The global spread of coronavirus disease 2019 (COVID-19), resulting in the World Health Organization (WHO) declaring COVID-19 as a pandemic, has become a medical serious concern across more than 200 countries worldwide (Wang et al., 2020; World Health Organization [WHO], 2020). The rapid spread of the COVID-19 resulted in many deaths, mostly due to respiratory problems. Kosovo has been affected by the pandemic since March 13, in 2020 when the first COVID-19 cases were confirmed. By December 22, 2020, in the time when the study was initiated, in Kosovo there were 49,169 confirmed cases of COVID-19, 173,145 suspected and tested and 1,262 deaths (National Institute of Public Health [NIPH], 2020). To restrain the spread of the virus, restrictions in local and international travel, in-house isolation or quarantine were the most common responses and measures enforced by the governments worldwide (Chopra et al., 2020).

Recent studies provide evidence of unprecedented psychological impact of COVID-19 on healthcare providers engaged in the diagnosis, treatment, and care for patients with COVID-19 due to restrictions and the work under stressful conditions (lack of hospital facilities, fear of contagion and spreading the virus, working over-time, wearing personal protection equipment— PPE-, restraining from food, drinks, and the toilet during working hours due to PPE, and more) while managing critical issues daily (Barello et al., 2020; Gupta et al., 2020; Kalaitzaki et al., 2020; Lai et al., 2020). Frontline healthcare providers are continuously reporting increasing levels of anxiety (Neto et al., 2020), associated with functional impairments, alcohol or drug coping, symptoms of depression like extreme hopelessness, and passive suicidal ideation (Lee, 2020). Approximately 50% of physicians have reported poor sleep (Zhang et al., 2020) due to contagious nature of the disease and emergency nature of their work during COVID-19 pandemic (Qiu et al., 2020).

Having been infected with COVID-19 infection and being exposed to risk in work settings, frontline healthcare providers are consistently exposed to potentially traumatic events while assisting patients with COVID-19 (Wu et al., 2019; Kalaitzaki et al., 2020) involving a threat to life and mental health in daily basis, a major upheaval of their life habits linked to confinement and the difficulty of projecting themselves into the future (Constant, 2020). Work-related trauma can act as a catalyst for positive post-trauma changes (Wu et al., 2019) involving “life-changing” psychological shifts in thinking and relating to the world that is deeply meaningful (Tedeschi and Moore, 2021). Although the negative psychological impact of COVID-19 on mental health have been examined in recent studies, little is known about the potential positive outcomes that may occur from the pandemic (Kalaitzaki et al., 2020). Despite the adversities of trauma, some individuals report positive life changes, known as post-traumatic growth (PTG), including an increased appreciation for life, meaningful interpersonal relationships, sense of personal strength, changed priorities, and a richer existential/spiritual life (Tedeschi and Calhoun, 1995, 1996, 2004; Rogan et al., 2013), as a result of their cognitive efforts to deal with challenging life events (Tedeschi and Calhoun, 2004, 1995). A systematic review found that 53% of individuals who endure trauma have experienced PTG from having to cope with life stressors (Wu et al., 2019), enjoying greater psychological and even physical wellbeing (Manning-Jones et al., 2015).

In addition, adaptive coping strategies may be a way to foster PTG in healthcare providers (Rodríguez-Rey et al., 2017). Coping strategies refer to behavioral and cognitive efforts that help to reduce the influence of a stressful condition and are used when its demands exceed individual resources (Girma et al., 2021). Significant cognitive structures nullified by the traumatic events for purposefully thinking about the trauma were found to play an important role to construct the worldview (Yang and Ha, 2019). According to Tedeschi and Calhoun (2004), the coping strategies used to manage stressors are significant in the development of PTG. It is also suggested that PTG mutually interacts with life wisdom and the development of the life narrative, and that it is an ongoing process, not a static outcome. A meta-analysis conducted by Prati and Pietrantoni (2009) showed that, of the many stress coping strategies, positive reappraisal and religious coping have the largest effect on PTG. The same was found in other studies, emphasizing meaning-focused coping strategies, in particular positive reappraisal among cancer patients (Sears et al., 2003) and HIV/AIDS population (Siegel et al., 2005). Conversely, avoidance coping strategies hinder the probability of growth after trauma (Helgeson et al., 2006).

To the best of our knowledge, to date, no published studies have examined PTG among frontline healthcare providers during pandemic in limited resource settings such as Kosovo. Gaining a more comprehensive understanding of the potential positive psychological impact of COVID-19 on healthcare providers is essential to developing interventions that would help manage and minimize the consequences of mental health related to pandemic. Therefore, this study sought to provide insight into PTG levels among healthcare providers in Kosovo, following the adversity of the COVID-19 outbreak.

Our study tests the following two hypotheses. First, based on the PTG theoretical model (Tedeschi and Calhoun, 2004; Calhoun and Tedeschi, 2006; Calhoun et al., 2010), coping skills will moderate the relationship between PTG and mental health. And second, the COVID-19 outbreak will have a negative impact on the mental health of healthcare providers.

A considerable proportion of participants reported symptoms above the clinical cut off across all scales. Participants reported fewer clinical symptoms for the four GHQ subscales (Table 1) except somatic symptoms. 44% reported clinical symptoms for the anxiety subscale, 26% for depression, 50% for somatic symptoms, and 39% for social dysfunction.

Table 2 summarized subgroup comparisons across key variables. For GHQ subscales, there was a significant difference for symptom severity on anxiety (χ² = 8.08, p < 0.01). Kruskal Wallis analysis showed no statistical differences for all PTG subscales according to symptom severity, and no statistical differences for coping skills (χ² = 59.12, p = 0.403).

Self-reported clinical somatic symptoms (χ² = 13.62, p < 0.001) and anxiety (χ² = 5.80, p < 0.01) differed significantly for participants who experienced COVID-19 infection as opposed to those who didn’t. Results also showed statistical differences across all PTG subscales except relation to others when comparing participants who experienced COVID-19 infection and those who did not. No significant difference was found for coping skills.

While women had more self-reported clinical symptoms than men for four GHQ subscales, only the somatic symptoms differed significantly by gender, χ² = 16.02, p < 0.001. Women also had significantly higher coping skills scores than men (t = 1.99, p < 0.05). No significant difference was found between genders for the post-traumatic growth subscales.

To observe predictor variables for PTG scores, we ran a hierarchical regression analysis with three models, adding variables stepwise to observe variance change. Results in Table 3 show the period of attending to COVID-19 patients significantly predicted PTG in the three models, however the adjusted R2 value did not show changes across each step.

This study aimed to assess the extent of PTG among a sample of healthcare providers, and to further understand both positive and negative psychological consequences of the current global COVID-19 pandemic, by examining the relationship between PTG, mental health symptomatology and dispositional factors such as coping.

The study revealed alarming data on how COVID-19 outbreak has had an impact on the mental health of healthcare providers. As shown in the Table 1, a considerable proportion of participants reported anxiety symptoms, social dysfunction, depression, with somatic symptoms leading to the escalation. Potential explanations point to the new conditions presented by the pandemic situation, including social withdrawal, excessive hand washing, use of hand sanitizers, protective masks, and medication. Increased focus on protective hygiene behaviors may be linked to the observed somatic symptoms, whereas withdrawal and added work hours may contribute to anxiety. This was particularly true at the time the study was conducted, when also vaccines were not still available as found in Luo et al. (2020) study as well. This may explain why depressive symptoms were less present in the results. Our findings are consistent with recent studies, showing that healthcare providers are at great risk of mental consequences while providing care to patients during COVID-19 pandemic (Shaukat et al., 2020), with high prevalence of somatization associated with medical service-related factors (Song et al., 2021).

The difference on mental health symptoms by gender was found in four subscales and significantly differing particularly in reported somatic symptoms as shown in Table 2. Similar data were found in Gallopeni et al. (2020) study measuring anxiety and depression in healthcare providers in Kosovo, where female healthcare providers have reported almost 20% more anxiety symptoms and 13% more depressive symptoms than their male counterparts’ men. In addition to gender characteristics and etiological research data, this might be influenced by the social norms where women including those employed take more responsibility for childcare, which in turn may have influenced the more pronounced onset of symptoms.

Our findings show low mean scores on PTG. Comparative to previous findings performed in similar settings, the PTG scores of our study lie on mid to high range among samples of healthcare providers similar to Cui et al. (2021) study and is low when compared to firefighters (Yang and Ha, 2019) or to students in the general population (Zeng et al., 2021). A possible explanation could be the time when the study was carried out, as the healthcare providers were still facing tremendous life-threatening situations. Nevertheless, the results showed statistical differences across all PTG subscales except relation to others when comparing participants who experienced COVID-19 infection as opposed to those who did not, as shown in Table 2. In line with other studies (Lau et al., 2006; Bridgland et al., 2021; Huecker et al., 2021; Hyun et al., 2021); COVID-19 as severe acute respiratory syndrome appears to have been experienced as a harmful and traumatic stressful event by healthcare providers, eliciting post-traumatic stress responses. However, overcoming the trauma seems to lead them to constructive outcomes, underlining that PTG can occur after infectious diseases. Upon closer investigation, Relating to Others was the highest scoring PTGI factor, with New Possibilities as second. As a tendency to find meaning in facing this life-threatening disease, healthcare providers seem to change their sense of relationship, resulting in building closer bond with their family members and friends and a willingness to help others, as noted in other studies (Khanjani et al., 2017; Rzeszutek, 2017; Tamiolaki and Kalaitzaki, 2020; Sun et al., 2021) when social support became an important source in coping with challenging events.

Consistent with previous studies (Smith et al., 2008; Lelorain et al., 2010; Rajandram et al., 2011; He et al., 2013; Kunz et al., 2018; Yan et al., 2021), the effect of mental health on PTG was found to be mediated by coping skills in the sample we examined. The link between experiencing COVID-19 infection and the extent of PTG experience indicates that growth may take place not as a direct result of trauma, but a result of the individual’s attempt to adapt to the new post-traumatic reality, as highlighted by Tedeschi et al. (1998). Our findings are congruent with those of other studies (Lelorain et al., 2010; Rajandram et al., 2011; Mesidor and Sly, 2019) suggesting that high scores on adaptive coping strategies is associated with better ability to cope with stressful situations and higher scores on PTG. Coping strategies appear to be influencing factors in well-being (Freire et al., 2016), resilience (Craparo et al., 2018) and post-traumatic growth (as highlighted in this study), which should be further investigated in a tailored study, based on specific events.

Women had significantly higher coping skills scores than men. Similar findings were found in a recent study of Graves et al. (2021) when testing for gender differences in coping and perceived stress among college students. Women are more likely to use emotion-focused strategies such as distraction, and emotional and religious support than men (Park et al., 2020) and more likely to seek instrumental/emotional support, attempt cognitive restructuring, and use spirituality as a “grounding” strategy (Kolakowsky-Hayner et al., 2021). These findings should be further investigated to test whether personality traits have an important role to play in relation to gender difference. While, when it comes to PTG, gender roles did not differentiate for post-traumatic growth. This result supports the finding of Barlow and Hetzel-Riggin (2018) study. Although further investigation is needed to validate our findings and reach a reliable conclusion, the present study results are still meaningful as they show that levels of mental health exacerbation may not playing a conclusive role in determining levels of PTG, if coping mechanism are in place.

Some limitations must be considered. First, this study was conducted in the early stages of the COVID-19 pandemic when vaccines were not available, and it may reflect on the data regarding the prevalence of mental health symptoms and the extent of post-traumatic growth. Second, self-report measures were used as the primary source of data collection, and are therefore based on perceived capacities, which may lead to the deviation of self-choice. Third, Coping Skills questionnaire due to time constrains, was not standardized; it was only translated and back translated into Albanian. Fourth, the nature of the cross-sectional design was one of the limitations as it limited the course of PTG, it could not reflect the causal-effect relationship. PTG could be related to any pre-trauma events experienced by the participants, and it was not possible to cue measure solely to the experiences of COVID-19. Fifth, this study focused only on quantitative data, lacking triangulation with other methods such as qualitative methods, which should be remedied in future research to give an in-depth insight of PTG experiences of the participants.

Our findings indicate an urgent need for psychological intervention to recover from mental health struggles and guidelines on how to cope with COVID-19 for this population. The development and implementation of interventions to minimize COVID-19-related mental health consequences and to foster PTG among healthcare providers could be highly beneficial in pandemic response work: providing continues psychological support to healthcare providers, by helping them identify and activate adaptive coping strategies that can lead them to positive life change, regardless the adversity of the COVID-19 outbreak. Mental health care providers should recognize positive changes and growth among their colleagues and use them as a source for improving their skills when facing the negative effects of COVID-19 infection. The growth in relationships exemplified the importance of social support and relationships in the process of facing trauma, which should be considered when developing PTG interventions. The study results fill the gap in the study area of positive changes during the pandemics, by providing baseline information for other researchers to conduct similar studies by considering the limitations of this study.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Heimerer College. The participants provided their written informed consent to participate in this study.

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.