Sex differences in psychological impact on healthcare workers during the COVID-19 pandemic

Abstract

Introduction

Sex differences in the psychological burden of the COVID-19 pandemic are of particular interest among Iranian healthcare workers (HCWs), given the distinct cultural and societal roles of Iranian women compared to their Western counterparts. This study aimed to assess the sex disparities in psychological symptoms—including anxiety, perceived stress, and depression—among Iranian HCWs.

Methods

In this multicenter cross-sectional study, participants were recruited from four different hospitals and community health centers in Babol, northern Iran. Data were collected using grouped, validated psychological and behavioral scales.

Results

Female HCWs reported significantly higher levels of perceived stress and anxiety than males (P = 0.001), while no significant sex differences were observed for depression, overall health-promoting lifestyle scores, self-efficacy, or self-esteem. However, males exhibited significantly higher levels of physical activity than females in the HPL subscale. After adjusting for potential confounders, the mean differences in perceived stress and anxiety scores between women and men were β = 2.32 (95% CI: 0.95–3.68, P = 0.001) and β = 1.72 (95% CI: 0.56–2.88, P = 0.004), respectively.

Conclusion

This study reveals a significant sex disparity in psychological outcomes, particularly in perceived stress and anxiety, with female HCWs experiencing a greater burden than males during the COVID-19 pandemic. Supportive interventions targeting the mental health of healthcare workers are therefore necessary.

Introduction

The COVID-19 pandemic has become a global public health emergency, resulting in significant morbidity, mortality, and social and economic impacts worldwide. Global healthcare systems have been placed under unprecedented strain, with high patient volumes, resource constraints, and overwhelming workloads [1, 2]. Beyond the physical health consequences, COVID-19 has placed severe psychological stress on the frontline healthcare workforce, with severe mental health problems consistently presenting frontline healthcare workers with increased exposure to illness and mortality and occupational hazards [3]. Numerous studies in both high- and middle-income countries have reported a high prevalence of perceived stress, anxiety, depression and sleep disturbances in healthcare workers during the pandemic, with varying degrees of severity depending on the national and regional context and infrastructure of health systems and their dynamic ability in the management of the disease [4–11].

Iran, like many countries severely affected by Covid-19, including European and North American countries [8–11], has faced profound challenges during the Covid-19 pandemic. Major challenges include limited access to protective equipment, a shortage of ICU beds, and overwhelming pressure on hospital systems, which have been plagued by high mortality rates and high rates of infectious disease transmission. However, in addition to these structural and epidemiological challenges, the psychological stress on Iranian healthcare workers has been significant. This is arguable given the unique culture, norms, and economic conditions of Iranian society. Despite the similarities in clinical practice, the mental health outcomes of health workers can be influenced by social norms, local values, sexual norms, and coping strategies and access to mental health support, with regional conditions varying significantly.

Globally, women have consistently been found to be more psychologically vulnerable. In particular, they report higher levels of anxiety and depression compared to men. Several biological, psychological, and social factors explain such vulnerability. These factors include hormonal changes and adverse pregnancy outcomes, exposure to violence in interpersonal relationships, gender inequality, and excessive caregiving burdens [12, 13]. Although these vulnerabilities exist universally, their effects are expressed in specific sociocultural contexts. In Iran, traditionally, the role of female health workers and the expectations of them and the responsibilities of women in the workplace and family have been formed and are still in place. That is, female health workers simultaneously provide services in the workplace and have multiple other duties in providing basic services for the family and children, which is likely to make them more vulnerable in crisis situations such as a pandemic.

Despite global interest in understanding the psychological impacts of COVID-19 on healthcare workers, there is little information specifically focusing on how gender differences play out in the context of Iranian culture. Most existing studies of psychological data collected in different countries have focused on populations in Western countries, which oversimplifies the notion that sexual interactions and distress can be generalized to other cultures and regions. In Iran, this knowledge gap is particularly important given that healthcare workers—especially women—are on the front lines of the pandemic response under extremely challenging conditions. Thus, this study was designed to examine gender differences in psychological symptoms—especially perceived stress, anxiety, and depression—among healthcare workers during the COVID-19 pandemic. Within a culturally specific framework, it aims to gain a more detailed understanding of how gender in the intersectional context impacts mental health in public health emergencies, and this insight may help inform the development of targeted intervention programs and support systems for health workers in similar settings.

Methods

Design and study participants

A multicenter cross-sectional study was conducted in Babol, northern Iran, during the COVID-19 epidemic in 2020. Participants aged 18–64 years included healthcare workers and nurses recruited from four major hospitals and ten healthcare centers affiliated with Babol University of Medical Sciences. In brief, proportional stratified sampling was employed across various hospital wards and ten randomly selected healthcare center clusters. A total of 400 participants were recruited, yielding a response rate of 89%. The individuals previously taking psychiatric medication before COVID-19 outbreak, diagnosed with cancer, on the end-stage of renal disease under hemodialysis and those who lost their first relatives during the last 3 months were excluded from the study.

Measurements, scales and data collection

Data were collected using several standard questionnaires. First, a self-structured scale was employed to gather demographic information and workplace-related variables, including age, sex, educational level, workplace status, COVID-19 morbidity among participants and their family members, and the death of first-degree relatives. Second, validated tools were grouped under broader categories of “mental health,” “lifestyle,” and “self-perception” scales to collect data [14–18]. The Persian versions of these scales, used in this study, have demonstrated good psychometric properties in previous research [19–24]. All questionnaire items were rated using Likert scales. Data collection was conducted through self-administered questionnaires, completed by participants under the supervision of trained nurses. To minimize measurement errors, all participants received face-to-face instruction from trained nurses on how to complete each scale. The questioners were responsible for reviewing the completed questionnaires, and any missing items were addressed immediately by asking the respondents to fill them in. Therefore, the number of missing items was negligible. Reliability analysis indicated that the Cronbach’s alpha coefficients for all scales exceeded 0.85, confirming high internal consistency.

Ethical considerations

The study protocol has been approved by the ethical institution board of the National Institute for Medical Research Development (NIMAD), Tehran, Iran (Ethical code: IR.NIMAD.REC.1399.279). All participants had given informed consent prior participation in the study.

Statistical analysis

Data were analyzed using SPSS software, version 22.0. In the bivariate analysis, frequencies and percentages were used to describe the distribution of categorical variables across genders, and the Chi-square test was applied for group comparisons. For quantitative variables, total scores of each scale were presented as medians with interquartile ranges (IQRs) across sexes, and the nonparametric Wilcoxon rank-sum test was used for comparisons. We dichotomized the anxiety, stress, and depression scores using appropriate cut-point values to estimate their prevalence among HCWs. Additionally, we considered an alternative analytical approach—continuous regression modeling—to preserve data granularity and enhance sensitivity in adjusting for potential confounders when comparing psychological outcome scores between sexes. Thus, to examine adjusted differences in anxiety, stress, and depression scores between sexes, multiple linear regression models were employed, controlling for demographic characteristics and workplace variables. Additional adjustments were made when analyzing self-esteem and self-efficacy scores. All statistical tests were two-sided, and 95% confidence intervals (CIs along with p-values were reported for the adjusted coefficients.

Results

Demographic characteristics of participants

The mean age of male and female participants was 40.50 ± 10.26 and 36.04 ± 8.85 years, respectively (P = 0.001). Their mean work experience was 15.60 ± 9.43 years for males and 12.06 ± 7.73 years for females (P = 0.001). The majority of healthcare workers (HCWs) were female (82%), and most held a bachelor’s degree or higher (88.5%). Additionally, approximately 81.5% of participants were married. More than half of the HCWs (53.0%) had experienced COVID-19 infection, and 61.8% reported that at least one first-degree relative had also been infected with COVID-19.

Bivariate analysis of HPL scores and other scales in relation to gender and workplace

Table 1 presents the median (IQR) scores for each of the six subscales of Health-Promoting Lifestyles (HPL), along with total HPL scores, perceived stress, anxiety, depression, self-esteem, and self-efficacy, stratified by gender. No significant gender differences were observed in most variables, except that, men reported significantly higher physical activity levels in the HPL subscale (P = 0.001), while women reported higher levels of perceived anxiety (P = 0.002) and perceived stress (P = 0.001). The prevalence of anxiety and stress was significantly higher in women than in men—53.3 vs. 39.4% (P = 0.03) and 90.4%vs. 77.4% (P = 0.009), respectively. The males tended to have higher level of depression than females. However, the difference was no significant between the sexes (35.5% in males vs. 42.2% in females; P = 0.54).

Table 1.

The median (IQR) scores of the different scale used in the study and the prevalence of psychological symptoms according to gender

Scales	Males	Females	P-value
	Med (IQR)	Med (IQR)
HPL (total score)	78.00(30.00)	76.00(26.00)	0.41
HR	1.67(0.67)	1.55(0.56)	0.97
PA	1.25(0.88)	1.00(0.75)	0.001
Nutr	1.44(0.67)	1.44(0.56)	0.34
SG	1.89(0.78)	1.78(0.78)	0.47
IPR	1.67(0.67)	1.78(0.67)	0.37
SM	1.25(0.62)	1.12(0.62)	0.10
Total score of perceived stress	16.00(5.00)	19.50(5.00)	0.001
Total score of self- esteems	21.00(8.00)	22.0(8.0)	0.24
Total score of anxiety	6.00(4.0)	8.0(7.0)	0.002
Total score of depression	7.0(60)	6.0(5.0)	0.24
Total score of self-efficacy	61.0(16.0)	61.0(13.0)	0.79
Anxiety n (%)	28 (39.4)	172 (53.3)	0.03
Perceived stress n (%)	55 (77.4)	293 (90.4)	0.009
Depression n (%)	30 (42.2)	115 (35.5)	0.54

Table 2 shows that healthcare workers employed in hospital settings had significantly higher total HPL scores compared to those working in primary healthcare centers (P = 0.003). Moreover, hospital workers reported higher scores in the subscales of physical activity (P = 0.007), nutrition habits (P = 0.001), social growth (P = 0.04), and stress management (P = 0.001). However, nurses working in hospitals experienced significantly higher levels of perceived stress (P = 0.001) and lower levels of self-esteem (P = 0.02) compared to healthcare workers in primary health centers.

Table 2.

The median (IQR) scores of the different scales used with respect to workplace

Sub-scales	Workplace		P-value
	Hospitals	Health care centers
	Med (IQR)	Med (IQR)
HPL (total score)	75.0 (28.5)	79.0 (25.5)	0.003
HR	1.55 (0.67)	1.67 (0.67)	0.07
PA	1.00 (0.75)	1.12 (0.94)	0.007
Nutr	1.44 (0.56)	1.67 (0.56)	0.00
SG	1.78 (0.67)	1.89 (0.78)	0.01
IPR	1.78 (0.67)	1.78 (0.78)	0.40
SM	1.12 (0.50)	1.25 (0.62)	0.001
Total score of perceived stress	20.0 (5.0)	18.0 (7.0)	0.001
Total score of self- esteem	21.0 (7.0)	23.0 (7.0)	0.02
Total score of anxiety	8.0 (6.0)	7.0 (7.0)	0.26
Total score of depression	6.0 (5.0)	6.0 (5.0)	0.25
Total score of self-efficacy	61.0 (11.0)	62.0 (17.5)	0.85
Anxiety n (%)	132 (51.9)	70 (48.2)	0.69
Perceived stress n (%)	230 (90.1)	123 (84.9)	0.12
Depression n (%)	95 (37.3)	52 (35.9)	0.18

HPL: Health promoting lifestyles, HR: Health Responsibility, PA: Physical Activity, Nutr: Nutrition habits, SG: Social Growth, IPR: Interpersonal Relationship, SM: Stress Management. Med: Median, IQR: Inter Quartile Range

Regression analysis of adjusted sex differences

Table 3 presents the unadjusted regression coefficients, adjusted coefficients, and the results after additional adjustments for HPLs, self-esteem, and self-efficacy scores. These coefficients represent both unadjusted and adjusted mean differences in total scores of perceived stress, anxiety, and depression between females and males’ participants. These coefficients were almost positive. It means that females’ HCWs almost had higher level of psychological symptoms than males’ HCWs. For example, the adjusted mean difference in perceived stress between women and men was 2.28 (95% CI: 0.72–3.84, P = 0.004). This positive coefficient is interpreted that the total score in perceived stress 2.28 unit in rating scale was higher than females. This value remained relatively unchanged after additional adjustments for HPLs, self-esteem, and self-efficacy. The adjusted sex difference in total anxiety scores between males and females was 1.45 (95% CI: 0.08–2.81, P = 0.04), with a slight increase in the regression coefficient following additional adjustments. However, surprisingly, no significant difference in total depression scores was observed between the sexes. Overall, these findings indicate that female healthcare workers experienced significantly higher levels of perceived stress and anxiety compared to their male counterparts, but there was no significant sex difference in depression levels.

Table 3.

The unadjusted and adjusted regression coefficients (95% confidence interval (CI)) of sex differences in perceived stress, anxiety and depression scores

Dependent variables	Unadjusted coefficient B(95% CI)	P	Adjusted€ coefficient Β(95% CI)	P	Additional ¥ adjustment coefficient Β(95% CI)	P
Stress score	2.58(1.33, 3.84)	0.001	2.28(0.72, 3.84)	0.004	2.32(0.95, 3.68)	0.001
Anxiety score	1.87(0.78, 3.84)	0.001	1.45(0.08, 2.81)	0.04	1.72(0.56, 2.88)	0.004
Depression score	−0.61(−1.57, 0.35)	0.35	−0.18(−1.32, 0.97)	0.76	−0.09(−0.98, 0.80)	0.84

¥ Adjusted by age, educational level, working experience, COVID19 morbidity, COVID-19 morbidity at 1st relatives.

¥ Additional adjustment by total scores of health promoting lifestyles, self-esteem and self-efficacy sores.

HPLs: Health promoting lifestyles, HR: Health Responsibility, PA: Physical Activity, Nutr: Nutrition habits, SG: Social Growth, IPR: Interpersonal Relationship, SM: Stress Management, IQR: Inter Quartile Range.

Discussion

Our findings indicate a significant sex disparity in the psychological impact of COVID-19, particularly regarding perceived stress and anxiety among healthcare workers (HCWs). Although both male and female participants experienced a high overall psychological burden, the effect was notably greater among women. This heightened burden may be attributed to increased patient loads, frequent shift work, and limited workplace resources during the pandemic. Similar findings have been reported in other studies on Iranian HCWs [4–7].

The greater psychological impact observed in female HCWs may partly be explained by individual characteristics, behavioral tendencies, and coping styles that differ by gender, as documented in Western cultural contexts. Additionally, the dual responsibilities often shouldered by women—especially those who are married—such as professional duties alongside caregiving roles within the household, may contribute to their heightened vulnerability. Several studies conducted in Iran have consistently shown a higher prevalence of mental health disorders among women compared to men in the general population as well [25]. This suggests that Iranian women, particularly housewives, are generally more susceptible to psychological distress. However, it is important to note that the participants in our study differ from the general population, as they represent a high-risk occupational group whose mental health is more directly influenced by workplace stressors—especially during epidemic conditions. The observed gender differences in psychological outcomes may also be influenced by varying levels of self-confidence, self-efficacy, and stress management strategies between women and men. These behavioral and psychological traits could help explain the differential impact of the pandemic across genders. In addition, the challenges women face in balancing their professional and personal lives. Women around the world have particularly impaired work-life balance. In some cases, having a family can serve as a mitigating factor for distress and provide emotional support, while in other situations the dual of household duties and professional responsibilities can place an additional burden of stress on women.

Moreover, health-promoting lifestyle (HPL) factors—such as physical activity, interpersonal relationships, social engagement, and leisure-time activities—are known to influence mental health, and these behaviors may differ between genders. In the present study, although the total HPL scores did not significantly differ between men and women, men reported a significantly higher level of physical activity. These findings are consistent with those reported by Zheng et al. [26]. In addition to the higher prevalence of psychological disorders among women, previous studies have also demonstrated that women tend to report lower scores in health-related quality of life, including psychological, social, and physical dimensions, and a higher rate of comorbidities compared to men [27, 28]. Moreover, gender may act as a modifier in the relationship between loneliness and health status among the elderly [29].

The presence of predisposing factors, when compounded by the demanding workload of HCWs during epidemic conditions, may lead to an amplified psychological burden among women. While global data often indicate that women are more susceptible to depression than men, our findings revealed no significant sex difference in total depression scores among healthcare workers. This result may be attributed to several cultural and contextual factors specific to Iran or lack of enough sample size to detect the observed effect size to be significant. First, the social stigma surrounding mental health, particularly among men, may lead to underreporting of depressive symptoms and thus mask underlying sex differences. Second, the unprecedented and prolonged stressors of the COVID-19 pandemic—including high workload, exposure risk, and emotional fatigue—may have exerted a uniformly high psychological burden on both sexes, thereby reducing typical disparities. Third, women in our sample may have employed more adaptive coping strategies (e.g., emotional expression, use of social support), which could have mitigated depressive symptoms.

During the COVID-19 pandemic, women in the general population also reported significantly higher levels of depression, anxiety, and post-traumatic stress symptoms (PTSS) compared to men [30, 31]. These outcomes may, in part, be attributed to economic hardships caused by the pandemic, which affected both genders but were often more burdensome for women. The increased prevalence of mental disorders among women may therefore be linked not only to the pandemic itself but also to pre-existing gender disparities in domestic and professional responsibilities. These findings underscore the urgent need to strengthen psychosocial support systems, particularly for female HCWs, to mitigate the risk of mental health disorders. Enhancing gender-sensitive workplace policies and promoting equitable division of responsibilities both at home and in professional settings could play a critical role in addressing these disparities [32]. Therefore, intervention models such as mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT)-based modules are needed for HCWs to alleviate workplace pressure and improve mental health through concrete coping strategies. MBSR interventions, which include simple stretches and postures, have been shown to help manage stress, depression, anxiety, and other chronic disorders more effectively [33]. Similarly, ACT-based interventions enhance psychological flexibility by encouraging individuals to accept their thoughts and feelings rather than struggle against them [34]. However, the feasibility of such interventions should be assessed through future pilot studies. These models should initially be implemented on a small scale to evaluate their advantages and limitations, and subsequently expanded to large-scale multicenter trials.

The current study makes unique contributions within the context of Iranian culture. To date, no published research has examined psychological symptoms of mental health problems alongside behavioral and lifestyle characteristics, which may act as potential confounders when comparing sex differences in mental health. This multidimensional approach is particularly important because lifestyle and behavioral patterns, such as physical activity, dietary habits, and social engagement, are strongly influenced by cultural and societal norms. Ignoring these factors may lead to an incomplete or biased understanding of gender-related differences in psychological well-being. By integrating cultural, occupational, and gender-specific considerations, the present study provides a more nuanced perspective on mental health disparities and offers insights that can inform both preventive strategies and targeted interventions. Furthermore, the findings contribute to bridging the gap between global knowledge and local realities, emphasizing the need for culturally sensitive approaches in mental health research and practice. Additionally, societal expectations—such as norms regarding patient visits or educational standards—influence how HCWs experience psychological stress and how this, in turn, affects their coping strategies and psychological resilience.

Study limitations

This cross-sectional study is inherently limited in its ability to infer causal relationships between the COVID-19 pandemic and mental health symptoms among HCWs. To draw more valid conclusions regarding gender disparities in future epidemics, a representative cohort of HCWs should be assessed using a longitudinal study design. Another limitation lies in the unequal distribution of male and female participants, with the majority being female HCWs. Although this reflects the actual gender distribution within the Iranian HCWs population and thus does not introduce sampling bias, the smaller sample size of male participants limits the statistical power to detect sex-based differences. Consequently, comparisons between genders should be interpreted with caution. Additionally, data were collected through self-reported questionnaires, which may be subject to reporting bias. Participants might have overestimated their levels of perceived stress, anxiety, and depression. However, such misclassification is likely to be non-differential with respect to gender and therefore would not result in systematic bias. Nonetheless, this could lead to a dilution of observed effect size and a reduction in the statistical power of the analyses. Moreover, for adjustment sex differences in regression coefficients, the possible collinearity among constructs such as self-esteem and self-efficacy may limit our findings. However, we did not observe potential collinearity in regression diagnosis. Finally, we focused exclusively on three common psychological outcomes. Future research should investigate additional psychological and contextual variables. Moreover, to increase the explanatory power of regression models, future studies could enhance predictive strength by incorporating factors such as coping styles, social support, and workplace pressure.

Conclusion

Our findings indicate a significant sex disparity in psychological outcomes, particularly in perceived stress and anxiety, with female HCWs experiencing greater psychological burden compared to their male counterparts. These results highlight the importance of strengthening social support mechanisms and implementing specific workplace interventions—such as mental health screening, flexible scheduling, peer support, and psychological counseling and education programs—to reduce the risk of mental disorders among healthcare workers (HCWs). To establish a more robust understanding of gender disparities in psychological health, future research should employ longitudinal cohort designs that track HCWs over time and across epidemic conditions.

Author contributions

E.H. contributed conception in design, interpretation, drafting of manuscript, and supervision. K.H. developed the conception of design, analysis, supervision, interpretation and drafting manuscript. M.N. also helped in data collection, interpretation, and drafting manuscript.

Funding

The research reported in this publication was supported by the Elite Researcher Grant Committee under the award number [995874] from the National Institute for Medical Research Development (NIMAD), Tehran, Iran.

Data availability

The datasets analyzed during the current study are not publicly available due to privacy of participant’s data but are available from the corresponding author on reasonable request.

Declarations

Ethics approval

The study has conformed to the standard of the World Medical Association, as embodied in the Declaration of Helsinki. The related protocol was approved by the ethics committee of National Institute for Medical Research Development (NIMAD), Tehran, Iran.

Consent to participate

All participants had given informed consent prior participation in the study.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.