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Background: The COVID-19 pandemic has significantly disrupted the work-life balance of frontline workers by increasing workload, stress and exposure risks. Despite their crucial role, limited research has examined the specific factors influencing this balance, hindering the development of evidence-based interventions. Aims: This study explored the challenges frontline workers faced during the pandemic. Methods: A cross-sectional study was conducted amongst 112 frontline workers recruited through convenience sampling. Work-life balance, mental health and recreational activities were assessed using validated instruments. Data were analysed using factor analysis, multiple regression and ANOVA to identify determinants of work-life balance and evaluate the mediating role of recreational activities. Results: Three key factors-responsibility, flexibility and hierarchical culture-were identified as significant influences on work-life balance. Regression analysis showed that the pandemic accounted for approximately 50% of the variance in balance scores, while ANOVA further confirmed its substantial disruptive effect. Recreational activities played a mediating role, with flexibility and supportive organisational culture contributing positively to both mental health and overall well-being. Conclusion: The findings underscore the importance of organisational policies that promote flexible work arrangements, supportive supervisory structures and opportunities for recreational engagement. Such interventions are essential for protecting the well-being and resilience of frontline workers during health crises.

ABSTRACTFrontline workers have been fighting hard since the novel coronavirus, also known as COVID-19, was declared a global pandemic by the WHO on March 12th, 2020.  This study assessed the level of knowledge of frontline workers, attitudes of frontline workers, and how well the frontline workers of the area adapted to the ongoing epidemic. This study used a cross-sectional research design conducted among 440 frontline workers Palwal district in Haryana. Information regarding knowledge, attitude, practice, and socio-demographic characteristics was obtained using semi-coded and pretested questionnaire. Data were analysed using SPSS version 20. Independent t-test, ANOVA, Pearson’s rank correlation test, and multivariate linear regression were used. A p-value of <0.05 was considered significant. The mean of knowledge, attitude, and practice scores were 79.67 (SD = 1.81), 27.4 (SD = 0.98), and 22.47 (SD = 1.4), respectively. 94.8% of frontline workers had excellent knowledge, 68.6% had excellent attitude, and 57.7% had reasonable practice with significant positive correlation between the three. Knowledge score varied significantly with occupation (p = 0.003). Regression analysis showed that attitude score varied significantly with age, gender, and occupation (p<0.05). Practice score varied significantly with age (p<0.05). The majority of the HCWs had had excellent knowledge and attitude, but moderate practice towards COVID-19 with a significant positive correlation between them. Knowledge appeared to be significantly associated with profession; attitude with age, gender, occupation, source of information; and practice with age alone. Healthcare workers (HCWs) were using less authentic sources for information, which is an important aspect that needs immediate correction as ultimately it affects knowledge and can be reflected in attitude and practice. Keywords: COVID-19, knowledge, attitude, practice, frontline workers 

Background Inconsistent findings regarding the factor structure of the Depression Anxiety and Depression Scale (DASS-21) have been reported in the literature. The present study attempted to validate the factor structure and internal consistency of DASS-21 during COVID-19 pandemic with two different samples: the frontline workers and non-frontline workers. A critical time period and nature of work were two key factors during pandemic that made it important to test the factor structure of the scale. Method Using an online survey with snowball sampling, DASS-21 was administered on 265 frontline workers (associated with hospital, police, and security) and 835 non-frontline workers in India across 5 states. Result Several models were evaluated using confirmatory factor analysis. Among them, a three-factor model comprising Physiological arousal , Anhedonia , and General Negative Affect demonstrated the best fit, differing from the originally proposed structure. Additionally, the DASS-21 subscales exhibited a very high intercorrelations (r = .94–.96). This pattern may suggest that the subscales assess highly overlapping dimensions of psychological distress in the context of the COVID-19 pandemic. An alternative explanation is that the pandemic elicited a pervasive and heightened distress response, resulting in a convergence of symptom expression across domains. Conclusion Based on the findings of the present study, it may be concluded that the DASS-21 is a reliable measure of negative psychological affect; however, the originally conceptualized factor structure could not be replicated, indicating the need for theoretical refinement and further exploration of the construct’s dimensionality.

Racial/ethnic disparities in COVID-19, including incidence, hospitalization, and death rates, are serious and persistent. Among those at highest risk for COVID-19 and its adverse effects are African American/Black and Latine (AABL) frontline essential workers in public-facing occupations (e.g., food services, retail). Testing for COVID-19 in various scenarios (when exposed or symptomatic, regular screening testing) is an essential component of the COVID-19 control strategy in the United States. However, AABL frontline workers have serious barriers to COVID-19 testing at the individual (insufficient knowledge, distrust, cognitive biases), social (norms), and structural levels of influence (access). Thus, testing rates are insufficient and interventions are needed. The present study is grounded in the multiphase optimization strategy (MOST) framework. It tests the main and interaction effects of a set of candidate behavioral intervention components to increase COVID-19 testing rates in this population. The study enrolled adult AABL frontline essential workers who were not up-to-date on COVID-19 vaccination nor recently tested for COVID-19. It used a factorial design to examine the effects of candidate behavioral intervention components, where each component was designed to address a specific barrier to COVID-19 testing. All participants received a core intervention comprised of health education. The candidate components were motivational interviewing counseling (MIC), a behavioral economics intervention (BEI), peer education (PE), and access to testing (either self-test kits [SK] or a navigation meeting [NM]). The primary outcome was COVID-19 testing in the follow-up period. Participants were assessed at baseline, randomly assigned to one of 16 experimental conditions, and assessed six- and 12-weeks later. The study was carried out in English and Spanish. We used a logistic regression model and multiple imputation to examine the main and interaction effects of the four factors (representing components): MIC , BEI , PE , and Access. We also conducted a sensitivity analysis using the complete case analysis. Participants ( N  = 438) were 35 years old on average (SD = 10). Half identified as men/male (52%), and 48% as women/female/other. Almost half (49%) were African American/Black, and 51% were Latine/Hispanic (12% participated in Spanish). A total of 32% worked in food services. Attendance in components was very high (~ 99%). BEI had positive effect on the outcome (OR = 1.543; 95% CI: [0.977, 2.438]; p -value = 0.063) as did Access , in favor of SK (OR = 1.351; 95% CI: [0.859, 2.125]; p -value = 0.193). We found a three-way interaction among MIC * PE * Access (OR: 0.576; 95% CI: [0.367, 0.903]; p-value = 0.016): when MIC was present, SK tended to increase COVID testing when PE was not present. The study advances intervention science and takes the first step toward creating an efficient and effective multi-component intervention to increase COVID-19 testing rates in AABL frontline workers. Trial registration Registered at clinicaltrials.gov (NCT05139927), November 29, 2021.

Racial/ethnic disparities in COVID-19 morbidity and mortality are serious in the United States, particularly among African American/Black and Latine (AABL) populations. Staying up-to-date on COVID-19 vaccination is essential for mitigating risk, but AABL vaccination rates are low. The present qualitative study explores perspectives on COVID-19 among AABL persons at high-risk for exposure to the SARS-CoV- 2 virus: frontline essential workers engaged in public-facing professions (e.g., retail). From a larger study of AABL frontline essential workers not up-to-date on COVID-19 vaccination, N  = 50 participants were purposively sampled for maximum variability. Participants engaged in semi-structured qualitative interviews in English or Spanish that were audio-recorded, professionally transcribed, and translated into English as needed. Data were analyzed using a directed content analysis approach that was both inductive and theory-driven. Participants were 37 years old, on average, and most (65%) were men. Approximately half (56%) were Latine/Hispanic and 44% were African American/Black. Occupations included food preparation (40%), retail (28%), construction (12%), in-home health care (8%), and building maintenance and personal services (12%). Approximately a third (38%) had received ≥ 1 COVID-19 vaccine dose. We found COVID-19 vaccination perspectives were grounded in a larger context of medical and institutional distrust and past/ongoing systemic racism. In this context, results were organized into the following themes: general perspectives on COVID-19; barriers/facilitators related to race/ethnicity, social class, and community; specific aspects of the COVID-19 vaccine as barriers; mandates, incentives, and pressures to be vaccinated; and mixed effects of public health initiatives. Overall, participants were knowledgeable about COVID-19. Social norms reduced vaccine intentions but altruism and community/family concern could motivate it. Aspects of the public health response (e.g., advertisement campaigns targeting AABL populations) increased distrust and reduced vaccination willingness. However, at least some ambivalence about vaccination was common (participants would consider it). Yet there was a large gap between considering and receiving vaccination. Thus, barriers to COVID-19 vaccination for AABL frontline essential workers operate at multiple levels of influence, but are addressable. The present study yields recommendations to improve vaccination, including increasing the trustworthiness of systems and institutions, reducing systemic/structural barriers, harnessing social forces, and engaging AABL communities in program planning.

Background Healthcare is responsible for 8.5% of greenhouse gas emission in the United States. Physicians are becoming increasingly concerned about the climate crisis, particularly in the field of ophthalmology where there is a growing body of literature related to sustainability. Although emissions of cataracts surgery, one of the most performed surgical procedures in the world, have been quantified, modifications to practice have yet to be made. This study aims to uplift the perspectives of a diverse set of healthcare workers on implementing environmentally sustainable practices in the cataract surgery setting. Methods 16 semi-structured interviews were conducted with professionals working in various direct patient care or administrative roles at a large health center to gain insight on implementing a variety of sustainability initiatives. We focused on initiatives related to supply reduction, reusable supplies, multi-dosing pharmaceuticals, and health system process and policy shifts. Results Participants most frequently identified infection prevention and control (IPC) concerns as a primary barrier to implementation. Additionally, the IPC department was most often cited as a key stakeholder in implementation. However, participants from this department did not share these same concerns. Additionally, participants most often cited that these initiatives would be successfully implemented by those providing direct patient care. Conclusions Themes generated from the collection of responses underscore a broader discussion of disconnect between policy and practice in healthcare as a barrier to implementation of these initiatives and an opportunity in harnessing clinically led change to implement sustainable practices in a growing healthcare system.

The COVID-19 pandemic provided opportunities to learn from healthcare workers involved in implementing pandemic plans within healthcare settings. This study explores healthcare workers' reflections on the first 3 years of the COVID-19 pandemic and their experiences activating health service pandemic plans. A qualitative exploratory descriptive study design was used to explore through focus groups' frontline healthcare workers' experiences related to emergency response planning, operationalizing the pandemic response plan, the workforce mindset, and re-evaluation of the organizations' response once the crisis had abated. Thematic analysis guided by Braun and Clark's six-steps was used to identify themes. Thirty-two healthcare workers participated in 10 focus group discussions. The following six key themes were identified and explored (1): unprepared emergency response systems and processes, (2) adaptive crisis management under pressure, (3) the evolving reality of the pandemic response and embedding the basics, (4) leadership styles and communication challenges when managing a crisis, (5) psychological challenges of leading the workforce during a prolonged crisis, and (6) organizational preparedness for future pandemics. Healthcare workers were required to respond rapidly to maintain safety and meet healthcare needs, with little understanding of the organization's pandemic plan. This study provides an opportunity to learn from the experiences of healthcare workers in integrating the frontline perspective into the design and execution of emergency response plans, to enhance workforce sustainability and organizational preparedness.

Pneumonia remains the leading cause of mortality in individuals aged 5 years or younger globally, with India bearing a disproportionately high burden. The introduction of the pneumococcal conjugate vaccine (PCV) in India necessitated innovative approaches to support frontline health workers (FLHWs), particularly in remote settings. To address this, a customizable WhatsApp-based PCV chatbot was developed as a complementary tool to traditional training and reference materials. This study aimed to document the opportunities, challenges, and mitigation measures encountered during the development and rollout of the PCV chatbot, and to explore its use and user experience as a capacity-building and support tool for FLHWs during new vaccine introduction. A qualitative study was conducted across 4 Indian states-Arunachal Pradesh, Delhi, Karnataka, and West Bengal-using purposive sampling at the district and block levels. Data collection involved key informant interviews with immunization officials and chatbot developers, and focus group discussions with auxiliary nurse midwives. A Likert scale-based tool captured quantitative feedback on user satisfaction. Stakeholders appreciated the chatbot's accessibility, familiarity (through WhatsApp), and multilingual functionality. Most auxiliary nurse midwives found it easy to use and rated responses highly for completeness and usefulness. The chatbot enabled immediate access to information, saving time and bridging gaps, especially when traditional training was delayed or unavailable in hard-to-reach areas. Challenges included occasional technical issues, limited content related to dropout and left-out scenarios, and difficulties in typing regional languages. Recommendations included implementing predictive text, expanding scenario coverage, and strengthening user-centered design and field testing. The PCV chatbot demonstrated acceptability and perceived value as an on-demand knowledge tool among FLHWs. Continuous user-driven refinement, expanded content, and enhanced usability are essential for its scalability and sustained use in vaccine introduction and capacity-building efforts.

The COVID-19 pandemic has resulted in many frontline health-care workers vulnerable to developing various mental health conditions. This study aimed to determine prevalence and associated factors of such conditions among frontline workers at Eka Kotebe National COVID-19 Treatment Center in Addis Ababa, Ethiopia. This institution-based cross-sectional study was conducted between May and June 2020 on 280 frontline workers. Mental health outcomes (depression, anxiety, insomnia, and posttraumatic stress disorder) were assessed using the Patient Health Questionnaire9, Generalized Anxiety Disorder 7 questionnaire, PTSD Checklist - civilian version, and Pittsburgh Sleep Quality Index. Responses were coded, entered into EpiData 3.1 and analyzed using SPSS 20. Associations between outcomes and independent variables were identified using bivariate and multivariate logistic regressions, statistical significance set at <0.05. A total of 238 subjects participated in the study, with a response rate of 85%. Estimated prevalence was 31.1% (95% CI 24.8%-37%) for anxiety, 27.3% (95% CI 21.8%-32.4%) for depression, 16% (95% CI 11.3%-21%) for PTSD, and 40.8% (95% CI 33.6%-47.5%) for insomnia. Female sex (AOR 2.99, 95% CI 1.49-5.97), being married, (AOR 13.2, 95% CI 3.42-50.7), being single (AOR 11.5, 95% CI 3.38-39.8), duration of exposure 1-2 hours (AOR 0.29, 95% CI 0.14-0.64), and assigned place of work (critical ward -AOR 2.26, 95% CI 1.03-4.97; ICU - AOR 4.44, 95% CI 1.51-13.05) were found to be significant predictors of depression. We found a high estimated prevalence of mental health outcomes. Sex, marital status, duration of exposure, and assigned place of work were found to be associated with depression.

The experience of working on the frontlines of the COVID-19 healthcare crisis has presented a cumulative traumatic experience that affects healthcare professionals’ well-being. Psychological resources such as resilience and adaptive defense mechanisms are essential in protecting individuals from severe stress and burnout. During September 2020, 233 healthcare workers responded to an online survey to test the impact of demographic variables, COVID-19 exposure, and psychological resources in determining stress and burnout during the COVID-19 emergency. Frontline workers reported higher scores for stress, emotional exhaustion, and depersonalization (p < 0.001) as compared to colleagues working in units not directly serving patients with COVID-19. Mature defensive functioning was associated with resilience and personal accomplishment (r = 0.320; p < 0.001), while neurotic and immature defenses were related to perceived stress and burnout. Stress and burnout were predicted by lower age, female gender, greater exposure to COVID-19, lower resilience, and immature defensive functioning among healthcare professionals (R2 = 463; p < 0.001). Working on the frontlines of the COVID-19 pandemic appears to provoke greater stress and burnout. On the other hand, resilience and adaptive defense mechanisms predicted better adjustment. Future reaction plans should promote effective programs offering support for healthcare workers who provide direct care to patients with COVID-19.