.936	0.876-1.001	0.07
Sex
Male	Contract	-	-
Female	1.074	1.019-1.131	0.009b
Clinical practice during COVID-19
Isolated care of COVID-19 contacts	Contract	-	-
Hospitalized care of infections	1.085	1.016-1.159	0.01a
None	0.971	0.743-1.271	0.83
Experience of families/friends
Hospitalization related to COVID-19	Contract	-	-
Death related to COVID-19	2.082	1.765-2.510	< 0.001b
None	0.986	0.904-1.029	0.19

^aP < 0.05.

^bP < 0.01.

HCWs: Healthcare workers; ISI: Insomnia Severity Index; COVID-19: Coronavirus disease 2019; OR: Odds ratio.

DISCUSSION

Epidemiological studies are important resources and evidence for guiding healthcare practice, decision making, and disease prevention, thus benefiting public health[29,30]. This large-scale multicenter cross-sectional study involving 1412 samples from a representative cohort of HCWs revealed that 18.0%, 16.4%, and 20.5% of HCWs had symptoms of anxiety, depression, and insomnia, respectively, and severe symptoms were found in 4.1%, 3.5%, and 7.9% of participants, respectively. Several studies concerning mental health and sleep problems in HCWs during the COVID-19 pandemic have been performed. Lai et al[9] performed a cross-sectional study in early 2020 with Chinese HCWs and revealed a considerable proportion of symptoms of depression (50.4%), anxiety (44.6%), and insomnia (34.0%)[9]. Evidence from meta-analyses has also shown that high proportions of global HCWs have psychological and sleep problems[10-12]. Two meta-analyses by Saragih et al[12] and Pappa et al[10] conducted reported prevalences of anxiety, depression, and insomnia symptoms in HCWs of 23%-40%, 22%-37%, and 38%, respectively, while another meta-analysis by Aymerich et al[11] performed in 2022 suggested that 42%, 33%, and 42%, respectively, of HCWs exposed to COVID-19 reported depressive symptoms, anxiety features, and insomnia. Compared with these studies concerning HCWs during the COVID-19 pandemic, the results of the present study performed half a year after the pandemic suggested overall improvements in mental health and sleep problems.

However, it should be noted that, compared with HCs in the general population during the normal period and during the COVID-19 pandemic, HCWs in the post-COVID-19 era still have a greater risk of severe psychological and sleep symptoms. According to an epidemiological study by Huang et al[24] before the COVID-19 pandemic (during the normal period), the lifetime prevalence of anxiety and depression in the general Chinese population should be 6.8% and 7.6%, respectively[24]. Our team also performed several cross-sectional studies during different periods of the COVID-19 pandemic and revealed that overall, 11.0%-21.7% of the general Chinese population had anxiety, depression, or insomnia symptoms, and 1.9%-5.6% had severe symptoms[6,21,22]. The prevalence of depression, anxiety, and insomnia was also reported to be 15.97%, 15.15%, and 23.87%, respectively, for the global general population in previous studies[31]. After the COVID-19 pandemic, the general population reported decreased risks and levels of mental health problems, and their long-term prevalence gradually became comparable to that during normal periods; additionally, they typically experienced no or mild symptoms[15]. However, this study revealed a considerable prevalence of psychological and sleep symptoms in HCWs after COVID-19. Importantly, experience from the 2003 SARS epidemic suggested that the psychological impact of HCWs can be sustained for at least 1 year[18], suggesting that additional attention needs to be given to the long-term mental and sleep health of HCWs, even in the post-COVID-19 era. Together, our findings suggest that although the mental health and sleep problems of HCWs were relieved after the COVID-19 pandemic, they still faced challenges and greater risks than did the general population.

Another major finding is the identification of factors influencing psychological and sleep symptoms, thus providing guidance for targeted interventions for high-risk HCWs. In general, being a nurse or female and being hospitalized for COVID-19 infection were risk factors for anxiety, depression, and insomnia. Moreover, the experience of death from family or friends was a risk factor for insomnia symptoms. Nurses were also found to be at high risk of having psychological symptoms during the COVID-19 pandemic[9,10]. Frontline nurses were likely to be at the highest risk of infection and became witnesses of COVID-19 patients and deaths[10,32]. Additionally, they might even work longer hours than usual and undertake more night shifts and overtime during the COVID-19 pandemic[8]. All these factors might lead to a high risk of psychological and sleep problems for nurses even after COVID-19. Previous studies also reported higher rates and levels of affective symptoms in female HCWs than in male HCWs[9,10]. In addition, studies of the general population during the COVID-19 pandemic also suggested that females were affected more by the pandemic than males were[33,34]. In summary, particular attention is warranted regarding mental health and sleep problems for nurses and women. The clinical practice and experience of families or friends during the COVID-19 pandemic were also related to mental health and sleep problems. These traumatic experiences, such as witnessing deaths and suffering patients, might cause long-term psychological symptoms and even lead to posttraumatic stress disorder (PTSD)[35]. It will be critical to provide effective targeted psychological interventions for HCWs with COVID-19 even after its onset to reduce their risk of mental health and sleep problems and to enhance their resilience after the pandemic.

Finally, this study revealed that most (76.9%) of the participating HCWs received psychological intervention during the COVID-19 outbreak. This proportion is significantly greater than that in the general population (16.2%-17.4%)[6,21,22]. This finding provides encouraging evidence that a major proportion of HCWs have received timely psychological interventions. However, as 3.5%-7.9% of HCWs reported severe psychological and sleep problems after the COVID-19 pandemic, additional efforts are still needed to provide further interventions in the post-COVID-19 era. Crucially, only 7.2% of the HCWs had individual counseling, while the others only received public psychological education. For HCWs with severe symptoms, individualized systemic psychological interventions with standard phases are preferred[29], but the current supply is insufficient. This epidemiological study of the factors influencing psychological symptoms would be helpful for identifying groups at high risk and providing targeted interventions.

It should be noted that this study has several limitations. First, to reduce the duration of the survey and due to limitations in the study design, this study did not cover symptoms of PTSD, which could be a future research direction. Second, although we applied province-level cluster sampling, additional efforts are still needed to develop a nationwide random sampling study for improved representativeness. Third, although a tolerable response rate (70.6%) and sample size (n = 1412) were needed in this study, response bias may still exist. Finally, the study was carried out half a year after the COVID-19 pandemic, and further exploration is needed in the future; longitudinal follow-up could provide additional findings.

CONCLUSION

The results of this survey on mental health and insomnia problems in HCWs after the COVID-19 pandemic revealed that 18.0%, 16.4%, and 20.5% of the HCWs experienced symptoms of anxiety, depression, and insomnia, respectively; additionally, severe symptoms were found in 4.1%, 3.5%, and 7.9% of the participants, respectively. Although the mental health and sleep problems of HCWs were relieved after the COVID-19 pandemic, they still faced challenges and greater risks than did the general population. Nurses, female sex, and hospitalization for COVID-19 were risk factors for anxiety, depression, and insomnia symptoms; moreover, death from family or friends was a risk factor for insomnia symptoms. Identification of these risk factors would help in providing targeted interventions. In addition, although a major proportion of HCWs have received public psychological education, individual interventions are still insufficient.

ACKNOWLEDGEMENTS

We would like to thank all participants of this study. Dr. Shu Wang is a collaborator of the Global Burden of Disease Collaborator Network, which is sustained by the Institute for Health Metrics and Evaluation (IHME), the University of Washington School of Medicine.