**4. Discussion**

This study investigated the quality of life and insomnia among hospital personnel during the first wave of the COVID-19 pandemic in Italy. The adoption of different coping strategies was also analyzed. In particular, we investigated the differences in sociodemographic characteristics and work-related factors in two different Italian metropolitan areas, located in Northern and Southern Italy (group N and group S, respectively). We also identified work-related and sociodemographic predictors of specific outcomes.

Our results showed an overall good perceived quality of life despite a high prevalence of insomnia among the participants in both groups. The Brief-COPE questionnaire revealed that the subjects experienced adequate adaptive mechanisms, demonstrating that Active, Planning, and Acceptance were the most frequently adopted coping strategies in both groups.

The EQ-5D and EQ-VAS questionnaires showed good health status and perceived quality of life in both groups. We can hypothesize that this finding might be explained by different possible factors: low incidence of COVID-19 cases in the two metropolitan areas may have been adequately managed. Furthermore, since the survey was conducted during the first wave, the interviewed subjects may have underestimated the magnitude of the pandemic; another explanation might be found in a good level of organizational support with adequate provision of medical equipment and PPE (personal protective equipment). In particular, group S participants reported higher scores which their sociodemographic characteristics may explain: the majority of subjects was <40 y (56.9% vs. 27.4% in group N), the percentage of male participants was higher than group N (34.6% vs. 24.8%, respectively) and most of the interviewees were graduated (55% vs. 37.8% in group N). In fact, aging is associated with an increased burden of disease, and a higher education level is reported to confer knowledge and consciousness regarding the risk of infection and correct preventive measures, particularly in the COVID-19 pandemic [34–38].

Moreover, regarding work-related features, it can be highlighted that only in group S did high seniority act as a predictor of worse overall life quality, whereas working in COVID wards predicted its perception. This relation was not present in group N: probably, the organization of the healthcare system with a higher readiness level in the working context of this group may have played a role in buffering the negative impact of the pandemic on mental health and social life on HCWs [39,40]. In fact, the investigated northern metropolitan area was in proximity to the most affected Italian regions during the first pandemic wave.

As demonstrated in other research, in frontline hospital workers, working conditions increased the perception of personal threat, increasing stress levels with an inevitable worsening of the perception of health status and quality of life [41,42]. In contrast, another study on nurses reported that the social domain of quality of life had a significant positive association with working experience [43].

In our total sample, we found that high education level was a predictor of better perceived health status in the two study groups, in accordance with the existing literature [34–36]. In fact, as mentioned above, an elevated level of education generally corresponds to higher career profiles with greater earnings and a better perception of life quality as well as more robust mechanisms to face situations of initial disability or deterioration in health status. Moreover, male gender was related to better life quality, both overall (*p* < 0.001) and perceived (*p* < 0.05), confirming that men are more likely to report good scores when compared with women [37]; during this period of a whole disruption concerning many organizational aspects in daily life, the social pressure exerted by family may have negatively impacted the quality of life, especially in women.

As is well known, the new living arrangement, mainly due to social distancing, has led to unprecedented social experiences, resulting in an increase of anxiety, stress, depression, burnout, and sleep disorders [14]. In particular, insomnia was revealed to be one of the most frequent disturbances [15]. In accordance with other research [44,45] and a recent meta-analysis [46], we found a high prevalence of insomnia in our study population, with

almost half of participants reporting insomnia symptoms in both groups. Our data revealed that different factors in the two groups could represent a risk to the onset of insomnia. In group S, subjects with a higher number of contacts per week with COVID patients had a greater risk of insomnia. Literature suggests that working conditions linked to an elevated number of contacts with COVID-19 patients may justify the higher levels of distress, resulting in sleep problems [47–49].

The stratification of the study population by gender and professional category highlighted an increased risk of insomnia among women (OR 2.09, *p* < 0.001) and nursing personnel (OR 1.62, *p =* 0.018), similarly to other studies [48,49]. Evidence suggests that women are more susceptible to sleep disorders, also due to a double burden of work hanging on them [50]. Since women are more disposed to suffer from psychological symptoms, including mood disorders [51,52], subsequently to stressful events, the COVID-19 pandemic represented a traumatic component that may have revealed this greater vulnerability. These conditions may negatively influence sleep quality [53]. Though explaining this gender difference is not straightforward, individual features (e.g., genetics, hormones) and social disparities might represent the possible causes [54]. Additionally, the literature suggests that nurses are more exposed to the pandemic burden [49].

The female gender was also a predictor of higher scores in almost all coping strategies encountered by the Brief-COPE questionnaire, especially those related to support.

In general, women showed a more intense effort in their attempt to cope with the difficulties linked to the pandemic situation and were confirmed to be more likely to use emotion-focused coping strategies, while men tend to rely more on problem-focused strategies [55].

Concerning the capacity to handle stressful situations, the most commonly used strategies, equally adopted in both study groups, were those with a positive attitude towards the workplace (Active, Planning, and Acceptance), similar to previous studies on HCWs [56,57]. The functional coping strategies permit to favorably decode adverse circumstances, positively affecting mental wellbeing and life quality [58]. Following the application of the statistical model, in group N we only found a sociodemographic characteristic, age > 40 y, as a predictor of Acceptance; in fact, age could be considered as a protective characteristic against the development of stress and a greater individual experience may orientate coping to the adoption of positive strategies in this working population [59]. Differently, in group S data showed that a work-related factor, the number of contacts per week with COVID-19 patients, played a role in predicting Planning attitude. Contrary to other research in which greater exposure to SARS-CoV-2 infection has led HCWs to adopt maladaptive behaviors [58], this work-related factor in our Southern population acted as a positive stimulus in adopting a more functional coping strategy. We can hypothesize that there are not only demographic features but also cultural and environmental factors that can influence the use of this strategy, so a higher workload with challenging tasks seems to correspond to more significant planning activity.

Moreover, the national lockdown and government restrictive preventive measures limited social relationships also outside the work environment, with a consequent impact on coping strategies involving social support (emotional and instrumental support). Notwithstanding, our study population demonstrated to rely on social interactions, confirming other data in the literature [60,61]. In particular, being part of group N acted as a predictor of the Instrumental Support strategy, which is a problem-focused strategy whereby subjects seek information, advice, and assistance [62]. Considering the higher prevalence of the pandemic in most regions of Northern Italy, these subjects may have been more afraid to infect their families, leading them to the choice to live far from their loved ones [7], resulting in a greater search for social support, especially counseling and enlightenment.

Furthermore, our results showed a significant difference between the two groups: religion was a frequent mechanism in group S, particularly in older subjects and those working remotely; whereas in group N females and more COVID-exposed participants tended to practice their spirituality in critical situations [63]. Some people have shown a significant attitude to draw resources from their religious feelings in the current pandemic [64], although explaining individual motivations is not straightforward.

Working from home has resulted in being predictive of relying not only on religion but also on maladaptive coping strategies, particularly in group S of this population (Table 6B). The strategies aiming to avoidant behaviors (Self-distraction, Denial, and Disengagement) constitute a risk factor for elevated distress levels, in fact, they are categorized among dis-functional reactions to stressful situations [65,66]. Despite our investigation showing low scores in most of these strategies, group S was related to Denial, pretending that the situation was not real [67]. It is possible that due to cultural and environmental characteristics, these subjects tended to minimize the threat, keep feelings to themselves and avoid mental distress by making an effort to forget.

Overall, our data underline that dissimilar variables play distinct roles in affecting coping tactics in the two geographical areas. Actually, as predictors for psychological distress depend on the specific context, also the consequent coping strategies are not absolute and depend on a multiplicity of variables.

The first limitation of this study is the cross-sectional design that does not permit to define the direction of causality. Second, despite the fact that we used all validated questionnaires, the online administration of a survey could be affected by a responder bias: the sample was recruited through network invitation, so enrolled subjects had to be able to use web resources. Finally, due to the self-administration of questionnaires, we cannot generalize our findings because of the risk of overestimating psychological disturbs and insomnia.

In spite of these limitations, the strength of this survey has been to evaluate the quality of life, insomnia, and coping strategies in facing COVID-19 physical and emotional burden, through the comparison of two groups residing in distinct Italian metropolitan areas with matching low SARS-CoV-2 incidence rate but dissimilar sociodemographic features and work-related factors. Only a few Italian investigations were conducted among different regions, assessing the impact of COVID-19 on HCWs, in terms of psychological safety and workload [57,68–71]. This kind of comparison has permitted us to achieve new insights on how sociodemographic characteristics and work-related factors may have played different roles depending on different organizational settings, in a preventive perspective.

Since the first year of this ongoing pandemic, the lesson learned is that, for a future similar emergency, public health authorities should implement support programs dedicated explicitly to more vulnerable personnel between HCWs. Given the gender-linked mental health challenges and coping attitudes, women would particularly benefit from psychosocial support delivered according to their work schedules to avoid interference with parental tasks.

A multilevel integrated approach should be implemented on the individual HCW aiming to monitor psychological distress and help in accepting negative emotions; at the interpersonal dimension, to favor regular sharing and communication between peers, also to allow conciliation of work with family life; in particular, for remote workers, the organization of frequent online meetings could help in maintaining contact between coworkers and avoid disengagement. Moreover, at the organizational level, preventive and protective measures adequate to work-related risk to COVID-19 [72] should be adopted, allowing timely availability of clear information, guidelines, and protective equipment.

#### **5. Conclusions**

Globally, our study population reported good perceived quality of life and selfreported health status, despite the pandemic situation.

Women confirmed their attitude to positively react to the difficulties linked to the pandemic, adopting emotion-focused and support-related coping strategies.

A high prevalence of insomnia was reported, particularly by women and nurses. Considering the high feminization of healthcare professions in western countries, as well as the higher probability for women to develop mental health disturbs, gender perspective

should be considered at the organizational level; we suggest enhancing health protection actions dedicated to these more vulnerable categories, through prevention and intervention programs oriented towards psychosocial support to mitigate the impact of stressful events, such as the COVID-19 pandemic.

**Author Contributions:** Conceptualization, C.F., C.C. and S.I.; methodology, C.M., M.R.A.M., C.F., C.C.; software and data curation, A.A., S.I.; validation, G.B.; formal analysis, A.A. and S.I.; investigation, M.T.; resources, G.S. and F.L.F.; writing—original draft preparation, S.I., M.T.; writing—review and editing, C.F., C.C., S.I.; supervision, C.C., C.F.; project administration, C.F.; funding acquisition, C.F. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** This study was carried out in accordance with the Declaration of Helsinki's ethical standards. The study needed no formal approval by the local Ethics Committee.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.
