Introduction

Healthcare professionals face high workloads and resource shortages in emotionally demanding environments on an everyday basis [1]. This can lead to stress, which is defined as a psychological state of worry or mental tension with potentially harmful effects on physical and emotional well-being, according to the World Health Organization [2]. By extension, work-related stress is called occupational stress [3,4] . In Vietnam, the prevalence of occupational stress among HCWs ranges from 26.7% to 40.6%, primarily at mild to moderate levels [5–7]. This statistic sharply increased during the COVID-19 pandemic, with roughly 34% experiencing moderate and approximately 30% severe stress [8]. Previous studies show that prolonged stress among HCWs is associated with burnout, increased risks of errors, and diminished quality of patient care. Not addressing prolonged stress may lead to or worsen anxiety, depression, sleep disturbances, and emotional dysregulation [8–10]. The problem of stress has been explored in various populations, including athletes [11], students [12], and patients [13]. Among HCWs, risk factors for stress include age, education level, marital status, work conditions, and comorbid mental health conditions [14–17]. In Vietnam, studies addressing HCWs’ occupational stress were mostly conducted in hospitals [5–7,14,15], while little is known about the stress levels of HCWs working at the primary care level. Therefore, this study aims to address the gap in understanding stress among this particular population in Ho Chi Minh City, Vietnam, to inform population- and setting-specific interventions.

Several explanatory theories have been developed to evaluate perceived stress. The Richard Lazarus and the Susan Folkman Transactional Model of Stress emphasize that cognitive appraisal shapes subjective stress experiences [18]. The Robert Karasek Job Demand-Control model focuses on the impacts of high job demands and low autonomy [19]. The Johannes Siegrist Effort-Reward Imbalance model addresses the mismatches between effort and rewards [20]. The Stevan Hobfoll Conservation of Resources theory emphasizes resource loss and protection as central to stress responses [21]. Chronic work stress theory discusses the health impact of prolonged exposure to stressors [22]. Lastly, the Transactional Model provides a unifying framework for understanding how individuals perceive and respond to stressors. Therefore, this study uses that model as its theoretical framework.

The Perceived Stress Scale (PSS) is recognized as the gold standard for assessing perceived stress and evaluating the degree to which individuals perceive their life situations as unpredictable, uncontrollable, or overwhelming [23–26]. Unlike objective checklists of life events [27,28], the PSS captures the subjective appraisal of stress specifically and whether they perceive external demands as exceeding their adaptive capacity [23]. The PSS-10 is a brief, psychometrically robust, and widely used tool that comprises perceived helplessness and perceived self-efficacy [29,30]. Moreover, the Brief Coping Orientation to Problem Experienced (Brief COPE) scale is also widely used to assess coping strategies. It has been validated across a range of populations and contexts with an acceptable internal consistency across subscales (median Cronbach’s α = 0.75, ranging from 0.54 to 0.91) [26,31,32]. Coping strategies in the Brief COPE are categorized as problem-focused, emotion-focused, or avoidant. Research has shown that adaptive coping mechanisms are associated with lower stress levels and, therefore, improved psychological resilience [33,34]. These mechanisms include seeking social support, problem-solving, and positive reframing. In contrast, avoidance, denial, or substance use are linked to increased stress and burnout risks [34].

Materials and methods

Study design and population

This cross-sectional study targeting healthcare workers at 12 health stations serving approximately 485,000 residents in Ho Chi Minh City, Vietnam, where staff are responsible for a wide range of public health duties- including disease prevention, health promotion, and outpatient care- despite substantial workloads and limited staffing [35].

The sample size was calculated using the formula for estimating a population proportion, based on the following assumptions: a prevalence of stress among HCWs (p) of 15.4% as reported in prior research of Bui HC et al [36] a Z-score () of 1.96 corresponding to a Type I error (α) of 0.05 for a 95% confidence level, and an estimation error (d) of 5% [37].

Therefore, the minimum required sample size for the study was 201 participants to ensure adequate statistical power.

The study population included all HCWs from the 12 health stations in Ho Chi Minh City, Vietnam. The HCWs including physicians, pharmacists, physical assistants, nurses, midwives, technicians, administrative staff and support staff.

A convenience sampling strategy was considered on all eligible HCWs were invited to participate between 19 February 2025 and 31 March 2025. Eligible participants were healthcare workers who had at least six months of continuous service and provided informed consent to participate in the study. All participants were informed about the objective of the study and completed the consent form before participating. Those absent on two or more occasions during data collection or who failed to complete the entire survey questionnaire were excluded. Finally, a total of 212 HCWs were recruited using total population sampling.

Results

A total of 212 questionnaire responses were obtained, and the sociodemographic is presented in Table 1. Most participants were male (61.3%), of Kinh ethnicity (93.4%), and affiliated with a religion (83.0%). A bachelor’s degree was held by 67.9% of them, while 37.3% reported alcohol consumption and 13.7% reported smoking. Most lived with others (90.1%) and perceived their relationships with relatives as very good (57.5%) or good (29.7%). The most common professional roles were Physician assistant/Nurse/Midwife/Technician/administrative staff/support staff (54.7%). Participants had a median of 10 years of experience (IQR: 3–18) and nearly three-quarters rated their work environment as somewhat unsuitable.

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Table 1. Characteristics of the participants (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t001

Table 2 depicts the items’ score of the perceived stress of participants. As shown in Table 3, the overall mean PSS-10 score was 16.7 ± 2.3, indicating a predominance of moderate stress levels with 93.4% experiencing moderate stress.

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Table 2. Descriptive statistics of perceived stress (PSS-10) by items (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t002

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Table 3. Descriptive statistics of perceived stress (PSS-10) by levels (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t003

Coping strategies employed by participants are summarized in Table 4. Among the 14 subscales of the Brief COPE inventory, the most frequently used strategies were denial (5.8 ± 1.2), behavioral disengagement (5.4 ± 1.4), and active coping (5.3 ± 1.4), whereas the lowest mean scores were observed for planning (3.5 ± 1.3) and venting (3.8 ± 1.4).

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Table 4. Descriptive statistics of coping strategies (Brief COPE) (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t004

Bivariate analysis in Table 5 revealed a significant negative correlation between age and stress levels (r = −0.150, p = 0.029), while self-blame was positively correlated with stress (r = 0.148, p = 0.031). Instrumental and emotional support showed marginal associations with stress but did not reach statistical significance.

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Table 5. Factors related to occupational stress (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t005

Table 6 presented the results of the correlational analysis. Multivariate linear regression showed that age remained a significant negative predictor of stress (β = −0.03; 95% CI: −0.06 to −0.01; p = 0.043). Participants with chronic diseases exhibited significantly higher stress levels (β = 1.19; 95% CI: 0.23–2.15; p = 0.016). Moreover, physicians reported significantly greater stress compared to individuals in other occupational groups (β = 0.72; 95% CI: 0.01–1.43; p = 0.046).

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Table 6. Multiple Linear Regression Analysis of stress and participant characteristics (N = 212).

https://doi.org/10.1371/journal.pone.0349770.t006

Discussion

This study demonstrated that the majority of healthcare workers experienced moderate levels of perceived stress. These results differ from previous studies that reported the prevalence of stress at relatively low levels, ranging from 15.4% to 21.7% [15,36]. During the COVID-19 pandemic, Yubonpunt P et al and Michalak M et al reported stress levels were higher, at 41.97% and 47%, respectively [34,44]. The differences across these studies can be explained by the diversity in instruments, cut-off criteria, pandemic exposure, work environment, and cultural attitudes toward stress expression. Similarly, studies using the EASE scale and Occupational Stress Index have reported substantial levels of stress among HCWs [33,45]. Although primarily measurement-based, these findings can be interpreted within broader frameworks beyond the Lazarus and Folkman transactional model of stress, particularly the Conservation of Resources theory and the Job Demand-Control model. With 93.4% of HCWs reporting moderate stress, it is likely that there is an issue within the healthcare environment. This is consistent with the Job Demand-Control model and the Effort-Reward Imbalance model, which emphasize the effects of high job demands, low control, and insufficient rewards [19,20]. From the perspective of the Conservation of Resources theory, this may also reflect cumulative resource depletion over time [21]. Such widespread stress has important implications for workforce well-being, quality of care, and patient safety that necessitate the need for system-level interventions.

Coping strategies mediate between stressors and responses and are categorized as adaptive coping (active problem-solving, acceptance, positive reframing) or maladaptive coping (avoidance, withdrawal, substance use). We observed a strong association between perceived stress level and the type of coping strategies used. Interestingly, HCWs with higher stress levels relied more heavily on avoidant strategies such as denial, behavioral disengagement, and substance use, while still concurrently engaging in adaptive approaches. This concurrent use of coping styles suggests stress dynamism; however, the overall psychological outcome is more likely shaped by the predominance one coping strategy category over the other. This finding is consistent with the study by Aryal S et al, conducted among community health workers in Mangalore Taluk, Karnataka, which reported that avoidant coping strategies, particularly self-distraction, denial, substance use, behavioral disengagement, and self-blame, were significantly associated with occupational stress [33]. Similarly, Gonzalez Delgado M et al found that those who relied on avoidance and disengagement coping had significantly higher rates of acute stress and depression, greater declines in mental well-being, and the highest levels of intention to leave the profession [45]. This reiterates that while avoidant coping may provide short-term relief, its overuse is closely linked to worsened psychological health if not balanced by adaptive coping.

On the other hand, the previous research by Folkman and Lazarus has emphasized that problem-focused coping strategies can enhance perceived control, reduce anxiety, and promote psychological recovery more effectively than strategies focused on emotional relief [46]. However, a noteworthy observation in our study is that some individuals use active coping, planning, and seeking emotional or instrumental support but remain at high levels of perceived stress. Using adaptive strategies may not guarantee stress reduction if those strategies are not implemented effectively; for example, a healthcare worker may attempt to seek help but encounter negative reactions from colleagues or supervisors. In such cases, a potentially helpful coping strategy may backfire and cause increased frustration and emotional burden.

We found that older healthcare workers had significantly lower levels of perceived stress. This finding is consistent with that of Tran et al and Aldarmasi MA et al., who reported that HCWs under 30 years experience higher levels of stress compared to their older colleagues [15,47]. This may be because of greater psychological resilience among older individuals. It is therefore possible that age is as a protective factor against occupational stress. Previous studies conducted in Germany [48] and Ethiopia [49] further illustrate that newly graduated doctors and nurses are more vulnerable to stress due to the onset of demanding work schedules and limited clinical experience [50]. In contrast, older staff may possess more refined coping mechanisms, better emotional regulation, and greater familiarity of workplace dynamics [51]. Therefore, interventions aimed at reducing stress should prioritize younger HCWs’ needs.

Consistent with findings from Nguyen et al and previous studies conducted in Saudi Arabia, we also identified a statistically significant association between the presence of chronic comorbidities and elevated occupational stress levels [14,16]. One possible explanation is that individuals with chronic health conditions may be more sensitive to health-related stressors, such as fear of disease progression, fatigue, or concerns about access to care. These can in turn amplify their overall stress perception. At the same time, these individuals might not necessarily report higher stress related to work environment or interpersonal relationships, potentially resulting in variability across stress domains.

In our multivariate model, physicians had significantly higher perceived stress scores compared to other healthcare roles, which contrasts with the study by Tran et al, where nurses and administrative staff reported higher stress levels [15]. This discrepancy may be explained by differences in workplace context. Our study was conducted in health stations, where physicians are responsible for public health, administrative tasks, and other duties beyond clinical care. In contrast, the study by Tran et al took place in a large hospital with more structured role divisions and institutional resources. These findings highlight that interventions to reduce occupational stress should consider organizational structure, role expectations, and system-level support.

This study has several strengths. First, it offers a comprehensive reflection of perceived stress and coping strategies within the context of urban primary care by surveying HCWs across 12 different health stations. Second, by focusing on primary healthcare staff, a group frequently faced with high pressure, this study provides practical insights with high relevance for workforce support and policy planning. Additionally, the inclusion of multiple domains such as individual, family, and occupational factors in the analysis allows for a more holistic understanding of stress and its determinants, thereby better informing interventions. However, some limitations can be considered in this study. First, the use of a self-administered questionnaire may introduce recall bias or social desirability bias, potentially affecting the accuracy of self-reported stress and coping behaviors. Second, a convenience sampling may reduce the representativeness of the sample and limit the generalizability of the findings. Third, the study did not assess comorbid mental health conditions such as depression or anxiety, which limits its ability to evaluate the broader picture of psychological well-being.

Conclusion

This study highlights a substantial burden of perceived stress among healthcare workers at the primary care level in a densely populated district of Ho Chi Minh City, Vietnam, with the vast majority experiencing moderate stress levels. Ineffective coping strategies, particularly denial, behavioral disengagement, and substance use, were prominently reported and associated with higher stress, while the protective effects of adaptive coping appeared to be influenced by situational and organizational factors. The reveal of age, chronic illness, and job title as significant predictors of stress emphasize that the interaction between personal, health-related, and occupational determinants are complex. These findings call for targeted mental health interventions that not only promote adaptive coping mechanisms but also address structural contributors to stress, such as workload distribution and systemic support.

Supporting information

Acknowledgments

The authors extend their gratitude to the healthcare workers at 12 health stations in Ho Chi Minh City, Vietnam, for facilitating data collection. We deeply appreciate the participation of all healthcare workers who contributed their time and insights to this study.