ORIGINAL RESEARCH

published: 17 January 2022

doi: 10.3389/fpsyt.2021.735861

ICD-11 Posttraumatic Stress

Disorder and Complex PTSD Among
Hospital Medical Workers in China:
Impacts of Wenchuan Earthquake
Exposure, Workplaces, and
Sociodemographic Factors
Sijian Li 1 , Chunlan Guo 1,2* and Sunshine S. S. Chan 1
1
School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China, 2 World Health Organization
Collaborating Center for Community Health Services, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR,
China

Background: Previous studies address posttraumatic stress disorder (PTSD) following

disasters as a public health issue. However, few studies investigate the long-term effect
of disaster exposure on PTSD among hospital medical workers (HMWs).
Edited by:
Objectives: This study aimed to study the prevalence of ICD-11 PTSD and complex
Umberto Volpe,
Marche Polytechnic University, Italy PTSD (CPTSD) among exposed and non-exposed HMWs 11 years after the Wenchuan
Reviewed by: earthquake in China, to identify the factors associated with PTSD and CPTSD scores,
Cai-Lan Hou, and to examine the factor structures of PTSD and CPTSD models.
Guangdong Mental Health
Center, China Methods: A cross-sectional study was conducted using a self-administered online
Simone Pompili,
questionnaire. Two thousand fifty-nine valid samples were collected from four hospitals
Marche Polytechnic University, Italy
in 2019. Descriptive statistical analysis, multivariate regression models, and confirmatory
*Correspondence:
Chunlan Guo factor analysis (CFA) were performed.
chunlanguo@outlook.com
Results: The prevalence of PTSD and CPTSD was 0.58 and 0.34%, respectively. The
Specialty section: unexposed group reported higher PTSD and CPTSD scores than the exposed group.
This article was submitted to The type of workplace and marital status were significantly associated with the PTSD
Public Mental Health,
and CPTSD scores of HMWs. The CFA results indicate that both the correlated first-order
a section of the journal
Frontiers in Psychiatry model and the correlated two-layer model were a good fit to explain the structure of PTSD
Received: 03 July 2021 and CPTSD.
Accepted: 09 December 2021
Published: 17 January 2022
Conclusion: These findings suggest that few HMWs who were exposed to the
Citation:
Wenchuan earthquake suffered from PTSD or CPTSD 11 years following the disaster.
Li S, Guo C and Chan SSS (2022) However, psychological support was still necessary for all HMWs, especially for
ICD-11 Posttraumatic Stress Disorder
unmarried HMWs who were Working in smaller hospitals. Further research is required
and Complex PTSD Among Hospital
Medical Workers in China: Impacts of to analyze mental health status using ICD-11 PTSD and CPTSD to provide ongoing
Wenchuan Earthquake Exposure, evidence to help HWMs cope effectively with the challenges of future disasters.
Workplaces, and Sociodemographic
Factors. Front. Psychiatry 12:735861. Keywords: posttraumatic stress disorder, complex PTSD, hospital medical workers, 2008 Wenchuan earthquake,
doi: 10.3389/fpsyt.2021.735861 cross-sectional study, Sichuan

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

INTRODUCTION of public health, disease-related, and clinical applications to

maintain diagnostic and screening reliability and validity (18).
Posttraumatic stress disorder (PTSD) is one of the most Brewin et al. (17) further suggest that the value of ICD-11 is that it
common types of psychopathologies experienced after a mass provides a brief set of systems to distinguish between two sibling
traumatic incident caused by a disaster (1). The disorder involves disorders, PTSD and complex PTSD (CPTSD). Several studies
substantial functional impairment and often coexists with other examine the association of PTSD with disasters, such as studies
mental health conditions, such as depression, generalized anxiety of earthquake survivors in China (19, 20), Australian accident
disorder, and substance abuse. For these reasons, PTSD is the victims (21), and preadolescent children exposed to a hurricane
most frequently studied postdisaster mental health disorder (2– in the United States (22). The findings of these studies indicate
4). Moreover, disasters and disaster response can have long-term that the ICD-11 model has an acceptable fit for data collected
effects on individuals’ mental health (5, 6). A cohort study of the from postdisaster settings.
link between hurricane experience and mental health found that Therefore, this study investigated ICD-11 PTSD and CPTSD
adolescents at the time of the disaster had a reduced incidence of among hospital medical workers (HMWs) 11 years after the
depression and PTSD up to 9 years postdisaster compared with Wenchuan earthquake. Specifically, the objectives were to
those who were adults at the time of the disaster (7). examine (1) the prevalence of PTSD and CPTSD among
According to a report released by China’s Ministry of Civil earthquake-exposed and non-exposed HMWs, (2) the factors
Affairs in 2008, the Wenchuan earthquake event of May 12, 2008, associated with their PTSD and CPTSD scores, and (3) the
claimed 69,227 lives and injured 374,643 people, whereas 17,923 factor structure of PTSD and CPTSD models. The findings are
people were missing at the time of the report and 46,240,000 significant as they demonstrate the long-term effects of PTSD
people were affected (8). The earthquake had a magnitude of and CPTSD. This helps us understand the effect of disasters
8.0 on the Richter scale, and its epicenter had a maximum on healthcare professionals’ well-being and provides evidence to
intensity of 11.0 in Sichuan Province, southwest China. There inform policies on the prevention of mental health disorders in
were approximately 10,630 medical workers deployed to the the long term.
affected areas to offer assistance with the rescue efforts, such
as providing emergency response services, collaboration and
cooperation, large-scale transportation, and the rehabilitation of
those injured while responding to the earthquake (8). As the
MATERIALS AND METHODS
largest component of the medical care workforce, healthcare Design
professionals often play a vital role in providing emergency This was a cross-sectional study. Data were collected from four
medical relief when a disaster strikes (5, 9, 10). They are also hospitals from June 2019 to October 2019. These four hospitals
vulnerable to developing PTSD (11) because they may witness were selected based on the following criteria: (1) geographic
mass causalities, deaths, and severe injuries, which may cause location as they were located either at the epicenter of the
psychological shock or intense fear. Wenchuan earthquake (Hospital D in Mianzhu, Sichuan), near
The prevalence of PTSD was relatively high directly following the epicenter (Hospitals B and C, Chengdu, Sichuan), or a great
the Wenchuan earthquake, but its prevalence declined over time distance from the epicenter (Hospital A, Quanzhou, Fujian) and
for the majority of people, according to a systematic review, (2) the size of the hospital, including the total number of beds and
which analyzed 58 original studies of PTSD prevalence in the HMWs and the number of potential participants. Hospital B was
10 years after the earthquake among community populations the largest hospital (4,300 beds and more than 10,000 healthcare
(12). The prevalence of PTSD among medical rescue workers workers), and Hospital D was the smallest hospital (800 beds and
was 19.3% (13), 30.0% (11), 17.0% (14), and 1.7% (15) at 3, approximately 1,000 healthcare workers; Table 1).
6–12, and 14–17 months and 2 years after the earthquake,
respectively. A longitudinal study examined adult survivors and
found that the prevalence of PTSD was 58.2% at 2 months, Participants
22.1% at 8 months, 19.8% at 14 months, 19.0% at 26 months, HMWs were included in the study if they were (1) medical
and 8.0% at ∼44 months after the Wenchuan earthquake (16). doctors or registered nurses working in one of the four selected
However, studies of the long-term effects (e.g., more than 10 hospitals and (2) willing to participate in the study and complete
years) of disaster exposure on the mental health of medical the online questionnaire. Those who were taking prolonged
rescue workers are lacking. In addition, most previous studies leave due to illness or maternity were excluded from the study.
focusing on individuals’ mental health after disasters do not The sample size was large enough to ensure that parameter
include unexposed comparison groups to distinguish the effect estimates were within the acceptable margin of error of 4% with a
of disaster exposure on PTSD (5). confidence level of 95%. Approximately 500 valid questionnaires
The World Health Organization has published the 11th were collected from each of the hospitals (Table 1). However,
version of the International Classification of Diseases (ICD-11), the numbers of participating medical doctors and registered
which was approved by the World Health Assembly in 2017 nurses varied among these hospitals. The largest participation
(17). The initial criteria for PTSD can be traced back to 1980 rate was from medical doctors from Hospital D (149 out of 535,
in the third edition of the Diagnostic and Statistical Manual. 27.9%), whereas only one medical doctor (0.2%) from Hospital C
The purpose of this updated version is to improve the utility completed the questionnaire.

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

TABLE 1 | General information about the four hospitals.

Hospital A Hospital B Hospital C Hospital D

Geographical location Quanzhou, Fujian Chengdu, Sichuan Chengdu, Sichuan Mianzhu, Sichuan
Hospital size Tertiary grade A Tertiary grade A Tertiary grade A Tertiary grade B
Number of
Beds 2,305 4,300 1,450 800
Hospital medical workers 3,398 ∼10,000 ∼3,500 1,163
Number of participants 532 (100%) 503 (100%) 489 (100%) 535 (100%)
Medical doctor 97 (18.2%) 1 (0.2%) 22 (4.4%) 149 (27.9%)
Registered nurse 435 (81.1%) 488 (99.8%) 481 (95.6%) 386 (72.1%)

Measurements Wenchuan earthquake exposure: The participants were

The International Trauma Questionnaire (ITQ) (23) was used as divided into the following three groups according to their level
a self-reported measure of ICD-11 PTSD and CPTSD. CPTSD is a of exposure to the Wenchuan earthquake: unexposed HMWs,
disorder comprising PTSD and disturbances in self-organization earthquake survivors (who were adolescents in 2008 and were
(DSO) symptoms. exposed to the earthquake as survivors), and earthquake relief
The ITQ measurement assesses six symptoms of PTSD workers (who were adults in 2008 and were exposed to the
distributed across the following three clusters: re-experiencing earthquake as HMWs).
(RE with the symptoms of RE1, upsetting dreams, and RE2, Workplaces: Four hospitals participated in the survey
reliving the events), avoidance (AV with the symptoms of AV1, (Hospitals A, B, C, and D). They had different geographical
internal avoidance, and AV2, external avoidance), and a sense of locations and different numbers of HMWs and beds (Table 1).
threat (TH with the symptoms of TH1, being on guard, and TH2, Sociodemographic factors: The sociodemographic data that
being easily startled). The six symptoms of DSO are distributed were collected included gender (male/female), educational
across the following three clusters: affective dysregulation (AD level (college or below/university or above), marital status
with the symptoms of AD1, intense reaction, and AD2, long time (unmarried/married), profession (medical doctor/registered
to calm down), negative self-concept (NSC with the symptoms of nurse), age, and length of service in years.
NSC1, feelings of failure, and NSC2, feelings of worthlessness),
and disturbances in relationships (DR with the symptoms of Data Analysis
DR1, feeling cut off from others, and DR2, difficulty staying close First, a descriptive analysis was performed to understand the
to others). All symptoms were assessed using a five-point Likert characteristics of the sample and determine the prevalence
scale ranging from 0 = “not at all” to 4 = “extremely” (Table A1 of PTSD and CPTSD. Second, the PTSD and DSO scores
in Appendix I). were calculated for different groups of HMWs. Multivariate
PTSD and CPTSD prevalence: Three additional questions regression models were established to examine the effect of
were used to evaluate PTSD-related functional impairment Wenchuan earthquake exposure, the type of workplace, and
(PTSDI1, social life distress; PTSDI2, work affected; and PTSDI3, sociodemographic factors on the PTSD and DSO scores of
other aspects of life affected) and DSO-related functional the HMWs. All analyses were performed using SPSS software,
impairment (DSOFI1, DSOFI2, and DSOFI3), also in the version 25.0 (IBM, Armonk, NY, the United States) with the
domains of social life, work life, and other important areas threshold for statistical significance at a two-tailed α value of
of life, respectively. Scores ≥ 2 (“moderately”) indicated the 0.05. The beta coefficient (β), the associated two-tailed p-values
presence of a symptom. PTSD and DSO prevalence requires the (p), and 95% confidence intervals (CIs) were reported for each
presence of at least one symptom in each PTSD/DSO cluster independent variable in the regression models. An analysis of
plus the presence of functional impairment associated with variance test was performed, and p- and R2 -values were reported
these symptoms. CPTSD prevalence requires a PTSD prevalence, to evaluate the performance of each regression model.
one symptom in each DSO cluster, and associated functional Third, confirmatory factor analysis (CFA) was performed
impairment. For example, if RE1 or RE2 > 2 (“moderately”), using Mplus 7.11 (Muthén and Muthén, Los Angeles, CA, the
RE criteria were met; if AV1 or AV2 > 2, AV criteria were met; United State) to examine the structure of PTSD and CPTSD in
if TH1 or TH2 > 2, TH criteria were met; if PTSDI1, PTSDI2, HMWs. Four different models were established for CFA based on
or PTSDI3 > 2, PTSDI criteria were met; and if RE, AV, TH, data from multiple trials (24–26). Model 1 was a one-layer, one-
and PTSDI criteria were all met, a diagnosis of PTSD was made. factor model in which the latent factor of CPTSD was constructed
The same criteria were used for CPTSD prevalence. PTSD and by the 12 ITQ symptoms. Model 2 was a correlated six-factor
CPTSD were assessed using a self-reported measure rather than model in which each of the clusters of PTSD (RE, AV, and TH)
a clinician-administered assessment. For this reason, the term and DSO (AD, NSC, and DR) was a latent factor. The correlation
“probable” is used when referring to estimating the prevalence between the six latent factors was tested in Model 2. Model 3 was
of PTSD and CPTSD. a two-layer model in which CPTSD was constructed using the

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

TABLE 2 | Rates of PTSD and CPTSD in HMWs 11 years after the Wenchuan Earthquake.

Total ICD-11 PTSD and CPTSD

(N = 2,059)
N (%) Normal PTSD prevalence CPTSD prevalence
(N = 2,040) (N = 12) (N = 7)
N (%) N (%) N (%)

Wenchuan earthquake exposure

Unexposed HMWs 1,538 (100%) 1,521 (98.9%) 12 (0.8%) 5 (0.3%)
Earthquake survivors 204 (100%) 203 (99.5%) 0 (0.0%) 1 (0.5%)
Earthquake relief workers 317 (100%) 316 (99.7%) 0 (0.0%) 1 (0.3%)
Workplace
Hospital A 532 (100%) 520 (97.7%) 7 (1.3%) 5 (0.9%)
Hospital B 503 (100%) 501 (99.6%) 2 (0.4%) 0 (0.0%)
Hospital C 489 (100%) 487 (99.6%) 1 (0.2%) 1 (0.2%)
Hospital D 535 (100%) 532 (99.4%) 2 (0.4%) 1 (0.2%)
Gender
Male 268 (100%) 264 (98.5%) 3 (1.1%) 1 (0.4%)
Female 1,791 (100%) 1,776 (99.2%) 9 (0.5%) 6 (0.3%)
Education
College or below 1,193 (100%) 1,181 (99.0%) 6 (0.5%) 6 (0.5%)
University or above 866 (100%) 859 (99.2%) 6 (0.7%) 1 (0.1%)
Marital status
Unmarried 704 (100%) 697 (99.0%) 5 (0.7%) 2 (0.3%)
Married 1,355 (100%) 1,343 (99.1%) 7 (0.5%) 5 (0.4%)
Profession
Medical doctor 269 (100%) 265 (98.5%) 4 (1.5%) 0 (0.0%)
Registered nurse 1,790 (100%) 1,775 (99.2%) 8 (0.4%) 7 (0.4%)
Age 31.4 (7.1) 31.4 (9.6) 31.7 (10.7) 28.1 (4.9)
Length of service in years 9.6 (7.6) 9.6 (7.6) 10.5 (10.7) 6.4 (4.6)

six latent factors in Model 2. Model 4 was a correlated two-layer 2,059), and 74.7% did not experience the earthquake (1,538 out
model in which PTSD accounted for the covariation between the of 2,059; Table 2). There were more female than male HMWs in
latent factors of RE, AV, and TH, whereas DSO accounted for the total sample (1,791 vs. 268). More participants had a college
the covariation between the latent factors of AD, NSC, and DR. education level or below (including diploma and subdegree) than
The maximum likelihood estimation was used, and the STDYX a university educational level or above (1,193 vs. 866). More of
standardization of estimate together with its standard errors (SE) the participants were married than unmarried (1,355 vs. 704).
were reported for each path in the CFA. More than 80% of the participants were registered nurses (1,790
The comparative fit index (CFI), root mean square error of of 2,059, 86.9%). The mean age of the participants was 31.4 with
approximation (RMSEA) with 95% CI, and Tucker–Lewis index a standard deviation (SD) of 7.1, whereas the mean length of
(TLI) were used to assess the fit of the hypothetical model. Cutoff service as an HMW was 9.6 years with an SD of 7.6 years.
values of 0.95 for CFI and TLI (a higher value is better) and The prevalence of PTSD and CPTSD was 0.58% (12 of
0.06 for RMSEA (a lower value is better) (27, 28) were used 2,059) and 0.34% (7 of 2,059), respectively. All participants with
to determine the goodness of fit. To identify the model with PTSD (100%, 12 of 12) and most of those with CPTSD (71.4%,
the optimal fit, changes in the CFI (1CFI), TLI (1TLI), and 5 of 7) had not been exposed to the Wenchuan earthquake.
RMSEA (1RMSEA) values were assessed. 1CFI ≥ 0.01, 1TLI Approximately equal numbers of participants were recruited
≥ 0.01, and 1RMSEA ≥ 0.015 were considered to be evidence of from the four hospitals. However, Hospital A reported the highest
a meaningful difference in the fit of the respective models (29). prevalence of PTSD (1.3%, 7 of 521) and CPTSD (0.9%, 5 of
521). Moreover, male participants reported a higher prevalence
RESULTS of both PTSD (1.1 vs. 0.5%) and CPTSD (0.4 vs. 0.3%) than their
female HMW counterparts. The participants with an education
Demographic Characteristics and at the university level or above reported a higher prevalence of
Prevalence of ICD-11 PTSD and CPTSD PTSD (0.7 vs. 0.5%) and a lower prevalence of CPTSD (0.1 vs.
Of the 2,059 HMWs in the study, 9.9% experienced the 0.5%) than their counterparts with lower educational levels. A
Wenchuan earthquake as survivors (204 out of 2,059), 15.4% higher prevalence of PTSD (0.7 vs. 0.5%) but a lower prevalence
experienced the earthquake as disaster relief workers (317 out of of CPTSD (0.3 vs. 0.4%), was reported by unmarried participants

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

TABLE 3 | Dimensional PTSD and DSO scores of HMWs. [F (3) = 12.973, p < 0.001] scores. Participants from Hospital
A reported the highest PTSD (mean = 6.24, SD = 6.08) and
PTSD score DSO score
DSO (mean = 6.49, SD = 6.55) scores, followed by those from
ICD-11-defined PTSD and F(2)= 154.896, F(2)= 89.685, Hospital C (PTSD: mean = 5.01, SD = 5.19; DSO: mean = 5.36,
CPTSD prevalence p < 0.001 p < 0.001 SD = 5.79). Moreover, participants with different marital statuses
Normal 4.95 (4.98) 5.11 (5.54) had significantly different DSO scores [F (1) = 7.453, p < 0.01].
PTSD 24.00 (2.49) 18.33 (4.70) According to the multivariate regression models (Table 4),
CPTSD 26.86 (3.58) 27.29 (5.82) experiencing the Wenchuan earthquake as a survivor had a
Wenchuan earthquake F(2)= 17.281, F(2)= 20.547, significant negative effect on PTSD (β = −1.326, 95% CI: −2.160,
exposure p < 0.001 p < 0.001 −0.493) and DSO (β = −1.153, 95% CI: −2.053, −0.253) scores.
Unexposed HMWs 5.53 (5.58) 5.73 (6.06) Being a relief worker after the earthquake also had a significant
Earthquake survivors 3.74 (4.12) 3.93 (4.54) negative effect on PTSD (β = −1.188, 95% CI: −1.883, −0.492)
Earthquake relief workers 4.12 (4.41) 3.85 (4.51) and DSO (β = −1.481, 95% CI: −2.232, −0.729) scores.
Workplace F(3)= 11.985, F(3)= 12.973, The type of workplace also had a significant effect on the
p < 0.001 p < 0.001 HMWs’ PTSD and DSO scores. Specifically, working in Hospital
Hospital A 6.24 (6.08) 6.49 (6.55) D (located at the epicenter) was associated with a decrease in the
Hospital B 4.35 (4.74) 4.68 (5.28) PTSD score of 0.859 SDs (β = −0.859, 95% CI: −1.556, −0.163)
Hospital C 5.01 (5.19) 5.36 (5.79) and a decrease in the DSO score of 1.279 SDs (β = −1.279,
Hospital D 4.89 (4.99) 4.52 (5.11) 95% CI: −2.032, −0.527) while holding Wenchuan earthquake
Gender F(1)= 2.741, F(1)= 3.221, exposure and sociodemographic factors constant. Similarly,
p = 0.098 p = 0.073 working in Hospital B (close to the epicenter) was associated with
Male 5.64 (5.68) 5.85 (6.39) a decrease in the PTSD score of 1.521 SDs (β = −1.521, 95% CI:
Female 5.06 (5.27) 5.18 (5.66) −2.211, −0.831) and a decrease in the DSO score of 1.335 SDs
Education F(1)= 0.192, F(1)= 2.360, (β = −1.335, 95% CI: −2.080, −0.590) while holding Wenchuan
p = 0.662 p = 0.125 earthquake exposure and sociodemographic factors constant.
College or below 5.09 (5.36) 5.10(5.68) In addition, being married was associated with a decrease
University or above 5.20 (5.29) 5.49(5.87) in the DSO score of 0.697 SDs (β = −0.697, 95% CI: −1.280,
Marital status F(1)= 0.593, F(1)= 7.453, −0.115) while holding Wenchuan earthquake exposure, type of
p = 0.441 p < 0.01
workplace, and other sociodemographic factors constant. Finally,
Unmarried 5.26 (5.44) 5.75 (6.34)
none of the associations of HMWs’ PTSD or DSO scores with
Married 5.07 (5.27) 5.02 (5.43) gender, educational level, profession, age, and length of service
Profession F(1)= 3.647, F(1)= 1.464, was statistically significant (Table 4).
p = 0.056 p = 0.227
Medical doctor 5.71 (5.69) 5.66 (6.37)
Registered nurse 5.05 (5.27) 5.21 (5.67) The Structure of ICD-11 PTSD and CPTSD
in HMWs
The CFA results are presented in Table 5; Figure 1. The chi-
compared with married participants. Medical doctors reported a
square statistics were significant for all four models. However,
much higher prevalence of PTSD (1.5 vs. 0.4%) than registered
Models 1 and 3 were rejected because of their poor fit. Models
nurses, whereas all cases of CPTSD were found in registered
2 and 4 had acceptable fits based on the CFI, TLI, RMSEA, and
nurses. The mean age was lower and the length of service as an
standardized root mean squared residual (SRMR) values. Model
HMW was shorter in those with CPTSD than in those with PTSD
2 demonstrated the highest CFI and TLI values and the lowest
and those without CPTSD or PTSD.
RMSEA and SRMR values. However, the 1CFI and 1TLI values
between Models 2 and 4 were lower than 0.01, and the 1RMSEA
Dimensional Scores of PTSD and DSO and value was lower than 0.015. Thus, the difference in fit between
Their Determinants Models 2 and 4 was not significant. Therefore, both Models 2 and
Participants, who were probable with CPTSD, reported 4 had a good fit to examine the constructs of PTSD and CPTSD
the highest PTSD (mean = 26.86, SD = 3.58) and DSO in HMWs.
(mean = 27.29, SD = 5.82) scores, followed by those with PTSD All of the factors loaded in Models 2 and 4 were significant
(Table 3). Participants with different types of Wenchuan (p < 0.001) with coefficients ranging from 0.693 (SE = 0.013,
earthquake exposure reported significantly different of AD1 loaded on affective dysregulation) in Model 4 to 0.930
PTSD [F (2) = 17.281, p < 0.001] and DSO [F (2) = 20.547, (SE = 0.008, negative self-concept loaded on DSO; SE = 0.011,
p < 0.001] scores. Unexposed HMWs reported the highest affective dysregulation loaded on DSO) in Model 4. All
PTSD (mean = 5.53, SD = 5.58) and DSO (mean = 5.73, correlations between the six latent factors were significant with
SD = 6.06) scores. coefficients ranging from 0.508 (RE with DR, SE = 0.22;
Participants from different hospitals showed significantly and AV with NSC, SE = 0.20) to 0.875 (NSC with DR,
different PTSD [F (3) = 11.985, p < 0.001] and DSO SE = 0.009) in Model 2. In Model 4, the latent factors of

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

TABLE 4 | Multivariate regression analysis of the effects of disaster exposure and sociodemographic factors on the dimensional scoring of PTSD and DSO.

PTSD score DSO Score

β 95% CI P-value β 95% CI P-value

Wenchuan earthquake Earthquake survivors −1.326 −2.160, <0.001 −1.153 −2.053, <0.05
exposure (Ref. −0.493 −0.253
unexposed HMWs)
Earthquake relief −1.188 −1.883, <0.01 −1.481 −2.232, <0.001
workers −0.492 −0.729
Workplace (Ref. Hospital B −1.521 −2.211, <0.001 −1.335 −2.080, <0.001
Hospital A) −0.831 −0.590
Hospital C −0.985 −1.669, <0.01 –0.708 –1.447, 0.060
−0.300 –0.031
Hospital D −0.859 −1.556, <0.05 −1.279 −2.032, <0.01
−0.163 −0.527
Gender (Ref. male) Female –0.315 –1.156, 0.463 –0.485 –1.394, 0.295
0.526 0.424
Education (Ref. College University or above –0.006 –0.518, 0.983 0.296 –0.258, 0.295
or below) 0.507 0.849
Marital status (Ref. Married –0.133 –0.673, 0.628 −0.697 −1.280, <0.05
unmarried) 0.406 −0.115
Profession (Ref. Registered nurse –0.111 –1.039, 0.814 0.198 –0.805, 0.699
medical doctor) 0.817 1.200
Age Years 0.001 –0.103, 0.995 0.057 –0.055, 0.320
0.104 0.169
Length of service Years 0.030 –0.062, 0.524 –0.013 –0.113, 0.803
0.123 0.087
Model performance F(11)= 5.451, p < 0.001 F(11)= 6.937, p < 0.001
R2 = 0.028 R2 = 0.033

β coefficients, p-values, and 95% CIs are reported for each factor.

TABLE 5 | Fit of CFA models of ICD-11 PTSD and CPTSD.

Model χ2 df P-value CFI TLI RMSEA (95% CI) SRMR

Model 1 4638.142 54 <0.001 0.724 0.663 0.203 (0.198-0.208) 0.108

Model 2 215.328 39 <0.001 0.989 0.982 0.047 (0.041-0.053) 0.015
Model 3 1699.787 48 <0.001 0.901 0.863 0.129 (0.124-0.135) 0.092
Model 4 277.450 47 <0.001 0.986 0.981 0.049 (0.044-0.055) 0.026

N = 2,059; estimator, maximum likelihood (ML); χ2, chi-square goodness-of-fit statistic; df, degrees of freedom; CFI, comparative fit index; TLI, Tucker–Lewis index; RMSEA (95% CI),
root-mean-square error of approximation with 95% confidence interval; SRMR, standardized root mean squared residual.

RE, AV, and TH constructed the second-layer latent factor of have had PTSD had left the HMW labor market and could not
PTSD, while AD, NSC, and DR constructed DSO. PTSD was be recruited for this study. Moreover, in general, the prevalence
significantly correlated with DSO with a medium-sized effect of PTSD is lower after natural disasters than after manmade
(β = 0.655, SE = 0.016). disasters (30). For example, the prevalence of PTSD ranged from
7 to 24% (mean 18%) in medical responders in the first 1 or 2
DISCUSSION years following the 2004 tsunami in Asia (31), the 2010 Yushu
earthquake (32), and the 2011 Great East Japan Earthquake (33).
PTSD and CPTSD in HMWs After the However, after manmade disasters, the prevalence of PTSD has
Wenchuan Earthquake a wide range from 1 to 90% (34–36). The low PTSD prevalence
The prevalence rate of PTSD and CPTSD in HMWs was low (1%) reported for nurses and doctors during violent events in
(0.58 and 0.34%, respectively) 11 years after the Wenchuan Judea and Samaria (36) was mostly related to a highly restricted
earthquake. Moreover, none of the participants who reported selection process and more comprehensive training. A high
Wenchuan earthquake exposure were probable for PTSD. After prevalence of PTSD was identified during violent wars in 2012
such a long time, many cases of PTSD may have been treated (35, 70%) and Israel-Gaza in 2014 (34, 90%). As these wars
or spontaneously resolved. In some cases, the rescuers who may continued for a long duration, they may have caused daily

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

FIGURE 1 | Factor models of ICD-11 PTSD and CPTSD tested using confirmatory factor analysis. The STDYX standardization of estimate and SE for Model 2: RE
with AV, 0.802(0.007)***; RE with TH, 0.795(0.016)***; RE with AD, 0.596(0.022)***; RE with NSC, 0.505(0.022)***; RE with DR, 0.508(0.022)***; AV with TH,
0.837(0.012)***; AV with AD, 0.605(0.019)***; AV with NSC, 0.508(0.020)***; AV with DR, 0.525(0.019)***; TH with AD, 0.636(0.019)***; TH with NSC, 0.558(0.020)***;
TH with DR, 0.525(0.019)***; AD with NSC, 0.861(0.012)***; AD with DR, 0.855(0.012)***; NSC with DR, 0.875(0.009)***.

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

traumatic events. Therefore, all HMWs are urged to be equipped past 11 years may be warranted to evaluate the effect of other
with competency-driven, high-quality disaster education and traumatic events during this period. Third, we used an online
training to enhance their knowledge and skills to meet the global self-reported survey, and we did not conduct interviews to make
challenge of disasters (9, 10, 37). the diagnoses. Finally, this was a cross-sectional study with a
non-random sampling strategy. With the recent increase in the
The Factors Associated With HMWs’ PTSD number of disasters globally, a long-term longitudinal study is
and CPTSD Scores needed to serve as a guide to advocating for the protection of the
The factors that had a significant and positive association with mental health of healthcare professionals working in hospitals of
HMWs’ PTSD and CPTSD scores were not being exposed to different sizes.
the earthquake and working in a hospital that was distant from
the epicenter (i.e., Hospital A). These findings confirm that CONCLUSIONS
geographical location has a significant role in an individual’s
adaptation following a disaster as previously reported (38). The findings of this study suggest that HMWs who were
Another possible explanation for these findings is that we only exposed to the Wenchuan earthquake rarely reported PTSD or
examined the effect of Wenchuan earthquake exposure on PTSD CPTSD 11 years following the disaster. However, psychological
and did not evaluate the effects of other natural disasters (e.g., support is still necessary for all HMWs, especially for single
floods) on HMWs’ mental health. Hospital A was distant from HMWs working in smaller hospitals. Further research is required
the epicenter of the Wenchuan earthquake but is located in a to evaluate the mental health status of HMWs using the
coastal area where typhoons, rainstorms, and high tides have ICD-11 criteria for PTSD and CPTSD to provide ongoing
become common in recent years (39). For example, in 2016, evidence to help HMWs cope effectively with the challenges of
Typhoon Megi, which landed in Fujian, resulted in 91 deaths, 16 future disasters.
missing persons, and the collapse of 10,203 houses (40). HMWs
who were working in Hospital A may have been deployed to DATA AVAILABILITY STATEMENT
the affected area of Fujian and exposed to traumatic incidents
during flood relief work, which may have contributed to the The raw data supporting the conclusions of this article will be
development of PTSD in these HMWs (41). made available by the authors, without undue reservation.
In addition to earthquake exposure and the type of workplace,
sociodemographic factors were also associated with HMWs’ ETHICS STATEMENT
PTSD and CPTSD scores. An unmarried status was positively
associated with PTSD and CPTSD scores, which is consistent The studies involving human participants were reviewed and
with the findings of previous studies (41). This may be due to approved by the Human Subjects Ethics Sub-Committee in the
a lack of family and social support. Hong Kong Polytechnic University (Ref.HSEARS20190416035).
The patients/participants provided their written informed
The Structure of ICD-11 PTSD and CPTSD consent to participate in this study.
in HMWs
The results from the CFA indicate that both the correlated AUTHOR CONTRIBUTIONS
first-order model (Model 2) and the correlated two-layer model
(Model 4) had a good fit to explain the structure of PTSD and SL and SC designed and performed data collection. CG, SL,
DSO. The correlated first-order model, which was constructed and SC analyzed the data. CG and SL drafted the manuscript.
with three latent variables (RE, AV, and TH) representing PTSD All authors contributed to the article and approved the
and three latent variables (AD, NSC, and DR) representing DSO, article submission.
was the model with the best fit. The correlated two-layer model
included two second-order latent variables, PTSD and DSO, to
explain the covariation among the six first-order factors. These FUNDING
results are consistent with previous studies showing that these
This study was supported by Dean’s Reserve Grants (FHSS
two models are generally the best-fitting models (42–44).
and FENG) from the Hong Kong Polytechnic University
Limitations and Further Research (Project ZZHH).
First, this study was limited by its sampling methodology and
the unbalanced ratio between medical doctors (18.2%) and ACKNOWLEDGMENTS
registered nurses (81.1%) from the four selected hospitals. This
may limit the generalizability of the finding that being a medical We thank Thanos Karatzias and Dr. Grace Ho for providing
doctor predicted the development of PTSD and CPTSD. Second, us with valuable guidance on the research tools in both English
this study only assessed HMWs’ exposure to the Wenchuan and Chinese. We also thank Xianqiong Feng, Dr. Xin Jiang,
earthquake, which occurred 11 years prior to the survey. There Ms. Shaohua Chen, Ms. Xuemei Luo, and Ms. Rui Xia for their
may have been other traumatic events during that period that assistance with data collection. We also give special thanks to all
caused PTSD or CPTSD. Therefore, a life event checklist for the of the participants in this study.

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

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Validation of post-traumatic stress disorder (PTSD) and complex PTSD distribution or reproduction is permitted which does not comply with these terms.

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Li et al. PTSD and CPTSD Among Hospital Medical Workers in China

APPENDIX I
TABLE A1 | Descriptive analysis of items of ICD-11 posttraumatic stress disorder (PTSD) and Complex PTSD.

Items 0 1 2 3 4 Mean
N(%) N(%) N(%) N(%) N(%) (S.D.)

Post-traumatic stress Re-experiencing RE1. Having upsetting 892 957 143 61 6 0.7
disorder dreams that replay part of (43.3%) (46.5%) (6.9%) (3.0%) (0.3%) (0.7)
(PTSD) the experience or are clearly
related to the experience
RE2. Having powerful 951 903 142 53 10 0.7
images or memories that (46.2%) (43.9%) (6.9%) (2.6%) (0.5%) (0.8)
sometimes come into your
mind in which you feel the
experience is happening
again in the here and now
Avoidance AV1. Avoiding internal 1,057 738 190 63 11 0.7
reminders of the experience (51.3%) (35.8%) (9.2%) (3.1%) (0.5%) (0.8)
(for example, thoughts,
feelings, or physical
sensations)
AV2. Avoiding external 1,109 736 144 57 13 0.6
reminders of the experience (53.9%) (35.7%) (7.0%) (2.8%) (0.6%) (0.8)
(for example, people,
places, conversations,
objects, activities, or
situations)
Sense of threat TH1. Being “super-alert,” 1,129 665 (32.3%) 176 71 18 0.6
watchful, or on guard (54.8%) (8.5%) (3.4%) (0.9%) (0.8)
TH2. Feeling jumpy or easily 1,053 747 182 60 (2.9%) 17 0.7
startled (51.1%) (36.3%) (8.8%) (0.8%) (0.8)
PTSD functional PTSDI1. Affected your 1,430 497 (24.1%) 96 30 6 0.4
impairment relationships or social life (69.5%) (4.7%) (1.5%) (0.3%) (0.7)
PTSDI2. Affected your work 1,431 494 95 26 (1.3%) 13 0.4
or ability to work (69.5%) (24.0%) (4.6%) (0.6%) (0.7)
PTSDI3. Affected any other 1,402 512 94 41 10 0.4
important part of your life (68.1%) (24.9%) (4.6%) (2.0%) (0.5%) (0.7)
such as parenting, school or
college work, or other
important activities
Disturbances in Affective AD1. I react intensely to 722 971 285 68 (3.3%) 13 0.87
self-organization Dysregulation things that do not seem to (35.1%) (47.2%) (13.8%) (0.6%) (0.81)
(DSO) affect other people so much
AD2. When I am upset, it 1,202 636 (30.9%) 142 66 13 0.57
takes me a long time to (58.4%) (6.9%) (3.2%) (0.6%) (0.81)
calm down
Negative NSC1. I feel like a failure 985 789 185 75 25 0.72
self-concept (47.8%) (38.3%) (9.0%) (3.6%) (1.2%) (0.86)
NSC2. I feel worthless 1,207 625 145 64 18 0.57
(58.6%) (30.4%) (7.0%) (3.1%) (0.9%) (0.82)
Disturbances in DR1. I feel distant or cut off 1,290 577 (28.0%) 127 53 12 0.50
relationships from people (62.7%) (6.2%) (2.6%) (0.6%) (0.77)
DR2. I find it hard to stay 1,142 692 147 57 21 0.60
emotionally close to people (55.5%) (33.6%) (7.1%) (2.8%) (1.0%) (0.82)
DSO functional DSOI1. Affected your 1,213 668 (32.4%) 127 40 11 0.53
impairment relationships or social life (58.9%) (6.2%) (1.9%) (0.5%) (0.74)
DSOI2. Affected your work 1,341 571 102 37 (1.8%) 8 0.45
or ability to work (65.1%) (27.7%) (5.0%) (0.4%) (0.71)
DSOI3. Affected any other 1,355 540 114 40 10 0.45
important part of your life (65.8%) (26.2%) (5.5%) (1.9%) (0.5%) (0.73)
such as parenting, school or
college work, or other
important activities

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