TYPE Original Research

PUBLISHED 01 September 2023

DOI 10.3389/fpsyg.2023.1228515

Effects of COVID-19 stress,

OPEN ACCESS proximity, and adverse childhood
experiences on healthcare
EDITED BY
Vasfiye Bayram Deger,
Mardin Artuklu University, Türkiye

REVIEWED BY
Alessia Renzi,
workers’ mental health
Sapienza University of Rome, Italy
Majed Wadi,
Qassim University, Saudi Arabia
Tannaz Mirhosseini 1,2,3*, Andrea D. Guastello 1,3,4, Lourdes P. Dale 5,
*CORRESPONDENCE
Nicola Sambuco 2,3,4, Brandon R. Allen 6 and Carol A. Mathews 1,3,4
Tannaz Mirhosseini 1
Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL, United States,
[email protected] 2
Department of Clinical and Health Psychology, College of Public Health and Health Professions,
RECEIVED 24 May 2023 University of Florida, Gainesville, FL, United States, 3 UF Center for OCD, Anxiety, and Related Disorders,
ACCEPTED 08 August 2023 University of Florida, Gainesville, FL, United States, 4 Evelyn F. and William L. McKnight Brain Institute,
PUBLISHED 01 September 2023 University of Florida, Gainesville, FL, United States, 5 Department of Psychiatry, College of Medicine-
Jacksonville, University of Florida, Jacksonville, FL, United States, 6 Department of Emergency Medicine,
CITATION
College of Medicine, University of Florida, Gainesville, FL, United States
Mirhosseini T, Guastello AD, Dale LP,
Sambuco N, Allen BR and Mathews CA (2023)
Effects of COVID-19 stress, proximity, and
adverse childhood experiences on healthcare
Past research has shown that healthcare workers (HCWs) experience high levels
workers’ mental health. of psychological distress during epidemics and pandemics, resulting in cascading
Front. Psychol. 14:1228515. effects that have led to chronically understaffed hospitals and healthcare centers.
doi: 10.3389/fpsyg.2023.1228515
Due to the nature of their responsibilities and workplace stress, HCWs are among
COPYRIGHT
vulnerable groups especially during global health crises. During COVID-19
© 2023 Mirhosseini, Guastello, Dale, Sambuco,
Allen and Mathews. This is an open-access many healthcare workers reported greater symptoms of anxiety, depression,
article distributed under the terms of the and COVID-19 related worries. Furthermore, adverse childhood experiences
Creative Commons Attribution License (CC BY). increase vulnerability for psychological conditions, especially during pandemics.
The use, distribution or reproduction in other
forums is permitted, provided the original This study sets out to (1) investigate the moderating effects of adverse childhood
author(s) and the copyright owner(s) are experiences on healthcare workers’ COVID-19 related stressors and depression/
credited and that the original publication in this anxiety symptoms, and (2) investigate the moderating effects of adverse childhood
journal is cited, in accordance with accepted
academic practice. No use, distribution or experiences on proximity to the COVID-19 virus and depression/anxiety
reproduction is permitted which does not symptoms. Participants included 438 employed HCWs recruited from academic
comply with these terms. medical centers and smaller healthcare agencies in northcentral Florida between
October to December 2020. Mean age of participants was 38.23 (SD = 11.5)
with most of the HCWs being white (72.1%), non-Hispanic (86.8%) and female
(82%). Healthcare workers completed several online questionnaires, including the
Adverse Childhood Experiences scale, Patient Health Questionnaire, Generalized
Anxiety Disorder Scale, a COVID-19 specific worries scale, and a Social Proximity
to COVID-19 scale. Healthcare workers experiencing specific COVID-19 worries
reported experiencing anxiety and depressive symptoms. A significant positive
interaction was seen between childhood adverse experiences globally and
COVID-19 worries on anxiety symptoms. A significant positive interaction was
observed between childhood maltreatment specifically and COVID-19 worries
on depressive symptoms. Additionally, a positive interaction effect was seen
between childhood adverse experiences and COVID-19 social proximity for both
depression symptoms and anxiety symptoms. Findings from the present study
indicate that adverse childhood experiences strengthen the relationship between
COVID-19 worry/proximity and negative psychological symptoms. Vulnerable
populations such as individuals who have experienced ACEs could benefit from
targeted and specific interventions to cope with the collective trauma experienced
globally due to COVID-19. As COVID-19 becomes endemic, hospital leadership
and authorities should continue addressing COVID-19 worries and HCWs’
psychological symptoms through mental health support and organizational
interventions.

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KEYWORDS

healthcare workers, COVID-19, stress, anxiety, depression, adverse childhood

experiences, mental health, cross-sectional study

1. Introduction prevalent such as worrying about the health of family and friends, due
to the possibility of bringing the virus home, as well as an individual’s
The onset of the COVID-19 pandemic caused many individuals own health (Hidaka et al., 2021). These COVID-19 specific worries
to experience specific COVID-19 related worries, such as infecting can in turn increase other anxiety and depressive symptoms. For
family members with COVID-19, or becoming seriously ill from example, higher perceived risk has been shown to predict higher
COVID-19 (Hidaka et al., 2021). These worries were related to greater depressive symptoms (Kim et al., 2022). In particular, this is seen in
anxiety and depressive symptoms more generally (Gupta et al., 2021). HCWs due to their proximity to the illness and the uncertainty
The healthcare workforce was particularly at risk for developing involved with medical care and precautions needed. Additionally,
COVID-19 related worries as well as mental health symptoms, pandemics elicit anticipatory anxiety for both real and perceived
resulting in cascading effects that have led to chronically understaffed threats which can create high stress environments in hospitals and
hospitals and healthcare centers (Gupta et al., 2021; Søvold et al., burnout in HCWs (Denning et al., 2021). Similarly, Carmassi and
2021). Understanding the risk factors that make individuals more colleagues found that HCWs were at a higher risk for PTSD during
vulnerable to pandemic related worries and associated mental health pandemics due to infection rates, high mortality, and the constant
symptoms is an important public health concern. Prior to the change of guidelines experienced during COVID-19 (Carmassi
pandemic, adverse childhood experiences were shown to predict et al., 2020).
mental health disorders in adulthood (McKay et al., 2022; Tzouvara In HCWs, anxiety is commonly seen during pandemics due to the
et al., 2023). However, little is known about the interaction effect uncertainty and anticipation that comes from an unknown disease
between adverse childhood experiences and COVID-19 specific (Labrague and Santos, 2020). COVID-19 specific worries in this
worries on healthcare workers’ (HCWs) psychological symptoms. population can be due to fear of being infected, fear of unknowingly
Similarly, the interaction effect between adverse childhood experiences infecting others, lack of personal protective equipment, and lack of
and COVID-19 social proximity on HCWs’ psychological symptoms access to testing (Mo et al., 2020; Shanafelt et al., 2020).
has also not been explored. COVID-19 social proximity refers to the Kim and colleagues found that higher perceived COVID-19 risk
impact COVID-19 has had on an individual’s social circle. predicted greater depression symptoms among the general population
In the general population, the COVID-19 pandemic has negatively in South Africa (Kim et al., 2022). A U.S. sample of young adults ages
impacted individuals’ mental well-being and coincided with increased 18 to 25 indicated that this population reported up to a 55% increase
levels of anxiety, depression, and posttraumatic stress symptoms in COVID-19 related stressors (Ballou et al., 2020). Importantly, past
(Prout et al., 2020; Marvaldi et al., 2021). Recent research has shown research has shown that among young adults COVID-19 related
that these adverse mental health outcomes have been exacerbated in worry is related to negative mental health outcomes (Rogers et al.,
HCWs, potentially due to their proximity to COVID-19 patients, 2020; Mayorga et al., 2022). Research has also shown that proximity
COVID-19 quarantine rules and those rules changing, and work to an individual with the SARS-COV2 virus that causes COVID-19
environment (Labrague and Santos, 2020; Dobson et al., 2021; Tiete can also have a psychological impact on the people around them (Su
et al., 2021). Similar trends have been seen in non-clinical staff who et al., 2020). Several studies have reported on the connection between
work in healthcare settings, such as custodians and technicians social proximity to COVID-19 cases and increased anxiety and
(Dobson et al., 2021; Jang et al., 2021). A meta-analysis identified 38 depression (Su et al., 2020; Wang et al., 2020; Shabahang et al., 2021;
studies that reported an increase in mental health symptoms among Vigo et al., 2021).
doctors, nurses, and allied health workers since the start of the Another factor that can have a negative impact on mental health
pandemic (Saragih et al., 2021), with a pooled prevalence among these outcomes is adverse childhood experiences (ACEs). ACEs are
HCWs for anxiety of 40, and 37% for depression. identified as experiences that can negatively harm a child (0–17 years
Psychological symptoms have been seen in the United States in old). These experiences can be in the form of childhood maltreatment
both general and healthcare populations (Amsalem et al., 2021; (emotional, physical, and sexual abuse), neglect (emotional and
Guastello et al., 2022). Additionally, studies have shown that nurses in physical), familial challenges and dysfunction (caregiver separation,
particular are at higher vulnerability for psychological distress during poor or impaired caregiver mental health, and caregiver drug abuse)
infectious disease outbreaks (Greenberg et al., 2020; Magalhaes et al., (Felitti et al., 1998; LeMoult et al., 2020). It is estimated that 61% of US
2021). A five-month longitudinal study of HCWs in the United States adults have experienced at least one ACE, and approximately 16%
in the early stages of the COVID-19 pandemic found that anxiety and have experienced four or more categories (Merrick et al., 2019). These
depression symptoms were related to decreased fulfilment and experiences are associated with an increase in psychiatric disorders
elevated burnout (Guastello et al., 2022). (such as depression and anxiety) in adolescence and adulthood (Felitti
The burden of the COVID-19 pandemic has had major impacts et al., 1998; Cicchetti and Toth, 2005; Cicchetti, 2016; Iob et al., 2022).
on HCWs and the healthcare system. This burden has impacted the For example, a study of 1,142 participants aged 22–24 in the Chicago
physical and mental health of individuals who work in healthcare Longitudinal Study found that ACEs scores were related to increased
(Luo et al., 2020). At the onset of COVID-19 certain worries were depressive symptoms in early adulthood (Mersky et al., 2013). These

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relationships have also been examined by some research teams during service, where their responses to the survey questions were recorded.
the pandemic. A cross-sectional survey of 1,399 German adults found This study is part of a larger dataset which had a 5-month longitudinal
that ACEs were a significant risk factor for an increase in depression data collection (Guastello et al., 2022.) Recruitment was on a rolling
during the first wave of the pandemic (Clemens et al., 2022). ACEs put basis between October and December 2020. The present study focused
individuals at a higher vulnerability for psychological conditions, and on solely baseline findings. Lastly, participants were reimbursed with
several studies have examined the relationship between ACEs and $10 Amazon gift cards for completing the baseline surveys.
negative mental health symptoms during the pandemic (Castellini
et al., 2022; Kim et al., 2022; Békés et al., 2023). However, this specific
relationship has not been extensively examined with HCWs’ to the 2.2. Participants
others knowledge at the time of the study.
HCWs’ mental health symptoms during pandemic times is well- Participants included 438 employed HCWs recruited from
documented (Labrague and Santos, 2020; Amsalem et al., 2021; academic medical centers and smaller healthcare agencies in north
Saragih et al., 2021; Guastello et al., 2022). However, less is known central Florida. Specific workplace location was not collected to
about the way past adverse childhood experiences can impact their protect the participants anonymity, however based on the collection
worries about the pandemic and/or their own proximity to COVID-19 of the zip code data, the majority of the participants resided in Florida
and their mental health and well-being. The current study aims to (95.3%). Mean age of participants was 38.23 (SD = 11.5) with most of
examine the relationships between these variables in HCWs during an the HCWs being white (72.1%), non-Hispanic (86.8%) and female
early stage of the COVID-19 pandemic (from October to December (82%). See Table 1 for a summary of the sample characteristics.
2020). The aims of this study were:
Aim 1: To examine the role that adverse childhood experiences
plays in the relationship between COVID-19 specific worries and 2.3. Measures
negative psychological symptoms.
2.3.1. Adverse childhood experiences
Hypothesis 1.1: We hypothesized an interaction between The Adverse and Traumatic Experiences Scale (Dale et al., 2020,
COVID-19 specific worries and adverse childhood experiences, 2022; Kolacz et al., 2020) was administered to assess adverse childhood
such that the association between HCWs COVID-19 specific experiences (ACEs). This is a 30-question instrument that asks about
worries and depression/anxiety would be stronger in participants adversity and traumatic experiences, and covers both childhood and
who had more adverse childhood experiences. adulthood. This measure is comprised of items from: ACES (Felitti
et al., 1998), Trauma History Questionnaire (Hooper et al., 2011), Life
Aim 2: To examine the role that adverse childhood experiences Events Checklist for DSM-5 (Weathers et al., 2013), and Brief Trauma
plays in the relationship between proximity to COVID-19 and Questionnaire (Schnurr et al., 1999). The participants specify the
negative psychological symptoms. occurrence and impact of each event via a 5-point Likert scale (0 = event
did not occur, 1 = occurred and had no impact on my life, 2 = minimal
Hypothesis 2.1: We hypothesized an interaction between proximity
to COVID-19 cases and adverse childhood experiences, such that TABLE 1 Healthcare workers demographic.
the association between HCWs proximity to COVID-19 cases and
depression/anxiety would be stronger in participants who had n %
more adverse childhood experiences. Sex

Female 357 81.5

Male 73 16.7
2. Methods
Missing 8 1.8

2.1. Procedures Racial groups

American Indian 3 0.7

All procedures in this study were approved by the University of Asian 27 6.2
Florida’s Institutional Review Board. Participants were largely
Black/African American 58 13.2
recruited from two academic medical centers in north central Florida.
Announcements were posted throughout clinics, hospitals, and Multiracial 17 3.9

nursing homes in Florida via brochures emailed to relevant Native Hawaiian 1 0.2
departments or clinical services from an administrator. Also, flyers White 316 72.1
were given to smaller medical groups and private practices in two
Other 16 3.7
cities near the academic medical centers. Additionally, the study was
Missing 7 1.6
incorporated into the comprehensive Healthcare Worker Exposure
Responses & Outcomes (HERO) registry of studies (heroesrearch. Ethnicity
org). In order to maintain anonymity, the exact location of a Non-Hispanic 380 86.8
participant’s workplace was not included in their responses. Using a Hispanic/Latinx 46 10.6
QR code or link provided on the brochure, participants were directed
Missing 12 2.7
to Research Electronic Data Capture (REDCap), a secure survey

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TABLE 2 Principal components analysis with varimax rotation for COVID-19 specific worries.

Infection Childcare Economic

Item
worries worries worries
How worried are you that you will…

Infect an immediate family member if you get COVID-19 0.83* 0.04 0.10

Be infected with COVID-19 in your home or community (e.g., while at grocery store or pharmacy) 0.73* 0.14 0.05

Become seriously ill because of COVID-19 0.83* −0.00 0.12

Be infected with COVID-19 while providing medical care 0.68* 0.20 0.13

How worried are you that an immediate family member…

Will be infected with COVID-19 0.82* 0.13 0.04

Will become seriously ill with COVID-19 0.72* 0.27 0.20

Is having trouble coping with fear of getting COVID-19 0.47* 0.44 −0.01

How worried are you about the following…

My child’s emotional wellbeing 0.33 0.76* 0.22

My child’s education 0.11 0.83* 0.20

My child’s behavior at home 0.05 0.74* 0.21

How worried are you that you will…

Accessing or paying for childcare 0.06 0.21 0.75*

Lose your job 0.19 0.21 0.86*

Have trouble paying your bills 0.18 0.21 0.75*

Numbers indicate factor loadings. *Items included in the indicated factor.

impact on my life, 3 = some impact on my life, and 4 = big impact on my they have experienced the following symptoms of anxiety: feeling
life). The items are grouped to form the following scales: Childhood nervous, anxious or on edge; difficulty controlling worry; psychomotor
Adverse Experiences, Childhood Maltreatment, Intimate Partner agitation; trouble relaxing; general worries; fear that something
Maltreatment, Other Person Maltreatment, Life-threatening Situations, terrible will happen; and irritability. Responses are recorded on a
Sudden Losses, and Personal Health Situations. For the purpose of 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day).
examining ACEs, the subscales Childhood Adverse Experiences and The total score of the 7 items of the GAD-7 ranges from 0 to 21, with
Childhood Maltreatment were used in this study. The subscale scores exceeding 10 representing clinically significant anxiety. In our
Childhood Adverse Experiences captures caregiver unavailability, sample, the internal consistency of the GAD-7 was 0.93.
caregiver separation, caregiver drug abuse, caregiver medical or mental
illness, caregiver experience of emotional/physical/sexual abuse. The 2.3.4. COVID-19 specific worries
subscale Childhood Maltreatment captures emotional abuse, physical A COVID-19 specific worries and experiences questionnaire was
assault, sexual abuse of the participant by the caregiver. In our sample, created by the research team which consisted of various HCWs
the internal consistency for Childhood Adverse Experiences was 0.72, including psychiatrists, psychologists, and emergency medicine
and for Childhood Maltreatment it was 0.69. physicians. The scale consisted of 13 items, rated on a 0 to 3 scale with
the following descriptors: 0 (Not worried), 1 (A little worried), 2
2.3.2. Depression (Somewhat worried), and 3 (Very worried). The principal components
The Patient Health Questionnaire (PHQ-8; Kroenke et al., 2001) analysis produced 3 terms accounting for 68.12% of the variance. The
was administered to assess depression symptoms. On the PHQ-8 the items and their accompanying factor loadings are presented in Table 2,
participant is asked to rate over the last two weeks how frequently they and the derivation of the subscales can be found in the paper
have experienced the following symptoms of depression: low mood, (Guastello et al., 2022). The first component, termed Infection
anhedonia, hyper/hyposomnia, increased/decreased appetite, difficulty Worries, was comprised of seven items regarding worry about self and
concentrating, self-blame, psychomotor retardation/agitation. family members being infected and/or becoming seriously ill from
Responses are recorded on a 4-point Likert scale ranging from 0 (not COVID-19; the internal consistency of this factor was 0.89. The
at all) to 3 (nearly every day). The total score of the eight items of the second component, termed Childcare Worries, was comprised of
PHQ-8 ranges from 0 to 24, with a cut point of 10 indicating clinically three items related to worries about emotional wellbeing, education,
significant symptoms of depression (Kroenke et al., 2009). In our and behavior; the internal consistency of this factor was 0.77. Lastly,
sample, the internal consistency of the PHQ-8 was 0.89. the third component, termed Economic Worry, was comprised of
three items regarding financial concerns such as accessing or paying
2.3.3. Anxiety for childcare, loss of job, and having trouble paying bills; the internal
The Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., consistency of this factor was 0.86. See Table 2 for full factor analysis.
2006) was administered to assess anxiety symptoms. On the GAD-7 The Infection Worry factor, also referred to as the COVID-19 Worries
the participant is asked to rate how frequently over the last two weeks subscale, was utilized in this study.

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TABLE 3 Principal components analysis with varimax rotation for social proximity to COVID-19.

Known Household
Item Deaths
infections infections
I personally know someone (not close friend or relative) diagnosed with COVID-19 0.88* 0.04 0.15

I know someone at work that was diagnosed with COVID-19 0.85* 0.02 −0.04

A close friend or relative was diagnosed with COVID-19 0.60* 0.31 0.34

I cared for a member of my household that was diagnosed with COVID-19 0.08 0.86* 0.13

I have been diagnosed with COVID-19 0.06 0.86* −0.05

A close friend or relative passed away from COVID-19 −0.02 0.05 0.91*

I personally know someone (not close friend or relative) who passed away from COVID-19 0.47 0.01 0.64*
*Items included in the indicated factor.

TABLE 4 Descriptive statistics for predictor and outcome variables.

n M(SD) Median Range

Childhood adverse experiences 430 6.34 (5.8) 5 0–24
Childhood maltreatment 431 2.11 (2.9) 0 0–12
COVID-19 specific worries 435 10.72 (5.3) 11 0–21
Childcare worries 177 4.75 (3.41) 4 0–12
Economic worries 435 1.98 (2.23) 1 0–10
COVID-19 known infections 432 5.47 (3.1) 5 0–12
Household infections 435 0.71 (2.15) 0.00 0–20
COVID-19 deaths 435 1.31 (1.87) 0.00 0–8
Depression 434 6.08 (5.3) 5 0–24
Anxiety 434 5.55 (5.4) 4 0–21
Total sample was 438 participants.

2.3.5. Social proximity to COVID-19 statistics were first used to assess the distributions, normality,
A Social Proximity to COVID-19 scale was created by the research missing data, and any outliers among variables. Out of 438
team to measure the degree to which COVID-19 was impacting an participants, only 177 had children and answered for the variable
individual’s social circle (Table 3). The scale originally consisted of 8 Childcare Worries. Therefore, this subscale was dropped due to the
items, though one item (i.e., a member of my household passed away significant loss in sample size. Additionally, the subscale Economic
from COVID-19) was removed due to low endorsement. Each item worries was not used due to high cross-loading with Childcare
was rated on a 0 to 4 scale with the following descriptors: 0 (Did not Worries subscale. For Aims 1 and 2, four separate hierarchical linear
occur), 1 (Occurred, and no impact on my life), 2 (Minimal impact on regressions were conducted in order to examine the models with
my life), 3 (Some impact on my life), 4 (Big impact on my life). A COVID-19 worries, COVID-19 social proximity, childhood adverse
principal components analysis for the remaining 7 items was experiences and childhood maltreatment as predictors, and
conducted using varimax rotation. Items were considered to load on depression and anxiety as outcome variables. An interaction variable
a factor if they had a factor loading of ≥0.50. Items that loaded onto was computed for the variables of interest and added to the second
more than one factor were included in all factors. The principal block of the regression.
components analysis produced 3 factors that accounted for 72.65% of
the variance. The factor loadings are presented in Table 3. The first
component, termed Known Infections, contained three items 3. Results
regarding the social proximity to COVID-19 infections; internal
consistency was 0.74. The second component, termed Household 3.1. Descriptive statistics and preliminary
Infections, contained two items regarding members of the participant’s findings
household and they themselves being infected; internal consistency
was 0.69. The third component, termed, Deaths, contained two items The mean number of childhood adverse experiences reported in
regarding social proximity to COVID-19 related deaths; internal the sample was 6.35 (SD = 5.8), and the mean number of childhood
consistency 0.53. See Table 3 for full factor analysis. maltreatment experiences reported in the sample was 2.11 (SD = 2.9).
A floor effect was observed for both scales, with 21.9% of HCWs
reporting no childhood adverse experiences, and 54.1% reporting no
2.4. Overview of statistical analyses childhood maltreatment. Variability was seen across all variables. See
Table 4 for a summary of the findings. Correlational analyses were
All analyses were conducted in SPSS Statistics Version 26 [IBM used to examine the relationship between the variables of interest. See
Corp (SPSS Inc.), 2019], using data collected at baseline. Descriptive Table 5 for a summary of the findings.

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TABLE 5 Correlations.

M(SD) (1) (2) (3) (4) (5) (6) (7) (8) (9)
1. Childhood adversity 6.34 (5.8) –

2. Childhood maltreatment 2.11(5.9) 0.62** –

3. COVID worry 10.72 (5.3) 0.10* 0.07 –

4. Childcare worry 4.75 (3.41) 0.26** 0.24** 0.41** –

5. Economic worry 1.98 (2.23) 0.23** 0.22** 0.24** 0.51** –

6. Known infection 5.47 (3.1) 0.09 0.01 0.31** 0.36** 0.16** –

7. Household infection 0.71 (2.15) 0.07 0.05 −0.22** 0.02 0.15** 0.23** –

8. COVID-19 deaths 1.31 (1.87) 0.00 −0.01 0.13** 0.11 0.09 0.42** 0.07 –

9. Depression symptoms 6.08 (5.3) 0.32** 0.33** 0.30** 0.44** 0.39** 0.17** 0.05 0.06 –

10. Anxiety symptoms 5.55 (5.4) 0.28** 0.31** 0.27** 0.38** 0.34** 0.13** 0.03 0.03 0.77**
*p ≤ 0.05, **p ≤ 0.01.

TABLE 6 Hierarchical linear regression of COVID-19 worry on depression.

Unstandardized Standardized
Model coefficients coefficients Sig. R2 change Cumulative R2
B SE Beta
1 (Constant) 1.52 0.56 0.007 – 0.21

COVID Worry 0.27 0.04 0.27 <0.001

CAE 0.14 0.05 0.16 0.005

CM 0.40 0.10 0.22 <0.001

2 (Constant) 0.83 0.45 0.063 0.29 0.50

COVID Worry 0.19 0.04 0.19 <0.001

CAE 0.10 0.04 0.11 0.016

CM 0.41 0.08 0.23 <0.001

Worry X CAE 0.02 0.02 0.16 0.321

Worry X CM 0.06 0.02 0.40 0.012

Dependent variable is depression as assessed by PHQ-8 total score. CAE, Childhood Adverse Experiences; CM, Childhood Maltreatment; COVID Worry, COVID-19 specific worries.

3.2. Aim 1 was not seen for childhood adverse experiences, suggesting that the
level of exposure to childhood adverse experiences did not
To investigate the effects of childhood adverse experiences and influence the relationship between COVID worries and depression.
childhood maltreatment on the relationship between COVID-19 See Table 6 for hierarchical linear regression analyses, and Figure 1
related stressors and depression, main effects were examined in step for graphical representation of the interaction.
one of the linear regressions. Model 1 included childhood adverse To investigate the effects of childhood adverse experiences and
events, childhood maltreatment, and COVID-19 worries as childhood maltreatment on the relationship between COVID-19
predictors and depression as the outcome, shows that COVID related worries and anxiety main effects were examined. Model 1
worry significantly predicted depression (B = 0.27, p < 0.001), shows that COVID worry significantly predicts anxiety (B = 0.25,
childhood adverse experiences significantly predicted depression p < 0.001), and childhood maltreatment significantly predicts anxiety
(B = 0.14, p = 0.005), and childhood maltreatment significantly (B = 0.43, p < 0.001). The R2 change between model 1 and model 2 was
predicted depression (B = 0.40, p < 0.001). Model 2 included all of 0.34, with a significant F change (F = 128.01, p < 0.001). Model one
these predictors and interaction terms between COVID-19 worry consisting of main effects explains 17% of the variance, whereas model
and the two childhood experiences variables. The R2 change 2 with interactions added explains 50% of the variance. This indicates
between model 1 and model 2 was 0.29, with a significant F change that the regression model improved when accounting for the
(F = 132.01, p < 0.001). Model 1 explained 20% of the variance, interactions between childhood maltreatment and childhood adverse
whereas model 2 explained 49% of the variance, indicating that the experiences with COVID worry. The relationship between COVID
model fit improved when accounting for the interactions between worry and anxiety was stronger among individuals who scored higher
childhood maltreatment and childhood adverse experiences with in childhood adverse experiences (B = 0.05, p = 0.03). The same
COVID worry. The relationship between COVID worry and interaction was not seen for childhood maltreatment, meaning that
depression was stronger among individuals who scored higher in the level of exposure to childhood maltreatment did not influence the
childhood maltreatment (B = 0.06, p = 0.01). The same interaction relationship between COVID worries and anxiety. See Tables 3, 4 for

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FIGURE 1
Interaction effect of childhood maltreatment and COVID-19 worries on depression.

FIGURE 2
Interaction effect of childhood adverse experiences and COVID-19 worries on anxiety.

hierarchical linear regression analyses, and Figure 2 for graphical interaction models. The R2 change between model 1 and model 2 was
representation of the interaction. 0.31, with a significant F change (F = 122.00, p < 0.001). Model one
consisting of main effects explained 16% of the variance, whereas
model 2 with interactions added explained 47% of the variance. This
3.3. Aim 2 indicates that the regression model improved when accounting for the
interactions between childhood maltreatment and childhood adverse
To investigate the effects of childhood adverse experiences and experiences with Known COVID-19. The relationship between
childhood maltreatment on the relationship between Known Known COVID-19 infection and depression was stronger among
COVID-19 Infection and depression main effects were examined. individuals who scored higher in childhood adverse experiences
Model 1 shows that Known COVID worry significantly predicted (B = 0.05, p = 0.03). The same interaction was not seen for childhood
depression (B = 0.26, p = 0.003), childhood adverse experiences maltreatment, meaning that the level of exposure to childhood
significantly predicted depression (B = 0.15, p = 0.005) and childhood maltreatment did not influence the relationship between Known
maltreatment significantly predicted depression (B = 0.41, p < 0.001). COVID-19 infection and depression. See Tables 3–5 for hierarchical
Household infections and COVID-19 Deaths did not significantly linear regression analyses, and Figure 3 for graphical representation
predict depression and therefore were not included in the subsequent of the interaction.

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Mirhosseini et al. 10.3389/fpsyg.2023.1228515

FIGURE 3
Interaction effect of childhood adverse experiences and known COVID-19 infections on depression.

FIGURE 4
Interaction effect of childhood adverse experiences and known COVID-19 infections on anxiety.

To investigate the effects of childhood adverse experiences and experiences (B = 0.07, p = 0.003). The same interaction was not seen
childhood maltreatment on the relationship between Known for childhood maltreatment, meaning that the level of exposure to
COVID-19 Infection and anxiety main effects were examined. Model childhood maltreatment did not influence did not influence the
1 shows that Known COVID Infection significantly predicts anxiety relationship between Known COVID-19 infection and anxiety. See
(B = 0.21, p = 0.024), childhood adverse experiences on anxiety is Tables 3–6 for hierarchical linear regression analyses, and Figure 4 for
significant (B = 0.11, p = 0.046), and childhood maltreatment on graphical representation of the interaction.
anxiety is significant (B = 0.43, p < 0.001). Household infections and
COVID-19 Deaths did not significantly predict depression and
therefore were not included in the interactions. The R2 change between 4. Discussion
model 1 and model 2 was 0.37, with a significant F change (F = 149.04,
p < 0.001). Model one consisting of main effects explains 12% of the The current study aimed to examine the relationships between
variance, whereas model 2 with interactions added explains 49% of adverse childhood experiences, worries about the COVID-19
the variance. This indicates that the regression model improved when pandemic, proximity to COVID-19, and the mental health symptoms
accounting for the interactions between childhood maltreatment and of HCWs during the early stage of the pandemic. The findings of this
childhood adverse experiences with Known COVID. The relationship study can provide insights into the complex interplay between these
between Known COVID-19 infection and anxiety was stronger variables and highlight the potential impact of childhood experiences
among individuals who scored higher in childhood adverse on HCWs’ psychological well-being. Consistent with previous

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Mirhosseini et al. 10.3389/fpsyg.2023.1228515

TABLE 7 Hierarchical linear regression of COVID-19 worry on anxiety.

Unstandardized Standardized
Model Coefficients Coefficients Sig. R2 change Cumulative R2
B SE Beta
1 (Constant) 1.37 0.58 0.019 – 0.17

COVID Worry 0.25 0.05 0.29 <0.001

CAE 0.10 0.05 0.11 0.059

CM 0.43 0.10 0.23 <0.001

2 (Constant) 0.24 0.45 0.592 0.34 0.51

COVID Worry 0.19 0.04 0.18 <0.001

CAE 0.09 0.04 0.10 0.023

CM 0.29 0.08 0.19 <0.001

WorryXCAE 0.05 0.02 0.37 0.028

WorryXCM 0.03 0.02 0.23 0.160

Dependent Variable is Anxiety as assessed by GAD-7 total score. CAE, Childhood Adverse Experiences; CM, Childhood Maltreatment; COVID Worry, COVID-19 specific worries.

TABLE 8 Hierarchical linear regression of social Proximity to COVID-19 on depression.

Unstandardized Standardized
Model Coefficients Coefficients Sig. R2 change Cumulative R2
B SE Beta
1 (Constant) 2.88 0.53 <0.001 – 0.16

Known COVID 0.26 0.09 0.15 0.003

Household 0.20 0.15 0.06 0.184

Death −0.03 0.14 −0.01 0.813

CAE 0.15 0.05 0.16 0.005

CM 0.41 0.10 0.23 <0.001

2 (Constant) 1.69 0.43 <0.001 0.31 0.47

Known COVID 0.19 0.07 0.11 0.006

Household 0.11 0.18 0.04 0.337

Death −0.08 0.11 −0.03 0.464

CAE 0.13 0.04 0.14 0.002

CM 0.36 0.09 0.20 <0.001

KnownXCAE 0.05 0.02 0.38 0.025

KnownXCM 0.03 0.02 0.18 0.286

Dependent variable is depression as assessed by PHQ-8 total score. Known COVID, Known COVID-19 infections; Household, COVID-19 Household Infections; Death, COVID-19 Deaths;
CAE, Childhood Adverse Experiences; CM, Childhood Maltreatment.

research documenting the mental health challenges faced by HCWs results partially supported these hypotheses, as the interaction
during the pandemic (Labrague and Santos, 2020; Amsalem et al., between childhood maltreatment and COVID-19 worries was found
2021; Saragih et al., 2021; Guastello et al., 2022), the study findings to significantly predict depression. Specifically, individuals with higher
show a significant association between COVID-19 worries and levels of childhood maltreatment demonstrated a stronger relationship
negative psychological symptoms, including depression and anxiety. between COVID-19 worries and depressive symptoms. Similar results
These results highlight the substantial burden placed on HCWs due have been seen in a study done in South Africa during the first wave
to the pandemic-related concerns they face, emphasizing the of the COVID-19 pandemic which found that adults with histories of
importance of addressing these worries to support their well-being childhood trauma experience higher depressive impacts of perceived
(Tables 7–9). COVID-19 infection risk compared to individuals with no or minimal
One novel contribution of this study is the exploration of the role childhood trauma (Kim et al., 2022). These findings could imply that
of adverse childhood experiences in moderating the relationship childhood maltreatment may amplify the impact of COVID-19
between COVID-19 worries and mental health outcomes among worries on HCWs’ mental health. Gaining insight into this interaction
HCWs. The study hypotheses proposed that the association between can inform interventions to support HCWs with a history of
COVID-19 worries, and depression/anxiety would be stronger for childhood maltreatment and alleviate the negative psychological
HCWs who had experienced more adverse childhood events. The consequences of COVID-19 worries.

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Mirhosseini et al. 10.3389/fpsyg.2023.1228515

TABLE 9 Hierarchical linear regression of social proximity to COVID-19 on anxiety.

Unstandardized Standardized
Model Coefficients Coefficients Sig. R2 change Cumulative R2
B SE Beta
1 (Constant) 2.89 0.56 <0.001 – 0.12

Known COVID 0.21 0.09 0.12 0.024

Household 0.10 0.15 0.03 0.517

Death −0.04 0.15 −0.01 0.779

CAE 0.11 0.06 0.12 0.046

CM 0.43 0.11 0.24 <0.001

2 (Constant) 0.99 0.44 0.025 0.37 0.49

Known COVID 0.22 0.07 0.11 0.001

Household 0.04 0.12 0.01 0.744

Death −0.09 0.11 −0.03 0.445

CAE 0.11 0.04 0.12 0.010

CM 0.27 0.09 0.15 0.001

KnownXCAE 0.07 0.02 0.52 0.003

KnownXCM 0.01 0.03 0.10 0.589

Dependent variable is anxiety as assessed by GAD-7 total score. Known COVID, Known COVID-19 infections; Household, COVID-19 Household Infections; Death, COVID-19 Deaths; CAE,
Childhood Adverse Experiences; CM, Childhood Maltreatment.

Furthermore, the interaction between childhood adverse of individuals with COVID-19 in their building (Su et al., 2020).
experiences and COVID-19 worries was found to significantly predict Similarly, a web-based survey of 398 university students in Iran found
anxiety. This interaction was not seen with childhood maltreatment that individuals who personally knew of someone with COVID-19
suggesting that individuals who have experienced childhood experienced more COVID-19 anxiety than individuals who did not
maltreatment will report anxiety independent of having COVID-19 (Shabahang et al., 2021). A study of university students in Vancouver
specific worries. Similarly, to our findings, Békés and colleagues found found that knowledge of COVID-19 cases was associated with
that the number of reported adverse childhood experiences positively probability of elevated anxiety symptoms (Vigo et al., 2021). When
predicted reported levels of COVID-19 related fears, anxiety, and examining the interaction effects for this model, the relationship
depression (2022). However, unlike our results, Castellini and colleagues between Known COVID-19 infection and anxiety was only stronger
found in a general population sample of 101 Italian women that among individuals who scored higher in childhood adverse
individuals that experienced childhood trauma, specifically emotional experiences and not childhood maltreatment.
abuse, had increased levels of distress at the onset of the pandemic The current study has several implications in line with current
compared to individuals that did not report emotional abuse (2022). literature (Greenberg et al., 2020; Amsalem et al., 2021; Magalhaes
Moreover, the study examined the role of adverse childhood et al., 2021), for understanding and addressing the mental health
experiences in the relationship between HCWs’ proximity to needs of HCWs during pandemic times. Firstly, it emphasizes the
COVID-19 cases and negative psychological symptoms. The importance of recognizing and addressing the specific worries and
hypothesis proposed that the association between proximity to concerns related to the COVID-19 pandemic that HCWs experience.
COVID-19 cases and depression/anxiety would be stronger for HCWs Interventions and support systems should be implemented to help
with more adverse childhood experiences. When we examined the HCWs manage these worries effectively, providing them with
interaction effects, the relationship between Known COVID-19 resources and coping strategies to mitigate the negative psychological
infection and depression was stronger among individuals who scored symptoms associated with the pandemic. Secondly, the study
higher in childhood adverse experiences and not childhood highlights the potential long-lasting impact of childhood
maltreatment. This finding builds on previous research done by Wang maltreatment on HCWs’ mental health during the pandemic.
and colleagues which found that having knowledge of COVID-19 Expanding on past literature, this study demonstrates how the
cases in relatives and family members was associated with elevated presence of childhood adverse experiences such as caregiver
levels of depression symptoms (2020). unavailability, caregiver separation, caregiver drug abuse, caregiver
Similar interaction was seen when examining this model with medical or mental illness, caregiver experience of emotional/physical/
anxiety symptoms as the outcome variable, results show that Known sexual abuse can exacerbate the relationship between COVID-19
COVID-19 infection, childhood adverse experiences, and childhood specific worries and anxiety, as well as proximity to COVID-19
maltreatments all significantly predicted anxiety symptoms. These (Known COVID-19 infection) and depression and anxiety.
results were hypothesized given the previous research on COVID-19 Due to the nature of their responsibilities and workplace stress,
proximity and anxiety symptoms. In a housing compound in HCWs are among vulnerable groups especially during global health
Guangzhou, China, the results of 403 participants showed that higher crises. Considering the prevalence rates of ACEs in the United States,
anxiety levels were associated with residents that knew of the presence the results of this study emphasize the importance of keeping in mind

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Mirhosseini et al. 10.3389/fpsyg.2023.1228515

HCWs who have experienced past aversive childhood experiences as leaderships and authorities need to continue addressing COVID-19
these experiences can experience more psychiatric symptoms. In worries and HCWs’ psychological symptoms through mental health
addition to daily life stressors, HCWs are responding to unknown support and organizational interventions. More specifically, vulnerable
virus outbreaks and patient crises. For them to provide effective care populations such as individuals who have ACEs will benefit from
without experiencing burnout and significant depression and or targeted and specific interventions to cope with the collective trauma
anxiety, they need to attend to their own mental health well-being first. experienced globally due to COVID-19.
Seeking mental health care can be intimating and may be accompanied
with stigma even in medical settings. Therefore, the sole presence of
resources is not enough. Creating an environment where HCWs feel Data availability statement
encouraged to seek out mental health services is imperative for hospital
leaders, policymakers, and direct supervisors. Trauma-informed The original contributions presented in the study are included in
approaches and evidence-based interventions for individuals with a the article/supplementary materials, further inquiries can be directed
history of childhood maltreatment should be considered to enhance to the corresponding author.
their resilience and well-being during these challenging times.

Ethics statement
4.1. Strengths and limitations
The studies involving human participants were reviewed and
One of the strengths of this study is the inclusion of non-clinical approved by the University of Florida Institutional Review Board. The
HCWs in the sample. Many studies on HCWs focus on doctors and patients/participants provided their written informed consent to
nurses, and as prior research has shown non-clinical HCWs face participate in this study.
psychological distress given the environment of their work (Dobson
et al., 2021; Jang et al., 2021). Another strength of this study is the
sample size which allowed for better statistical power to detect Author contributions
relationships. One of the limitations when examining this study is its
limited diversity, the majority of the sample were white American TM conceptualized the manuscript, wrote the majority of the
women, and the sample was drawn from one health system in Florida. manuscript, and revised the manuscript. AG contributed funding for the
Gender of the participant could impact both adverse childhood parent study, conceptualized the manuscript, assisted with statistical
experiences and the manifestation of psychological symptoms. analyses and write up, and revised the manuscript. LD conceptualized
Diversifying the data by examining multiple different academic the parent study and inclusion of the measures of interest, and edited and
medical centers with different policies will provide a more revised the manuscript. NS conceptualized and secured funding for the
comprehensive insight to HCWs mental health given that it will parent study. BA and CM conceptualized the parent study and edited and
provide a larger variance in gender, ethnicity, and socioeconomic status. revised the manuscript. CM contributed funding for the parent study. All
This data was collected from October to December 2020, a time authors contributed to the article and approved the final version.
where many COVID-19 outcomes were still uncertain. It is worth
emphasizing that high-risk medical workers in these health systems
gained access to COVID-19 vaccines starting from December 2020. Funding
The pandemic could have affected HCWs that participated in the first
month of the study differently than HCWs that participated in the last This work was supported in part by the University of Florida,
month of the study given the availability of the vaccines and more Clinical and Translational Science Institute (supported in part by the
understanding of the virus. Therefore, due to the rapid change in NIH National Center for Advancing Translational Sciences under
policies at both state level and hospital level, as well as the award number UL1TR001427), and in part by the Evelyn F. and
unpredictability and unknown nature of COVID-19 at the beginning William L. McKnight Brain Institute and the UF Center for OCD,
stages of the pandemic, the generalizability of this data can be a Anxiety, and Related Disorders.
limitation. Nevertheless, this study provides an insight into the impact
COVID-19 had on HCWs at the end of the first year of the pandemic.
Future research could explore the long-term impact of COVID-19 Acknowledgments
stress and adverse childhood experiences on HCWs’ mental health
throughout different phases of the pandemic. The authors would like to acknowledge with gratitude the
healthcare workers who took time from their stressful jobs during the
pandemic to participate in our study.
5. Conclusion
This study expands on previous literature regarding the impact of Conflict of interest
COVID-19 on HCWs’ mental health. The current study found that
adverse childhood experiences strengthen the relationship between The authors declare that the research was conducted in the
HCWs COVID-19 worries and proximity when predicting their absence of any commercial or financial relationships that could
psychological symptoms. As COVID-19 becomes endemic, hospital be construed as a potential conflict of interest.

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Mirhosseini et al. 10.3389/fpsyg.2023.1228515

Publisher’s note organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
All claims expressed in this article are solely those of the claim that may be made by its manufacturer, is not guaranteed or
authors and do not necessarily represent those of their affiliated endorsed by the publisher.

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