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Open Access

Peer-reviewed

Research Article

A longitudinal study of the COVID-19 pandemic impact on mental health in ophthalmic personnel and students

  • Yi Pang ,

    Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft, Writing – review & editing

    ypang@ico.edu

    Affiliation Illinois College of Optometry, Chicago, IL, United States of America

    ⨯
  • Connor Robbs,

    Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

    Affiliation Illinois College of Optometry, Chicago, IL, United States of America

    ⨯
  • Jingyun Wang

    Roles Conceptualization, Formal analysis, Methodology, Software, Supervision, Validation, Writing – original draft, Writing – review & editing

    Affiliation State University of New York College of Optometry, New York, NY, United States of America

    ⨯

Abstract

Background

Our previous study revealed that the COVID-19 pandemic posed mental health challenges to eye care professionals and students. The intent of this study was to identify the longitudinal impact of the COVID-19 pandemic on mental health among ophthalmic personnel and students. Additionally, the potential risk factors for mental health problems were investigated.

Methods

A two-phase survey among eye care professionals and students in the USA and Canada was conducted. Phase 1 was administrated from June 23 to July 8, 2020, and has been published; Phase 2 was conducted from January 21 to February 2, 2021. A total of 824 eye care professionals and students participated in Phase 2, with a response rate of 44.1%. Symptoms of depression, anxiety, and stress were measured and calculated.

Results

Compared with Phase 1, stress scores in Phase 2 were significantly reduced (P<0.001) although they were still higher than the pre-COVID level (P < .001). Scores for depression (P = 0.20) and anxiety (P = 0.40) showed no change, comparing Phase 2 to Phase 1. Reduction of stress scores significantly differed among occupations (P = 0.005); students had less reduction of stress than other eye care professionals (all P<0.05). Vaccination status was significantly associated with a reduction in stress scores (P = 0.04).

Conclusions

With the continuing COVID pandemic, although stress level was reduced at 7-month follow-up, the mental health of eye care professionals was still impacted. In this population, COVID-19 vaccination was associated with fewer stress symptoms. These results indicate that the COVID-19 pandemic continues impacting mental health among eye care professionals, especially students. These study results warrant future interventions for eye care personnel and students to prevent or treat mental health disorders.

Citation: Pang Y, Robbs C, Wang J (2024) A longitudinal study of the COVID-19 pandemic impact on mental health in ophthalmic personnel and students. PLoS ONE 19(3): e0300144. https://doi.org/10.1371/journal.pone.0300144

Editor: Darrell Eugene Singer, Uniformed Services University: Uniformed Services University of the Health Sciences, UNITED STATES

Received: July 27, 2022; Accepted: February 21, 2024; Published: March 13, 2024

Copyright: © 2024 Pang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The dataset for this study is accessible to the public in the Open Science Framework repository (https://osf.io/9v3k5/).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: GAD-2, 2-item Generalized Anxiety Disorder scale (measuring anxiety disorder); HIPPA, Health Insurance Portability and Accountability Act; IRB, Institutional Review Board; NPR, National Public Radio; OR, Odds Ratio; PHQ-2, 2-item Patient Health Questionnaire (measuring depression disorder); PSS-4, 4-item Perceived Stress Scale; U.S., United States of America

Introduction

Mental health problems during the COVID-19 pandemic have been extensively studied [1–11]. Numerous studies have reported the burden of mental health problems among the general population as well as among healthcare providers during the pandemic [12–15]. Previously, we reported a high prevalence of mental health problems and revealed mental health disparities among eye care professionals [16]. Our previous findings suggest that it is crucial to detect mental health problems more effectively and develop interventions to address this important public health issue. In addition, COVID-19 dramatically impacted academic eye care including didactic and clinical teaching, patient care, and both clinical and basic research [17], which could further challenge optometry students and impact their mental health.

Although there are many studies to investigate mental health of health care professionals, there are very few papers reporting the long-term impact of COVID-19 on eye care professionals. The aims of this study were 1) to determine whether there was a change in mental health problems including depression, anxiety, and stress in eye care professionals, staff, and optometry students over 7 months during the COVID-19 pandemic; 2) to evaluate whether the COVID-19 vaccine status of individuals had an impact on their mental health status; 3) to study the following potential predictors on their mental health status: participants’ sex, age range, race, ethnicity, occupation, and childcare responsibilities.

Methods

The study protocol and consent forms were approved by the Institutional Review Board of the Illinois College of Optometry (Chicago, IL) with Institutional Review Board number 19032. Adherence to the Health Insurance Portability and Accountability Act (HIPAA) was maintained.

This was a longitudinal, survey-based study. The Phase 1 survey was administered from June 23 to July 8, 2020, and has been published [16]. From January 21 to February 2, 2021, the Phase 2 survey (Table 1) was sent to the individuals who participated in the first survey and voluntarily provided their email address (n = 1869). Multiple email reminders were sent to increase the response rate. A total of 824 individuals responded to the Phase 2 survey with a response rate of 44.1%. Twelve participants were excluded due to missing critical data such as Phase 1 stress score, depression score, or Phase 2 vaccine status data. Therefore, data from 812 participants were analyzed.

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Table 1. Phase 2 survey questions.

https://doi.org/10.1371/journal.pone.0300144.t001

Predictor measures

Demographic information and information about potential predictors were collected, including sex, age range, race, ethnicity, vaccine status, occupation, and childcare responsibilities. Participants’ names were not collected. The survey ID (email) was utilized to assign each participant number. No time limit was given to participants to finish the survey. Participants were allowed to review the previous questions during the survey. We did not use the IP addresses of the participants’ computers to track survey entry. The order of survey questions was altered to reduce answering order biases.

Mental health measures

Depression, anxiety, and psychological stress were assessed using validated questionnaires [18–20]. The questionnaire measurements and score calculations were described in our previous publication1. Probable cases of depression and anxiety were calculated based on the clinical threshold from the depression and anxiety scales (greater than or equal to 3 points on a 0–6-point scale), respectively. The threshold for detecting a probable case of depression and anxiety in each scale was a score greater than or equal to 3 [18].

Sample size calculation

If the true difference in the mean stress score is 0.33 with a standard deviation of 1.227 in 812 participants (12 participants were excluded because of missing data), we would be able to reject the null hypothesis that this response difference is zero with probability (power) 1.000. The Type I error probability associated with this test of the null hypothesis is 0.05.

Statistical analysis

All data were analyzed using the R 3.5.0 Statistics software (R Core Team. URL http://www.R-project.org/). Descriptive statistics were applied including mean and standard deviation of depression, stress, and anxiety scores. Shapiro-Wilk’s test was used to determine normality; we found the differences in these scores were not normally distributed and thus, we used nonparametric tests to analyze data. The differences in scores of stress, depression, and anxiety between Phase 1 and Phase 2 were calculated and further analyzed using the paired Wilcoxon test.

For the variables that significantly differed from the Phase 1 survey, we performed subgroup analyses stratified by gender, race, ethnicity, age, vaccine status, occupation, and childcare responsibility. The Kruskal-Wallis test was used to determine differences among the subgroups. When the Kruskal-Wallis test revealed a difference among the groups, post-hoc pairwise comparisons were performed using the Wilcoxon rank sum test. A P < 0.05 indicates statistical significance.

Results

The demographic characteristics of the participants are listed in Table 2.

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Table 2. Demographic characteristics of the participants (n = 812).

https://doi.org/10.1371/journal.pone.0300144.t002

Scores on depression, anxiety, and psychological stress scale in Phase 2

In the Phase 2 survey, there were a total of 19 questions including 18 questions identical to the first survey and one additional question related to vaccination (Table 1). The depression and anxiety screening questions showed 37.6% of all participants (n = 812) having probable cases of either depression, anxiety, or both. This includes 35.1% of participants scoring higher than the threshold as probable cases of anxiety (score ≥ 3 on the 6-point scale), 18.2% scoring above the threshold as probable cases of depression (score ≥3 on the 6-point scale), and 15.8% scoring above the threshold for both.

Overall stress, anxiety, and depression level in Phase 2 compared with Phase 1

Fig 1 summarizes the change in stress, depression, and anxiety from Phase 1 to Phase 2. Phase 2 stress scores were significantly lower than Phase 1 scores (3.21 ± 1.10 for Phase 2 and (3.54 ± 1.12 for Phase 1, W = 3e+05, P < .001). The depression scores did not change significantly between Phase 2 (1.38 ± 1.50) and Phase 1 (1.49 ±1.56) (W = 5e+05, P = .20). The anxiety level also did not change between Phase 2 (2.17 ± 1.75) and Phase 1 (2.24 ±1.78) (W = 3e+05, P = .40). Thus, only the stress scores were reduced at Phase 2 and the depression and anxiety scores were still high. We further studied potential key factors related to the significant change in stress scores.

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Fig 1. Change in stress scores according to age group (n = 812).

https://doi.org/10.1371/journal.pone.0300144.g001

  1. Gender, race, and ethnicity: The change in stress level between Phases 1 and 2 was not associated with gender (χ2 = 0.90, P = .60), race (χ2 = 8.00, P = .30), or ethnicity (χ2 = 4.00, P = .10).
  2. Age Impact (Fig 1): Age was significantly associated with changes in stress level between Phase 1 and Phase 2 (χ2 = 20.00, P = .006). Pairwise Wilcoxon tests showed the major difference was between the age-subgroup (20–29 YR) and age-subgroup (30–39 YR) (P = .03), indicating the change in stress level was less in the youngest group aged from 20 to 29 years when compared with other age subgroups.
  3. Vaccine Impact (Fig 2): By Phase 2, the stress level was significantly reduced by -0.40 ± 1.17 for those vaccinated or vaccine-scheduled compared to -0.20 ± 1.33 for the unvaccinated subgroup (χ2 = 4.00, P = .04). There was no statistically significant difference in change in depression (χ2 = 2.00, P = .20) or anxiety (χ2 = 0.20, P = .70) between vaccinated and unvaccinated individuals.
  4. Occupation impact (Fig 3): For the Phase 2 survey, the mean stress level was 3.02 ± 0.93 for ophthalmologists, 2.99 ± 1.08 for optometrists, 3.55 ± 1.04 for students, and 2.83 ± 1.17 for staff (χ2 = 60.00, P< .001). Pairwise Wilcoxon tests showed that students had significantly higher stress score compared with ophthalmologists (P = .001), optometrists (P< .001), and staff (P< .001). Fig 3 shows the mean change in stress level between Phase 1 and Phase 2 among occupations. The change in stress scores was statistically significantly associated with type of occupation (χ2 = 10.00, P = .005). Pairwise Wilcoxon tests showed significant differences between the students and optometrists (P = .03), and marginal difference between students and ophthalmologists (P = .05) as well as students and staff (P = .05).
  5. Childcare responsibility: There was no significant difference in the change in stress level related to childcare responsibility (χ2 = 4.00, P = .60).
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Fig 2. Changes in stress, depression, and anxiety scores according to vaccine status from Phase 1 (n = 812).

https://doi.org/10.1371/journal.pone.0300144.g002

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Fig 3. Change in stress scores according to occupation (n = 812).

https://doi.org/10.1371/journal.pone.0300144.g003

Discussion

To the best of our knowledge, this is the first longitudinal study to assess mental health status in eye care professionals in the United States during the COVID-19 pandemic. We found a high prevalence (37.6%) of probable depression, anxiety, or both among eye care professionals. The follow-up survey showed that stress was reduced significantly, especially for those vaccinated or scheduled to be vaccinated. Unfortunately, stress scores in vaccinated students were still high, which indicates that more attention and care should be given to students’ mental health. Interestingly, both depression and anxiety scores remained the same in the follow-up survey. Furthermore, vaccination status was not significantly associated with depression and anxiety scores. More research is warranted to determine the associated factors with mental health problems relative to eye care professionals.

Our previous study revealed that being Black, Asian, female, or young was associated with more mental health problems during the COVID-19 pandemic. Interestingly, having greater proportions of childcare responsibilities at home or more frequent interactions with patients appeared to be protective against depression [16]. This study focused on the changes in mental health over 7 months between Phase 1 and Phase 2. The stress level was significantly reduced at the follow-up; however, both depression and anxiety remained at a high level.

In Phase 2, our finding that students and the youngest eye care professionals showed less reduction of stress levels than other occupations and age subgroups is consistent with recent publications [21–26]. Younger physicians or adults reported higher mental stress [21, 22]. The psychosocial effects of COVID-19 disproportionately affect young people [23]. Du et al. also reported that students had higher stress levels during the COVID-19 pandemic [26]. A study conducted at Texas A&M University showed that 71.26% of 2031 total student participants reported that their stress/anxiety levels increased during the pandemic [27], which is consistent with our study findings. Our longitudinal study demonstrated that students and younger professionals are vulnerable to mental stress, consistent with our previous findings [16].

Although there was no association between vaccination status and anxiety or depression scores, we found that vaccination status was associated with stress level. According to a study on mental health in nurses, vaccination reduced anxiety and depression in an early-vaccination cohort [28, 29]. On the other hand, probably due to apprehension about vaccine efficacy, preliminary trials, and associated side effects, individuals might experience more stress or anxiety when making the vaccination decision or not [30, 31]. Our results are consistent with the findings that mental health issues related to COVID still require attention even with the availability of vaccination [32].

Efforts have been made to manage mental health problems in health care workers during the COVID-19 pandemic [33–38]. However, we found that 37.6% of eye care professionals still demonstrate potential clinical depression and anxiety, which indicates that eye care practitioners need further mental health support.

This study has several limitations. First, our study might underestimate the influence of the COVID-19 pandemic on mental health because the study was conducted before new variants such as delta and omicron emerged. New variants brought uncertainty and doubts about the vaccine [39], which might influence long-term mental health but is beyond the scope of this study. Our follow-up was limited to seven months. Second, this study enrolled a convenient sample of individuals based on professional connections, which may not represent the general eye care professional. The assessment of the vaccination status and stress is also subject to selection bias because the exposure was not randomly assigned. Our sample was 73.1% female, which may reflect a bias towards women. Female health care providers were reported to have a higher likelihood than male providers to experience mental health problems during the COVID-19 pandemic [40]. According to a narrative review on women’s mental health and COVID-19 [25], women demonstrate more risk factors known to increase during a pandemic [41–43]. It is challenging to achieve a high response proportion in external surveys, which have an average response proportion of about 10–15% [44]. Our Phase 2 study had a 44.1% response proportion, which is higher than the reported average proportion. Finally, both medical doctors (21.0%) [45] and optometrists (18.8%) [46] have a higher percentage of Asian than the general population (6.3%) [47], more Asians participated in our study (26.1%) than the general population.

Conclusion

Stress level was significantly reduced in eye care personnel and students after 7 months, however not for depression and anxiety. Vaccinated participants reported a lower stress level compared to unvaccinated participants. These results indicate that the COVID-19 pandemic can continue impacting mental health among eye care professionals, especially students, for extended periods after the initial pandemic onset. This study suggests that additional research is warranted to better understand the impact of the COVID-19 pandemic relative to mental health so that future preventions and treatments can be implemented.

Acknowledgments

The authors thank Drs. Kelly Frantz and Daniel Roberts in their assistance in editing the manuscript.

References

  1. 1. Lindert J., Jakubauskiene M., and Bilsen J., The COVID-19 disaster and mental health-assessing, responding and recovering. Eur J Public Health, 2021. 31(Supplement_4): p. iv31–iv35. pmid:34751367
  2. 2. Chen Y., et al., Bibliometric analysis of mental health during the COVID-19 pandemic. Asian J Psychiatr, 2021. 65: p. 102846. pmid:34562753
  3. 3. Wang C., et al., A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun, 2020. 87: p. 40–48. pmid:32298802
  4. 4. Wang C., et al., Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health, 2020. 17(5). pmid:32155789
  5. 5. Tang W., et al., Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students. J Affect Disord, 2020. 274: p. 1–7. pmid:32405111
  6. 6. Roy D., et al., Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr, 2020. 51: p. 102083.
  7. 7. Ozdin S. and Bayrak Ozdin S., Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. Int J Soc Psychiatry, 2020. 66(5): p. 504–511. pmid:32380879
  8. 8. Ni M.Y., et al., Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan, China: Cross-Sectional Survey. JMIR Ment Health, 2020. 7(5): p. e19009. pmid:32365044
  9. 9. Liang L., et al., The Effect of COVID-19 on Youth Mental Health. Psychiatr Q, 2020. 91(3): p. 841–852. pmid:32319041
  10. 10. Li S., et al., The Impact of COVID-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users. Int J Environ Res Public Health, 2020. 17(6).
  11. 11. Zeng W., et al., Prevalence of mental health problems among medical students in China: A meta-analysis. Medicine (Baltimore), 2019. 98(18): p. e15337. pmid:31045774
  12. 12. Shah M., et al., Mental Health and COVID-19: The Psychological Implications of a Pandemic for Nurses. Clin J Oncol Nurs, 2021. 25(1): p. 69–75. pmid:33480882
  13. 13. Riedel B., et al., Mental Health Disorders in Nurses During the COVID-19 Pandemic: Implications and Coping Strategies. Front Public Health, 2021. 9: p. 707358. pmid:34765579
  14. 14. Harvey S.B., et al., Mental illness and suicide among physicians. Lancet, 2021. 398(10303): p. 920–930. pmid:34481571
  15. 15. Suryavanshi N., et al., Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India. Brain Behav, 2020. 10(11): p. e01837. pmid:32918403
  16. 16. Pang Y., et al., Risk factors for mental health symptoms during the COVID-19 pandemic in ophthalmic personnel and students in USA (& Canada): a cross-sectional survey study. BMC Psychiatry, 2021. 21(1): p. 528.
  17. 17. Wong T.Y. and Bandello F., Academic Ophthalmology during and after the COVID-19 Pandemic. Ophthalmology, 2020. 127(8): p. e51–e52. pmid:32359842
  18. 18. Lowe B., et al., A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord, 2010. 122(1–2): p. 86–95. pmid:19616305
  19. 19. Cohen S., Kamarck T., and Mermelstein R., A global measure of perceived stress. J Health Soc Behav, 1983. 24(4): p. 385–96. pmid:6668417
  20. 20. Cohen S. Perceived stress in a probability sample of the United States. The social psychology of health. The Claremont Symposium on Applied Social Psychology. Thousand Oaks, C., US: Sage Publications, Inc; 1988. p. 31–67.
    • 21. Li W., et al., Mental Health of Young Physicians in China During the Novel Coronavirus Disease 2019 Outbreak. JAMA Netw Open, 2020. 3(6): p. e2010705. pmid:32478846
    • 22. Pieh C., Budimir S., and Probst T., The effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (COVID-19) lockdown in Austria. J Psychosom Res, 2020. 136: p. 110186. pmid:32682159
    • 23. Power E., et al., Youth mental health in the time of COVID-19. Ir J Psychol Med, 2020. 37(4): p. 301–305. pmid:32611470
    • 24. Batra K., et al., Assessing the Psychological Impact of COVID-19 among College Students: An Evidence of 15 Countries. Healthcare (Basel), 2021. 9(2). pmid:33671363
    • 25. Almeida M., et al., The impact of the COVID-19 pandemic on women’s mental health. Arch Womens Ment Health, 2020. 23(6): p. 741–748. pmid:33263142
    • 26. Du J., et al., Mental Health Burden in Different Professions During the Final Stage of the COVID-19 Lockdown in China: Cross-sectional Survey Study. J Med Internet Res, 2020. 22(12): p. e24240.
    • 27. Wang X., et al., Investigating Mental Health of US College Students During the COVID-19 Pandemic: Cross-Sectional Survey Study. J Med Internet Res, 2020. 22(9): p. e22817.
    • 28. Kim S.C., Rankin L., and Ferguson J., Nurses’ mental health from early COVID-19 pandemic to vaccination. J Nurs Scholarsh, 2022. 54(4): p. 485–492. pmid:34967492
    • 29. Kim S.C., Rankin L., and Ferguson J., Nurses’ mental health from early COVID-19 pandemic to vaccination. J Nurs Scholarsh, 2021. pmid:34967492
    • 30. Ta Park V.M., et al., Vaccine willingness: Findings from the COVID-19 effects on the mental and physical health of Asian Americans & Pacific Islanders survey study (COMPASS). Prev Med Rep, 2021. 23: p. 101480.
    • 31. Batty G.D., Deary I.J., and Altschul D., Pre-pandemic mental and physical health as predictors of COVID-19 vaccine hesitancy: evidence from a UK-wide cohort study. medRxiv, 2021. pmid:34013297
    • 32. Pandey K., et al., Mental Health Issues During and After COVID-19 Vaccine Era. Brain Res Bull, 2021. 176: p. 161–173. pmid:34487856
    • 33. Feinstein R.E., et al., A health care workers mental health crisis line in the age of COVID-19. Depress Anxiety, 2020. 37(8): p. 822–826. pmid:32667106
    • 34. Gonzalez A., et al., Supporting health care workers during the COVID-19 pandemic: Mental health support initiatives and lessons learned from an academic medical center. Psychol Trauma, 2020. 12(S1): p. S168–S170. pmid:32584111
    • 35. Hou T., et al., Social support and mental health among health care workers during Coronavirus Disease 2019 outbreak: A moderated mediation model. PLoS One, 2020. 15(5): p. e0233831. pmid:32470007
    • 36. Kavoor A.R., Chakravarthy K., and John T., Remote consultations in the era of COVID-19 pandemic: Preliminary experience in a regional Australian public acute mental health care setting. Asian J Psychiatr, 2020. 51: p. 102074. pmid:32294583
    • 37. Kuzman M.R., Curkovic M., and Wasserman D., Principles of mental health care during the COVID-19 pandemic. Eur Psychiatry, 2020. 63(1): p. e45. pmid:32431255
    • 38. Sockalingam S., et al., Responding to Health Care Professionals’ Mental Health Needs During COVID-19 Through the Rapid Implementation of Project ECHO. J Contin Educ Health Prof, 2020. 40(3): p. 211–214. pmid:32658015
    • 39. van Oosterhout C., et al., COVID-19 evolution during the pandemic—Implications of new SARS-CoV-2 variants on disease control and public health policies. Virulence, 2021. 12(1): p. 507–508. pmid:33494661
    • 40. Sheraton M., et al., Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Res, 2020. 292: p. 113360. pmid:32771837
    • 41. Street A.E. and Dardis C.M., Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder. Clin Psychol Rev, 2018. 66: p. 97–105. pmid:29580673
    • 42. Hao F., et al., Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun, 2020. 87: p. 100–106. pmid:32353518
    • 43. Sediri S., et al., Women’s mental health: acute impact of COVID-19 pandemic on domestic violence. Arch Womens Ment Health, 2020. 23(6): p. 749–756. pmid:33068161
    • 44. Rutherford C., Research interests: Higher Education, Leadership, Teacher Education, EdTech, Social Media. http://www.drcamillerutherford.com/2016/05/survey-research-and-acceptable-response.html.
    • 45. DATAUSA: Physicians & Surgeons, D., races [cited 6 September 2023], Available from: https://datausa.io/profile/soc/physicians-surgeons#demographics.
    • 46. DATAUSA: Optometrist, D., races [cited 6 September 2023], Available from: https://datausa.io/profile/soc/optometrists#demographics.
    • 47. Population Estimates, J., 2022: Race and Hispanic Origin. [cited 6 September 2023]., Available from: https://www.census.gov/quickfacts/fact/table/US#.