The role of COVID-19 work-related stigma in the relationship between character strength and mental health among primary-level workers

Introduction

Background

The global mental health crisis has been becoming increasingly severe, with the World Health Organization (WHO) indicating that 970 million people globally were living with a mental disorder in 2019 (1). The coronavirus disease 2019 (COVID-19) pandemic exacerbated this crisis as economic decline, changes in social interactions, and disrupted interpersonal connections intensified mental health issues (2). This issue did not only happen to the general population but also health workers who face chronic stressful work conditions (3).

The 1978 Declaration of Alma-Ata stated that primary health care relied on health workers trained to respond to community health needs as a team (4). This study focused on primary-level healthcare and social support workers, who were crucial during the COVID-19 response in China’s border minority regions. Their demand increased, driven by demographic, epidemiological, economic, and technological changes, as well as evolving population expectations and diverse service providers (5). These workers were at the forefront of information collection medical treatment, health education, public awareness campaigns, and psychological support (6). Additionally, Rural Revitalization Team members collaborated with local officials to enhance communication, integrate resources, help villagers adapt to modern precautions, support agriculture, and ensure community stability during COVID-19 pandemic (7). To address the varied needs of border emergency responders, China employed a strategy of self-nomination and organizational recommendation to dispatch volunteers to bolster grassroots efforts. These workers, mostly from inland areas or cities, faced diverse geographical environments, heavy workloads, and multiple responsibilities. Prolonged high-pressure work often led to anxiety, exacerbated by limited social support (8,9). Working in different regions also posed risks of communication barrier, straining family relationships. Thus, researching and providing professional psychological support introduced to access their mental well-being, improving work efficiency of the primary-level worker, and safeguarding public health.

Multinational surveys revealed that healthcare workers experienced social discrimination (10,11) [with 56.6% frontline workers affected (12)] and violence (13) due to their contact with patients during the pandemic. Other studies noted that the public avoided or criticized them for high-risk roles, with stigma leading to consequences such as increased anxiety, depression, and psychological burdens (14,15). Further research indicated that social support workers struggled with balancing work and family life, suffered from impaired professional identity, and internalized stigma, exacerbating mental health issues (16). It is important to understand how to prevent and alleviate these unwanted outcomes.

Similar to the dedication exhibited by volunteers in previous studies for crisis response, character strengths such as hope, zest, prudence, love, and forgiveness have been identified as key psychological traits linked to resilience and well-being (17). However, the effectiveness of these traits could be undermined by negative social factors. Stigma when combined with other social stressors, could have a devastating impact on the expression of character strengths, inhibiting their protective functions (15). COVID-19 work related stigma was especially pronounced during the pandemic and had significant repercussions on healthcare and coworkers (18). Mechanisms of stigma formation involve public fear of disease, misconceptions about health-related workers, and unsupportive social and systemic environments. Furthermore, to better understand the role of character strengths under adverse conditions, the stress-buffering hypothesis suggested that psychosocial resources, such as collaboration, could mitigate the negative impact of stressors like stigma on mental health (19,20).

Rationale and knowledge gap

Our study hypothesizes that COVID-19 work-related stigma mediates the relationship between character strength and mental health outcomes. Specifically, we proposed that COVID-19 work related stigma weakens the protective effect of character strength by reducing individuals’ perceptions of social support and increasing psychological stress (21). This hypothesis aligns with prior evidence of social discrimination and violence against frontline workers during the pandemic, while addressing a critical gap in understanding how personal strengths interact with stigma to influence mental health.

Objective

The objective of this research was to identify the character strength traits of primary-level workers and then examine the mediating role of COVID-19 work-related stigma in the relationship between character strength and mental health. We present this article in accordance with the STROBE reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-10/rc) (22).

Methods

Study setting and participants

This cross-sectional study focused on the COVID-19 prevention and control work in a border area of a province in China, which is a minority inhabited area. Due to its special geographical location, long land borders, and fragile health systems, this area faces extremely severe challenges in epidemic prevention and control. These border areas not only bear higher public health risks but also face tremendous pressure, imposing stringent requirements on their emergency response capabilities (23).

The study participants included different types of workers from the fields of health and social support, specifically divided into three categories: the first category was staff from local governments and health institutions; the second category was epidemic prevention and control personnel dispatched from inland areas to the border area; the third category was members of the Rural Revitalization Work Team. Since May 2021, the government has dispatched resident cadres and work teams to the border areas of the province to strengthen health and social support for minority areas, ensuring the smooth progress of epidemic prevention and control work and the sustained stability of economic development (7,24). In this process, externally dispatched personnel closely cooperated with local medical and social support staff, forming a multi-level collaborative network.

These frontline workers, as the main force of epidemic prevention and control, not only had to deal with the high-risk threat of infection but also needed to flexibly adjust their roles and responsibilities to cope with the constantly changing needs of epidemic prevention and control. Especially under extreme pressure, they demonstrated mutual support and collaboration between different levels of prevention and control forces, while making significant contributions to epidemic prevention and control and its derivative tasks.

The preliminary list of participants was provided by the local government, but given the timeliness issue of the list, we collaborated with the local health committee to further supplement the list, especially adding those who participated in caring for suspected or confirmed cases, conducting tests, and epidemiological investigations. In addition, by forwarding research information through the aforementioned frontline workers, we also invited more grassroots workers to participate in this study, ensuring the breadth and representativeness of the research sample.

Instruments

Mental health problems

The Depression, Anxiety, and Stress Scale (DASS-21) was utilized to evaluate mental health through three distinct subscales: depression, anxiety, and stress. Each subscale comprises seven items, scored on a 4-point Likert scale ranging from 0 (did not apply to me at all) to 3 (much or mostly applied to me). The Cronbach’s alpha reliability coefficients for the subscales are as follows: depression (α=0.94), anxiety (α=0.87), and stress (α=0.91) (25).

COVID-19 work related stigma

Work-related stigma in the context of COVID-19 refers to the negative social reactions experienced by primary-level workers serving as COVID-19 responders due to their occupational exposure to the virus. This includes being labeled, stereotyped, or excluded because of perceived contagion risk. In this study, stigma was measured using a 17-item scale, scored on a 4-point Likert scale, where higher scores signified an increased perception of stigma. The scale adopted from the SARS outbreak scale (26) and is based on the HIV Stigma Scale, which has been widely employed in measurements involving healthcare personnel (27). Prior factor analysis has identified four subscales within this framework: personalized stigma, disclosure concerns, negative self-image, and apprehension regarding public attitudes towards workers.

Character strength

Character strength referred to positive, trait-like capacities for thinking, feeling, and behaving that are morally valued and contribute to individual well-being and resilience. In this study, character strength was assessed using the Values in Action (VIA) framework, which identifies core virtues that individuals demonstrate in various life situations. The Global Assessment of Character Strengths-24 (GACS-24) was employed to assess these traits by inviting participants to describe elements of their personality. It includes single-item measures for each strength (e.g., bravery, perseverance, kindness), which have been well-validated across diverse populations and exhibit high reliability (28).

Procedure

Ethics

In our study, we adhered rigorously to ethical standards, securing approval from the Prince of Songkla University (REC 64-446-18-1). To ensure data security, we employed measures such as anonymized data handling and encrypted storage. During recruitment, participants were presented with a detailed informed consent form that articulated the study’s objectives, methodology, potential risks and benefits, and their rights and obligations. After thoroughly reviewing and understanding this information, participants provided informed consent, either in paper form or electronically. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Data collection team

Our team consisted of personnel from the local Health Commission, the Centers for Disease Control and Prevention (CDC), and the Office of the Leading Group for Pilot Work in the Social Psychological Service System Construction, as well as Master students with medical backgrounds and experience in survey research. These investigators underwent extensive professional training over a specific period and became proficient in the use of research tools and data collection processes. Prior to data collection, the research team engaged in preliminary discussions on the mental health of COVID-19 emergency responders, during which relevant international and domestic studies were shared via WeChat (a widely used social media platform in China). Following this, a structured professional training program was organized by the Lincang Municipal Health Commission, with the lead researcher (X.X.) serving as the main speaker. The training consisted of four sessions, each lasting 3–4 hours. Key components included a review of global research progress, discussion of mental health issues and influencing factors, standardized use of survey instruments, research ethics and informed consent, data privacy protocols, and guidance on effective communication and rapport-building. This comprehensive training ensured that the research team was well-equipped to address sensitive topics with both professionalism and cultural sensitivity.

Invitation

All potential participants were invited to participate via push notifications sent through their work platforms. The invitation letters contained detailed information about the study’s purpose, participation requirements, expected benefits, and the steps involved in participating. To maximize response rates, we designed concise and clear invitation letters and sent them during staff rest periods. Participants were given two weeks to respond after receiving the invitation to confirm their willingness to participate. Following confirmation, we delivered the informed consent forms and detailed research questionnaires in person. For those still in quarantine (due to the risk of COVID transmission), we sent the materials via WeChat. To achieve a broader range of occupational groups, we asked frontline personnel who had accepted the invitation to forward the survey information to their colleagues working at the grassroots level.

Benefits for participants

After completing the survey, participants received information about mental sub-health warning standards. Depending on their individual needs, our research team facilitated access to free psychological counseling services. Furthermore, the positive psychology content of our study may have had a beneficial impact on primary-level workers.

Data analysis

Data was gathered using both paper questionnaires (around 80%) and online questionnaires (around 20%) (utilizing WJX.cn). Participants completing the survey online due to being under quarantine or belonging to COVID-19 high risk groups. The data collection phase spanned from December 2021 to August 2022 in a minority region of China. All data underwent rigorous cleaning and coding processes to ensure accuracy and consistency. Online questionnaire data were directly exported, paper-based questionnaire data were double-entered to minimize data entry errors and validated using EpiData software version 3.1 and subsequently analyzed using R software version 4.2.3.

Our hypothesis was that character strength tended to reduce mental health problems, whereas stigma increased them (Figure 1). Stigma acted as a mediating factor that weakened the protective function of character strength. Age, work role, and gender were identified as confounders.

Figure 1 Hypothesis model. Structure: left: 24-character strengths (e.g., gratitude, perseverance) → protective factor; center: stigma (public attitude, disclosure, negative self-image, personalized) → mediator; right: mental health outcomes (stress, anxiety, depression); top: confounders (age, gender, job role) controlled in analysis. Key hypotheses: direct effect: character strength → mental health; indirect effect: character strength → stigma → mental health; confounders: age/gender/role influence all variables.

During the data cleaning phase, records with missing values were removed prior to analysis, which resulted in the exclusion of 0.79% of the total responses (n=17). The statistical analysis methods employed in this study included descriptive statistics to summarize data characteristics, Linear Regression for assessing relationships between variables, and analysis of variance (ANOVA) tests to compare means across groups. Factor analysis was used to identify underlying structures of character strength, while path analysis provided insight into the direct and indirect relationships among variables. Exploratory factor analysis (EFA) was conducted using the maximum likelihood (ML) extraction method with rotation to allow for correlated factors. Parallel analysis was performed to determine the number of factors. The mediating effect of stigma was tested using structural equation modeling (SEM), which allowed for the assessment of both direct and indirect effects within the hypothesized framework. SEM integrated these approaches to assess complex causal relationships and model the interactions between multiple latent and observed variables comprehensively. In SEM, (I) draw path diagram of the mediating process; (II) the standardized path coefficients were estimated to assess the influence of each pathway on the outcome variable; (III) both the direct effect of the main predictor and the indirect effect through the mediator were included in the model to evaluate their independent contributions; (IV) total effects were calculated by summing the direct and indirect (mediated) effects; (V) non-significant mediating paths were removed from the diagram.

Statistical significance was determined at an alpha level <0.05. We utilized Epicalc and tidyr packages for basic data analysis and tabulation, the psych package for EFA, and the lavaan package for path analysis, confirmatory factor analysis (CFA), and SEM. The goodness-of-fit indices used for evaluating the CFA and SEM models, as well as the established cutoff criteria for an acceptable model fit, were specified a priori. For detailed information on the specific indices and their recommendation level, please refer to Table S1 (fitness test results). The R package ggplot2 was used to plot the factor loading heatmap, and DiagrammeR was employed to visualize the results equation model (29).

Results

During the COVID-19 pandemic from 2021 to 2022, there were approximately 10,000 frontline workers in three border counties of Lincang City. They were all invited to participate in this survey. Due to the nature of their work, most frontline workers were unable to promptly review the invitation. Ultimately, 1,550 frontline workers accepted the invitation, and 1,328 completed the questionnaire, yielding a response rate of 15% and a completion rate of approximately 85.7%. Invitations were also relayed by frontline workers to their colleagues at the original workplaces, resulting in around 1,120 responses, with 834 non-frontline workers successfully completing the questionnaire, representing a completion rate of approximately 74.5% among this group (see Figure S1). The total number of participants was 2,162 in this study. During data exploration, we discovered that the 24 items of character strength included in our study did not fully align with the classic six sub-group structure. After reviewing existing literature, we determined that there was no consensus on certain aspects, leading us to conduct factor analysis on these sections to identify latent variables.

Figure 2 illustrates the modeling framework utilized in our factor analysis. The dataset was randomly divided into two subsets: a training set (n1=648, approximately 30% for EFA) and a testing set (n2=1,514, approximately 70% for CFA). Figure S2A displays the scree plot and the initial factor loading heatmap (see Figure S2B). The scree plot indicated that a three-factor solution was optimal, with the first factor explaining the majority (66%) of variance. Although we initially considered a two-factor solution, a three-factor structure provided a better fit (see Table S1). Figure S2B’s heatmap visually represents the factor loadings, highlighting key variables associated with specific factors. This information guided our selection of variables for constructing latent variables in the structural model. Following EFA, we conducted CFA on the test data (1,514 records) incorporating additional target variables (stigma, psychological impacts), achieving an acceptable level of fit [root mean square error of approximation (RMSEA) =0.074, see Table S1]. Path analysis was then used to estimate direct and indirect effects within the hypothesized model (Figure 1), demonstrating satisfactory structural model fit indices.

Figure 2 Modeling framework. The three core components of this study were psychological impact, stigma, and character strength. Existing research had already established the structure of the psychological impact and stigma components. Therefore, only variables related to character strength were explored during the EFA phase. The dataset (N=2,162) was randomly split into a training set for EFA and a testing set for CFA. CFA, confirmatory factor analysis; EFA, exploratory factor analysis; SEM, structural equation modeling.

Figure 3’s heatmap visualized the clustering of character strengths within each of the three factors following the EFA factor analysis, namely, serenity, collaboration, and intelligence. The number of variables was reduced from 24 to 17 after reviewing factor loadings, communalities (h²), uniqueness (u²), and complexity (com). The criteria for determining factor retention included factor loadings greater than 0.40, communalities above 0.30 to ensure adequate shared variance, and a minimum average factor loading of 0.50 across retained variables (see Figure S2B for specific details). It demonstrated strong model fit, indicated by a root mean square residual (RMSR) of 0.02, a RMSEA index of 0.078, and a Tucker Lewis Index of 0.939 (see Table S1).

Figure 3 Heatmap of factor loadings after adjustment. This figure presents the adjusted factor loadings derived from EFA for the 24-character strength variables. Following the results in Figure S2 and Table S2. EFA, exploratory factor analysis.

Serenity includes traits such as modesty, gratitude, forgiveness, and appreciation of beauty, emphasizing inner peace. Collaboration encompassed social and teamwork-oriented traits like teamwork and fairness, while intelligence covered intellectual and reflective strengths, with high values for creativity, courage, wisdom, and hope. High factor score adequacy, with correlations between factor scores and their respective factors ranging from 0.95 to 0.97, further supported the reliability of this factor structure.

In Figure 4A-4C, the results showed a weak relationship between the total score of character strength and stress, anxiety, and depression, with low regression coefficients and adjusted R² values close to zero, indicating limited explanatory power. Only stress demonstrated a significant but weak association with character strength in the linear regression model (β=−0.02, P<0.05). In Figure 4D-4F, COVID-19 work related stigma showed a significant association with stress, anxiety, and depression, and the adjusted R² values were higher, with the models explaining approximately 21–30% of the variance, suggesting that COVID-19 work related stigma had a more pronounced negative impact on mental health.

Figure 4 Scatter plots of linear regression results: exposure factors and psychological impacts. (A-C) X-axis are character strength. Only image (A) shows a significant effect on stress. (D-F) X-axis shows stigma significantly correlated with stress, anxiety and depression.

Table 1 breaks down means and standard deviation of character strength domains, COVID-19 work related stigma and mental health problems by age, gender and whether the subject was a healthcare worker. significant difference among subgroup effect using one-way ANOVA test. The younger group perceived significantly lower levels of stigma compared to the older group, but their mean depression score was significantly higher than that of the older group (P<0.05). Compared to the female group, males showed significantly higher means in character strength, stigma perception, and depression scores (P<0.05). Non-health care personnel showed significantly higher mean levels of character strength and stigma perception (P<0.05), suggesting that different job roles may influence individuals’ psychosocial states and expressions. Notably, these job role differences remained consistent when analyzing the original 24-factor character strength framework (see Table S2).

In Figure 5, the structural equation model is visualized, with arrows indicating significant paths and coefficients labeled after adjusting for age, job role and gender. Combined with the results on Table 2, a deeper understanding of the direct, indirect, and total effects of depression, anxiety, stress, COVID-19 work related stigma, and character strengths were achieved. Stigma itself had strong effects on mental health (β range from 0.449 to 0.564). Most significant pathways from character strengths to mental health issues were direct. While the serenity and intelligence domains (latent factors of character strength) were not significantly associated with stigma, the collaboration (representing teamwork and fairness) showed a small but significant negative association with stigma (β=−0.272). Stigma subsequently served as a key mediator in the relationship between collaboration and mental health outcomes.

Figure 5 Structural equation model diagram with marked coefficients. The figure displayed only the significant paths. This diagram shows that stigma loads well to four observed variables below. It had significant effects on anxiety, depression and stress. The model retains only 3-character strength (serenity, collaboration and intelligence). Mediation role of stigma was significant only from collaboration. ***, P<0.001; **, P<0.005; *, P<0.05.

Discussion

Key findings

This study examined the distribution of character strengths among primary-level workers and the possible mediated role of COVID-19 work related stigma on mental health outcomes. Key factors such as serenity, collaboration, and intelligence within character strengths were identified and linked to mental health indicators. Character strengths themselves had a relatively modest direct impact on mental health problems, but COVID-19 work related stigma played a more significant mediating role in the relationship between collaboration and psychological distress.

Strengths and limitations

The relationship between character strength, COVID-19 work-related stigma, and mental health outcomes among primary-level workers was examined using structural equation model. The findings provided insights into the complex interplay between character strength and mental health during a global pandemic, highlighting collaboration and intelligence as key strengths for fostering psychological well-being and work effectiveness.

However, the generalizability of the findings was limited to primary-level workers in China’s border minority regions during the COVID-19 pandemic. In addition, several methodological limitations should be noted. First, the absence of a centralized database made it difficult to conduct proportional sampling across different worker categories. Second, the rapidly evolving nature of the pandemic may have resulted in varying levels of risk and stress exposure among participants during data collection. Furthermore, the dynamic nature of character strength and their changing relationship with mental health highlighted the need for future longitudinal research.

Comparison with similar research

Compared to the six subgroups in the classic theoretical framework (30), the latent variables generated from factor analysis for character strengths in this study showed some interesting changes. Specifically, wisdom and courage were grouped as intelligence because of its uniqueness high. Collaboration and justice were combined, and serenity covered elements of temperance and transcendence. These shifts likely reflect the influence of social support and healthcare personnel’s practical experiences in the COVID-19 work context on the expression of character strengths. The combination of wisdom and courage highlights the close link between decision-making and action, essential for addressing pandemic challenges and rural support efforts (from cities to villages, transitioning from inland to border areas) (31). In researching the relationship between character strengths and mental health, we found that the total score of character strengths had a weak association with stress, anxiety, and depression. Some studies indicated that character strengths were limited and context-dependent, meaning that individuals could shift from self-focused strengths (such as self-regulation and introspection) to other-focused strengths (such as compassion and caring for others) in different situations (32,33). This contextual dependency did not sufficiently explain the dynamic relationship between character strengths and mental health. Similarly, although we found that character strengths exhibited a certain significance in coping with stress, the regression analysis indicated that the influence of character strengths on stress was statistically significant but small (β=−0.02, P<0.05). Depression and anxiety typically involve more complex emotional and cognitive processes, and the role of character strengths in these contexts may have been limited. Furthermore, coping with depression and anxiety often relies on social support and environmental factors (34). In specific work environments, individuals might have lacked support in these areas, preventing character strengths from effectively exerting their positive influence. In summary, the relationship between character strengths and mental health was complex, and future research needed to explore these potential mechanisms and dynamic changes more deeply to better understand the role of character strengths in mental health. The context of COVID-19 control events required timely, effective decisions in high-pressure environments, uniting wisdom and courage as a cohesive whole, emphasizing the adaptability. Similarly, merging collaboration and justice might reflect the interdependence of teamwork and fairness in pandemic response and rural revitalization (35,36). Serenity’s integration with temperance and transcendence emphasizes mental resilience, crucial during uncertainty and pressure. These insights underscore the practicality of fostering traits like collaboration and intelligence for better psychological well-being and work effectiveness.

Regarding the impact of COVID-19 work related stigma on mental health, our findings aligned with previous studies, indicating that age was significant factor influencing individuals’ perceptions of stigma (14,37). Although gender was not a statistically significant factor in our model, we observed that males did not perform strongly as females in the intelligence dimension, prompting us to reconsider the potential role of gender—particularly masculinity—in shaping stigma experiences. The increased perception of stigma among male may have been related to societal expectations regarding their roles in professions, emotions, and social contexts, making them more susceptible to the pressure of social evaluation during the pandemic (38). Additionally, stigma under this context is likely to stem from the conflicts on responsibilities and role they faced during the pandemic. On the other hand, these workers’ professional identity may have provided them with some degree of protection against external stigma (15). Our analysis also revealed a clear correlation between stigma and stress, anxiety, and depression. This finding underscored stigma as a social phenomenon that not only affected individuals’ emotional and psychological states but also exacerbated mental health issues. Relevant literature indicated that during the pandemic, the unequal nature of social interactions challenged the dominant role of emergency responders (39). The threat to the authority of emergency responders weakened their sense of control in their work. These changes in self-perception could have triggered emotional reactions such as shame, anger, sadness and moral conflict (39). Future interventions addressing stigma became particularly crucial. Strategies should include public education and awareness campaigns to reduce misunderstandings, while also strengthening social support networks (18). Additionally, interdisciplinary responses and support involving social psychology, law, and management sciences were also necessary.

Specifically, collaboration, a latent variable of character strength, not only directly reduced individuals’ perceived risk of stigma but also indirectly alleviated psychological stress by decreasing the perception of stigma, thereby reducing mental health issues. These findings align with the stress-buffering hypothesis, suggesting that collaborative engagement functions as a form of psychosocial support that reduces the psychological toll of stigma (19,40). And further supported a wealth of psychological research demonstrating the benefits of positive traits, states, and experiences on well-being and performance (17).

Explanations of findings

In contrast to most initial expectations, our findings revealed a positive association between the pursuit of serenity and psychological burdens, suggesting that individuals with higher levels of serenity may also report greater mental distress. This phenomenon could be explained through several classical theories. Aristotle’s concept of the “cost of virtue” and Confucius’s “Doctrine of the Mean” suggests that the overdevelopment of positive traits, such as self-regulation and forgiveness, could lead to adverse effects (41,42). This may result in heightened stress, feelings of inadequacy when these traits are pushed to extremes, and an increased psychological burden from constantly striving for perfection and maintaining harmony at the expense of one’s own emotional needs. Similarly, the psychological “Too-Much-of-a-Good-Thing” (TMGT) effect emphasized the need to maintain positive traits at moderate levels to support mental health (43). In high-stress environments like the COVID-19 pandemic, Freud’s theory of the superego further sheds light on the issue, as internalized moral ideals and social standards might have pushed primary-level workers towards excessive self-control and perfectionism, leading to self-criticism (44). Bion’s concept of the “destructive superego” highlighted how a distorted pursuit of knowledge could enhance moral superiority, intensifying self-imposed standards (44). Primary-level workers, under high social expectations and feelings of shame and work-family conflicts, may have fallen into a cycle of self-criticism, driven by the compulsion to meet unattainable standards. This dynamic between the superego, ego, and id could explain the increased psychological strain associated with striving for serenity. While these interpretations reflect complex dynamics behind psychological responses in high-stress settings, we emphasize that our use of character strength measures was intended to offer a resilience-oriented perspective, rather than to attribute mental health challenges to individual shortcomings. This approach aligns with a strengths-based framework that aims to support, not stigmatize, individuals facing psychological challenges.

Implications and actions needed

Understanding these psychological mechanisms can offer insights into the relationship between character strengths and mental health, especially in high-stress settings. Future research should focus on helping individuals balance moral development with self-compassion. For primary-level workers, managing the risks of overdeveloping positive traits is crucial for promoting mental health and reducing anxiety and depression.

Conclusions

Our study reveals that COVID-19 work-related stigma significantly worsens mental health issues among primary-level workers, while character strengths have a limited direct effect. Stigma served as a mediator in the relationship between the collaboration domain and mental health, indicating a modest indirect effect. Additionally, we observed that higher levels of serenity, when imbalanced or overemphasized, were associated with greater psychological burden, indicating that character strengths are not universally protective and may relate to mental health challenges in specific contexts. To address these issues, we recommend implementing targeted mental health interventions for at-risk groups, strengthening anti-stigma programs, promoting balanced character strengths, and advocating for comprehensive mental health support policies for primary-level workers.

Acknowledgments

The authors would like to thank all the participants for taking part in the study. Special thanks to Tianfu Lu, Jiwen Guo, Tianlan Wang, Yujuan Zuo, Chengchuan Shu, Hongxia Zhu, and Xu Wang for their support and assistance during the data collection process.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-10/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-10/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-10/prf

Funding: This study was funded by the B.E. 2562 Prince of Songkla University Research Grant for Thesis from the Graduate School.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by Human Research Ethics Committee, Faculty of Medicine, Prince of Songkla University (REC 64-446-18-1). The studies were conducted in accordance with the local legislation and institutional requirements. All participants, whether participating online or offline, completed a rigorous informed consent process prior to the survey.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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