Health-Promoting Leadership During an Infectious Disease Outbreak

Abstract Infectious disease outbreaks are uniquely stressful for essential employees. One way to support workers is for supervisors to engage in behaviors promoting employees' well-being and attitudes toward preventive medicine practices. We examined whether health-promoting leadership contributes to these outcomes in a population of active-duty soldiers (N = 173) deployed to provide nonmedical support in Liberia during the 2014 Ebola epidemic using data reported in Sipos, Kim, Thomas, and Adler (Mil Med 183[3–4]:e171–e178, 2018). Soldiers completed surveys assessing posttraumatic stress disorder (PTSD), depression, anxiety, sleep problems, burnout, morale, and attitudes and rated their leaders on health-promoting behaviors. Using mixed-effects logistic regression, health-promoting leadership focused on psychological health was associated with decreased odds of PTSD, depression, anxiety, and burnout, and increased odds of high morale and avoiding unnecessary risk. Health-promoting leadership focused on preventive medicine was associated with decreased odds of depression and anxiety, and increased odds of high morale, positive attitudes, and avoiding unnecessary risk. Findings suggest health-promoting leadership could be valuable for workers responding to epidemics.

Moreover, there is some evidence that nonmedical experts, such as clinical sanitation staff (Li et al., 2015), also report anxiety and other behavioral health concerns. However, the degree to which the behavioral health of these nonmedical groups is impacted by having to operate within the context of an infectious disease outbreak is less clear. Similarly, employees such as public transportation and delivery workers may be asked to function outside of the scope of their regular responsibilities. In their new roles, they may experience pressure to adapt to new unexpected demands in a setting where mistakes in following preventive measures have high-stakes consequences. Thus, it is important to understand the impact of these demands on employee behavioral health and what mitigates these effects.
One opportunity to understand this dynamic is the deployment of nonmedical US Army units to Liberia in response to the Ebola outbreak of 2014. These soldiers were deployed as part of Operation United Assistance in which 3000 service members built laboratories and Ebola treatment units, disseminated knowledge to local nationals on personal protective equipment, and provided logistical and security support (Sipos et al., 2018; The White House, Office of the Press Secretary, 2014). In a survey conducted with these deployed soldiers, Sipos et al. (2018) reported the range of stressors, behavioral health concerns, and attitudes toward the deployment. These attitudes included knowledge of preventive medicine measures and positive attitudes toward the deployment. Combined, these positive attitudes were inversely correlated with stressors and behavioral health. These data also offer an opportunity to examine factors that may mitigate the impact of stressors on behavioral health, burnout, sleep, morale, and positive attitudes in personnel tasked with operating in high-stakes environments.
Indeed, infection is a real risk facing personnel responsible for responding to a disease outbreak. Engaging in preventive medicine practices at the individual and organizational level addresses this risk. Although organizations, including the military, can institute these practices, they rely on personnel to adopt them. Attitude is a core construct that drives intention according to the theory of planned behavior (Ajzen, 1991), which has successfully predicted health behaviors such as physical activity and diet (McEachan et al., 2011), hand washing (Clayton and Griffith, 2008), and wearing gloves (Levin, 1999). Thus, attitudes about disease risk and preventive medicine measures may signal the willingness of personnel to comply with preventive medicine practices.
Given the stressors encountered by nonmedical employees and the need to ensure that they follow preventive medicine practices, it is important to examine what influences employee adaptation during an epidemic. In a high-risk occupational context like the military, leadership is one key mitigating factor. Numerous studies have documented the role of leaders in influencing behavioral health and attitudes of military personnel (Jones et al., 2012;Lopez et al., 2019;Wright et al., 2009).
Although leadership in general is associated with better outcomes for military units, emerging research highlights the potential utility of focusing on specific leadership behaviors targeting specific domains. Domain-specific leadership has been studied in a variety of contexts from family-supportive supervisory behaviors (Hammer et al., 2016) to safety leadership (Barling et al., 2002;Kelloway and Barling, 2010). In the military, this concept has included combat operational stress control leadership (Adler et al., 2014), sleep leadership (Gunia et al., 2015;Sianoja et al., 2020), and health-promoting leadership (Adler et al., 2014(Adler et al., , 2017(Adler et al., , 2018. This research identifies specific areas that leaders can focus on to support relevant outcomes. Health-promoting leadership may offer an important perspective on behaviors that are associated with health-related outcomes during an infectious disease outbreak. Health-promoting leadership is defined as the set of leader behaviors intended to support the maintenance of team member psychological and physical health and well-being while fulfilling professional responsibilities. This construct has been associated with decreased burnout symptoms, specifically exhaustion and depersonalization, among medical staff deployed to Afghanistan (Adler et al., 2017). It was also associated with fewer depression and anxiety symptoms, more positive attitudes toward the mission, and more positive attitudes toward preventive medicine measures in soldiers quarantined for 21 days after deployment to Liberia, even after controlling for general leadership (Adler et al., 2018).
Although these studies demonstrate that health-promoting leadership may be useful, there are several key remaining questions that address the utility of this construct in an applied setting. First, it is not clear whether health-promoting leadership is a single construct or composed of multiple factors. Second, it is not known whether health-promoting leadership is related to better outcomes during a mission in which units have to perform their tasks while confronted with the profound threat of infectious disease. Finally, although the relationship between health-promoting leadership and behavioral health (Adler et al., 2014), and attitudes toward quarantine (Adler et al., 2018) has been established, it is unknown whether these same leadership behaviors are associated with morale and attitudes toward disease risk and preventive medicine practices, over and above the role of general leadership. Addressing these questions can inform the development of leadership training to optimize the development of specific leadership strategies. Thus, we aim to examine the components of health-promoting leadership and identify which factors are associated with better behavioral health, well-being (defined in this study as sleep, burnout, and morale), attitudes toward knowledge of disease risk, deployment, and preventive medicine practices, and avoiding unnecessary risks in a sample of soldiers deployed to Liberia during the Ebola outbreak.

Study Design
The present study analyzed existing data from anonymous and cross-sectional surveys collected as part of a larger study on psychological stressors associated with deployment in support of a humanitarian mission (Sipos et al., 2018). Study participants were all active-duty soldiers supporting the US response to the Ebola crisis in mainly nonmedical roles. Surveys were administered in Liberia in February 2015. Participants were briefed in groups, provided an information sheet, and 84.8% (N = 173) provided informed consent and were included in the analytic sample. Study activities were reviewed and approved under an exempt protocol by the Walter Reed Army Institute of Research Human Subjects Protection Branch.

Health-Promoting Leadership
Health-promoting leadership measured soldiers' perceptions of leader behaviors focused on the preventive medicine goals of the mission as well as overall psychological health. This scale has been used in previous research with military units (Adler et al., 2017). Individual items are described in Table 2. Study participants were asked to rate their current team/unit leadership on 13 items in terms of how frequently they occurred (1 = never to 5 = always). Mean response scores for each of the 13 items were calculated. Cronbach's alpha for this scale was 0.96.

General Leadership
Soldiers' perceptions of general leadership behaviors were assessed using the four-item Walter Reed Army Institute of Research Leadership Scale-Short Form, a scale frequently used in research with military units (Adler et al., 2014;Bliese, 2006;Lopez et al., 2019). A sample item includes "leader tells soldiers they have done a good job" and response options ranging from 1 (never) to 5 (always). Negative items were reverse scored. Response scores were averaged. Internal consistency was 0.82.

Behavioral Health and Well-being
An adapted form of the 17-item Posttraumatic Stress Disorder (PTSD) Checklist-Specific assessed PTSD symptoms (Riviere et al., 2011;Weathers et al., 1993). The scale was dichotomized using a diagnostic algorithm for each cluster and overall score of 50 as the cutoff, which is consistent with other studies conducted with military populations (Hoge et al., 2004). Internal consistency was 0.94.
The eight-item version of the Patient Health Questionnaire for Depression (PHQ-8) assessed depression symptoms of study participants (Kroenke et al., 2009). Items in the PHQ-8 are scored with four response options (0 = not at all to 3 = nearly every day). Items were summed, which resulted in a composite score ranging from 0 to 24. Respondents were indicated as a positive screen for depression if a summary score of 10 or more was met (Dhingra et al., 2011). Internal consistency was 0.90.
The seven-item Generalized Anxiety Disorder scale (GAD-7) assessed anxiety symptoms (Spitzer et al., 2006). Items were scored with four response options (0 = not at all to 3 = nearly every day). The seven items were summed, resulting in a composite score ranging from 0 to 21. Respondents were indicated as a positive score for anxiety if a summary score of 10 or more was met (Kim et al., 2016). Internal consistency was 0.92. in addition to their satisfaction and distress regarding sleep problems. Each item was scored on a scale ranging from 0 to 4. The seven items were summed, resulting in a composite score ranging from 0 to 28. The summed scores were categorized to include no sleep problems (0-7), subthreshold insomnia (8-14), moderate insomnia (15-21), and severe insomnia (22-28) based on validated literature guidelines (Bastien et al., 2001). The scale was further dichotomized to no sleep problems (0-14) and sleep problems (15-28). Internal consistency was 0.91.
Burnout was measured using a single item that asked soldiers to rate their level of burnout on a 5-point scale (1 = very low, 2 = low, 3 = medium, 4 = high, and 5 = very high). The item was dichotomized so that a response of 3 or below was considered low-to-medium burnout and a score of 4 or higher was considered high burnout.
A single item measured morale. The item asked participants to rate their personal morale on a 5-point scale (1 = very low, 2 = low, 3 = medium, 4 = high, and 5 = very high). Morale was dichotomized so that a response of 3 or below was considered low-to-medium morale and a score of 4 or above was considered high morale.  Attitudes toward preventive measures were constructed using one positively worded item ("Taking our temperature twice a day makes sense to me") and two negatively worded items that were reverse scored ("Taking our temperature twice a day is a waste of time" and "Preventive medicine measures recommended for this deployment are not practical").

Attitudes Reflecting Knowledge of Disease Risk, Deployment, and Preventive Medicine Practices
Three items ("I understand the level of risk from disease"; "I know what to do to protect myself from disease"; and "This deployment will make a meaningful difference in fighting the Ebola epidemic") developed for this study by Sipos et al. (2018) were selected to assess attitudes toward the deployment and preventive medicine practices. Items were rated on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). The items were further dichotomized so that a score of 4 or higher was indicated as agreement.
A three-item scale developed for this study examined attitudes toward preventive medicine measures during deployment. Response questions included both positive ("Taking our temperature twice a day makes sense to me") and negative ("Taking our temperature twice a day is a waste of time" and "Preventive medicine measures recommended for this deployment are not practical") items with response options ranging from 1 (strongly disagree) to 5 (strongly agree). A positive score was indicated by a response of 4 or higher for the first item and a score of 2 or lower for the two negative items. Internal consistency was 0.73.

Avoiding Unnecessary Risks
A single item developed for this study ("I avoided unnecessary risks on this mission") assessed preventive behaviors during deployment. Response options ranged from 1 (strongly disagree) to 5 (strongly agree) and were dichotomized so that a score of 4 or higher was indicated as agreement.

Analysis
An exploratory factor analysis (extraction method: principal factor; rotation method: oblique promax with Kaiser normalization) of the health-promoting leadership scale was conducted. Two subscales were discovered: psychological health-promoting leadership and preventive medicine health-promoting leadership. Rotated factor loadings for each scale item are reported in Table 2. Internal consistency values were 0.96 and 0.92 for the two factors, respectively.
We aimed to examine the association between health-promoting leadership and behavioral health, attitudes, and behaviors of soldiers.
The sample population is inherently hierarchical due to clustering effects by organizational unit, and therefore, assumptions of independence could not be met (Hox, 2002). Indeed, the main exposure of interest, health-promoting leadership, introduces nonindependence, as clusters of participants in our sample had the same leaders. To account for nonindependence, mixed-effects logistic regression models indicated associations between health-promoting leadership behaviors and outcomes of interest. Military units (companies nested within battalions) were modeled as the random intercepts. All models were adjusted for rank (junior enlisted, NCOs, and officer/warrant officer) and general leadership (continuous). Other demographic and background covariates were tested for inclusion in the model but did not meet the criteria for confounding (i.e., associated with the exposure and outcome, change in odds ratios [ORs] by >10%). Listwise deletion was used to handle any missing data. All data analyses were conducted using STATA 14. Table 1. Nearly all participants received training about infectious disease (99%), managing medical threats other than infectious disease (99%), managing emotional stress of deployment (96%), and cultural awareness (95%). Only 16% of respondents reported that they have experienced dealing with infectious disease threats on other missions.

Demographic and background data are shown in
Participants were asked to rank their current unit leaders on various behaviors. Health-promoting leadership items are displayed in Table 2. When examining health-promoting leadership as two separate factors, soldiers rated preventive medicine health-promoting leadership (mean, 3.79; SD, 0.97) significantly higher than psychological health-promoting leadership (mean, 3.28; SD, 1.06; t[169] = 8.68; p < 0.001).
Adjusted odds ratios (AORs) reporting the association between overall health-promoting leadership and measures of behavioral health, well-being, and attitudes are displayed in Table 3. Overall, soldiers who rated health-promoting leadership higher had significantly reduced odds of PTSD, depression, anxiety, and high burnout, whereas health-promoting leadership increased the odds of high morale. In addition, higher ratings of health-promoting leadership were associated with increased odds of both believing the deployment will make a meaningful difference in fighting the Ebola epidemic and avoiding unnecessary risks. Results from the two health-promoting leadership factors are presented in Table 3. Increases in psychological health-promoting leadership ratings were associated with reduced odds of PTSD, depression and anxiety, and high burnout, as well as increased odds of high morale and avoiding unnecessary risks. Increases in preventive medicine health-promoting leadership were associated with increased odds of high morale and reduced odds of depression and anxiety, although the AORs were attenuated relative to psychological health-promoting leadership. In addition, increased ratings of preventive medicine health-promoting leadership were associated with increased odds of understanding the level of risk from disease, positive attitudes toward deployment making a meaningful difference, positive attitudes toward preventive practices, and avoiding unnecessary risks. Sleep problems and knowing how to protect oneself from disease were not associated with any health-promoting leadership behaviors.

DISCUSSION
Working within an environment characterized by the threat of infectious disease can expose employees outside of the medical community to unusual occupational stressors, including the risk of infection. Thus, understanding how to help these employees function is essential given that they are expected to continue performing their jobs under difficult circumstances.
The present study analyzed data from a survey of nonmedical soldiers deployed to Liberia in response to an Ebola outbreak. Results documented that ratings of health-promoting leadership were associated with positive soldier behavioral health, well-being, and morale, even after controlling for general leadership. Such results are consistent with existing literature indicating that specific leader behaviors are associated with behavioral health and well-being outcomes (Adler et al., 2014(Adler et al., , 2017 and positive attitudes toward quarantine (Adler et al., 2018). Findings from the present study reinforce the fact that leaders may influence not only employee behavioral health and well-being but also their attitudes and health-related behaviors as well.
Our results identified two health-promoting leadership factors. These factors differentially predicted study metrics, underscoring the need to consider specific leader behaviors when targeting specific employee outcomes. One health-promoting leadership factor focused on psychological health and was associated with lower odds of soldiers reporting PTSD, depression, anxiety, and burnout. These leadership behaviors were also associated with higher levels of morale and avoiding unnecessary risks. This finding suggests that leaders who encourage self-care and support team goals have soldiers with fewer behavioral health difficulties. Similarly, the health-promoting leadership factor focused on preventive medicine was associated with lower odds of depression and anxiety and greater odds of high morale, avoiding unnecessary risks, and positive attitudes toward preventive medicine practices. This finding suggests that leaders who emphasize the importance of these measures and lead by example are more likely to have soldiers who follow these practices and feel positively about them.
Our findings are consistent with research documenting the importance of perceived control in reducing stress (Keeton et al., 2008) and increasing emotional well-being (Yang and Ma, 2020), by suggesting that leaders who focus on actions soldiers can take to reduce risk of infection may help reduce depression and anxiety as well. Although both factors were associated with behavioral health measures, the factor focused on preventive medicine was more clearly linked with attitudes toward preventive medicine practices, specifically attitudes related to knowledge of disease, deployment, preventive medicine measures, and avoiding unnecessary risks. This suggests that targeting specific leadership behaviors aimed at emphasizing preventive medicine practices may increase occupational safety among those responding to infectious disease outbreaks.
As can be seen from the study findings, leader behaviors are linked to soldier attitudes. According to the theory of planned behavior, attitudes are predictive of intention, which drives subsequent behaviors (Ajzen, 1991). Thus, one strategy that employers may want to implement   to mitigate the risk of infection among their employees is to promote favorable attitudes toward preventive medicine protocols; however, attitudes are not the only drivers of intention. Although beyond the scope of the present study, other factors may influence intention, such as workplace norms, culture, and perceived behavioral control. New research from the COVID-19 pandemic provides support for the importance of these factors (Lin et al., 2020). Interestingly, neither the overall health-promoting leadership scale nor the factors were associated with reports of sleep problems. This is consistent with findings from a study of soldiers in quarantine in which health-promoting leadership behaviors were not associated with insomnia (Adler et al., 2018). In contrast, studies examining sleep leadership have demonstrated links to sleep outcomes in military units (Adler et al., 2021). The current study's distinctive pattern of results further demonstrates the need to address leadership behaviors by focusing on domain-specific topics.
Another outcome that was not associated with health-promoting leadership behaviors was "knowing how to protect oneself from disease." Although this result was unexpected given that one factor specifically emphasized preventive health, more than 90% of soldiers were confident in their knowledge of how to protect themselves. Thus, a ceiling effect may have prevented this particular item from being significantly predicted by leadership behaviors.
Although there are strengths of the current study, including the unusual sample and identification of specific leader behaviors, there are limitations that must be taken into account. First, findings are based on self-reported data, although studies have shown that anonymous self-reported measures can be a valid indicator of mental health and attitudes among this population (Warner et al., 2011). Second, the data are cross-sectional and cannot address questions of causality, although the fact that general leadership served as a control variable helps strengthen confidence in the observed associations. Likewise, it may be that the behavioral health of individuals influences their ratings of leadership, but the study design cannot assess directionality of effect. To assess temporality, we encourage future research to use a longitudinal study design. Third, the survey was conducted after most of the soldiers had been deployed for a period of 3 months or less; it is not known if the same findings would be observed after longer exposure to this kind of high-stress context. Fourth, the study sample may have reduced the power to observe effects of leadership behavior, although several significant associations were identified. Fifth, several of our measures (burnout, morale, avoiding unnecessary risk, and specific attitudes) relied on single items, although single items can be valid measures (Wanous et al., 1997).
Despite these limitations, these findings offer direction for practical application such as leadership training programs. Although the study focused on the Ebola epidemic, the findings may be relevant to other epidemics, including the COVID-19 pandemic, by offering insight into how leaders can effectively support personnel in nonmedical positions. For example, as of June 2020, more than 62,000 service members have responded to the COVID-19 pandemic, and only 3500 of these are medical personnel (Department of Defense, 2020). This demonstrates that behavioral health, well-being, and attitudes in service members are relevant not only for medical personnel but also for nonmedical support when operating within an infectious disease context. Future research should assess the degree to which health-promoting leadership is related to employee outcomes in nonmilitary settings given the unique nature of military culture and role of leaders within the military context (Adler and Castro, 2013;Atuel and Castro, 2018). Future research should also assess factors that may influence the impact of health-promoting leadership on employees, including leader likability, perceived trustworthiness, and competence, to identify potential boundary conditions. We also encourage the inclusion of objective measures of leadership in future studies where feasible.
In addition, future research should build on the health-promoting leadership behaviors included here and examine the relevance of additional behaviors specific to particular infectious disease outbreaks. More specific preventive medicine behaviors may enable organizations to identify a wider range of behaviors for frontline supervisors to emphasize in order to optimally support employee health and adaptation. Finally, future research should examine the degree to which these leadership behaviors can be easily trained and encouraged in frontline supervisors, drawing on other models of domain-specific leadership training (Adler et al., 2021;Hammer et al., 2019).

CONCLUSIONS
The COVID-19 pandemic has drawn attention to the vulnerability of essential workers such as supermarket cashiers, bus drivers, and custodial staff who provide vital support for their communities while confronting the threat of infectious disease. This increased risk may be outside the employee's typical scope of work, thus elevating the likelihood of behavioral health difficulties. Besides providing measures such as personal protective equipment, physical distancing, and hygiene resources, it may be useful for leaders to consider engaging in specific behaviors that support their employees during these difficult times. Such behaviors can be integrated into management training and company culture.
Results from our study demonstrate that health-promoting behaviors are within the repertoire of supervisor actions given that many soldiers identified their leaders as frequently engaging in these behaviors. Still, between 6% and 30% of soldiers reported that their leaders did not or seldom engaged in health-promoting behaviors, including encouraging preventive medicine practices. These results suggest opportunities for improvement in leader behavior within the military context and are a potential frame of reference for nonmilitary occupational settings. Given the importance of management in providing essential workers support during a disease outbreak, these results provide an avenue for organizations to deliberately engage in health-promoting practices.

ACKNOWLEDGMENTS
We would like to thank COL Maurice Sipos for his role in initiating the overall study and Dr Paul Bliese for statistical consultation.

DISCLOSURE
This study was funded by the US Army Military Operational Medicine Research Program. There is no objection to the presentation and/ or publication of this article. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting true views of the Department of the Army or the Department of Defense. The investigators have adhered to the policies for protection of human subjects prescribed in AR 70-25. All study procedures have been reviewed by the Walter Reed Army Institute of Research Institutional Review Board. All participants provided consent before participation in any component of this study.
The authors declare no conflict of interest.