Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019 Jianbo Lai Simeng Ma Ying Wang Zhongxiang Cai Jianbo Hu Ning Wei Jiang Wu Hui Du Tingting Chen Ruiting Li Huawei Tan Lijun Kang Lihua Yao Manli Huang Huafen Wang Gaohua Wang Zhongchun Liu Shaohua Hu

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Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019 2020 JAMA Network Open 10.1001/jamanetworkopen.2020.3976 lai2020-factors-associated-with-mental-hea lai2020-factors-associated-with-mental-hea.txt, the project's staged copy 9223dc1206b885de46ca357c6541e1b6cd3ba701 cc-by health-psychology

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0 spans located by searching the stored text for the quote's exact words, allowing any whitespace between them the mental health of 1257 physicians and nurses in 34 Chinese hospitals with fever clinics or COVID-19 wards, surveyed over six days at the start of the outbreak Quotation withheld because this record is not cleared for redistribution. what is the magnitude of depression, anxiety, insomnia and distress among health care workers treating patients with COVID-19, and which occupational and geographic factors are associated with it Quotation withheld because this record is not cleared for redistribution. a prevalence-and-risk-factor survey filling a gap the authors name: psychological assistance was already being deployed nationally while evidence-based evaluation of frontline workers was scarce Quotation withheld because this record is not cleared for redistribution. existence Quotation withheld because this record is not cleared for redistribution. psychological burden in health care workers during an epidemic: 50.4% reported symptoms of depression, 44.6% anxiety, 34.0% insomnia and 71.5% distress Quotation withheld because this record is not cleared for redistribution. survey survey Quotation withheld because this record is not cleared for redistribution. the authors' account of why frontline nurses fare worst - close, frequent contact and longer hours than usual, which is exposure to the hazard and exposure to the workload at once exposure intensity Quotation withheld because this record is not cleared for redistribution. human-to-human transmissibility and potential fatality are offered as intensifying the perception of personal danger - a belief about the disease rather than a dose of it perceived personal danger Quotation withheld because this record is not cleared for redistribution. predictable shortages of supplies together with rising case influx are named as contributors to pressure, separately from contact with patients resource shortage Quotation withheld because this record is not cleared for redistribution. 71.5% of nurses held junior titles, which the authors read as fewer years of work experience - offered as why the most exposed group is also the least practised inexperience Quotation withheld because this record is not cleared for redistribution. a list of distress sources taken from the SARS literature: vulnerability or loss of control, concern for self and family, changed work, isolation loss of control Quotation withheld because this record is not cleared for redistribution. limited in scope - 81.2% of participants were from Hubei province, so the findings do not generalise to less affected regions Quotation withheld because this record is not cleared for redistribution. six days of collection and no longitudinal follow-up, so nothing here speaks to how the symptoms developed or resolved; the authors expect they worsened Quotation withheld because this record is not cleared for redistribution. NO COMPARATOR GROUP. The study cannot separate being a clinician in the region from living in the region, and cannot separate preexisting symptoms from new ones Quotation withheld because this record is not cleared for redistribution. response bias may remain at a 68.7% response rate, in either direction - the nonrespondents may have been too stressed to answer or not stressed enough to care Quotation withheld because this record is not cleared for redistribution. the headline prevalences and the stated detection cutoffs are two different thresholds and the paper does not reconcile them in the abstract, where only the lower one appears Quotation withheld because this record is not cleared for redistribution. multivariable logistic regression adjusting for sex, age, marital status, educational level, technical title, place of residence, working position and type of hospital eliminates: the crude frontline-versus-second-line difference being an artefact of the front line's composition - sex, age, marital status, education, technical title, residence and hospital type are each held fixed, and those are the ones this quote names · outcome: held Quotation withheld because this record is not cleared for redistribution. all tests two-tailed at a significance level fixed in the Statistical Analysis section eliminates: a one-tailed test chosen after the direction of an effect was already visible · outcome: held Quotation withheld because this record is not cleared for redistribution. nonparametric tests (Mann-Whitney U, Kruskal-Wallis) after checking that none of the four score distributions was normal eliminates: a normality assumption the data do not meet - the authors report the check and then choose the test that does not need it · outcome: held Quotation withheld because this record is not cleared for redistribution. four previously validated Chinese-language instruments with published band boundaries and cutoffs, rather than questions written for this study eliminates: instrument novelty as the source of the prevalence figures, and makes the numbers comparable with other studies using the same scales · outcome: held Quotation withheld because this record is not cleared for redistribution. occupational and geographic data of the nonrespondents compared with those of respondents eliminates: nonresponse being concentrated in one occupation or one region - but NOT response bias itself, which the authors say may still exist because the two things it would turn on, stress and interest, are exactly what was not measured in the people who declined · outcome: partial Quotation withheld because this record is not cleared for redistribution. target sample size set from a stated formula, a stated margin of error and a 35% prior from the SARS literature, then amplified by 50% for subgroup analysis eliminates: the subgroup comparisons being underpowered by accident - the amplification is declared in advance and for that purpose · outcome: held Quotation withheld because this record is not cleared for redistribution. reporting followed the AAPOR guideline for survey research eliminates: selective reporting of how the survey was conducted - a reporting standard is named in advance, which fixes the disclosures rather than leaving them to the authors' choice after the fact · outcome: held Quotation withheld because this record is not cleared for redistribution. a comparator group of people living in the same regions who were not clinicians eliminates: living in the region rather than working in it as a clinician - the paper says plainly there was no comparator group, so the two cannot be separated · outcome: absent-declared-unreported · would have ruled out, had it been run: nothing - THE CONTROL WAS NOT AVAILABLE. The authors state they cannot separate being a clinician in this region from simply living in it, so the entire prevalence finding is uncontrolled against the background rate in Wuhan at the same moment Quotation withheld because this record is not cleared for redistribution. ethics committee approval, verbal informed consent, the right to terminate at any time, anonymity and assured confidentiality eliminates: responses given under professional pressure during an outbreak being treated as freely given, when the respondents are staff of the reporting institution's own hospitals · outcome: held Quotation withheld because this record is not cleared for redistribution. frontline workers frontline workers Quotation withheld because this record is not cleared for redistribution. second-line workers second-line workers Quotation withheld because this record is not cleared for redistribution. nurses nurses Quotation withheld because this record is not cleared for redistribution. physicians physicians Quotation withheld because this record is not cleared for redistribution. depression depression Quotation withheld because this record is not cleared for redistribution. anxiety anxiety Quotation withheld because this record is not cleared for redistribution. insomnia insomnia Quotation withheld because this record is not cleared for redistribution. distress distress Quotation withheld because this record is not cleared for redistribution. PHQ-9 PHQ-9 Quotation withheld because this record is not cleared for redistribution. GAD-7 GAD-7 Quotation withheld because this record is not cleared for redistribution. ISI ISI Quotation withheld because this record is not cleared for redistribution. IES-R IES-R Quotation withheld because this record is not cleared for redistribution. COVID-19 COVID-19 Quotation withheld because this record is not cleared for redistribution. SARS SARS Quotation withheld because this record is not cleared for redistribution. Wuhan Wuhan Quotation withheld because this record is not cleared for redistribution. Hubei province Hubei province Quotation withheld because this record is not cleared for redistribution. tertiary hospital tertiary hospital Quotation withheld because this record is not cleared for redistribution. secondary hospitals secondary hospitals Quotation withheld because this record is not cleared for redistribution. multivariable logistic regression multivariable logistic regression Quotation withheld because this record is not cleared for redistribution. odds ratios odds ratios Quotation withheld because this record is not cleared for redistribution. confounders confounders Quotation withheld because this record is not cleared for redistribution. 2-stage cluster sampling 2-stage cluster sampling Quotation withheld because this record is not cleared for redistribution. response bias response bias Quotation withheld because this record is not cleared for redistribution. comparator group comparator group Quotation withheld because this record is not cleared for redistribution. longitudinal follow-up longitudinal follow-up Quotation withheld because this record is not cleared for redistribution. symptoms of depression / anxiety / insomnia / distress, AS USED IN THE FOUR HEADLINE PREVALENCES - a count of everyone scoring above NORMAL on each scale, which is a far lower bar than the cutoff the same paper defines for detecting each disorder. Read this figure with the band boundaries tagged under definitions and with the two statistics rows that quote Table 2's own band counts; the number is right and the sense is milder than the words suggest Quotation withheld because this record is not cleared for redistribution. severe symptoms - A SECOND AND HIGHER THRESHOLD IN THE SAME PAPER: a score greater than 10, 7, 15 or 26. For distress that cutoff of 26 falls at the boundary of the moderate band, while the 71.5% headline counts from the mild band up. SO `distress' IN THIS PAPER NAMES TWO DIFFERENT POPULATIONS DEPENDING ON WHICH SENTENCE YOU READ, and both are correct Quotation withheld because this record is not cleared for redistribution. distress - A SCORE ON THE IMPACT OF EVENT SCALE-REVISED, an instrument for the psychological impact of a specific event, not a clinical diagnosis and not general unhappiness. The same instrument carries the same sense in wang2020, where the label is `psychological impact` instead Quotation withheld because this record is not cleared for redistribution. frontline - SELF-REPORTED AND BINARY. It is a yes/no answer to whether the respondent was directly engaged in diagnosing, treating or nursing patients with fever or confirmed COVID-19; it carries no measure of hours, caseload or duration of exposure Quotation withheld because this record is not cleared for redistribution. risk factor / associated with - AN ADJUSTED CROSS-SECTIONAL ODDS RATIO. Confounders are named and controlled, which is more than wang2020's univariate analysis does, but the design still observes no temporal order: nobody was measured before becoming frontline Quotation withheld because this record is not cleared for redistribution. builds-on → the SARS-outbreak literature on health care workers (Maunder 2003, Bai 2004, Lee 2007, Chua 2004), which reported 89% with psychological symptoms in high-risk situations Quotation withheld because this record is not cleared for redistribution. confirms → the SARS emergency-department finding that nurses developed more distress and more behavioural disengagement than physicians note: the paper's own word is 'also showed', which is agreement reported after the fact and not a replication attempt - 'confirms' rather than 'replicates' for that reason Quotation withheld because this record is not cleared for redistribution. qualifies → the national deployment of psychological assistance hotlines and counselling during the outbreak, which this paper says ran ahead of any evidence base for frontline workers Quotation withheld because this record is not cleared for redistribution. frontline workers —causes→ insomnia frontline workers insomnia direction on the measure: increases · strength of the relation: 0.85 · note: the paper's word is 'independent risk factor', which is an adjusted cross-sectional association and not a demonstrated cause; the weight is below 1.0 for that reason and the largest of the four odds ratios is this one Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause. Quotation withheld because this record is not cleared for redistribution. frontline workers —causes→ depression frontline workers depression direction on the measure: increases · strength of the relation: 0.8 · note: adjusted association, CI lower bound 1.11 - the weakest of the four and the closest to no effect Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause. Quotation withheld because this record is not cleared for redistribution. frontline workers —causes→ anxiety frontline workers anxiety direction on the measure: increases · strength of the relation: 0.8 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause. Quotation withheld because this record is not cleared for redistribution. frontline workers —causes→ distress frontline workers distress direction on the measure: increases · strength of the relation: 0.8 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause. Quotation withheld because this record is not cleared for redistribution. depression —operationalised-as→ PHQ-9 depression PHQ-9 strength of the relation: 1 Quotation withheld because this record is not cleared for redistribution. anxiety —operationalised-as→ GAD-7 anxiety GAD-7 strength of the relation: 1 Quotation withheld because this record is not cleared for redistribution. insomnia —operationalised-as→ ISI insomnia ISI strength of the relation: 1 Quotation withheld because this record is not cleared for redistribution. distress —operationalised-as→ IES-R distress IES-R strength of the relation: 1 · note: the IES-R measures the psychological impact of a named event; 'distress' in this paper means nothing wider than that Quotation withheld because this record is not cleared for redistribution. frontline workers —distinct-from→ second-line workers frontline workers second-line workers strength of the relation: 1 · note: the distinction is the paper's independent variable and it is a self-reported yes/no Quotation withheld because this record is not cleared for redistribution. nurses —contrasted-with→ physicians nurses physicians strength of the relation: 0.95 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but attributed: the span reports a SARS-outbreak study's finding about nurses and physicians. Quotation withheld because this record is not cleared for redistribution. secondary hospitals —contrasted-with→ tertiary hospital secondary hospitals tertiary hospital strength of the relation: 0.95 Quotation withheld because this record is not cleared for redistribution. Wuhan —part-of→ Hubei province Wuhan Hubei province strength of the relation: 1 · note: and the paper's three strata are Wuhan, Hubei outside Wuhan, and outside Hubei, so the containment matters to how the comparison reads Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span compares working outside Hubei with working in Wuhan; part-of rests on world knowledge, not the span. Quotation withheld because this record is not cleared for redistribution. 50.4% reported symptoms of depression, 44.6% anxiety, 34.0% insomnia, 71.5% distress Quotation withheld because this record is not cleared for redistribution. frontline work was an independent risk factor for all four outcomes after adjustment; insomnia carried much the largest odds ratio at 2.97 Quotation withheld because this record is not cleared for redistribution. being a woman and holding an intermediate professional title were associated with severe depression, anxiety and distress Quotation withheld because this record is not cleared for redistribution. Working outside Hubei was associated with a lower risk of distress than working in Wuhan. Quotation withheld because this record is not cleared for redistribution. secondary-hospital staff reported more severe depression and anxiety than tertiary-hospital staff Quotation withheld because this record is not cleared for redistribution. but frontline workers in secondary and tertiary hospitals scored equally high on all four scales - the hospital-type difference disappears at the front line Quotation withheld because this record is not cleared for redistribution. nurses, women, frontline workers and those in Wuhan reported more severe symptoms on every measurement Quotation withheld because this record is not cleared for redistribution. frontline worker = answered yes to being directly engaged in diagnosing, treating or nursing patients with fever or confirmed COVID-19; everyone else is second-line frontline workers Quotation withheld because this record is not cleared for redistribution. cutoffs for detecting major depression, anxiety, insomnia and distress: 10, 7, 15 and 26; above the cutoff is called severe cutoff score Quotation withheld because this record is not cleared for redistribution. 1257 of 1830 contacted individuals completed the survey, a participation rate of 68.7% Quotation withheld because this record is not cleared for redistribution. 1257 health care workers in 34 hospitals, over six days from 29 January to 3 February 2020 Quotation withheld because this record is not cleared for redistribution. 20 hospitals in Wuhan, 7 elsewhere in Hubei, 7 in other provinces - 34 in total Quotation withheld because this record is not cleared for redistribution. median scores: PHQ-9 5.0, GAD-7 4.0, ISI 5.0, IES-R 20.0 Quotation withheld because this record is not cleared for redistribution. target sample of at least 1070 completed questionnaires, from a 35% prior and a 50% amplification for subgroups Quotation withheld because this record is not cleared for redistribution. frontline vs second-line, adjusted: depression OR 1.52 (1.11-2.09), anxiety 1.57 (1.22-2.02), insomnia 2.97 (1.92-4.60), distress 1.60 (1.25-2.04) Quotation withheld because this record is not cleared for redistribution. outside Hubei vs Wuhan, distress OR 0.62 (0.43-0.88), P = .008 Quotation withheld because this record is not cleared for redistribution. secondary vs tertiary hospital: depression OR 1.65 (1.17-2.34), anxiety OR 1.43 (1.08-1.90) Quotation withheld because this record is not cleared for redistribution. severe depression among women OR 1.94 (1.26-2.98); severe anxiety with an intermediate title OR 1.82 (1.38-2.39) Quotation withheld because this record is not cleared for redistribution. THE 71.5% DISTRESS FIGURE IS EVERY IES-R BAND ABOVE NORMAL: 459 mild + 308 moderate + 132 severe = 899 of 1257. The severe band alone is 132, or 10.5%, and the paper's own stated cutoff for detecting distress is 26 - the boundary of the moderate band, not of the mild one Quotation withheld because this record is not cleared for redistribution. the same shape on the PHQ-9: 448 mild + 108 moderate + 78 severe = 634 of 1257 = the reported 50.4%, while the stated cutoff for detecting major depression is 10 Quotation withheld because this record is not cleared for redistribution. all tests 2-tailed with the significance level fixed in advance; group comparisons by Mann-Whitney U and Kruskal-Wallis because none of the four distributions was normal Quotation withheld because this record is not cleared for redistribution.

The full text of this article is not redistributable, so it is not included here. The evidence sentences are withheld with it; the tag layer and its grounding status remain. The article itself is at https://doi.org/10.1001/jamanetworkopen.2020.3976.