{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,12]],"date-time":"2026-07-12T20:50:33Z","timestamp":1783889433655,"version":"3.55.0"},"reference-count":48,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2021,2,5]],"date-time":"2021-02-05T00:00:00Z","timestamp":1612483200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Institutes of Health Medical Scientist Training Program","award":["T32GM007205"],"award-info":[{"award-number":["T32GM007205"]}]},{"name":"Yale University\u2019s COVID-19 Response Coordination Team"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Healthcare workers are at increased risk of adverse mental health outcomes during the COVID-19 pandemic. Studies are warranted that examine socio-ecological factors associated with these outcomes to inform interventions that support healthcare workers during future disease outbreaks.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We conducted an online cross-sectional study of healthcare workers during May 2020 to assess the socio-ecological predictors of mental health outcomes during the COVID-19 pandemic. We assessed factors at four socio-ecological levels: individual (e.g., gender), interpersonal (e.g., social support), institutional (e.g., personal protective equipment availability), and community (e.g., healthcare worker stigma). The Personal Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise scales assessed probable major depression (MD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD), respectively. Multivariable logistic regression models were used to assess unadjusted and adjusted associations between socio-ecological factors and mental health outcomes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Of the 1,092 participants, 72.0% were female, 51.9% were frontline workers, and the mean age was 40.4 years (standard deviation = 11.5). Based on cut-off scores, 13.9%, 15.6%, 22.8%, and 42.8% had probable MD, GAD, PTSD, and AUD, respectively. In the multivariable adjusted models, needing more social support was associated with significantly higher odds of probable MD, GAD, PTSD, and AUD. The significance of other factors varied across the outcomes. For example, at the individual level, female gender was associated with probable PTSD. At the institutional level, lower team cohesion was associated with probable PTSD, and difficulty following hospital policies with probable MD. At the community level, higher healthcare worker stigma was associated with probable PTSD and AUD, decreased satisfaction with the national government response with probable GAD, and higher media exposure with probable GAD and PTSD.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>These findings can inform targeted interventions that promote healthcare workers\u2019 psychological resilience during disease outbreaks.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0246602","type":"journal-article","created":{"date-parts":[[2021,2,8]],"date-time":"2021-02-08T01:56:39Z","timestamp":1612749399000},"page":"e0246602","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":127,"title":["Socio-ecological predictors of mental health outcomes among healthcare workers during the COVID-19 pandemic in the United States"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6855-0402","authenticated-orcid":true,"given":"Rachel","family":"Hennein","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emma J.","family":"Mew","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah R.","family":"Lowe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,2,5]]},"reference":[{"key":"pone.0246602.ref001","unstructured":"Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Cases, Data, and Surveillance 2020. Available from: https:\/\/www.cdc.gov\/coronavirus\/2019-ncov\/cases-updates\/cases-in-us.html."},{"key":"pone.0246602.ref002","article-title":"Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis","author":"S Pappa","year":"2020","journal-title":"Brain Behav Immun"},{"key":"pone.0246602.ref003","doi-asserted-by":"crossref","first-page":"100144","DOI":"10.1016\/j.bbih.2020.100144","article-title":"The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review","author":"S Cabarkapa","year":"2020","journal-title":"Brain Behav Immun Health"},{"key":"pone.0246602.ref004","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.genhosppsych.2020.06.007","article-title":"Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic","volume":"66","author":"A Shechter","year":"2020","journal-title":"Gen Hosp Psychiatry"},{"key":"pone.0246602.ref005","volume-title":"Health behavior and health education: theory, research, and practice","author":"JF Sallis","year":"2008"},{"key":"pone.0246602.ref006","unstructured":"Centers for Disease Control and Prevention. The Social-Ecological Model: A Framework for Prevention [October 15, 2020]. Available from: https:\/\/www.cdc.gov\/violenceprevention\/publichealthissue\/social-ecologicalmodel.html."},{"issue":"7","key":"pone.0246602.ref007","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1037\/0003-066X.32.7.513","article-title":"Toward an experimental ecology of human development","volume":"32","author":"U Bronfenbrenner","year":"1977","journal-title":"American Psychologist"},{"issue":"3","key":"pone.0246602.ref008","doi-asserted-by":"crossref","first-page":"e203976","DOI":"10.1001\/jamanetworkopen.2020.3976","article-title":"Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019","volume":"3","author":"J Lai","year":"2020","journal-title":"JAMA Netw Open."},{"key":"pone.0246602.ref009","doi-asserted-by":"crossref","DOI":"10.1016\/j.comppsych.2020.152198","article-title":"Psychological distress surveillance and related impact analysis of hospital staff during the COVID-19 epidemic in Chongqing, China","volume":"103","author":"Y Juan","year":"2020","journal-title":"Comprehensive Psychiatry"},{"issue":"5","key":"pone.0246602.ref010","doi-asserted-by":"crossref","first-page":"e2010185","DOI":"10.1001\/jamanetworkopen.2020.10185","article-title":"Mental Health Outcomes Among Frontline and Second-Line Health Care Workers During the Coronavirus Disease 2019 (COVID-19) Pandemic in Italy","volume":"3","author":"R Rossi","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"6","key":"pone.0246602.ref011","article-title":"Work-Related and Personal Factors Associated With Mental Well-Being During the COVID-19","volume":"22","author":"BA Evanoff","year":"2020","journal-title":"Response: Survey of Health Care and Other Workers. J Med Internet Res"},{"key":"pone.0246602.ref012","doi-asserted-by":"crossref","first-page":"e923549","DOI":"10.12659\/MSM.923921","article-title":"The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China","volume":"26","author":"H Xiao","year":"2020","journal-title":"Med Sci Monit"},{"issue":"5","key":"pone.0246602.ref013","doi-asserted-by":"crossref","first-page":"e0233831","DOI":"10.1371\/journal.pone.0233831","article-title":"Social support and mental health among health care workers during Coronavirus Disease 2019 outbreak: A moderated mediation model","volume":"15","author":"T Hou","year":"2020","journal-title":"PLOS ONE"},{"key":"pone.0246602.ref014","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1016\/j.bbi.2020.05.010","article-title":"At the height of the storm: Healthcare staff\u2019s health conditions and job satisfaction and their associated predictors during the epidemic peak of COVID-19","volume":"87","author":"SX Zhang","year":"2020","journal-title":"Brain Behav Immun"},{"issue":"10","key":"pone.0246602.ref015","doi-asserted-by":"crossref","first-page":"e0240646","DOI":"10.1371\/journal.pone.0240646","article-title":"A hybrid inductive-abductive analysis of health workers\u2019 experiences and wellbeing during the COVID-19 pandemic in the United States","volume":"15","author":"R Hennein","year":"2020","journal-title":"PLOS ONE"},{"issue":"5","key":"pone.0246602.ref016","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/S1473-3099(20)30120-1","article-title":"An interactive web-based dashboard to track COVID-19 in real time","volume":"20","author":"E Dong","journal-title":"Lancet Infect Dis. 2020"},{"key":"pone.0246602.ref017","doi-asserted-by":"crossref","first-page":"806","DOI":"10.1136\/bmj.39335.541782.AD","article-title":"Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"335","author":"E vonElm","year":"2007","journal-title":"BMJ"},{"issue":"9","key":"pone.0246602.ref018","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9: validity of a brief depression severity measure","volume":"16","author":"K Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"issue":"22","key":"pone.0246602.ref019","doi-asserted-by":"crossref","first-page":"2373","DOI":"10.1001\/jama.2015.15845","article-title":"Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis","volume":"314","author":"DA Mata","year":"2015","journal-title":"JAMA"},{"issue":"10","key":"pone.0246602.ref020","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A brief measure for assessing generalized anxiety disorder: the GAD-7","volume":"166","author":"RL Spitzer","year":"2006","journal-title":"Arch Intern Med"},{"issue":"1","key":"pone.0246602.ref021","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1185\/135525703125002360","article-title":"The primary care PTSD screen (PC-PTSD): Development and operating characteristics","volume":"9","author":"A Prins","year":"2003","journal-title":"Prim Care Psychiatry"},{"issue":"7","key":"pone.0246602.ref022","doi-asserted-by":"crossref","first-page":"1208","DOI":"10.1111\/j.1530-0277.2007.00403.x","article-title":"AUDIT-C as a brief screen for alcohol misuse in primary care","volume":"31","author":"KA Bradley","year":"2007","journal-title":"Alcohol Clin Exp Res"},{"issue":"1","key":"pone.0246602.ref023","doi-asserted-by":"crossref","first-page":"7","DOI":"10.3121\/cmr.2016.1303","article-title":"Healthcare Workers Emotions, Perceived Stressors and Coping Strategies During a MERS-CoV Outbreak","volume":"14","author":"I Khalid","year":"2016","journal-title":"Clin Med Res"},{"issue":"7","key":"pone.0246602.ref024","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1097\/01.mlr.0000167181.36730.cc","article-title":"Risk perception and impact of Severe Acute Respiratory Syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn?","volume":"43","author":"D Koh","year":"2005","journal-title":"Med Care"},{"key":"pone.0246602.ref025","article-title":"Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study","volume":"9","author":"DW Eyre","year":"2020","journal-title":"Elife"},{"issue":"9","key":"pone.0246602.ref026","doi-asserted-by":"crossref","first-page":"4726","DOI":"10.1172\/JCI139587","article-title":"New York City COVID-19 resident physician exposure during exponential phase of pandemic","volume":"130","author":"MP Breazzano","year":"2020","journal-title":"J Clin Invest"},{"key":"pone.0246602.ref027","unstructured":"National Health and Nutrition Examination Survey Centers for Disease Control and Prevention [cited 2020 October 17]. Available from: https:\/\/wwwn.cdc.gov\/nchs\/nhanes\/Search\/variablelist.aspx?Component=Questionnaire."},{"issue":"1","key":"pone.0246602.ref028","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1111\/1475-6773.12136","article-title":"The association between EHRs and care coordination varies by team cohesion","volume":"49","author":"I Graetz","year":"2014","journal-title":"Health Serv Res"},{"issue":"3","key":"pone.0246602.ref029","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1111\/j.1475-6773.2006.00644.x","article-title":"Measuring organizational attributes of primary care practices: development of a new instrument","volume":"42","author":"PA Ohman-Strickland","year":"2007","journal-title":"Health Serv Res"},{"issue":"9","key":"pone.0246602.ref030","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1002\/da.21924","article-title":"Comorbidity and disease burden in the National Comorbidity Survey Replication (NCS-R)","volume":"29","author":"AM Gadermann","year":"2012","journal-title":"Depress Anxiety"},{"key":"pone.0246602.ref031","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1146\/annurev-publhealth-032013-182435","article-title":"Mental Health Consequences of Disasters","volume":"35","author":"E Goldmann","year":"2014","journal-title":"Annual Review of Public Health"},{"issue":"3","key":"pone.0246602.ref032","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1093\/pubmed\/fdaa110","article-title":"Threatening increase in alcohol consumption in physicians quarantined due to coronavirus outbreak in Poland: the ALCOVID survey","volume":"42","author":"A Silczuk","year":"2020","journal-title":"Journal of Public Health"},{"key":"pone.0246602.ref033","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1016\/j.bbi.2020.03.028","article-title":"Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study","volume":"87","author":"L Kang","year":"2020","journal-title":"Brain Behav Immun"},{"key":"pone.0246602.ref034","doi-asserted-by":"crossref","first-page":"113130","DOI":"10.1016\/j.psychres.2020.113130","article-title":"Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics","volume":"290","author":"RY Elbay","year":"2020","journal-title":"Psychiatry Res"},{"key":"pone.0246602.ref035","doi-asserted-by":"crossref","first-page":"386","DOI":"10.3389\/fpsyt.2020.00386","article-title":"Prevalence and Influencing Factors of Anxiety and Depression Symptoms in the First-Line Medical Staff Fighting Against COVID-19 in Gansu","volume":"11","author":"J Zhu","year":"2020","journal-title":"Front Psychiatry"},{"issue":"4","key":"pone.0246602.ref036","doi-asserted-by":"crossref","first-page":"317","DOI":"10.7326\/M20-1083","article-title":"Psychological impact of the COVID-19 pandemic on health care workers in Singapore","volume":"173","author":"BYQ Tan","year":"2020","journal-title":"Ann Intern Med"},{"issue":"12","key":"pone.0246602.ref037","doi-asserted-by":"crossref","DOI":"10.1097\/ACM.0000000000003651","article-title":"Will Losing Black Physicians Be a Consequence of the COVID-19 Pandemic?","volume":"95","author":"A Filut","year":"2020","journal-title":"Academic Medicine"},{"issue":"9","key":"pone.0246602.ref038","doi-asserted-by":"crossref","first-page":"e475","DOI":"10.1016\/S2468-2667(20)30164-X","article-title":"Risk of COVID-19 among frontline healthcare workers and the general community: a prospective cohort study","volume":"5","author":"LH Nguyen","year":"2020","journal-title":"The Lancet Public Health"},{"key":"pone.0246602.ref039","article-title":"National Center for Health Workforce Analysis","author":"U.S. Department of Health\\ and Human Services","year":"2017","journal-title":"Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2011\u20132015)"},{"issue":"12","key":"pone.0246602.ref040","doi-asserted-by":"crossref","first-page":"1787","DOI":"10.1097\/ACM.0000000000003621","article-title":"Being Black in Medicine in the Midst of COVID-19 and Police Violence","volume":"95","author":"KM Kwaning","year":"2020","journal-title":"Academic Medicine"},{"issue":"10144","key":"pone.0246602.ref041","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1016\/S0140-6736(18)31130-9","article-title":"Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study","volume":"392","author":"J Bor","year":"2018","journal-title":"Lancet"},{"key":"pone.0246602.ref042","article-title":"Assessing the Presence of Post-Traumatic Stress and Turnover Intention Among Nurses Post-Middle East Respiratory Syndrome Outbreak: The Importance of Supervisor Support","author":"H Jung","year":"2020","journal-title":"Workplace Health Saf"},{"issue":"7","key":"pone.0246602.ref043","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1016\/j.ajic.2018.01.012","article-title":"Nurses\u2019 experiences of care for patients with Middle East respiratory syndrome-coronavirus in South Korea","volume":"46","author":"Y Kim","year":"2018","journal-title":"Am J Infect Control"},{"issue":"10","key":"pone.0246602.ref044","doi-asserted-by":"crossref","first-page":"920","DOI":"10.3855\/jidc.11753","article-title":"Middle East Respiratory Syndrome Coronavirus epidemic impact on healthcare workers\u2019 risk perceptions, work and personal lives","volume":"13","author":"S Alsubaie","year":"2019","journal-title":"J Infect Dev Ctries"},{"key":"pone.0246602.ref045","unstructured":"U.S. Census Bureau. 2000 Census and 2017 American Community Survey 1-year estimates 2017. Available from: https:\/\/www.census.gov\/programs-surveys\/acs\/."},{"key":"pone.0246602.ref046","unstructured":"Bureau of Labor Statistics. State Occupational Employment Statistics Survey 2018. Available from: http:\/\/www.bls.gov\/oes\/tables.htm."},{"key":"pone.0246602.ref047","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1007\/s10597-020-00624-5","article-title":"COVID-19 Epidemic Peer Support and Crisis Intervention Via Social Media","volume":"56","author":"P Cheng","year":"2020","journal-title":"Community Mental Health Journal"},{"key":"pone.0246602.ref048","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1016\/j.genhosppsych.2020.11.005","article-title":"Mobilizing an institutional supportive response for healthcare workers and other staff in the context of COVID-19: The Yale experience","volume":"68","author":"JH Krystal","year":"2021","journal-title":"Gen Hosp Psychiatry"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0246602","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,2,8]],"date-time":"2021-02-08T01:57:21Z","timestamp":1612749441000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0246602"}},"subtitle":[],"editor":[{"given":"Joel Msafiri","family":"Francis","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,2,5]]},"references-count":48,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2021,2,5]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0246602","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,2,5]]}}}