Relationship Between Acute Stress Responses and Quality of Life in Chinese Health Care Workers During the COVID-19 Outbreak - Frontiers

                                                                                                                                             published: 16 March 2021
                                                                                                                                      doi: 10.3389/fpsyg.2021.599136

                                            Relationship Between Acute Stress
                                            Responses and Quality of Life in
                                            Chinese Health Care Workers During
                                            the COVID-19 Outbreak
                                            Lan Zhang 1† , Rongjian Ji 1† , Yanbo Ji 1 , Min Liu 2 , Renxiu Wang 3 and Cuiping Xu 1*
                                             Department of Nursing, Shandong Provincial Qianfoshan Hospital, Shandong University, Shandong, China, 2 School
                                            of Nursing, Shandong First Medical University, Shandong, China, 3 School of Nursing, Shandong University of Traditional
                                            Chinese Medicine, Shandong, China

                                            This study aimed to determine the relationship between acute stress and quality of
                                            life and explore their influencing factors on health care workers. A descriptive cross-
                                            sectional study was conducted, and a sample of 525 health care workers was recruited
                                            from 15 hospitals through a convenient sampling method. Participants completed an
                         Edited by:
                  Margarita Limon,          online self-report questionnaire to assess their acute stress and quality of life. Descriptive
    Autonomous University of Madrid,        and multiple linear regression statistics were used for this analysis. The results regarding
                                            acute stress responses varied significantly among the differences in marital status,
                         Reviewed by:
                  Paula Maria Di Nota,
                                            physical activity, work status, perceived risk of contracting COVID-19, and the expected
  Justice Institute of British Columbia     duration of the pandemic. Moreover, a younger age, lack of physical activity, being a
                        (JIBC), Canada
                                            front-line medical staff, and higher acute stress scores indicated a worse quality of
                            Sara Marelli,
  San Raffaele Hospital (IRCCS), Italy      life. Healthcare workers’ acute stress was negatively correlated with their quality of life.
                                Zezhi Li,   Therefore, the authorities should pay special attention to health care workers’ mental
 Shanghai Jiao Tong University, China
                                            health and provide them with timely protection during the pandemic.
                           Cuiping Xu       Keywords: acute stress, coronavirus, health care workers, quality of life, China
 † These   authors share first authorship
                     Specialty section:
           This article was submitted to    The coronavirus disease 2019 (COVID-19), an acute respiratory disease caused by β-coronavirus,
                      Health Psychology,    has spread worldwide since it first appeared in Wuhan, China, in December 2019 (Paules et al.,
                 a section of the journal   2020). As of June 26, 2020, more than 9.2 million confirmed cases and 470,000 deaths have been
                 Frontiers in Psychology    reported worldwide, including 85,119 confirmed cases and 4,647 deaths in China (World Health
            Received: 26 August 2020        Organization, 2020). The World Health Organization (WHO) officially declared the COVID-19
           Accepted: 19 February 2021       pandemic a public health emergency of international concern on January 30, 2020, marking the
            Published: 16 March 2021
                                            third pandemic of coronavirus in the 21st century (Mahase, 2020).
                             Citation:         To control the COVID-19 pandemic swiftly, health care workers throughout China actively
   Zhang L, Ji R, Ji Y, Liu M, Wang R       participated in medical treatment, disease prevention, and logistics support. However, due to the
         and Xu C (2021) Relationship
                                            shortage of personal protective materials in the early stages, the persistence of the disease, and the
   Between Acute Stress Responses
 and Quality of Life in Chinese Health
                                            highly contagious nature of the COVID-19 virus, health care workers were at risk of being infected
 Care Workers During the COVID-19           with COVID-19 (Van Doremalen et al., 2020). Previous studies have showed a link between chronic
Outbreak. Front. Psychol. 12:599136.        work-related stress among healthcare workers and post-traumatic stress disorder (Laposa et al.,
    doi: 10.3389/fpsyg.2021.599136          2003; Robertson and Perry, 2010). Meanwhile, long work hours and high-pressure environments

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Zhang et al.                                                                                                         Acute Stress and Quality of Life

increase the physical and psychological stress among medical             stress and QoL, and (3) to evaluate the influencing factors of
staff, leading to anxiety, depression, and, at worst, suicide            acute stress and QoL.
(Goyal et al., 2020).
   Quality of life (QoL) refers to an individual’s self-perception
of goals, expectations, standards, and concerns in the context           MATERIALS AND METHODS
of different cultures and value systems (Kuyken et al.,
1995). Traumatic life events have various psychological and              Sample
physiological consequences, affecting an individual’s well-being         Calculations were performed using G-Power statistical software
and QoL (Garfin et al., 2018). For example, adults who                   (G∗ Power Version, and the recommended sample
experienced an earthquake exhibit acute stress symptoms,                 size was 280. The inclusion criteria of the study were as
psychological distress, and maladaptive behaviors (Dorahy et al.,        follows: (a) people who obtained a certificate of professional
2016). Correspondingly, some studies reported that Ebola                 qualification, (b) staff on duty in hospitals during the COVID-
survivors suffered from various physical and mental sequelae             19 pandemic, (c) and people who volunteer to participate in
(James et al., 2019). Most existing studies have focused on              the research and sign the informed consent form. In total,
the victims of COVID-19. Furthermore, several studies have               525 participants from 15 hospitals were recruited using a
explored the mental health and QoL of health care workers                convenient sampling method. The participants were divided
during the outbreak. In their systematic review, de Pablo et al.         into three categories according to their occupation: (1) doctors;
(2020) summarized that 62.5% of health care workers reported             (2) nurses; (3) auxiliary staff, including technical executives
general health concerns during the outbreak of SARS, MERS-               (pharmacists, therapists, dieticians, and so others). Frontline
CoV, and COVID-19. Adverse psychological responses such as               medical staff were defined as individuals who had direct contact
high levels of anxiety, depression, and post-traumatic stress            with confirmed or suspected cases through diagnosis, treatment,
disorders may occur among front-line medical staff who are               nursing, nosocomial infection control, case sample collection,
in direct contact with the COVID-19 patients (Chersich et al.,           and pathogen detection. Otherwise, they were classified as non-
2020; Nochaiwong et al., 2020). Moreover, recent studies have            frontline medical staff.
demonstrated that the outbreak of COVID-19 had a significant
impact on QoL of health care workers (Huang et al., 2020;                Instruments
Suryavanshi et al., 2020).                                               Demographic Characteristics
   In facing this international health emergency, researchers            All participants were required to complete a demographic
strongly advise that everyone pay special attention to health            questionnaire, including gender, age, marital status, occupation,
care workers’ mental health and support them during the                  professional title, education level, disease, physical activity level,
COVID-19 outbreak (Xiang et al., 2020). Acute stress responses           and work status. Physical activity was defined as aerobic exercise
usually occur in the first month after a traumatic event,                that lasted for at least 30 min per session and was categorized into
accompanied by dissociative, re-experiencing, avoidance, and             never, low (1–2 times per week), moderate (3–5 times per week),
hyperarousal symptoms (Garfin et al., 2015). A study from                and high (6 or more times per week).
Toronto demonstrated that health care workers who had been                   Participants were invited to answer questions related to
in contact with SARS patients reported a severe acute trauma             COVID-19. They were required to give an honest response to the
response (Maunder et al., 2004). Front-line medical staff may            following questions: a) What is the current pandemic situation
report more severe psychological symptoms and worse QoL                  in your area? b) Have you been to Wuhan (in the last month)?
(An et al., 2020). Pietrzak et al. (2012) found that police              c) What is your current infection status regarding COVID-19?
who were older and widowed or divorced were more likely                  d) What do you think are your chances of being infected with
to suffer from post-traumatic stress disorder after experiencing         COVID-19? e) How long do you think the pandemic will last?
traumatic events. In addition, several recent studies have proved
that regular physical activity can lead to positive behavioral           Acute Stress Response
changes, strengthen the immune system, and reduce negative               Acute stress response was measured by the Stanford Acute
psychological impacts (Alsalhe et al., 2020; Jiménez-Pavón et al.,       Stress Reaction Questionnaire (SASRQ); it is a valid research
2020; Slimani et al., 2020). Although theoretical and empirical          instrument with good reported internal reliability (0.80–0.95)
evidence suggested that there might be a strong link between             and test-retest reliability (0.69) (Cardeña et al., 2000). Participants
acute stress and general health outcomes, acute post-traumatic           were invited to fill out the Chinese version of SASRQ to report
stress responses have not been well studied in health care               whether they had experienced acute stress related to COVID-
workers (Holman et al., 2014; Jeronimus et al., 2019). It is             19. The SASRQ is a 30-item questionnaire that rates acute
imperative to assess the acute stress responses after a traumatic        reactions to trauma on a 5-point Likert scale. It includes four
event to predict long-term health consequences (Dai et al.,              different subscales and three additional questions about the
2018). Accordingly, it is equally important to investigate the           traumatic event, which refers to COVID-19 in our study. The
physical and mental health of health care workers during the             questionnaire consists of the following: dissociative reactions (10
COVID-19 outbreak. The purpose of our study is as follows:               items), re-experiencing of trauma (6 items), avoidance (6 items),
(1) to determine the status of acute stress and QoL in health            hyperarousal (6 items), and impairment in social functioning
care workers, (2) to explore the relationship between acute              (2 items). The symptoms are considered positive if a score

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Zhang et al.                                                                                                         Acute Stress and Quality of Life

above three is obtained on at least one item of each subscale             IBM SPSS ver. 23.0 for Windows (IBM Corporation, Chicago,
(Roberge et al., 2010). A total score (range 0–150) is calculated         IL, United States).
through the sum of each item, with higher scores implying more
serious acute stress.

Quality of Life                                                           RESULTS
The Chinese version of the World Health Organization Quality
of Life Questionnaire (WHOQoL-BREF) demonstrated good                     Sample Characteristics and Distribution
reliability (0.76–0.90) and validity (0.72–0.82); it was used to          of SASRQ and QoL
assess the QoL of hospital employees in this study. This 26-              Among 525 volunteers, 502 completed the questionnaire, of
item instrument, rated on a 5-point Likert scale (range 1–5),             which 47 were excluded because of missing or implausible data.
consists of two questions on general health and four domains:             Finally, 455 individuals were included in this study, with a
physical health (7 items), psychological well-being (6 items),            response rate of 95.6% and an effective rate of 86.6%. Sample
social relationships (3 items), and environment (8 items).                characteristics of participants, SASRQ, and QoL scores are
The total score ranges from 26 to 130, with higher scores                 summarized in Table 1. More than half of the respondents were
reflecting a better QoL.                                                  under 35 years old (64.0%) and had received undergraduate
                                                                          education or above (94.7%). Of the total, 251 (55.2%) thought
Procedure                                                                 that the outbreak was under control, 292 (64.2%) believed
A non-probabilistic and convenience sampling method was                   the pandemic would last more than two months, and 408
conducted. Potential respondents were recruited exclusively               (89.7%) thought they were at risk of contracting COVID-
through online methods (QQ, Wechat, E-mail, etc.) and were sent           19. Regarding the participants’ scores for SASRQ, among
the questionnaire link. To reduce the risk of infection during the        the 455 volunteers (356 women) who enrolled in the study,
COVID-19 pandemic, all participants were invited to complete              nearly half (48.8%) experienced dissociative reactions; 26.6%
an online self-report questionnaire anonymously by clicking the           reported symptoms of trauma re-experience; 22.6% exhibited
survey link or scanning the Quick Response code.                          avoidance symptoms; 42.4% experienced hyperarousal, and
                                                                          31.9% suffered from maladaptive behaviors. The mean scores
Experimental Design                                                       on SASRQ and QoL were 25.88 (SD = 21.84) and 65.60
A cross-sectional descriptive correlational design was conducted          (SD = 12.60), respectively.
on health care workers to assess their acute stress response                 In the univariate analysis, the acute stress response levels
and QoL during COVID-19. Before recruitment commenced,                    varied significantly among differences in marital status (F = 4.062,
the study was designed following the Helsinki principles and              p = 0.018) and physical activity (F = 5.457, p = 0.002). Acute stress
approved by the Local Ethics Committee of Qianfoshan Hospital             was significantly higher in people who were divorced/widowed
Affiliated with Shandong University (2020S517). All respondents           and those who were not physically active. The statistical
provided informed consent (completed online) to participate in            differences in the degrees of acute stress were intimately tied
the research (10 February to 17 February, 2020). This study is            to the perceived risk of contracting COVID-19 (F = 12.698,
reported as per the STROBE checklist.                                     p < 0.001) and perceived pandemic status (F = 4.306, p = 0.014).
                                                                          Participants who perceived a medium or high risk of contracting
Statistical Analyses                                                      COVID-19 and perceived an upward trend in the pandemic’s
Descriptive statistics were generated for all variables. The              infection rate showed higher scores in SASRQ. Similarly, the
continuous demographic data included mean and standard                    front-line medical staff (t = 5.307, p < 0.001) and people who
deviation (SD), whereas frequencies and percentages were used             had been to Wuhan in the last month (t = 2.941, p = 0.003) were
to summarize the categorical variables. For each variable,                significantly more likely to exhibit acute stress.
Kolmogorov-Smirnov’s test was utilized to inspect the normality,             Regarding QoL, there was a significant difference in physical
and Levene’s test was performed to determine the homogeneity              activity (F = 8.072, p < 0.001), work status (t = −6.009,
of variance. The independent-samples t-test (or Mann–Whitney              p < 0.001), and the perceived risk of contracting COVID-19
U-tests) and the one-way analysis of variance (or Welch’s                 (F = 10.477, p < 0.001). The front-line medical staff was more
test) were used to evaluate the differences in continuous                 likely to report a worse QoL. Participants who were regularly
variables. The post hoc test was performed with Bonferroni                physically active and those who perceived themselves to be at
correction or Dunnet T3 test, depending on the homogeneity                no or low risk of contracting COVID-19 showed higher QoL
of variance test. Criteria for entry into the multiple linear             scores (Table 1).
regression included variables with p ≤ 0.10 in univariate
analysis (Kang et al., 2015). Subsequently, the bivariate Pearson’s       Correlations Among SASRQ and QoL
correlation analysis was utilized to determine the correlation            As shown in Table 2, the study participants’ acute stress
between acute stress and QoL. Stepwise multiple regression                response negatively correlated with QoL (r = −0.611, p < 0.001).
analysis was used to identify which variables influenced acute            Furthermore, the five dimensions of SASRQ significantly and
stress response and QoL. All statistical analyses were two-               negatively correlated with all QoL dimensions, which exhibited a
sided, and a p-value less than 0.05 was defined as statistically          strong negative association (r < −0.60) between acute stress and
significant. All original data were input and calculated by the           QoL in health care workers (all p < 0.001).

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Zhang et al.                                                                                                                            Acute Stress and Quality of Life

TABLE 1 | Univariate analysis of acute stress and quality of life with demographic (n = 455).

Variables                                         n (%)                    Acute stress response                                     Quality of life

                                                              Mean ± SD             t/F           p (post hoc)      Mean ± SD             t/F            p (post hoc)

Gender                                           −0.913           0.362                              0.588             0.557
Male                                            99 (21.8)    24.11 ± 23.34                                          66.26 ± 12.66
Female                                          356 (78.2)   26.38 ± 21.41                                          65.42 ± 12.59
Age (years)                                                                       1.197              0.303                               2.406              0.091
≤ 35                                            291 (64.0)   25.58 ± 21.09                                          64.65 ± 12.56
35–60                                           154 (33.8)   27.07 ± 23.67                                          67.19 ± 12.50
>60                                              10 (2.2)     16.40 ± 8.82                                          68.85 ± 13.46
Marital status                                                                    4.062              0.018                               0.393              0.675
Divorced/Widoweda                                7 (1.5)     27.86 ± 10.53                      a > b, p = 0.016†   61.53 ± 7.21
Marriedb                                        267 (58.7)    22.40 ± 1.37                      a > c, p = 0.007†   65.56 ± 12.12
Singlec                                         181 (39.8)    20.35 ± 1.51                                          65.82 ± 13.45
Occupation                                                                        0.456              0.634                               1.305              0.272
Nurse                                           229 (50.3)   25.42 ± 21.80                                          66.33 ± 12.99
Doctor                                          162 (35.6)   25.57 ± 21.66                                          65.41 ± 12.64
Auxiliary staff                                 64 (14.1)    28.30 ± 22.60                                          63.48 ± 10.87
Professional title                                                                0.053              0.949                               1.683              0.187
Primary                                         282 (62)     25.62 ± 21.08                                          64.78 ± 12.63
Intermediate                                    112 (24.6)   26.26 ± 23.30                                          67.27 ± 12.27
Senior                                          61 (13.4)    26.39 ± 22.86                                          66.33 ± 12.88
Educational level                                                                 1.334              0.264                               1.326              0.266
Associate degree or below                        24 (5.3)    24.96 ± 17.97                                          68.24 ± 12.23
Bachelor’s degree                               212 (46.6)   27.67 ± 23.06                                          64.69 ± 13.19
Master’s degree or above                        219 (48.1)   24.26 ± 20.94                                          66.19 ± 12.02
Chronic disease history                                                          −1.624              0.105                               0.416              0.677
Yes                                              14 (3.1)    16.57 ± 22.73                                          66.98 ± 11.82
No                                              441 (96.9)   26.18 ± 21.77                                          65.56 ± 12.63
Physical activity                                                                 5.457              0.002
Nevera                                          313 (68.8)   28.28 ± 22.78                      a > c, p = 0.029‡   63.71 ± 12.41        8.072              < 0.001
1–2 times/weekb                                 68 (14.9)    21.16 ± 20.68                                          69.01 ± 11.41                      b > a, p = 0.001†
3–5 times/weekc                                 60 (13.2)    21.07 ± 16.67                                          70.58 ± 11.79                      c > a, p < 0.001†
6 times or more/weekd                            14 (3.1)    15.79 ± 16.11                                          70.05 ± 16.19
Front-line medical staff                                                          5.307               b, p < 0.001‡   66.81 ± 12.76                      a > d, p < 0.001†


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TABLE 1 | Continued

Variables                                   n (%)                      Acute stress response                                           Quality of life

                                                           Mean ± SD             t/F            p (post hoc)           Mean ± SD            t/F            p (post hoc)

Medium riskc                              124 (27.3)      34.15 ± 25.67                       d > a, p = 0.005‡       61.78 ± 1 0.98                     b > c, p < 0.001†
High riskd                                 12 (2.6)       44.25 ± 22.23                       d > b, p < 0.042‡       56.17 ± 10.40                      b > d, p = 0.003†
Expected duration of the pandemic                                               5.173              0.072                                   1.014              0.386
1–2 monthsa                               163 (35.8)      23.32 ± 19.09                                               66.55 ± 12.27
2–3 monthsb                               253 (55.6)      26.01 ± 21.35                                               65.07 ± 12.41
3–6 monthsc                                33 (7.3)       32.49 ± 30.76                                               66.18 ± 14.91
≥6 monthsd                                  6 (1.3)       53.83 ± 32.15                                               59.08 ± 15.66

SD, standard deviation; COVID-19, coronavirus disease 2019.
† p-value of Bonferroni correction.
‡ p-value of Dunnet T3 test.

The variables such as physical activity, perceived pandemic status, perceived risk of contracting COVID-19 and expected duration of the pandemic were divided into four
categories: a, b, c, and d, respectively. Marital status was divided into three categories: a, b, and c.

TABLE 2 | Correlation between acute stress response and quality of life.

Variables                         Total score of QoL scale          Physical health            Psychological health         Social relationships           Environment

Total score of SASRQ                       −0.611**                        −0.586**                   −0.546**                    −0.417**                    −0.549**
Dissociation                               −0.571**                        −0.540**                   −0.522**                    −0.394**                    −0.503**
Re-experiencing of trauma                  −0.529**                        −0.519**                   −0.450**                    −0.354**                    −0.493**
Avoidance                                  −0.492**                        −0.475**                   −0.452**                    −0.315**                    −0.447**
Hyperarousal                               −0.624**                        −0.599**                   −0.554**                    −0.441**                    −0.545**
Impairment in functioning                  −0.414**                        −0.391**                   −0.354**                    −0.287**                    −0.390**

QoL scale, quality of life scale; SASRQ, Stanford Acute stress Reaction Questionnaire.
**p < 0.001 (2-tailed), based on Pearson’s correlation test.

Factors Influencing Acute Stress and                                                      hierarchical steps. Table 4 shows the results of the final multiple
Quality of Life                                                                           linear regression model. In our study, falling between 35 and
                                                                                          60 years of age (β = 0.143, p < 0.001), physically active 3–
Stepwise multiple linear regression analysis was conducted to
                                                                                          5 times per week (β = −0.109, p = 0.004), being a front-line
determine the factors that influenced acute stress and overall
                                                                                          medical staff member (β = 0.137, p < 0.001), and the total score
QoL. Seven variables, which were significant in univariate
                                                                                          of SASRQ (β = −0.545, p < 0.001) collectively accounted for
analysis, were gradually included in the regression model based
                                                                                          41.2% of the variance of QoL (R2 = 0.425, adjusted R2 = 0.412).
on the seven hierarchical steps. Finally, all explanatory variables
                                                                                          Additionally, acute stress response accounted for most of the
were incorporated into our regression model and summarized in
                                                                                          variance (1R2 = 0.373, adjusted 1R2 = 0.372) (Table 4).
Table 3. With respects to multivariate linear regression analysis,
Table 3 revealed the following: marital status (single: β = −0.424,
p = 0.017; married: β = −0.443, p = 0.012); physical activity
(3–5 times/week: β = −0.094, p = 0.035); front-line medical                               DISCUSSION
staff (β = −0.182, p < 0.001); perceived risk of contracting
COVID-19 (high risk: β = 0.130, p = 0.010; medium risk:                                   This study aimed to determine the relationship between acute
β = 0.276, p < 0.001); and the expected duration of the pandemic                          stress and QoL and explore the influencing factors on health care
(≥6 months: β = 0.095, p = 0.035) collectively accounted for                              workers during the outbreak of COVID-19. Our study presented
15.5% of the variance of SASRQ (R2 = 0.184, adjusted R2 = 0.155).                         that marital status, physical activity, work status, perceived risk
Since the variables in the regression analysis explain only a                             of contracting COVID-19, and the expected duration of the
small part of the variance, it also indicates that there may                              pandemic were significantly associated with the acute stress of
be other important predictive variables that have not been                                health care workers. Furthermore, age, physical activity, work
included, such as pre-existing mental and physical conditions or                          status, and acute stress responses significantly affected the QoL
pre-existing levels of acute stress and QoL. Therefore, further                           of health care workers.
research is needed.                                                                          In the multiple linear regression analysis, results indicated
   The dependent variable was computed as QoL. Acute stress                               that widowed individuals or those who experienced divorce
response and four significant variables derived from univariate                           reported more serious acute stress responses. As a traumatic
analysis were tested as independent variables. There were four                            event, divorce or loss of spouse is commonly accompanied
explanatory variables in the final regression model after five                            by numerous negative consequences and psychological distress.

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Pérez et al. (2017) observed that people who had experienced                                Our findings suggested that the front-line medical staff
negative life events were more likely to be affected by a                                exhibited greater levels of acute stress. Wang et al. (2020)
major traumatic event, showing higher levels of anxiety,                                 highlighted that acute stress disorder is a prominent
depression and post-traumatic stress. Consistent with previous                           psychological problem for front-line health professionals.
studies (Rosenbaum et al., 2015; Oppizzi and Umberger,                                   Working on the front-line is an independent risk factor for
2018), our findings suggested that engagement with moderate                              negative emotions (Lai et al., 2020). Zhou et al. (2020) showed
physical activity could alleviate the acute stress response. As                          that workload was associated with psychological disturbances
an auxiliary means to usual care, physical activity has been                             in frontline medical staff. However, health care workers with a
proven to improve the health conditions caused by PTSD                                   larger workload are less likely to participate in the survey and
(Rosenbaum et al., 2015; Oppizzi and Umberger, 2018). In a                               are more likely to receive psychological intervention, which
study conducted in New York, Shechter et al. (2020) found                                may lead to the underestimation of acute stress (Cole et al.,
that more than half of medical staff reported acute stress                               2009; Zhou et al., 2020). Furthermore, the degree of perceived
since the outbreak of COVID-19, and the most common                                      risk regarding contracting COVID-19 was associated with
coping style was physical activity. Based on the above findings,                         the level of acute stress response. Lin et al. (2007) reported
moderate and regular physical activity can help to deal                                  that a medical staff ’s self-perceived risk of infection caused
with the psychological problems associated with COVID-                                   by SARS could lead to severe PTSD. A study from Australia
19 quarantine.                                                                           showed that the perceived risk of contracting COVID-19 was

TABLE 3 | Multiple linear regression analysis of the influencing factors of acute stress response.

Variables                                        Unstandardized              Std. error (SE)          Standardized             t                         p
                                                 coefficients (B)                                    coefficients (β)

Marital status
Divorced/Widowed                                     Reference
Married                                              −19.608                      7.791                 −0.443             −2.517                     0.012*
Single                                               −18.905                      7.898                 −0.424             −2.394                     0.017*
Physical activity
Never                                                Reference
1–2 times/week                                        −5.024                      2.791                 −0.080             −1.800                     0.073
3–5 times/week                                        −5.911                      2.795                 −0.094             −2.115                     0.035*
6 or more times/week                                  −9.367                      5.528                 −0.074             −1.695                     0.091
Front-line medical staff
No                                                   Reference
Yes                                                   −8.275                      2.144                 −0.182             −3.859                  < 0.001**
Have been to Wuhan (in the last month)
No                                                   Reference
Yes                                                  −10.774                      5.982                 −0.085             −1.801                     0.072
Perceived pandemic status
Under control                                        Reference
Prevail peak                                            3.038                     4.022                   0.037              0.755                    0.451
Upward trend                                            3.430                     2.623                   0.063              1.308                    0.192
Indetermination                                         0.546                     2.670                   0.009              0.205                    0.838
Perceived risk of contracting COVID-19
No risk                                              Reference
Low risk                                                6.359                     3.244                   0.143              1.960                    0.051
Medium risk                                            13.530                     3.561                   0.276              3.799                 < 0.001**
High risk                                              17.693                     6.804                   0.130              2.600                    0.010*
Expected duration of the pandemic
1–2 months                                           Reference
2–3 months                                              0.004                     2.104                   0.000              0.002                    0.998
3–6 months                                              6.119                     3.992                   0.073              1.533                    0.126
≥6 months                                              18.096                     8.547                   0.095              2.117                    0.035*
R2                                                      0.184
Adjusted R2                                             0.155

COVID-19, coronavirus disease 2019.
*p < 0.05; **p < 0.001.

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associated with acute mental health responses (Newby et al.,                                   have more experience, professional skills, sophisticated
2020). The high perceived risk not only causes significant                                     coping strategies to deal with risks and crises, and pay
psychological distress and intense fear in individuals, but also                               less attention to negative information (Piotrkowska et al.,
prompts them to adopt protective measures (Lee et al., 2020;                                   2019). In the current study, people engaged in moderate
McCloskey and Heymann, 2020). We also demonstrated that a                                      physical activity reported higher QoL levels than those who
long expectation of disease duration might increase acute stress.                              never exercised. Our findings are partly consistent with
Previous studies showed that prolonged exposure to traumatic                                   Slimani et al. (2020), who reported that moderate physical
events usually indicated detrimental effects (Garfin et al.,                                   activity was positively correlated with all domains of QoL.
2015). When faced with emergencies, exposure to continuous,                                    Similarly, the WHO recommends at least 150 min of moderate
unpredictable threats, and overestimation of negative effects can                              exercise per week to improve QoL during the outbreak
lead to intense anticipatory anxiety (Grupe and Nitschke, 2013).                               of COVID-19.
Meanwhile, the excessive psychological expectation of potential                                   This study also highlighted that the QoL of front-line
negative stimuli is an important source of stress responses                                    medical staff was worse than those who were not in direct
such as anxiety and hopelessness (Simmons et al., 2011). Our                                   contact with patients. All health and safety personnel are
findings indicate that effective interventions are necessary                                   shown to be at high risk; notably, Lai et al. (2020) showed
to promote health care workers’ mental health. Moderate                                        that the more severe symptoms of depression, anxiety, and
physical activity and targeted psychological interventions                                     insomnia were reported by front-line workers. Moreover,
may be practicable.                                                                            heavy protective equipment and N95 masks make it difficult
   In our model, factors affecting the QoL of individuals                                      to breathe and communicate. Prolonged exposure to the
included age (36–60), being a front-line medical staff,                                        virus and the possible risk of infection could increase work-
physical activity (3–5 times per week), and the extent of                                      related and psychological stress. Furthermore, front-line
acute stress response. Older participants (ages between                                        medical staff is more likely to encounter patients dying from
35 and 60) had a higher QoL than younger participants                                          COVID-19. Research showed that the disposal of corpses
(age ≤ 35). Our conclusion is consistent with an air crash                                     results in negative psychological reactions and a poor QoL,
observation, which found that older individuals reported                                       which was the case in a sample of earthquake rescuers
a smaller increase in negative effects caused by the MH17                                      (Hsiao et al., 2019).
crash than younger participants (Jeronimus et al., 2019).                                         Furthermore, the multiple linear regression analysis showed
One possible explanation might be that older medical staff                                     that the most prominent potential risk factor was acute

TABLE 4 | Multiple linear regression analysis of the influencing factors of quality of life.

Variables                                          Unstandardized              Std. error (SE)           Standardized            t                         p
                                                   coefficients (B)                                     coefficients (β)

Age (years)
≤35                                                    Reference
36–60                                                     3.814                      1.001                   0.143              3.812                  < 0.001**
>60                                                     −0.693                       3.179                 −0.008             −0.218                     0.828
Physical activity
Never                                                  Reference
1–2 times/week                                            2.436                      1.342                   0.067              1.816                    0.070
3–5 times/week                                            3.935                      1.357                   0.109              2.900                    0.004*
6 or more times/week                                      1.449                      2.691                   0.020              0.539                    0.590
Front-line medical staff
No                                                     Reference
Yes                                                       3.601                      1.036                   0.137              3.476                    0.001*
Perceived risk of contracting COVID-19
No risk                                                Reference
Low risk                                                −1.553                       1.545                 −0.061             −1.006                     0.315
Medium risk                                             −2.589                       1.722                 −0.092             −1.504                     0.133
High risk                                               −3.071                       3.250                 −0.039             −0.945                     0.345
Acute stress response (SASRQ)                           −0.315                       0.022                 −0.545            −14.007                   < 0.001**
R2                                                        0.425
Adjusted R2                                               0.412

COVID-19, coronavirus disease 2019; SASRQ, Stanford Acute stress Reaction Questionnaire. Explained variance of acute stress response: 1R2 = 0.373, Adjusted
1R2 = 0.372.
*p < 0.05; **p < 0.001.

Frontiers in Psychology |                                            7                                    March 2021 | Volume 12 | Article 599136
Zhang et al.                                                                                                         Acute Stress and Quality of Life

stress responses, which contributed 37.2% of the variance,                a self-reported questionnaire, which does not include objective
while the remaining two factors only represented 4.0% of                  data or clinical diagnoses.
the variation on QoL. Our findings, along with previous
conclusions, indicated that acute stress response was associated
with QoL. A study on front-line health professionals during
the outbreak of COVID-19 showed that acute stress response                CONCLUSION
led to serious emotional distress and chest pain (Wang
et al., 2020). Chaudhury et al. (2015) demonstrated that a                This study displayed health care workers’ acute stress
history of acute stress increased individuals’ susceptibility to          responses and QoL during the outbreak of the COVID-19
depression by changing molecular activity in the brain. Lefebvre          pandemic. Factors such as marital status, physical activity,
et al. (2020) illustrated an inverse correlation between acute            work status, perceived risk of contracting COVID-19, and
stress and QoL in samples of victims of violent crime and                 the expected duration of the pandemic were significantly
added the evidence that health-related QoL to remain stable               associated with increased acute stress responses. In addition,
within 12 months. Another study emphasized that a serious                 younger individuals, lack of physical activity, front-line
onset of acute stress was significantly related to depressive             medical staff, and higher acute stress scores indicated a
disorders and anxiety symptoms; often manifesting a year                  worse QoL. It is imperative that the physical and mental
later for the first time (Bryant et al., 2012). Recurrent,                health of health care workers are improved, to help
acute stressors can increase the risk of hypertension by                  combat the COVID-19 pandemic. Our findings can help
activating the stress-mediating autonomic nervous system                  health practitioners and authorities to identify high-risk
(Gerin et al., 2012). Continuous fear stimuli are likely to               individuals and provide them with appropriate intervention and
cause abnormal neurocircuitry patterns, resulting in various              timely protection.
physiological damages (Olff et al., 2019). In other words, acute
stress not only affects the short-term QoL but also threatens
long-term health-related outcomes. It is, therefore, imperative           DATA AVAILABILITY STATEMENT
to reinforce the awareness of and intervention on the acute
stress of health care workers during the duration of the COVID-           The data analyzed in this study is subject to the following
19 pandemic.                                                              licenses/restrictions: The dataset presented in this article
   Generally speaking, our research may provide some ideas                involves 15 hospitals and the participants of this study
toward formulating protective measures for health care workers            did not consent to their data being shared. Requests
engaged in the COVID-19 pandemic. We recommend that                       to access these datasets should be directed to CX,
hospital managers pay close attention to the mental health      
of health care workers, especially front-line medical staff.
Professional psychological counseling services and an adequate
supply of personal protective equipment are needed to ensure the
safety of these health care providers (Banerjee, 2020).                   ETHICS STATEMENT
                                                                          The studies involving human participants were reviewed and
Limitations                                                               approved by the Local Ethics Committee of Qianfoshan
First, all respondents were asked to consider experiences with            Hospital Affiliated with Shandong University (2020S517).
COVID-19 as a specific stressful event and review the extent              Written informed consent for participation was not required for
to which the epidemic has interfered with their mental health             this study in accordance with the national legislation and the
and daily lives – thereby minimizing the effects of pre-                  institutional requirements.
existing stress and QoL on the results. Furthermore, due to
the sudden outbreak of the COVID-19 pandemic in China,
we only conducted a cross-sectional survey and could not
assess the psychological status at a baseline. Further longitudinal
                                                                          AUTHOR CONTRIBUTIONS
studies, with an extended follow up, will be needed to                    LZ, RJ, YJ, ML, and RW: study design, data collection, and
determine the causality between the acute stress response                 analysis plan. LZ, RJ, and CX: manuscript writing and revisions
and QoL. Second, an online investigation was conducted as                 for important intellectual content. All authors: statistical analysis
everyone was required to be quarantined. Hence, our sample                and final versions of the manuscript.
was not based on random selection from all hospital staff.
The use of convenience sampling meant that health care
workers who were under extreme stress or an extremely high
workload would be less likely to participate in the survey,               ACKNOWLEDGMENTS
causing selection bias and an underestimation of acute stress
and QoL. A more representative sample will be needed to                   Many thanks to all of the health care workers who
generalize our research results. Lastly, our study is limited to          participated in this study.

Frontiers in Psychology |                         8                                     March 2021 | Volume 12 | Article 599136
Zhang et al.                                                                                                                                           Acute Stress and Quality of Life

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   10.1002/hbm.21154                                                                           absence of any commercial or financial relationships that could be construed as a
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   11:1882. doi: 10.3389/fpsyg.2020.01882                                                      distributed under the terms of the Creative Commons Attribution License (CC BY).
Suryavanshi, N., Kadam, A., Dhumal, G., Nimkar, S., Mave, V., Gupta, A., et al.                The use, distribution or reproduction in other forums is permitted, provided the
   (2020). Mental health and quality of life among healthcare professionals during             original author(s) and the copyright owner(s) are credited and that the original
   the COVID-19 pandemic in India. Brain Behav. 10:e01837. doi: 10.1002/brb3.                  publication in this journal is cited, in accordance with accepted academic practice. No
   1837                                                                                        use, distribution or reproduction is permitted which does not comply with these terms.

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