In China, approximately 50% of the population had been infected COVID-19 by 2023 (1). The clinical impact of COVID-19 extends beyond the acute viral infection phase itself. Apart from physical symptoms, COVID-19 often leads to psychological problems and evokes widespread fear among the population. Fear associated with COVID-19 manifests across four dimensions: physical, interpersonal, cognitive and behavioral (2). The development of post-infection sequelae of COVID-19 (PISC), commonly referred to as Long COVID, is an emerging public health concern. Certain symptoms, such as sleep disturbances, myalgia, anosmia, dysgeusia, and headaches, often persist beyond several months, adversely impacting one’s long-term mental health and quality of life (3, 4). Therefore, it is crucial to examine the long-term influence of the pandemic on mental health among the population in the post-COVID era such as fear of COVID-19.

The mental health effects of the pandemic among mental health professionals (MHPs) have been previously studied (5–7). A study conducted in the Netherlands found that 30% of MHPs in mental health institutions exhibited symptoms of depression, while 4.2% had considered leaving their positions during the pandemic (8). In China, MHPs predominantly comprise psychiatrists, nurses, or technicians, working in psychiatric hospitals or psychiatric departments of general hospitals (9). These professionals provide most of the mental health services in China (10). Notably, their clinical practice often occurs without specialized respiratory protection, a critical measure for COVID-19 prevention. Such resource limitation may exacerbate anxiety among MHPs when encountering potential COVID-19 cases. Previous studies on MHPs during the pandemic mostly focused on symptoms such as insomnia, anxiety and depression, and few of them addressed the prevalence and correlates of COVID-19-related fear, particularly in the post-COVID era. However, COVID-19 fear might indicate underlying mental health problems, for instance, a previous meta-analysis revealed that COVID-19 fear was significantly related with anxiety and depression, especially among healthcare professionals (HPs) (11).

Apart from the COVID-19 infection itself, the implementation of strict public health preventive measures during the pandemic might have prolonged adverse socio-occupational impacts on MHPs even in the post-pandemic era. These effects could have both psychological and physiological manifestations, such as depressive and anxiety symptoms, sleep disturbances, palpitations, and post-traumatic stress symptoms, with many HPs reporting persistent fear when recalling their experiences during the pandemic (12). Furthermore, the heightened prevalence of mental health problems among the population during and immediately after the pandemic would significantly increase the workload of MHPs, thereby exacerbating the risk of mental health problems including COVID-19 fear. Moreover, compared to most of other HPs, MHPs were exposed to patients’ pandemic-related trauma narratives even during the post-pandemic period, potentially leading to vicarious fear (13). Such sustained exposure might result in empathic overload that could affect their psychological well-being. Among the professional development skills for MHPs, the physiological consequences of emotion regulation might have unwanted impacts. Previous research indicated that emotion suppression strategies, often employed in clinical settings, might elevate diurnal cortisol secretion, a biomarker of chronic stress (14). Striving to suppress emotions could increase cortisol concentration, which might paradoxically amplify pandemic-related distress (15). Thus, understanding COVID-19-related fear among MHPs is crucial for addressing their mental well-being, professional competence, work satisfaction and retention, which might serve as a model for other HPs and ultimately benefiting patient care.

Previous research found gender differences in the prevalence and experience of long COVID, with females being more likely to report persistent symptoms compared to males (16). This might be attributed to females being more prone to experience symptoms of mood and hyper-arousal (17). However, previous findings have been inconsistent. Some studies reported that females had higher levels of COVID-19-related fear than males (18, 19). Conversely, a study found that male HP expressed greater fear of COVID-19 than their female counterparts (20), while another study reported no significant gender differences in HPs during the pandemic (21). Such inconsistencies suggest that gender differences in COVID-19-related fear might vary across different populations and change over time. Therefore, it is important to further clarify gender differences in COVID-19-related fear.

It should be noted that most studies evaluated COVID-19 fear based solely on total scores of standard scales, weighing individual symptoms equally (22, 23). However, this approach obscures the meaningful inter-relationships between individual symptoms and hinders the identification of influential symptoms that might play a more significant role in the maintenance of COVID-19 fear. To address this limitation, network analysis has been used as a novel statistical method that could examine how psychiatric symptoms interact with each other and identify the most central (influential) symptoms (24). Network models consist of nodes and edges; nodes represent psychiatric symptoms, while edges reflect their statistical associations (25). Using such an approach, it is possible to identify the most central nodes whose activation could directly influence nearby connected nodes (26), potentially preventing the exacerbation of certain disorders through targeted attention to these nodes (27). Network analysis concerning the COVID-19 fear have been applied to the study of the general population (28), as well as forensic healthcare workers (28).

There are several common limitations among previous studies. First, most have primarily focused on mental health issues, such as anxiety and depression, among MHPs, with limited attention given to COVID-19-related fear, particularly in the post-pandemic context. Second, gender differences in COVID-19-related fear remain poorly understood, with available findings showing inconsistencies across different populations. Third, previous research on COVID-19-related fear has predominantly relied on aggregate scale scores, neglecting symptom-level interactions, and thus failing to identify the most influential symptoms. To address these gaps, we compared gender differences in the prevalence, correlates and network structure of COVID-19-related fear among MHPs in the post-pandemic era.

To the best of our knowledge, this was the first study that compared COVID-19 fear between male and female MHPs with PISC using network analysis. The prevalence of COVID-19 fear in this study was 63.5% (95% CI: 62.3%-64.6%). Due to a lack of studies comparing the prevalence of COVID-19 fear among HPs in China, a direct comparison with similar studies was not possible. Previous research found that MHPs with COVID-19 fear were usually at an increased risk of burnout and secondary traumatic stress (58). Our study adds to this literature by examining the gender differences in COVID-19 fear among MHPs with PISC. The results revealed that female MHPs with PISC (65.0%, 95% CI: 63.7%-66.2%) exhibited a higher prevalence of COVID-19 fear compared to their male counterparts (61.7%, 95% CI: 58.9%-64.4%). The gender discrepancy is partly consistent with previous findings from Saudi Arabia and Belgium that female HPs reported higher levels of COVID-19-related anxiety than their male counterparts (59, 60). Possible reasons for the gender difference might relate to females perceiving the COVID-19 as posing a higher risk to themselves and a greater threat to public health than males (61). Additionally, the hypothalamic-pituitary-adrenal axis in females might be more sensitive, potentially increasing their vulnerability to fear responses (62).

We found that having married status, insomnia, worse economic status, and depression were significantly associated with higher levels of COVID-19 fear in both genders, which aligns with previous studies on factors associated with the perceived COVID-19 fear among Brazilian college students, and the economic and societal influence of the COVID-19 lockdown on the general Japanese population (63, 64). While being married generally enhanced mental health and coping abilities, married MHPs during the pandemic often faced domestic caregiving responsibilities while also managing substantial clinical workloads, thereby exacerbating their perceived vulnerability and pandemic-related fear (65). The association between insomnia and COVID-19 fear among MHPs might be mediated through several factors. Clinically, the need to manage challenging behaviors among patients, including those exhibiting acute psychiatric disturbances, could lead to prolonged occupational stress (66). This heightened stress response could result in increased serum cortisol levels and reduced melatonin synthesis, which might in turn disrupt sleep patterns, initiation, and maintenance, thereby exacerbating insomnia (67). Further, participants with depression were more susceptible to COVID-19 fear, as depressive symptoms might deplete emotional resources, impairing their ability to provide high-quality patient care (68). Additionally, female MHPs with past quarantine experience exhibited higher levels of COVID-19 fear, aligning with findings from dental professionals who reported that quarantine measures were associated with increased pandemic-related fear (69). This heightened fear among female MHPs might be partially attributed to the separate quarantine locations in hotels or hospitals, that were remote from their established social networks. Consequently, they might perceive significantly less social support from colleague and families that is a critical stress-coping mechanism for females, compared to males (70, 71), thus amplifying their fear. Furthermore, quarantine restrictions might limit their ability to share domestic responsibilities with family members and exacerbate their psychological burden. In China, females usually had disproportionately more family and childcare duties (72) and their inability to fulfill these roles during quarantine could likely intensify their distress. Moreover, we found a significant association between lower economic status and heightened fear of COVID-19. A possible explanation might be related to economic vulnerability being a known predictor of poorer mental health outcomes (73). Specifically, MHPs in lower economic status might experience increased anxiety due to uncertainties about the future, which could amplify their fear of COVID-19.

Regarding the network comparison of COVID-19 fear between both genders, the overall structures were similar, but the global strengths differed significantly. Specifically, the female network model exhibited greater sparsity, which might be attributed to gender-specific variations in emotion regulation strategies. For instance, females tended to employ a broader range of emotion regulation strategies, including cognitive reappraisal, problem-solving, acceptance and distraction, compared to males (74). Such enhanced regulatory capacity might result in a more dispersed fear response among females, rather than a concentrated focus on specific fear-related items. Compared to their male counterparts, females tended to maintain broader, non-kin-centered social networks characterized by emotional communication and self-disclosure, which could enhance their access to social support (75). Such support could mitigate the association between specific aspects of fear, thereby weakening the overall connectivity within the female network model (76). Consequently, the global strength of internal connections in the female network model might be reduced.

In the male network, the most central symptom was “Sleep difficulties caused by worried about COVID-19” (FOC6), indicating its pivotal role within the network. This finding is consistent with previous research on COVID-19-related fear among fire service recruits (37). Sleep difficulties, defined as challenges in falling or staying asleep (77), represents a physical manifestation of fear and is associated with somatization symptoms. Such symptoms could significantly impair work performance and overall well-being (78). A nationwide study in China found that approximately 36.2% (95% CI: 35.0%–37.0%) of MHPs experienced insomnia, which was likely exacerbated by heightened work pressure and increased risks of infection during the pandemic (79). Many MHPs had direct care responsibilities for COVID-19 patients despite having limited experience in infectious disease management, which likely intensified their fear and sleep disturbances that had persisted into the post-pandemic era. Male MHPs were disproportionately assigned to leadership positions and high-risk clinical duties during the pandemic, which often led to extended work hours and heightened work pressure (80). Such occupational stressors likely contributed to higher rates of work burnout among male compared to female MHPs, which might have disrupted their sleep patterns (81). Additionally, stigma often prevented males from seeking mental health care (82), which could lead to unaddressed psychological distress manifesting as somatic symptoms.

In the female network model, “Palpitations when thinking about COVID-19” (FOC7) emerged as the most central symptom, which is consistent with a previous network analysis of COVID-19 fear among Brazilian adults (83). Palpitations, defined as the perception of an abnormal heartbeat (84), are strongly associated with intense psychological distress such as fear (85). For instance, a study on female participants found that fear-induced activation of the sympathetic nervous system could elevate heart pump function and induce vasoconstriction, potentially triggering palpitations (86). Additionally, palpitations were among the most common symptoms reported in persons with long COVID (87). In China, the abrupt termination of China’s Zero-COVID Policy and the subsequent surge in COVID-19 cases led to a sharp rise in hospital visits, overwhelming the healthcare systems and disrupting daily life (88). In this context, the ongoing uncertainty and fear of infection had likely aggravated psychological distress, which in turn contributed to persistent symptoms such as palpitations (FOC7). Further, MHPs of whom the majority were female nurses, often faced increased workload and night shifts, as reported in a study on occupational burnout among psychiatric medical staff (89). Night shifts could adversely affect the physical and mental health of MHPs, with palpitations emerging as a predominant concern, thus contributing to this being the most central symptom impacting COVID-19 fear, especially among female MHPs. In addition, research indicated greater emotional self-awareness in females compared with males, including the perception of internal bodily states (e.g., cardiac, respiratory, or gastrointestinal sensations) could be positively correlated with emotional processing capacity (90–92). This increased sensitivity to physical-emotional integration might explain why female MHPs disproportionately reported palpitations during fear states, as they were more attuned to psychosomatic manifestations of distress (93).

The strengths of this study included the large sample size, the unique sample of MHPs and use of the novel statistical approach, network analysis, that could examine the gender-specific COVID-19 fear at a symptom level. Additionally, we explored the correlates across both genders, thereby providing valuable insights into gender differences in fear responses. However, several limitations should be noted. First, as a cross-sectional study, the network structure could not establish either the temporal or causal relationships between symptoms; therefore, longitudinal studies are needed to capture dynamic symptom changes over time. Second, the assessment of COVID-19 fear was based on self-report, which might introduce recall bias. Third, the data collected on quarantine exposure did not distinguish between different quarantine settings (e.g., home vs. centralized facilities), which might influence mental health outcomes. Future studies should capture such details to understand context-dependent effects. Third, the use of an online survey might result in selection bias, thus limiting the generalizability of the findings. Fourth, due to the exploratory nature of the study (94, 95), the significance level was unadjusted for multiple comparisons, although this might potentially increase the risk of false positive results.

In conclusion, this network analysis found that COVID-19 fear was more common among female MHPs compared with male MHPs. Having married status, insomnia, worse economic status and depression were significantly associated with higher levels of COVID-19 fear in both genders. According to the network analysis, “Sleep difficulties caused by worried about COVID-19” (FOC6) was the most central symptom in the male network model while “Palpitation when thinking about COVID-19” (FOC7) was the most central symptom in the female model. Relevant interventions targeting such symptoms should be implemented in the post-pandemic era to alleviate COVID-19 fear effectively and improve the mental health of MHPs.