Anxiety Levels and Coping Strategies to Deal with COVID-19: A Cross-Cultural Study among the Spanish and Latin American Healthcare Populations

Abstract

Given its impact, COVID-19 has engendered great challenges in terms of health, highlighting the key role of health personnel. This study aims to analyze the level of anxiety, as well as coping strategies, among the health personnel in Latin American countries and Spain. An exploratory, descriptive, quantitative, cross-sectional study was conducted with 584 participants from the healthcare population. No significant differences were observed in anxiety levels due to COVID-19 between Latin American countries and Spain. In Spain, an active and passive coping style is used, while in Latin American countries, an avoidance coping style is employed; there is a direct correlation between anxiety levels and the avoidance coping style. There exists an inverse correlation between anxiety levels and the use of an active coping style; moreover, there are no significant differences in the anxiety level of health personnel depending on whether they have cared for patients with COVID-19. Low cognitive activity, use of the avoidance method and Spanish geography were the main predictive coping styles of anxiety. Effective measures are required for preserving the mental health of health professionals during pandemics.

Full text

Citation: Olivencia-Carrión, M.A.;
Olivencia-Carrión, M.D.; Fernández-
Daza, M.; Zabarain-Cogollo, S.;
Castro, G.P.; Jiménez-Torres, M.G.
Anxiety Levels and Coping Strategies
to Deal with COVID-19: A Cross-
Cultural Study among the Spanish
and Latin American Healthcare
Populations. Healthcare 2023,11, 844.
https://doi.org/10.3390/
healthcare11060844
Academic Editor: Florin Oprescu
Received: 23 October 2022
Revised: 2 February 2023
Accepted: 12 February 2023
Published: 13 March 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
healthcare
Article
Anxiety Levels and Coping Strategies to Deal with COVID-19:
A Cross-Cultural Study among the Spanish and Latin American
Healthcare Populations
María Angustias Olivencia-Carrión1, *, María Demelza Olivencia-Carrión2, Martha Fernández-Daza 3,4,
Sara Zabarain-Cogollo 3,4, Greys Patricia Castro 3,4 and Manuel Gabriel Jiménez-Torres 1,5
1Health Psychology/Behavioural Medicine Research Group (CTS-267), Universidad de Granada,
18071 Granada, Spain
2Torredonjimeno Health Centre, 23650 Jaén, Spain
3Psychology Program, Universidad Cooperativa de Colombia, Santa Marta 110000, Colombia
4Interdisciplinary Social Studies Research Group-ESI, Santa Marta 110000, Colombia
5Department of Personality, Evaluation and Psychological Treatment, Faculty of Psychology,
Universidad de Granada, 18071 Granada, Spain
*Correspondence: maolivencia@ugr.es
Abstract:
Given its impact, COVID-19 has engendered great challenges in terms of health, highlight-
ing the key role of health personnel. This study aims to analyze the level of anxiety, as well as coping
strategies, among the health personnel in Latin American countries and Spain. An exploratory, de-
scriptive, quantitative, cross-sectional study was conducted with 584 participants from the healthcare
population. No significant differences were observed in anxiety levels due to COVID-19 between
Latin American countries and Spain. In Spain, an active and passive coping style is used, while
in Latin American countries, an avoidance coping style is employed; there is a direct correlation
between anxiety levels and the avoidance coping style. There exists an inverse correlation between
anxiety levels and the use of an active coping style; moreover, there are no significant differences
in the anxiety level of health personnel depending on whether they have cared for patients with
COVID-19. Low cognitive activity, use of the avoidance method and Spanish geography were the
main predictive coping styles of anxiety. Effective measures are required for preserving the mental
health of health professionals during pandemics.
Keywords: anxiety; coping strategies; COVID-19; pandemic; healthcare population
1. Introduction
The COVID-19 pandemic has led to a major global public health crisis. It is an
unprecedented event in the 21st century and has posed a comprehensive challenge for
everyone due to its impact on and consequences in different areas of life, such as health,
the economy, and society in general [
1
–
4
]. As per [
1
,
5
–
9
] the COVID-19 health crisis has
had a global impact in a short period of time, given that health professionals went from a
stable situation, to living in a work environment characterized by overcrowded hospitals,
lack of personal protection equipment, nonexistent or contradictory work protocols, and
an increase in mortality.
Additionally, health professionals have been directly involved with their COVID-19
patients at different stages—diagnosis, treatment, care, and in the process of death—as
family members were unable to accompany COVID-19 patients, who ended up dying
alone. Because of this, they are more vulnerable to psychological disorders, such as
anxiety [2,5–27].
Anxiety is defined as a set of physical, mental, and motor manifestations, not attributable
to real danger, but arising suddenly or as a constant and imprecise state [17,18,25,28–31].
Healthcare 2023,11, 844. https://doi.org/10.3390/healthcare11060844 https://www.mdpi.com/journal/healthcare

Healthcare 2023,11, 844 2 of 15
Another important aspect is the coping strategies that individuals utilize during critical
events. Ref. [
32
] suggested that coping is a changing process for adaptation purposes,
in which the subject and the environment constantly interact, and that people modify
their coping strategies depending on the type of problem to be solved. Likewise, coping
strategies refer to a set of responses that a person puts into practice to resolve challenging
situations and reduce the tensions generated by them [
28
,
33
]. Therefore, coping has been
shown to be a key factor for psychological well-being and mental health problems during
the COVID-19 pandemic [17,21,25,33–36].
Regarding coping strategies and their relationship with anxiety, the ones most com-
monly used by people with anxiety are problem-solving and positive reappraisal. The
cognitive avoidance strategy is also used, which is based on trying to withdraw or flee from
the stressor and its consequences [
37
]; it is characterized by the use of passive strategies
that consist of avoidance behaviors [38].
Several studies have elaborated the possible coping strategies associated with anxi-
ety [21,25,28,31,33–35,39–48].
In the general population, there are several factors related to psychological impact,
such as a lower perceived state of health, being female, a highly perceived vulnerability
to COVID-19, and exposure to negative news [
3
,
33
–
35
,
49
]. These factors are linked to the
perception of less social support and resilience [21,29,50–56].
Ref. [
49
] showed that the COVID-19 preoccupations were significantly and positively
correlated with anxiety, depression, and stress severity, and increased the use of mal-
adaptive copings. Furthermore, their findings highlighted that the various stresses of the
21st century due to the COVID-19 pandemic are related to personal well-being, thus it is
important to consider the potential global mental health in general population.
Specifically, the healthcare population has had to fight with an unknown virus, unsafe
measures and constant work stress, where deaths increased at an unbridled rate without
the ability to find safe treatments [2,4,6–9,11,14,15,18,23,24,34,39–42,45,57–65].
Moreover, the psychological impact produced by the COVID-19 pandemic can manifest
itself as serious problems involving a deterioration in the health and operation of the healthcare
population, resulting in anxiety, sleep disorders, stress, depression, burnout, acute stress, and
post-traumatic stress
disorder [1,2,4–7,9–14,16,17,19,20,23,24,26,29,35,39–42,45,48,52,60,64,66–68].
Various studies have shown that the presence of anxiety is associated with symptoms of stress,
nervousness, fear, fatigue, viral symptoms, job disappointment, perception of discrimination,
and negative actions related to COVID-19 [1,5–7,9–11,19,20,22–24,36,59,62,63,69].
Regarding Spanish studies that dealt with anxiety levels and coping strategies in
health professionals, we found the following: Ref. [
29
] showed that being a health pro-
fessional, having a lower level of perceived subjective stress, and a greater proportion of
active coping were significant predictors of fewer psychopathological symptoms. Ref. [
13
]
highlighted that the high scores for resilience were significantly associated with a better
quality of life and lower levels of anxiety, depression, and post-traumatic stress in the
healthcare population. Ref. [
59
] revealed that anxiety levels were higher in women and that
working with patients with COVID-19 increased their anxiety levels. Ref. [
70
] emphasized
the critical value of mental health professionals during the early stages of the pandemic for
those caring for patients with COVID-19. Ref. [
71
] analyzed the anxiety levels of health
professionals derived from the death of their patients, and found that the lack of personal
protection equipment and exposure to death resulted in high levels of anxiety. Ref. [
53
]
examined anxiety and resilience in health professionals, showing negative correlations be-
tween resilience and symptoms of generalized anxiety disorder, which was more prevalent
among women.
Regarding Latin American studies related to anxiety and coping strategies in the
healthcare population, we found the following:
In Peru, Refs. [
11
,
14
] showed the relationship between fear of contagion and physical–
cognitive fatigue, and a significant relationship between generalized anxiety and physical–
cognitive fatigue. Ref. [
69
] revealed that female health workers in particular, such as nurses

Healthcare 2023,11, 844 3 of 15
and those who work directly with COVID-19 cases, dealt with anxiety. Further, Ref. [
68
]
obtained similar results. Additionally, Ref. [
67
] determined the relationship between the
high level of generalized anxiety disorder and health personnel who provided care for
patients with COVID-19.
In Argentina, Ref. [
5
] revealed that the factors most related to the presence of psychic
distress are: direct work with patients with COVID-19, female gender, younger age and
nursing profession. Ref. [
25
] examined the relationship between anxiety and coping in the
context of the COVID-19 pandemic in the healthcare population.
In Colombia, Ref. [
12
] found that there was a decline in the sleep quality of mental
health workers during the COVID-19 pandemic. Ref. [
72
] highlighted that with physicians
during the COVID-19 quarantine, detecting anxiety symptoms among health personnel
attending patients infected with COVID-19 was a current priority. Ref. [
15
] revealed a
higher prevalence of post-traumatic stress disorder, anxiety, and depressive symptoms in
healthcare workers during the COVID-19 pandemic in Colombia. Ref. [
62
] revealed the
relationship between generalized anxiety disorders and the fear of COVID-19 in doctors
during the pandemic, associating other symptoms of anxiety, such as stress, fear, job
disappointment, and perception of discrimination. In a previous study, anxiety related to
the pandemic and professional work was found to be highly prevalent and more frequent
among physicians with perceived discrimination [63].
In Mexico, Ref. [
73
] showed that the increase in psychological stress and work over-
load was associated with the appearance of a generalized anxiety disorder, among other
factors. Refs. [
22
,
23
] revealed higher anxiety scores among health professionals who had
coronophobia, a higher perception of risk of contracting COVID-19 or infecting family
members, greater uncertainty as to how to properly cope with the pandemic and those
working in emergency rooms with patients with COVID-19.
In Ecuador, Refs. [
20
,
36
,
54
] showed that the healthcare population presented psycho-
logical distress and used positive coping strategies to continue with their work.
In Brazil, Ref. [
7
] revealed that the prevalence of anxiety, depression and stress symp-
toms in the health personnel indicated a high risk of mental illness in health professionals
during the COVID-19 pandemic.
Finally, in Latin America, recent studies have determined that healthcare workers
suffered middle-higher acute stress due to the outbreak, and experienced acute stress,
increasing in intensity as the incidence of COVID-19 increased [
19
]. A previous study
proposed to disseminate resources to mitigate the effects of COVID-19 and reflect on the
role of psychologists as part of the healthcare population during the pandemic [74].
The general aim of this study was to analyze the anxiety levels and coping strate-
gies among health personnel in Latin American countries and Spain. The specific study
objectives are as follows:
1.
Comparing the levels of anxiety due to COVID-19 among health personnel in Latin
American countries and Spain;
2.
Checking the differences by sex in the levels of anxiety due to COVID-19 among
health personnel;
3. Comparing the strategies for coping with COVID-19 by health personnel;
4.
Determining the influence of coping strategies on the level of health personnel anxiety
because of COVID-19;
5.
Observing the difference in anxiety levels between health personnel who have cared
for patients diagnosed with COVID-19 and those who did not;
6.
Studying the predictive factors of anxiety due to COVID-19 among health personnel.
The main question addressed by the research is: Does the type of coping strategy used
by the healthcare population to deal with COVID-19 have an impact on the level of anxiety
experienced by health professionals?

Healthcare 2023,11, 844 4 of 15
2. Materials and Methods
2.1. Participants
The sample comprised 584 Hispanic American health professionals, who worked
during the COVID-19 pandemic and who participated in this study voluntarily. This was
an incidental sampling drawn from the Spanish and Latin American healthcare populations.
The age range was between 18 and 75 years, and participants had different personal and
sociodemographic conditions (Table 1). It was a non-probabilistic convenience sample.
The sample size was estimated before the study, using the online calculator of the Clinical
and Translational Science Institute (University of California, San Francisco, CA, USA) for
clinical correlational research [75].
Table 1. Sociodemographic data of the participants.
Variables N%
Sex Women 424 72.6
Men 160 27.4
Age
18–44 410 70.2
45–59 136 23.3
60–74 37 6.3
75–90 1 0.2
Marital status
Married 197 33.7
Divorced/separated 49 8.4
Single 258 44.2
Unformalized union 75 12.8
Widower 5 0.9
Country of residence
Spain 167 28.6
South America 275 47.1
Central America and Caribbean
Islands 54 9.2
North America 88 15.1
Profession
Technical careers 78 13.4
Psychologist 40 6.8
Educator 16 2.7
Male nurse 120 20.5
Sciencehealth student 39 6.7
Medical 207 35.4
Other 84 14.4
Provided care to COVID-19 patients Yes 334 57.2
No 250 42.8
2.2. Instruments
The following measures have been used for data collection: the Zung Anxiety Scale [
76
],
Spanish version [
77
], which is a self-report measure comprising 20 items, designed ac-
cording to a Likert-type scale of four points (1–4) that measures anxiety symptoms. It
presents a minimum score of 20 and a maximum of 80, with the highest values corre-
sponding to more anxiety. Items 5, 9, 13, 17, and 19 are written in reverse order (no
symptoms or anxiety). These items are distributed in four anxiety subscales: Cognitive
(Items 1–5), Motor (
Items 6–9
), Vegetative (Items 10–18) and Central Nervous System Anxi-
ety (
Items 19 and 20
). Results greater than or equal to 40 are values indicative of pathology.
This scale has good validity, reliability, and discrimination.
Total raw scores range from 20 to 80 points. This raw score is converted to an anxiety
index, using a conversion table. According to this anxiety index, four levels of anxiety are
differentiated: no anxiety (20–44 points), mild anxiety (45–59 points), moderate/severe
anxiety (60–74 points), and extreme anxiety (
≥
75 points). This scale has well-established

Healthcare 2023,11, 844 5 of 15
psychometric properties [
78
,
79
]. For the present study, a Cronbach’s
α
value of 0.95
was obtained.
Scale of Styles and Strategies for Coping with Stress [
38
] is a 72-item self-report that
assesses 18 different strategies: positive reappraisal, depressive reaction, denial, planning,
conforming, cognitive disengagement, personal development, emotional control, detach-
ment, suppression of distracting activities, restrain coping, avoidance coping, problem-
solving, social support for the problem, behavioral disconnection, emotional expression,
emotional social support and palliative response, and eight different coping styles depend-
ing on the methods, approach, and type of activity used: active, passive, and avoidance
coping; response-, problem-, and emotion-focused coping; and behavioral and cognitive
coping (Table 2). Subjects responded to each item using a Likert-type scale ranging from
0 (never) to 3 (always). The higher the score obtained, the more commonly the coping
strategy was used. Then, the coping styles were scored by adding the scores obtained in
the corresponding coping strategies, noting that each strategy style is equal to that of the
coping strategies. Ref. [
80
] reported a Cronbach’s
α
of 0.73 for the full scale and 0.83 for
styles. In the present study, αfor the full scale and styles were 0.93 and 0.96, respectively.
Table 2. Coping strategies and styles.
Coping Strategies
Adaptive/helpful coping Nonadaptive/unhelpful coping
1. Positive reappraisal: Creating a new meaning of the situation
by doing something good about the problem.
2. Depressive reaction: Feeling overwhelmed by the situation,
being distrustful of oneself, and pessimistic about the results of
the problem.
4. Planning: Efforts to change the situation based on an
analytical, rational, and experiential approach to the problem.
3. Denial: Lack of acceptance and avoidance of reality,
distorting or disfiguring the problem.
5. Acceptance: Acceptance of the lack of personal control over
the situation and acquiescence to its consequences and
tolerating having unmanageable problems.
6. Cognitive disengagement: Using distracting thinking to
avoid focusing on the problem
7. Personal development: Consider the problem as a stimulus
and an opportunity for learning and personal growth.
8. Emotional concealment: Efforts to hide personal emotions
from others.
10. Elimination of distracting activities: Efforts to stop activities
that prevent you from concentrating on understanding and
solving the problem.
9. Emotional distancing: Cognitive efforts to suppress the
emotional outcomes generated by the situation.
11. Coping constraint: Reduce and defer any management
efforts until complete information about the problem is
obtained.
12. Coping with suppression: Stopping courses of action for fear
that any effort might make things worse or deeming the
problem impossible to solve.
13. Problem-solving: Decide and take a direct and reasoned
action to manage the problem.
15. Behavioral disengagement: Avoidance of any response or
action to solve the problem.
14. Social support for problem-solving: Seeking information,
advice, or help from others to solve the problem.
17. Social emotional support: Seeking sympathy and comfort
from others for one’s own emotions.
16. Emotional expression: Express to others your own
emotional reactions generated by the situation.
18. Palliative response: Avoiding the problem through
maladaptive actions taken, in an attempt to feel better (e.g.,
alcohol).
Coping styles
[Strategies included in each style]
Method
Active coping [1, 4, 7, 10, 13 & 16]
Passive coping [2, 5, 8, 11, 14 & 17]
Avoidance [3, 6, 9, 12, 15 & 18]
Attention
Focused on response [1, 2, 3, 10, 11 & 12]
Focused on the problem [4, 5, 6, 13, 14 & 15]
Focused on emotion [7, 8, 9, 16, 17 & 18]
Exercise
Cognitive coping [1, 2, 3, 4, 5, 6, 7, 8 & 9]
Behavioral coping [10, 11, 12, 13, 14, 15, 16, 17 & 18]

Healthcare 2023,11, 844 6 of 15
Additionally, the participants answered questions about their sociodemographic and
personal data (age, sex/gender, marital status, educational level, employment status,
number of children, and number of cohabitants). Finally, they indicated whether they had
had symptoms of COVID-19, had been diagnosed with COVID-19 through a positive test,
or have not had symptoms or a disease diagnosis.
2.3. Procedure
The researchers distributed an online survey in a single document to health personnel
in the participating countries. The study was open from May 2020 to February 2021. This
survey brought together different sociodemographic data, questions related to
COVID-19
,
and the two aforementioned instruments. Participants were requested to answer the
survey and send it back. All measurements were completed in a single application by
the participants. Finally, the database was downloaded and verified. Participants who
did not meet the inclusion criteria (i.e., age 18 or older, read and write Spanish fluently,
and voluntary participation) or exclusion criteria (i.e., serious physical or mental health
problems) were removed from the analysis. As all questions in the survey were mandatory,
there were no participants with missing or incomplete data that had to be removed from
the analyses.
2.4. Data Analysis
A non-experimental, cross-sectional, descriptive, correlational design was used [
81
].
The statistical treatment of the data was conducted with the SPSS 25.0 program (Statistical
Package for Social Science, 2008). To verify the accuracy of the data entered and to know
their characteristics, preliminary and exploratory analyses were carried out. Since a Lev-
ene’s test confirmed the homogeneity of variances (p> 0.05), we decided to use parametric
tests in the statistical analyses. The level of significance for all analyses was set at p< 0.05
(bilateral). Descriptive analyses and independent sample comparisons using a Student’s
t-test, Pearson’s bivariate correlations, and stepwise multiple linear regression analysis
were performed.
3. Results
3.1. Comparison of Anxiety Levels due to COVID-19 among Health Personnel in Latin American
Countries and Spain
As can be seen in Table 3, there were no significant differences in anxiety levels due to
COVID-19 between Latin American countries and Spain (except in cognitive symptoms of
anxiety, which were higher in the Spanish population).
Table 3.
Comparison of anxiety levels due to COVID-19 among health personnel in Latin American
countries and Spain.
Anxiety Measures M (SD) tNext (2-Sided) p-Value
Spain (n = 167) Latin America (n = 417)
Direct anxiety score 34.18 33.52 0.857 0.392 (n.s.)
(8.514) (8.439)
Anxiety index 42.79 42.04 0.781 0.435 (n.s)
(10.583) (10.536)
Somatic symptoms 11.31 11.28 0.083 0.934 (n.s)
(3.585) (4.031)
Cognitive symptoms 7.51 7.04 2.066 0.039 *
(2.469) (2.557)
* = p< 0.05; ns = non-significant difference.
3.2. Differences by Sex in the Levels of Anxiety due to COVID-19 among Health Personnel
Women showed higher levels of anxiety during COVID-19 than men (Table 4).

Healthcare 2023,11, 844 7 of 15
Table 4. Differences by sex in the levels of anxiety due to COVID-19 among health personnel.
Anxiety Measures M (SD) tNext (2-Sided) p-Value
Women (n = 424) Men (n = 160)
Direct anxiety score
Anxiety index
Somatic symptoms
Cognitive symptoms
34.20 (8.407)
42.87 (10.484)
11.52 (3.945)
7.30 (2.550)
32.39 (8.480)
40.63 (10.570)
10.67 (3.741)
6.84 (2.487)
2.311
2.298
2.349
1.966
0.021 (*)
0.022 (*)
0.019 (*)
0.050 (*)
* = p< 0.05.
3.3. Comparison of Strategies for Coping with COVID-19 by Health Personnel
As can be seen in Table 5, a passive coping style was used more frequently in Spain
than in Latin American countries. In these countries, an avoidance coping style was more
commonly used.
Table 5.
Comparison of strategies for coping with COVID-19 between health personnel in Latin
American countries and Spain.
Coping Strategies M (SD) tNext (2-Sided) p-Value
Spain (n = 167) Latin America (n = 417)
Active method
Passive method
Avoidance method
Focus on response
Focus on the problem
Focus on emotion
Cognitive activity
Behavioral activity
40.48 (12.213)
31.69 (8.227)
20.85 (8.067)
27.97 (8.300)
32.10 (9.027)
32.95 (7.917)
50.28 (12.802)
42.74 (11.623
38.30 (14.227)
29.37 (10.549)
23.39 (10.056)
27.56 (10.069)
31.27 (11.212)
32.23 (10.991)
49.33 (16.684)
41.73 (15.163)
1.739
2.547
−2.908
0.471
0.851
0.768
0.658
0.779
0.083 (n.s.)
0.010 (**)
0.004 (**)
0.638 (n.s.)
0.395 (n.s.)
0.443 (n.s.)
0.511 (n.s.)
0.436 (n.s.)
** = p< 0.01; ns = non-significant difference.
3.4. Influence of Coping Strategies on the Level of Anxiety in Health Personnel (Correlations
between Anxiety and Coping)
As shown in Table 6, a direct correlation was found between the level of anxiety and
the use of an avoidance coping style (0.152 **). This coping style is significantly associated
with both somatic and cognitive symptoms of anxiety (0.146 ** and 0.134 **, respectively).
Table 6. Correlations between anxiety and coping.
Anxiety
P. Dir.
Anxiety
Index
Somatic
Symptoms
Cognitive
Symptoms
Active
Method
Passive
Method
Avoid.
Method
Focal
Answer
Focal
Problem
Focal
Emoc.
Active
Cond.
Anxiety index 0.999 **
Somatic symptoms 0.889 ** 0.889 **
Cognitive symptoms 0.834 ** 0.834 ** 0.695 **
Active method −0.122 ** −0.122 ** −0.021 −0.042
Passive method −0.018 −0.019 0.041 0.026 0.772 **
Avoid. method 0.152 ** 0.152 ** 0.146 ** 0.134 ** 0.397 ** 0.628 **
Focal answer 0.033 0.033 0.071 0.084 * 0.765 ** 0.852 ** 0.778 **
Focal problem −0.065 −0.065 0.018 −0.013 0.878 ** 0.884 ** 0.651 ** 0820 **
Focal emoc. −0.002 −0.003 0.063 0.029 0.838 ** 0.883 ** 0.679 ** 0.798 ** 0.843 **
Activated cognition −0.054 −0.055 0.025 −0.002 0.878 ** 0.868 ** 0.697 ** 0.877 ** 0.919 ** 0.903 **
Active cond. 0.032 0.032 0.080 0.070 0.805 ** 0.912 ** 0.729 ** 0.894 ** 0.892 ** 0.891 ** 0.824 **
**. The correlation is significant at the 0.01 level; *. The correlation is significant at the 0.05 level.
In contrast, an inverse correlation was found between the level of anxiety and the use
of an active coping style (−0.122 **).

Healthcare 2023,11, 844 8 of 15
3.5. Differences in Anxiety between Health Personnel Who Have Cared for Patients Diagnosed
with COVID-19 and Those Who Did Not
No differences were found in the level of anxiety of health personnel, whether or not
they cared for patients with COVID-19 (Table 7).
Table 7.
Differences in anxiety levels among healthcare personnel depending on whether they cared
for patients with COVID-19.
Anxiety Measures M (SD) tNext (2-Sided) p-Value
YES Pat. COVID (n = 334) NO Pat. COVID (n = 250)
Direct anxiety score
Anxiety index
Somatic symptoms
Cognitive symptoms
34.12 (8.538)
42.74 (10.679)
4.74 (1.857)
10.61 (2.570)
33.15 (8.336)
41.60 (10.352)
4.58 (1.727)
10.54 (3.097)
−1.369
−1.285
−1.065
−0.331
0.172 (n.s.)
0.199 (n.s.)
0.287 (n.s.)
0.741 (n.s.)
ns = non-significant difference.
3.6. Predictive Factors of Anxiety due to COVID-19 among Health Personnel
The avoidance method, low cognitive activity and location (Spain) were the main
predictors of anxiety (Table 8). The following factors were excluded: sex, having treated
COVID-19 patients, and other coping strategies.
Table 8. Summary of the hierarchical regression analysis for factors predicting anxiety.
Predictive Factors B EE β
Model 1
Avoidance Method 0.134 0.036 0.152 ***
(R2= 0.023)
F(1. 582) = 13.855 ***
Model 2
Avoidance Method 0.326 0.049 0.370 ***
Cognitive Activity −0.168 0.030 0.312 ***
(R2= 0.073)
F(2. 581) = 22.933 ***
Model 3
Avoidance Method 0.348 0.050 0.395 ***
Cognitive Activity −0.179 0.030 −0.331 ***
Location (Spain) −1.716 0.759 −0.092 *
(R2= 0.081)
F(3. 580) = 17.101 ***
***. Significant at the 0.001 level; *. Significant at the 0.05 level.
4. Discussion
This study aimed to analyze the level of anxiety and coping strategies among health
personnel in Latin American countries and Spain, and the specific goals were the following:
to compare the levels of anxiety due to COVID-19 among health personnel in Latin Ameri-
can countries and Spain and to study the predictive factors of anxiety due to COVID-19
among health personnel in Latin America and Spain, among others.
The study results indicated that there are no significant differences between the lev-
els of anxiety due to COVID-19 between Latin American countries and Spain among
health personnel. This seems to indicate that health professionals tried to protect their
psychological health, and therefore their levels of anxiety, in the face of such an unprece-
dented threat in our recent history. These results support other studies that revealed that
positive mental health and social, emotional, and psychological well-being have a posi-
tive effect, confer resilience, reduce the negative consequences of unpleasant experiences,

Healthcare 2023,11, 844 9 of 15
promote an adaptive response to uncertain situations, and reduce the risk of suicidal
ideation [13,14,24,25,29–31,34,36,40,45,49,53,54,82–85].
Thus, Refs. [
2
,
5
–
7
,
9
,
11
,
22
,
23
,
26
,
58
,
60
] contradict our findings, as they showed that
the main sources of anxiety among health professionals were due to patient care, concern
about becoming infected or infecting family members, work-related concerns, burnout, and
fear of the unknown. Our results are inconsistent with [
2
,
5
,
6
,
11
,
16
,
19
,
20
,
22
,
23
,
26
,
36
], that
reflected that the COVID-19 pandemic has generated higher levels of anxiety among health
workers, regarding factors such as having been in contact with the virus or fear at work.
Moreover, our results are contrary to the studies by [
18
,
60
], as they showed that health
professionals have had to develop their profession in a precarious environment, putting
both their individual and collective health at risk, considerably increasing their patients’
death anxiety; the predictor variables of this anxiety are the absence of personal protective
equipment and high levels of burnout, emotional exhaustion, and depersonalization.
However, the findings of [
52
] support ours, as they showed that the prevalence of
anxiety was similar between health workers and the general population.
Other Latin American studies contradict our results, as they narrate the effects of
the COVID-19 pandemic on mental health found in health personnel and those who
work directly with suspected or confirmed cases of COVID-19 [
5
,
7
,
11
,
15
,
19
,
22
,
23
,
36
,
69
].
Additionally, other studies that differs from our results is that of [
35
,
67
], which consider
that anxiety shows a steady increase from the beginning of the pandemic to the present
among the healthcare population. This could be because the pandemic itself is an anxiety-
generating agent.
In contrast, our results show that women present higher levels of anxiety regarding
COVID-19 than men among health professionals, and we found significant differences
based on gender. Our results are consistent with those of [
2
,
5
–
7
,
11
,
13
,
15
,
20
,
36
,
59
,
69
], given
that female health professionals present greater anxiety regarding COVID-19 compared to
male health professionals. This could be due to the caregiver role that women play in their
homes, thus resulting in greater anxiety due to the fear of contagion. However, the results
should be contextualized, because a little over 80% of the sample in this study were women,
with professions linked to gender (nurses and nursing assistants). Moreover, our findings
are supported by studies by [
2
,
3
,
6
,
11
,
15
,
33
,
39
,
40
,
42
,
45
,
52
,
62
–
64
,
68
,
86
], as they show that
being a woman is decisive in exhibiting high anxiety about the consequences of COVID-19,
regardless of the country of origin of the study.
When comparing coping styles between Spain and Latin American countries, Spain
used the passive coping style more, while in Latin American countries, health professionals
used the avoidance coping style more. From Spain, our results are inconsistent with study
by [
29
], which showed that being a health professional, having a greater proportion of active
coping and lesser passive coping were significant predictors of fewer anxiety symptoms.
These data also differ from a Spanish study by [
43
] of the general population, in which
avoidance coping was one of the main predictors of anxiety levels during the pandemic.
This shows that these strategies may reflect ineffective ways of coping, because problem-
solving and a perspective change could be a valid approach for moderate anxiety symptoms.
In accordance with [
17
,
87
], we examined the link between different coping strategies with
anxiety symptoms and quality of life, both cross-sectionally and longitudinally, finding
that avoidance coping was associated with greater anxiety and lower quality of life at the
start of the study, thus supporting our findings in the present study.
Our findings reflect that there is a direct correlation between the level of anxiety and
the avoidance coping style associated with somatic and cognitive symptoms of anxiety.
Our data support studies on the healthcare population. Health professionals perceived that
their psychological health worsened during the COVID-19 pandemic, and higher levels of
anxiety were associated with increased avoidance coping strategies [
7
,
14
,
17
,
41
,
45
,
50
,
57
].
Thus, people with high levels of anxiety symptoms were prone to a maladaptive response
to uncertain new situations [1,9,16,17,35,39,40,64].

Healthcare 2023,11, 844 10 of 15
However, there are studies that used more aggressive reaction strategies, expressions
of coping difficulty and sought professional support and emotional avoidance [
1
,
2
,
5
,
7
,
9
,
11
,
12
,
17
,
19
,
23
,
28
,
33
]. This may be due to more mental health problems, fear of getting sick and
infecting their families, fear of death, regret for being a health professional, not wanting
to face reality, less time to rest, more night shifts, having a family, a lack of confidence in
the fight against the virus, lack of training on pandemic protection, and an inadequate
professional attitude.
Furthermore, our results show an inverse correlation between anxiety levels and
the use of an active coping style. Studies that contradict our results indicate that at a
higher level of anxiety, there exists less use of adaptive coping strategies and, conse-
quently, greater use of maladaptive coping strategies, both in the healthcare and in general
population [21,25,28–30,33–35,40,49–51].
This could be justified given that people with the
self-perception of being healthier adopted more positive coping strategies, such as emo-
tional coping, behavioral coping, and social support, and therefore suffered less anxiety
than those with poorer self-perceived health.
Our results show that there are no significant differences between the anxiety levels of
health personnel depending on whether they provided care for patients with
COVID-19
.
These results differ from those of [
11
,
67
], and other authors who showed that there
were mental health problems, such as anxiety, depression, post-traumatic stress in the
healthcare population, mainly in people working in the front line with COVID-19 pa-
tients, which may be due to the fear of contagion, work stress, and witnessing coworkers
die [1,5–8,18,19,22,23,26,39–42,44,45,52,53,57–59,61–63,65,69,86].
Finally, our results show that the avoidance method, low cognitive activity and location
(Spain) were the main predictors of anxiety. These findings refute the conclusions of [
43
] that
avoidance coping was one of the main predictors of anxiety levels in the general population
during the pandemic. Thus, Ref. [
33
] study, conducted with a university population, differs
from ours in term of the results, as the students expressed high levels of coping strategies
and comparatively low levels of anxiety. Additionally, cognitive coping, emotional coping,
and social support proved to have a significantly negative predictive effect on anxiety, with
social support being the most powerful predictor. These results support [
6
,
51
] studies,
which found that social support was negatively correlated with the level of anxiety in
university students and health professionals, respectively. Social support not only reduces
psychological stress during pandemics, but also changes attitudes regarding help-seeking
methods. This result suggests that strong and effective social support is needed during a
health crisis.
Study Limitations
The present study has some limitations. First, it was based on an online self-reported
questionnaire (April 2020–January 2021), the hardest period in terms of psychological
impact, which may influence the data gathered. Another limitation is the lack of literature
on comparisons of the healthcare population in Latin America and Spain and their relation-
ships in terms of anxiety levels and coping strategies. Most of the studies consulted are
based in Asia, the United States, and Europe, and focus more on showing the pandemic
situation by country due to COVID-19, making it difficult to endorse or contradict our
results. Furthermore, we have faced serious difficulties in finding such specific studies that
support or refute our findings, due to the limited literature on health personnel and their
relationship with anxiety and coping strategies during the COVID-19 pandemic; however,
there is more literature on the general population.
In contrast, it is positively highlighted that as far as we could ascertain, our study is
the first work to be currently carried out based on analyzing the level of anxiety and its
relationship with coping strategies among the healthcare populations of Spain and Latin
America.
Regarding future implications for clinical practice and research, it should be em-
phasized that health professionals are directly involved with patients with COVID-19 in

Healthcare 2023,11, 844 11 of 15
different phases, such as diagnosis, treatment, care, and even in the process of death. As a
result of this whole situation, they are more vulnerable to psychological disorders, such
as anxiety; therefore, investigating the relationship between anxiety levels and coping
strategies in the healthcare population should continue. It is recommended to conduct
different follow-up assessments of health personnel from 6 to 12 months to analyze the
differences during the several critical periods of the duration of the COVID-19 pandemic.
5. Conclusions
Coping styles and strategies influence the level of anxiety experienced in the health-
care population due to the COVID-19 pandemic. In conclusion, it is essential to reduce
the psychological impact on health personnel. To do this, specific training on COVID-19
is recommended, such as reinforcing security measures, guaranteeing their basic needs,
practicing adequate coping strategies to reduce anxiety, providing greater emotional sup-
port networks, and continuing research on which predictive factors contribute to a greater
well-being in health promotion and anxiety prevention.
The pandemic nature of COVID-19 makes this a relevant and novel study (unprece-
dented). The study is relevant because it provides some knowledge of this recent COVID-19
pandemic among the healthcare population. Therefore, its results can be extrapolated to
other possible pandemics that may occur in the future. It is important to disseminate the
information of our results among the healthcare population, in order to reduce their anxiety
levels and to encourage the use of appropriate coping strategies in future pandemics.
This underlines the need to increase our understanding of the psychological needs of
individuals in the 21st century, in which people are under pressure from various problems
that impact their quality of life.
Understanding these coping strategies provides insight into areas that need to be
addressed, to build and maintain a workforce within the healthcare system.
More studies such as ours are needed to better describe coping strategies and styles
among healthcare workers, as they relate to anxiety during the COVID-19 pandemic, as well
as identify effective resources that support the psychological well-being of healthcare workers.
Author Contributions:
M.F.-D.: Conceptualization, Methodology, Data curation, Writing—Original
draft preparation, Investigation, Supervision, Project administration. M.A.O.-C., M.D.O.-C., M.F.-D.,
S.Z.-C. and G.P.C.; M.G.J.-T.: Visualization, acquisition of data, Writing—Original Draft, Reviewing
and Editing. M.G.J.-T.: Formal analysis. All authors have read and agreed to the published version of
the manuscript.
Funding:
This work was funded by the Universidad Cooperativa de Colombia, Research Project “Psy-
chological impact and coping with COVID-19 in health personnel from Spanish-speaking countries”
(grant number INV2871).
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Ethics Committee of Universidad Cooperativa de
Colombia, Sectional Medellín (Protocol 005, 14/08/2020).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study.Written informed consent has been obtained from the patient(s) to publish this paper.
Data Availability Statement: Data is not available due to privacy restrictions.
Acknowledgments:
The authors thank all the participants that participated in this study and Univer-
sidad Cooperativa de Colombia (accessed on 14 May 2022).
Conflicts of Interest: The authors declare no conflict of interest.

Healthcare 2023,11, 844 12 of 15
References
1.
Frenkel, M.O.; Pollak, K.M.; Schilling, O.; Voigt, L.; Fritzsching, B.; Wrzus, C.; Egger-Lampl, S.; Merle, U.; Weigand, M.A.; Mohr, S.
Stressors faced by healthcare professionals and coping strategies during the early stage of the COVID-19 pandemic in Germany.
PLoS ONE 2022,17, e0261502. [CrossRef] [PubMed]
2.
Guttormson, J.L.; Calkins, K.; McAndrew, N.; Fitzgerald, J.; Losurdo, M.H.; Loonsfoot, B.D. Critical Care Nurses’ Experiences
During the COVID-19 Pandemic: A US National Survey. Am. J. Crit. Care 2022,31, 96–103. [CrossRef] [PubMed]
3.
Valiente, C.; Contreras, A.; Peinado, V.; Trucharte, A.; Martínez, A.P.; Vázquez, C. Psychological Adjustment in Spain during the
COVID-19 Pandemic: Positive and Negative Mental Health Outcomes in the General Population. Span. J. Psychol.
2021
,24, E8.
[CrossRef] [PubMed]
4.
Zhen, R.; Zhou, X. Latent Patterns of Posttraumatic Stress Symptoms, Depression, and Posttraumatic Growth Among Adolescents
During the COVID-19 Pandemic. J. Trauma. Stress 2021,35, 197–209. [CrossRef] [PubMed]
5.
Bramajo, M.P.; Soruco, C.; Miana, V.V.; Aldegani, P.G.; Blanco-Villalba, F.T.; Camus, C.; Blanco-Villalba, M.; Camus, M.; González-
Prieto, E. Malestar Psíquico, Conciencia de Mortalidad y Fatiga Laboral en Profesionales de la Salud durante el Trabajo en
Pandemia. Desvalimiento Psicosoc.
2022
,9, 1–25. Available online: http://dspace.uces.edu.ar:8180/xmlui/handle/123456789/6277
(accessed on 22 October 2022).
6.
Lluch, C.; Galiana, L.; Doménech, P.; Sansó, N. The Impact of the COVID-19 Pandemic on Burnout, Compassion Fatigue, and
Compassion Satisfaction in Healthcare Personnel: A Systematic Review of the Literature Published during the First Year of the
Pandemic. Healthcare 2022,10, 364. [CrossRef]
7.
Garcia, G.P.A.; Fracarolli, I.F.L.; dos Santos, H.E.C.; de Oliveira, S.A.; Martins, B.G.; Junior, L.J.S.; Marziale, M.H.P.; Rocha, F.L.R.
Depression, Anxiety and Stress in Health Professionals in the COVID-19 Context. Int. J. Environ. Res. Public Health
2022
,19, 4402.
[CrossRef]
8.
Veerapen, J.D.; McKeown, E. Exploration of the views and experiences of research healthcare professionals during their redeploy-
ment to clinical roles during the COVID-19 pandemic. J. Adv. Nurs. 2021,77, 4862–4875. [CrossRef]
9.
Xue, Y.; Lopes, J.; Ritchie, K.; D’Alessandro, A.M.; Banfield, L.; McCabe, R.E.; Heber, A.; Lanius, R.A.; McKinnon, M.C. Potential
Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the
Globe During COVID-19: A Scoping Review. Front. Psychiatry 2022,13, 863232. [CrossRef]
10.
Azoulay, E.; De Waele, J.; Ferrer, R.; Staudinger, T.; Borkowska, M.; Povoa, P.; Iliopoulou, K.; Artigas, A.; Schaller, S.J.; Hari, M.S.; et al.
Symptoms of burnout in intensive care unit specialists facing the COVID-19 outbreak. Ann. Intensiv. Care
2020
,10, 1–8. [CrossRef]
11.
Becerra-Medina, L.T.; Meneses-La-Riva, M.E.; Ruíz-Ruíz, M.T.; Marcilla-Félix, A.; Suyo-Vega, J.A.; Fernández-Bedoya, V.H. Mental
health impacts of nurses caring for patients with COVID-19 in Peru: Fear of contagion, generalized anxiety, and physical-cognitive
fatigue. Front. Psychol. 2022,13, 917302. [CrossRef] [PubMed]
12.
Cabeza, G.; Caballero, H.; Castiblanco, F.; Cabrera, D.; Martinez, F.; Lara, G. Impact of the COVID-19 pandemic on the quality of
sleep of mental health workers in Colombia. Dreaming 2022,32, 124–134. [CrossRef]
13.
Cobo-Cuenca, A.I.; Fernández-Fernández, B.; Carmona-Torres, J.M.; Pozuelo-Carrascosa, D.P.; Laredo-Aguilera, J.A.; Romero-
Gómez, B.; Rodríguez-Cañamero, S.; Barroso-Corroto, E.; Santacruz-Salas, E. Longitudinal Study of the Mental Health, Resilience,
and Post-Traumatic Stress of Senior Nursing Students to Nursing Graduates during the COVID-19 Pandemic. Int. J. Environ. Res.
Public Health 2022,19, 13100. [CrossRef] [PubMed]
14.
Dominguez-Garcia, R.S.; Villarreal-Sosa, C.J. Prevalencia de la Ansiedad y Depresión durante la COVID-19 en Profesionales
de la Salud: Una Revisión Sistemática. Licentiate Thesis, Universidad César Vallejo, Trujillo, Peru, 2022. Available online:
https://repositorio.ucv.edu.pe/handle/20.500.12692/82523 (accessed on 22 October 2022).
15.
Guillen-Burgos, H.F.; Gomez-Ureche, J.; Acosta, N.; Acevedo-Vergara, K.; Perez-Florez, M.; Villalba, E.; Maloof, D.; Dau, A.; Salva, S.;
Mattar, S.; et al. Post-traumatic stress disorder, anxiety, and depression symptoms in healthcare workers during COVID-19
pandemic in Colombia. Eur. J. Trauma Dissociation 2022,6, 100293. [CrossRef]
16.
Huang, G.; Chu, H.; Chen, R.; Liu, D.; Banda, K.J.; O’Brien, A.P.; Jen, H.-J.; Chiang, K.-J.; Chiou, J.-F.; Chou, K.-R. Prevalence of
depression, anxiety, and stress among first responders for medical emergencies during COVID-19 pandemic: A meta-analysis.
J. Glob. Health 2022,12, 05028. [CrossRef]
17.
Kumar, M.K.N.; Francis, B.; Hashim, A.H.; Zainal, N.Z.; Rashid, R.A.; Ng, C.G.; Danaee, M.; Hussain, N.; Sulaiman, A.H.
Prevalence of Anxiety and Depression among Psychiatric Healthcare Workers during the COVID-19 Pandemic: A Malaysian
Perspective. Healthcare 2022,10, 532. [CrossRef]
18.
Lázaro-Pérez, C.; Martínez-López, J.Á.; Gómez-Galán, J.; López-Meneses, E. Anxiety about the Risk of Death of Their Patients in
Health Professionals in Spain: Analysis at the Peak of the COVID-19 Pandemic. Int. J. Environ. Res. Public Health
2020
,17, 5938.
[CrossRef]
19.
Martin-Delgado, J.; Poblete, R.; Serpa, P.; Mula, A.; Carrillo, I.; Fernández, C.; Vicente-Ripoll, M.A.; Loudet, C.; Jorro, J.; Garcia-
Elorrio, E.; et al. Contributing factors for acute stress in healthcare workers caring for COVID-19 patients in Argentina, Chile,
Colombia, and Ecuador. Sci. Rep. 2022,12, 8496. [CrossRef]
20.
Pajuelo, A.R.M.; Ramos, J.E.I.; Lazo-Porras, M. Anxiety, Depression, and Post-Traumatic Stress Disorder (PTSD) Symptomatology
According to Gender in Health-Care Workers during the COVID-19 Pandemic in Peru Shortened Title: “Psychological Impact of
the Pandemic on Women”. Int. J. Environ. Res. Public Health 2022,19, 11957. [CrossRef]

Healthcare 2023,11, 844 13 of 15
21.
Meyer, D.; Van Rheenen, T.E.; Neill, E.; Phillipou, A.; Tan, E.J.; Toh, W.L.; Sumner, P.J.; Rossell, S.L. Surviving the COVID-19
pandemic: An examination of adaptive coping strategies. Heliyon 2022,8, e09508. [CrossRef]
22.
Martínez, R.M. La salud mental de los médicos que atienden COVID-19 en la Ciudad de México: Una investigación antropológica.
Rev. Cienc. Salud 2022,20. [CrossRef]
23.
Mora-Magaña, I.; Lee, S.A.; Maldonado-Castellanos, I.; Jiménez-Gutierrez, C.; Mendez-Venegas, J.; Maya-Del-Moral, A.; Rosas-
Munive, M.D.; Mathis, A.A.; Jobe, M.C. Coronaphobia among healthcare professionals in Mexico: A psychometric analysis. Death
Stud. 2020,46, 280–289. [CrossRef]
24.
Mortensen, C.B.; Zachodnik, J.; Caspersen, S.F.; Geisler, A. Healthcare professionals’ experiences during the initial stage of
the COVID-19 pandemic in the intensive care unit: A qualitative study. Intensiv. Crit. Care Nurs.
2021
,68, 103130. [CrossRef]
[PubMed]
25.
Pérez, G.S. Afrontamiento frente a los síntomas de ansiedad durante la pandemia por COVID-19Afrontamiento frente a los
síntomas de ansiedad durante la pandemia por COVID-19. Rev. Científica Arbitr. Fund. MenteClara 2022,7. [CrossRef]
26.
¸Sahin, C.U.; Kulakaç, N. Exploring anxiety levels in healthcare workers during COVID-19 pandemic: Turkey sample. Curr.
Psychol. 2021,41, 1057–1064. [CrossRef]
27.
Salopek-Ziha, D.; Našice, N.G.C.H.; Hlavati, M.; Gvozdanovic, Z.; Gasic, M.; Placento, H.; Jakic, H.; Klapan, D.; Simic, H.
Differences in distress and coping with the COVID-19 stressor in nurses and physiciaNS. Psychiatr. Danub.
2020
,32, 287–293.
[CrossRef]
28. Andreo, A.; Hilario, P.S.; Orteso, F.J. Ansiedad y estrategias de afrontamiento. Eur. J. Health Res. 2020,6, 213–225. [CrossRef]
29.
Becerra-García, J.; Sánchez-Gutiérrez, T.; Barbeito, S.; Aguilar-Pascual, L.; Verdugo-Martínez, A.; Larrinaga-Pardo, M.E.; Valle-
Garrido, A.; Ortín-Aguilar, A.B.; Pérez-Márquez, N.; Calvo-Calvo, A. Psychopathology in Spanish health professionals during
the COVID-19 pandemic and associated sociooccupational and psychological factors. Behav. Psychol. Psicol. Conduct.
2022
,30,
709–726. [CrossRef]
30.
Montero, I.; León, O.G. Una guía para nombrar estudios de investigación en psicología. Rev. Int. Psicol. Clínica Salud
2007
,7,
847–862.
31.
Ulloa, E.; Apiquian, R.; Francisco, R.; Díaz, R.; Mayer, P.; Palacio, J.D.; Palacios-Cruz, L.; Hernández, A.; García, P.; Rosetti, M.F.
Age and sex differences in the impact of the COVID-19 pandemic on mental health and coping mechanisms in Latin American
youth. J. Psychiatr. Res. 2022,1, 372–378. [CrossRef]
32. Lazarus, R.S.; Folkman, S. Estrés y Procesos Cognitivos; Martínez Roca: Barcelona, Spain, 1984.
33.
Li, Y.; Peng, J. Coping Strategies as Predictors of Anxiety: Exploring Positive Experience of Chinese University in Health
Education in COVID-19 Pandemic. Creat. Educ. 2020,11, 735–750. [CrossRef]
34.
Badon, S.E.; Croen, L.A.; Ferrara, A.; Ames, J.L.; Hedderson, M.M.; Young-Wolff, K.C.; Zhu, Y.; Avalos, L.A. Coping strategies for
COVID-19 pandemic-related stress and mental health during pregnancy. J. Affect. Disord. 2022,309, 309–313. [CrossRef]
35.
Elkayal, M.M.; Shahin MA, H.; Hussien, R.M. Psychological distress related to the emerging COVID-19 pandemic and coping
strategies among general population in Egypt. J. Egypt. Public Health Assoc. 2022,97, 3. [CrossRef]
36.
Ger, M.C.V.; Pico, O.M.A.; Naranjo, O.E.V.; Martinez, B.S. Estrategias de afrontamiento ante la crisis sanitaria: Un estudio
comparativo en enfermeros de costa y sierra ecuatoriana. Boletín Malariol. Salud Ambient. 2022,62, 1079–1085. [CrossRef]
37.
Fernández-Abascal, E.G. Estilos y Estrategias de Afrontamiento. In Cuaderno De Prácticas De Motivación Y Emoción; En Fernández
Abascal, E.G., Palmero, F., Chóliz, M., Martínez, F., Eds.; Pirámide: Madrid, Spain, 1997.
38. Lazarus, R.S.; Folkman, S. Estrés y Procesos Cognitivos; Martínez Roca: Barcelona, Spain, 1986.
39.
Msc, N.G.B.; Uzun, S.; KULAKAÇ, N. The relationship between anxiety levels and anger expression styles of nurses during
COVID-19 pandemic. Perspect. Psychiatr. Care 2021,57, 1829–1837. [CrossRef]
40.
Cui, S.; Jiang, Y.; Shi, Q.; Zhang, L.; Kong, D.; Qian, M.; Chu, J. Impact of COVID-19 on Anxiety, Stress, and Coping Styles in
Nurses in Emergency Departments and Fever Clinics: A Cross-Sectional Survey. Risk Manag. Health Policy
2021
,14, 585–594.
[CrossRef] [PubMed]
41.
Du, J.; Mayer, G.; Hummel, S.; Oetjen, N.; Gronewold, N.; Zafar, A.; Schultz, J.-H. Mental Health Burden in Different Professions
During the Final Stage of the COVID-19 Lockdown in China: Cross-sectional Survey Study. J. Med. Internet Res.
2020
,22, e24240.
[CrossRef]
42.
Kim, S.C.; Quiban, C.; Sloan, C.; Montejano, A. Predictors of poor mental health among nurses during COVID-19 pandemic.
Nurs. Open 2020,8, 900–907. [CrossRef]
43.
Lara, R.; Fernández-Daza, M.; Zabarain-Cogollo, S.; Olivencia-Carrión, M.A.; Jiménez-Torres, M.; Olivencia-Carrión, M.D.;
Ogallar-Blanco, A.; Godoy-Izquierdo, D. Active Coping and Anxiety Symptoms during the COVID-19 Pandemic in Spanish
Adults. J. Environ. Res. Public Health 2021,18, 8240. [CrossRef]
44.
Lin, J.; Ren, Y.-H.; Gan, H.-J.; Chen, Y.; Huang, Y.-F.; You, X.-M. Factors associated with resilience among non-local medical
workers sent to Wuhan, China during the COVID-19 outbreak. BMC Psychiatry 2020,20, 417. [CrossRef] [PubMed]
45.
Pang, Y.; Fang, H.; Li, L.; Chen, M.; Chen, Y.; Chen, M. Predictive factors of anxiety and depression among nurses fighting
coronavirus disease 2019 in China. Int. J. Ment. Health Nurs. 2021,30, 524–532. [CrossRef]
46.
Sandín, B.; Valiente, R.M.; García-Escalera, J.; Chorot, P. Impacto psicológico de la pandemia de COVID-19: Efectos negativos y
positivos en población española asociados al periodo de confinamiento nacional. Rev. Psicopatología Psicol. Clínica
2020
,25, 1–22.
[CrossRef]

Healthcare 2023,11, 844 14 of 15
47.
Shechter, A.; Diaz, F.; Moise, N.; Anstey, D.E.; Ye, S.; Agarwal, S.; Birk, J.L.; Brodie, D.; Cannone, D.E.; Chang, B.; et al.
Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19
pandemic. Gen. Hosp. Psychiatry 2020,66, 1–8. [CrossRef]
48.
Savitsky, B.; Findling, Y.; Ereli, A.; Hendel, T. Anxiety and coping strategies among nursing students during the COVID-19
pandemic. Nurse Educ. Pract. 2020,46, 102809. [CrossRef] [PubMed]
49.
Barchielli, B.; Cricenti, C.; Gallè, F.; Sabella, E.A.; Liguori, F.; Da Molin, G.; Liguori, G.; Orsi, G.B.; Giannini, A.M.; Ferracuti, S.; et al.
Climate Changes, Natural Resources Depletion, COVID-19 Pandemic, and Russian-Ukrainian War: What Is the Impact on Habits
Change and Mental Health? Int. J. Environ. Res. Public Health 2022,19, 11929. [CrossRef]
50.
Barcelata-Eguiarte, B.E.; Bermúdez-Jaimes, M.E. Psychological responses associated with stress during pandemic by COVID-19
in Colombian and Mexican adolescents. J. Stress Trauma Anxiety Resil. J-STAR 2022,1, 1–24. [CrossRef]
51.
Cao, W.; Fang, Z.; Hou, G.; Han, M.; Xu, X.; Dong, J.; Zheng, J. The psychological impact of the COVID-19 epidemic on college
students in China. Psychiatry Res. 2020,287, 112934. [CrossRef]
52.
Luo, M.; Guo, L.; Yu, M.; Jiang, W.; Wang, H. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on
medical staff and general public–A systematic review and meta-analysis. Psychiatry Res.
2020
,291, 113190. [CrossRef] [PubMed]
53.
Peñacoba, C.; Velasco, L.; Catalá, P.; Gil-Almagro, F.; García-Hedrera, F.J.; Carmona-Monge, F.J. Resilience and anxiety among
intensive care unit professionals during the COVID-19 pandemic. Nurs. Crit. Care 2021,26, 501–509. [CrossRef] [PubMed]
54.
Peñafiel-León, J.E.; Ramírez-Coronel, A.A.; Mesa-Cano, I.C.; Martínez-Suárez, P.C. El impacto psicológico, la resiliencia y el
afrontamiento del personal de salud durante la pandemia del COVID-19. Arch. Venez. Farmacol. Ter.
2021
,40, 202–211. [CrossRef]
55. Pérez-Rojo, G.; López, J.; Noriega, C.; Martínez-Huertas, J.; Velasco, C.; Carretero, I.; López-Frutos, P.; Galarraga, L.; Pillemer, K.
Older People’s Personal Strengths during the First Wave of the COVID-19 Pandemic. Psicothema 2021,33, 423–432. [CrossRef]
56.
Talavera-Velasco, B.; Luceño-Moreno, L.; García-Albuerne, Y.; Martín-García, J. Perception of health, resilience, and engagement
in Spanish police officers during the COVID-19 pandemic. Psicothema 2021,33, 556–563. [CrossRef] [PubMed]
57.
Al-Hanawi, M.K.; Mwale, M.L.; Alshareef, N.; Qattan, A.M.; Angawi, K.; Almubark, R.; Alsharqi, O. Psychological Distress
Amongst Health Workers and the General Public During the COVID-19 Pandemic in Saudi Arabia. Risk Manag. Health Policy
2020,13, 733–742. [CrossRef] [PubMed]
58.
Comfort, A.B.; Krezanoski, P.J.; Rao, L.; El Ayadi, A.; Tsai, A.C.; Goodman, S.; Harper, C.C. Mental health among outpatient
reproductive health care providers during the US COVID-19 epidemic. Reprod. Health 2021,18, 1–9. [CrossRef]
59.
Santamaria, M.D.; Ozamiz-Etxebarria, N.; Rodríguez, I.R.; Albondiga-Mayor, J.J.; Gorrochategui, M.P. Impacto psicológico de
la COVID-19 en una muestra de profesionales sanitarios españoles. Rev. Psiquiatr. Salud. Ment.
2021
,14, 106–112. [CrossRef]
[PubMed]
60.
Karagöl, A.; Kaya, Z.T. Healthcare workers’ burn-out, hopelessness, fear of COVID-19 and perceived social support levels. Eur. J.
Psychiatry 2022,36, 200–206. [CrossRef] [PubMed]
61.
Lee, N.; Lee, H.-J. South Korean Nurses’ Experiences with Patient Care at a COVID-19-Designated Hospital: Growth after the
Frontline Battle against an Infectious Disease Pandemic. Int. J. Environ. Res. Public Health 2020,17, 9015. [CrossRef]
62.
Monterrosa-Castro, A.; Buelvas-De-La-Rosa, C.; Ordosgoitia-Parra, E. Probable trastorno de ansiedad generalizada en la pandemia
COVID-19: Valoración en médicos generales del Caribe colombiano. Duazary 2021,18, 7–19. [CrossRef]
63.
Monterrosa-Castro, A.; González-Sequeda, A.; Beltrán-Barrios, T. Perception of discrimination in a group of colombian general
practitioners during the COVID-19 pandemic and its relation to labor and psychological factors. Salud Uninorte
2021
,36, 25–45.
[CrossRef]
64.
Nie, A.; Su, X.; Zhang, S.; Guan, W.; Li, J. Psychological impact of COVID-19 outbreak on frontline nurses: A cross-sectional
survey study. J. Clin. Nurs. 2020,29, 4217–4226. [CrossRef]
65.
Pelaccia, T.; Sibilia, J.; Fels, É.; Gauer, L.; Musanda, A.; Severac, F.; Abbiati, M. And if we had to do it all over again, would we
send medical students to the emergency departments during a pandemic? Lessons learned from the COVID-19 outbreak. Intern.
Emerg. Med. 2021,16, 1967–1974. [CrossRef]
66.
Ramírez-Ortiz, J.; Castro-Quintero, D.; Lerma-Córdoba, C.; Yela-Ceballos, F.; Escobar-Córdoba, F. Consecuencias de la pandemia
COVID-19 en la salud mental asociadas al aislamiento social. SciELO Prepr. 2020,1, 1–21. [CrossRef]
67.
Valladolid-Marcos, F.S. Estrés Postraumático y su Relación con el Trastorno de Ansiedad Generalizada en Personal de Salud Que
Atienden Pacientes COVID-19 Enfermos en el Marco de la Pandemia Global-Hospital de Emergencias JoséCasimiro Ulloa 2020.
In Investigaciones en Salud Mental en Condiciones de Pandemia por el COVID-19. Memoria del I Encuentro Virtual Avances y Propuestas
de Investigaciones en Salud Mental en Condiciones de Pandemia por COVID-19; Universidad Ricardo Palma: Santiago de Surco,
Peru, 2020.
68.
de Ramírez, L.V. Cuidado de la salud mental de las enfermeras: Prioridad en la pandemia por la COVID-19. Aquichan
2021
,21,
1–4. [CrossRef]
69.
Huarcaya-Victoria, J. Consideraciones sobre la salud mental en la pandemia de COVID-19. Rev. Peru. Med. Exp. Salud Pública
2020,37, 327–334. [CrossRef]
70.
Inchausti, F.; García-Poveda, N.V.; Prado-Abril, J.; Sánchez-Reales, S. La Psicología Clínica ante la Pandemia COVID-19 en España.
Clínica Salud 2020,31, 105–107. [CrossRef]
71.
Figueroa-Domecq, C.; De Jong, A.; Williams, A.M. Gender, tourism & entrepreneurship: A critical review. Ann. Tour. Res.
2020
,
1, 102980. [CrossRef]

Healthcare 2023,11, 844 15 of 15
72.
Camargo, L.; Herrera-Pino, J.; Shelach, S.; Soto-Añari, M.; Porto, M.F.; Alonso, M.; González, M.; Contreras, O.; Caldichoury, N.;
Ramos-Henderson, M.; et al. Escala de ansiedad generalizada GAD-7 en profesionales médicos colombianos durante pandemia
de COVID-19: Validez de constructo y confiabilidad. Rev. Colomb. Psiquiatr. 2021.ahead of print. [CrossRef]
73.
Díaz-Victoria, A.R. Elementos para comprender la discriminación y agresiones en contra de personal sanitario durante la
pandemia de COVID-19. Rev. Univ. Ind. Santander. Salud 2020,53, 319–325. [CrossRef]
74.
Scholten, H.; Quezada-Scholz, V.; Salas, G.; Barria-Asenjo, N.; Rojas-Jara, C.; Molina, R.; García, J.E.; Jorquera, M.T.J.; Heredia,
A.M.; Zambrano, A.; et al. Abordaje psicológico del COVID-19: Una revisión narrativa de la experiencia latinoamericana. Rev.
Interam. Psicol./Interam. J. Psychol. 2020,54, 1–24. [CrossRef]
75.
Hulley, S.B.; Cummings, S.R.; Browner, W.S.; Grady, D.; Newman, T.B. Designing Clinical Research: An Epidemiologic Approach,
4th ed.; Lippincott Williams & Wilkins: Philadelphia, PA, USA, 2013; Appendix 6C; p. 79.
76. Zung, W.W. A Rating Instrument For Anxiety Disorders. Psychosomatics 1971,12, 371–379. [CrossRef] [PubMed]
77.
Lusilla, M.P.; Sánchez, A.; Sanz, C.; López, J. Validación estructural de la escala heteroevaluada de ansiedad de Zung [XXVIII
Congreso de la Sociedad Española de Psiquiatría]. An. Psiquiatr. 1990,6, 39.
78.
Dunstan, D.A.; Scott, N. Norms for Zung’s Self-Rating Anxiety Scale. BMC Psychiatry
2020
,20, 90. Available online: https:
//bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2427-6 (accessed on 16 April 2022). [CrossRef] [PubMed]
79.
Tanaka-Matsumi, J.; Kameoka, V.A. Reliabilities and concurrent validities of popular self-report measures of depression, anxiety,
and social desirability. J. Consult. Clin. Psychol. 1986,54, 328–333. [CrossRef]
80.
Martín, M.; Jiménez, M.; Fernández-Abascal, E. Estudio Sobre la Escala de Estilos y Estrategias de Afrontamiento. Rev. Electrónica
Motiv. Emoción
1997
,3, 58–69. Available online: https://www.researchgate.net/publication/28076493_Estudio_sobre_la_escala_
de_estilos_y_estrategias_de_afrontamiento_E3A (accessed on 10 April 2022).
81.
Montero, E.; Morales-Rodríguez, F. Evaluation of Anxiety, Suicidal Risk, Daily Stress, Empathy, Perceived Emotional Intelligence,
and Coping Strategies in a Sample of Spanish Undergraduates. Int. J. Environ. Res. Public Health 2021,18, 1418. [CrossRef]
82.
Baenas, I.; Caravaca-Sanz, E.; Granero, R.; Sánchez, I.; Riesco, N.; Testa, G.; Vintró-Alcaraz, C.; Treasure, J.; Jiménez-Murcia, S.;
Fernández-Aranda, F. COVID-19 and eating disorders during confinement: Analysis of factors associated with resilience and
aggravation of symptoms. Eur. Eat. Disord. Rev. 2020,28, 855–863. [CrossRef]
83.
Farooq, S.; Tunmore, J.; Ali, M.W.; Ayub, M. Suicide, self-harm and suicidal ideation during COVID-19: A systematic review.
Psychiatry Res. 2021,306, 114228. [CrossRef] [PubMed]
84.
Griffiths, M.D.; Mamun, M.A. COVID-19 suicidal behavior among couples and suicide pacts: Case study evidence from press
reports. Psychiatry Res. 2020,289, 113105. [CrossRef] [PubMed]
85.
Rayani, S.; Rayani, M.; Najafi-Sharjabad, F. Correlation between anxiety and resilience of healthcare workers during COVID-19
pandemic in the southwest of Iran. Environ. Sci. Pollut. Res. 2021,29, 21528–21536. [CrossRef] [PubMed]
86.
Foli, K.J.; Forster, A.; Cheng, C.; Zhang, L.; Chiu, Y. Voices from the COVID-19 frontline: Nurses’ trauma and coping. J. Adv. Nurs.
2021,77, 3853–3866. [CrossRef] [PubMed]
87.
Shamblaw, A.L.; Rumas, R.L.; Best, M.W. Coping during the COVID-19 pandemic: Relations with mental health and quality of
life. Can. Psychol. Can. 2021,62, 92–100. [CrossRef]
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