The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study

Abstract

Objective

During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare ‘heroes’ as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs.

Methods

This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs.

Results

We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19–related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

Conclusion

Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

Supplementary Information

The online version contains supplementary material available at 10.17269/s41997-022-00643-7.

Introduction

The COVID-19 pandemic is taking an enormous toll on healthcare workers (HCWs), from facing greater risk of contracting the virus (Nguyen et al., 2020) to experiencing mental burnout (Havaei et al., 2021). Despite these stressors, HCWs have continued to care for patients to the best of their capacity. A contingent of HCWs who have garnered much attention for their work throughout the pandemic are personal support workers (PSWs). They generally support people with their daily needs, such as hygiene and mobility, in long-term care homes (also known as nursing homes), hospitals, and community settings (Kelly & Bourgeault, 2015). Most residents of long-term care homes are seniors, have serious chronic health conditions like dementia, and require continuous monitoring (Canadian Institute for Health Information, 2021a). In contrast, PSWs working in community settings support people of all ages with complex health needs, including children and adults with developmental disorders and people needing end-of-life care (Canadian Healthcare Association, 2009). Some PSWs also work at adult day programs that offer leisure activities for elderly or those with chronic conditions and cognitive disability.

In Canada, the National Occupational Classification allows other titles to describe PSWs, including home support worker, healthcare aide, patient aide, and personal care attendant, among others (Government of Canada, 2021a, 2021b). PSWs are currently not self-regulated in many provinces, although some employers require PSWs to have vocational training certificates (Zagrodney & Saks, 2017). Some provinces have also begun the effort to regulate the PSW profession. For example, Alberta has developed a Health Care Aide Registry and a provincial curriculum for healthcare aides in Alberta (Government of Alberta, 2018).

Evidence suggests that PSWs in Canada tend to be the lowest paid and considered the least skilled group in the healthcare workforce (Zagrodney & Saks, 2017). The PSW workforce is characterized by high turnover rates and high numbers of short-term, casual, and part-time workers (Zeytinoglu et al., 2009). PSWs also experience a high degree of job stress due to repetitive and physically strenuous tasks, exposure to abuse and violence, and inadequate psychosocial support (Hignett et al., 2016; Van Den Tooren & De Jonge, 2008). Furthermore, many PSWs work in the long-term care sector, which has historically been underfunded and continues to be overlooked by policy makers despite the critical shortage of PSWs as the population ages (Armstrong & Day, 2017; Canadian Institute for Health Information, 2021b). In Ontario, where females make up 90% of the PSW workforce and 41% of PSWs identify as members of a visible minority (Ministry of Long-Term Care, 2020), it has been argued that the poor treatment of PSWs is emblematic of the general pattern of sexism and discrimination faced by women and ethnic minorities (Block & Galabuzi, 2011).

Across Canada, deadly COVID-19 outbreaks in long-term care homes spurred healthcare policy debates centering on PSWs and their essential role within the health system. In Ontario, the government launched the Long-Term Care COVID-19 Commission to investigate the spread of COVID-19 in long-term care homes and to identify promising measures to improve long-term care in the province. The commission found a correlation between the lack of PSWs and the severity of COVID-19 impacts during the first wave of the pandemic, which led to the recommendation of increasing the supply of PSWs (Marrocco et al., 2021). Subsequently, the Ontario government introduced measures to recruit and train more PSWs, and offered temporary wage increases (Marrocco et al., 2021). Similar initiatives were introduced in other provinces, including British Columbia and Quebec (CBC Radio, 2020).

Given the increased policy attention on PSWs in Canada during the COVID-19 pandemic, and to further highlight areas of improvement within the PSW sector that need to be addressed in anticipation of future public health crises, it is important to closely examine PSWs’ working conditions during the pandemic from the perspectives of PSWs. This paper therefore aims to explore the impact of the COVID-19 pandemic on PSWs, a marginalized workforce whose working conditions were difficult even prior to the pandemic. We specifically address the following research questions: (1) How did the early stages of the COVID-19 pandemic impact the work and well-being of PSWs in Ontario? (2) How did PSWs overcome any work-related challenges during the COVID-19 pandemic?

Methods

Setting and context

We conducted this study in the Greater Toronto Area (GTA) of Ontario, Canada, which is the country’s largest metropolitan area with a population of approximately 5.9 million (Statistics Canada, 2016). There are an estimated 90,000–100,000 PSWs in the province of Ontario (population of 14.5 million) (Kelly & Bourgeault, 2015). To our knowledge, there are no estimates for the number of PSWs working in the GTA or the municipalities of which it is composed. While not formally regulated by a professional college, there are accredited PSW training programs at colleges and vocational schools in Ontario. The average wage of PSWs across different work settings ranges from $17.30/h (home care) to $25.01/h (municipally operated long-term care homes) (Ministry of Long-Term Care, 2020). During the COVID-19 pandemic, the provincial government mandated that long-term care home workers only work in one facility to reduce the spread of the virus (O. Reg. 146/20: Limiting Work to a Single Long-Term Care Home, 2020). It also introduced a temporary wage increase of up to $3/h from October 1, 2020 until August 23, 2021, which was subsequently extended until March 31, 2022 (Government of Ontario, 2021a).

Study design

We used a community-based participatory action research approach (Israel et al., 1998) where an Advisory Committee of eight PSWs was engaged in all aspects of the study, including overall design, development of the survey and interview guide, and interpretation of data and results. Members of the Advisory Committee received training in research methods and community advocacy. To recognize their contributions and compensate them for their time, the PSW committee members received a $30 honorarium for each hour they contributed. To obtain a comprehensive picture of PSWs’ experiences related to their employment during the COVID-19 pandemic, we chose a mixed-methods design comprised of quantitative survey and qualitative interviews (Shorten & Smith, 2017). We used an exploratory sequential approach (Ivankova et al., 2006) where a quantitative survey was first administered to generate a summary of challenges faced by PSWs during the pandemic, followed by qualitative interviews to contextualize and complement the quantitative results.

Quantitative arm

We conducted a cross-sectional survey from June to December 2020 and recruited PSW participants using a respondent-driven sampling (RDS) approach. RDS is a chain-referral sampling method suitable for hard-to reach populations (Heckathorn, 2002), such as PSWs in Ontario who often work in multiple settings, are not registered, and have limited availability due to irregular work schedules. This approach improves upon regular snowball sampling methods by accounting for participants’ social network size and recruitment structure to calculate asymptotically unbiased population estimates (Heckathorn, 2011). The RDS-II estimator was chosen to create sampling weights based on the network size (Volz & Heckathorn, 2008), which was estimated by asking each participant “How many friends do you know who work as PSW in the Greater Toronto Area, whom you have communicated with regularly in the past year (in-person/online/by texts)?”.

A convenience sample of 24 ‘seeds’ were initially recruited through recommendations from the PSW Advisory Committee and online advertisements. These seeds then propagated into waves of referrals, whereby each participant received a $20 honorarium for completing the survey and an additional honorarium for referring up to 3 eligible peers ($10 per peer referral). Participants had to be at least 18 years old and had to have worked as a PSW in the GTA within the past year. Participants completed the survey online on Qualtrics (Qualtrics, 2020), with the exception of a small number of participants who preferred to complete the survey over the phone. A sample size of 600 was projected to allow for a proportion estimate of PSWs reporting poor quality of life within 5% accuracy and 95% confidence. Detailed descriptions of the survey recruitment and the applied RDS method have also been described elsewhere (Pinto et al., 2022).

Participants were asked sociodemographic questions that included age, gender, racial background, place of birth, current student status, educational attainment, and low-income status as measured by the 2018 Canadian low-income cut-off (LICO) (Statistics Canada, n.d.). The survey included COVID-19 pandemic-related questions on their work location, access to and training around protective personal equipment (PPE), COVID-19 testing and status, concerns around contracting and passing COVID-19 to family members, and the impact of the pandemic on their work conditions (e.g., got laid off or fired, reduced work hours). The survey also asked about job security concerns and childcare during the pandemic (see Supplement 1). RDS-II adjusted proportion estimates were generated for each variable.

Qualitative arm

Three members of the research team (APH, JWH, ESA) conducted 31 one-to-one interviews between March and June 2021, using a semi-structured interview guide that included open-ended prompting questions to further explore the subjects covered in the survey (see Supplement 2). In particular, the interviews aimed at understanding the impacts of the COVID-19 pandemic on PSWs’ work conditions, personal life, and health. They also focused on any challenges experienced by PSWs during the pandemic, including their experience with PPE, and on how PSWs navigated these issues.

To ensure breadth and depth of perspectives, participants were selected from the survey sample population who had agreed to be contacted for future research using a stratified random sampling based on their race and work location. Each interview participant received an additional honorarium of $30. All interviews were conducted in English and took place online via the Zoom platform video-conferencing and audio-conferencing. The duration of the interviews ranged from approximately 45 min to 1 h. All interviews were audio recorded and transcribed verbatim by a professional transcriptionist.

We employed a thematic analysis approach (Braun & Clarke, 2006) to analyze the interview transcripts. Data analysis was managed using NVivo 12 (QSR International Pty Ltd, 2020). Two members of the research team (APH, JWH) independently reviewed four transcripts and met to develop an initial codebook based on a consensus of common themes. The remaining 26 transcripts were divided randomly into half and analyzed by the same two researchers, who met on several occasions during the analysis process to revise and refine the codebook. The final codebook was developed by consensus between the principal investigator (AP) and the two coders. The final themes were presented to the PSW Advisory Committee as a means of respondent validation (Green & Thorogood, 2018). This study was approved by the St. Michael’s Hospital Research Ethics Board (#18-103), Toronto, Canada.

Results

Sociodemographic results

A total of 658 PSWs participated in the survey; 634 participants were included in the analysis after excluding the 24 seeds. Table 1 presents participants’ background, and Supplement 3 provides details on the recruitment structure. Participants were predominantly female (90.1%) and foreign-born (97.4%). In terms of racial background, most participants self-identified as non-white, with Black PSWs (76.5%) making up the largest proportion of the participants. Most participants were between 30 and 49 years of age (70.4%) and on average, participants had been working as a PSW for 4.4 years (standard deviation (SD): 4.9 years). One fifth (21.1%) were enrolled in school at the time of the survey. Over half of the participants were considered low income (55.1%) despite the majority of them having at least some college or university education (88.6%). The comprehensive sociodemographic characteristics of the survey participants are also presented elsewhere (Pinto et al., 2022).

Table 1.

Characteristics of PSW participants

Sociodemographic variables	Survey participants (N = 634)			Interview participants (N = 31)
	Unweighted counts	Unadjusted estimates, %	RDS-II adjusted estimatesa (95% CI), %	Counts	Estimates, %
Gender identity
Female	528	83.3	90.1 (85.1–95.1)	28	90.3
Male	57	9.0	9.6 (4.6–14.5)	3	9.7
Other	3	0.5	0.3 (0.0–0.8)	0	0
Missing	46	7.3	-	0	0
Born in Canada				-
No	576	90.9	97.4 (94.9–99.9)
Yes	11	1.7	2.6 (0.1–5.1)
Missing	47	7.4	-
Immigration/citizenship status	-
Canadian citizen				10	32.3
Permanent resident/landed immigrant				9	29.0
Temporary visa with work authorization				3	9.7
Convention refugee				8	25.8
Protected person				1	3.2
Racial background
Black	425	67.0	76.5 (68.2–84.9)	19	61.3
East Asian	32	5.0	3.7 (1.4–5.9)	0	0
South Asian	19	3.0	1.9 (0.1–3.0)	0	0
Southeast Asian	70	11.0	10.5 (5.6–15.4)	9	29.0
White	16	2.5	3.7 (0.0–9.0)	2	6.5
Mixed or other racial categories	26	4.1	3.7 (0.0–9.3)	1	3.2
Missing	46	7.3	-	0	0
Age category (years)				-
18–29	52	8.2	10.4 (4.7–16.1)
30–39	174	27.4	32.1 (23.8–40.3)
40–49	247	39.0	38.3 (30.6–46.1)
50+ and up	115	18.1	19.2 (10.6–27.7)
Missing	46	7.3	-
Current student status				-
Not a student	512	80.8	78.9 (72.4–85.5)
Student	113	17.8	21.1 (14.5–27.6)
Missing	9	1.4	-
Household income level				-
Above low-income cut-off	259	40.9	44.9 (36.1–53.7)
Below low-income cut-off	328	51.7	55.1 (46.3–63.9)
Missing	47	7.4	-
Educational attainment
Some grade school	7	1.1	1.6 (0.0–7.2)	0	0
Some high school	6	0.9	1.0 (0.0–2.7)	0	0
High school degree	45	7.1	8.7 (4.4–13.1)	0	0
Some college/universityb	241	38.0	41.2 (32.3–50.0)	10	32.3
College degree, university degree, or post-graduate degree	288	45.4	47.4 (39.0–55.9)	21	67.7
Missing	47	7.4	-	0	0
Main work location as PSW during the pandemic
Home care in the community	258	40.7	49.3 (40.9-57.7)	16	51.6
Long-term care	211	33.3	34.3 (27.1-41.5)	10	32.3
Other (e.g., hospitals, shelters, group homes, rehabilitation centres)	126	19.9	16.4 (9.2-23.6)	5	16.1
Missing	39	6.2	-
Main employerc
Do not know	74	35.1	35.2 (24.3–46.0)	9	29.0
Municipality/government	23	10.9	13.1 (4.4–21.8)	2	6.5
Private for-profit	78	37.0	37.8 (26.8–48.7)	9	29.0
Private not-for-profit	36	17.1	14.0 (6.7–21.2)	10	32.3
Private, individual clientd				1	3.2
Union membership
A union member	310	48.9	46.2 (38.1–54.3)	21	32.3
Not a union member	314	49.5	53.8 (45.7–61.9)	10	67.7
Missing	10	1.6	-	0	0

^aThe RDS-II adjusted percentage distribution for each variable excluded the missing data. Any negative values in the lower limit of the 95% confidence interval (CI) were curtailed at 0.0

^bFor interview participants, this category was replaced with “Attended trade or technical school (including CEGEP)”

^cFor survey participants, this question was only asked to those who worked in long-term care facilities (N = 211), whereas in the interview, this question was asked to all participants (N = 31)

^dThis option was not presented in the survey

During the pandemic, most survey participants worked in home care in the community (49.3%), followed by in long-term care (34.3%) (Table 1). Other work locations included hospitals, institutions for people with disabilities, shelters, and rehabilitation and reactivation centres. Among those working in long-term care, over a third (37.8%) reported working for private for-profit organizations, and a further 35.2% did not know their employer type.

The characteristics of the interview participants were comparable to those of the survey participants (Table 1). About half of them worked in home care (51.6%) and a third (32.3%) in long-term care. Slightly less than 30% worked for private for-profit organizations and a considerable proportion (29.0%) did not know their employer type. Approximately one third (32.3%) belonged to a union. Similar to the survey respondents, most interviewees were female (90.3%) and Black (61.3%), with an average age of 42.9 years old (SD: 7.3). They had worked as a PSW for an average of 5 years (SD: 4.5) and two thirds had a college or university degree (67.7%). Most participants (67.7%) were not Canadian citizens.

Overview of themes

Four major themes emerged from our analysis of the interview data and are supported by the survey results. Addressing the first research question, “How did the early stages of the COVID-19 pandemic impact the work and well-being of PSWs in Ontario?”, we found that: (1) the pandemic took a significant toll on the health and well-being of PSWs and required great sacrifices; (2) the pandemic significantly impacted the job security of PSWs; and (3) despite some improvements brought about by the pandemic policies, PSWs still experienced largely poor working conditions. Addressing the research question “How did PSWs overcome any work-related challenges during the COVID-19 pandemic?”, we found that: (4) PSWs demonstrated resilience by employing several coping mechanisms during difficult circumstances.

Theme 1: The pandemic took a significant toll on the health and well-being of PSWs and required great sacrifices

Comments on the impacts of COVID-19 on workers coalesced around several sub-themes: (1) mental health impacts, (2) anxiety about contracting COVID-19, and (3) contracting COVID-19.

PSWs in the interview noted that COVID-19-driven public health protocols influenced their mental health. For example, they had to limit their interactions with colleagues (e.g., during breaks and meals), which left them feeling isolated at work. In some circumstances, PSWs had to isolate themselves from their families, especially during the height of the pandemic. As an example, one PSW described living in a hotel for 7 weeks, which left them feeling lonely and depressed (Table 2, Quote 1).

Table 2.

Summary of themes and relevant quotes

Theme 1: The pandemic took a significant toll on the health and well-being of PSWs and required great sacrifices
No.	Sub-themes	Representative quotes
1	Mental health impacts	Quote 1: “… I feel depressed at times and also, it's like I cried with my Assistant DOC [Director of Care] and then they gave, she gave me a, she gave me a telephone number to reach out you know if you feel depressed and everything like that because I'm alone in the hotel; right, for almost seven weeks. So, it's just like I get ready, go to work, go home and then I'm alone so it's just like my routine is like that so ready, go to work, alone, get ready, work, alone so it's just like I feel so sad. I feel bad that I cannot even hug my baby. I cannot even see my husband so it's just like, yeah, I told them that I, every day I cried going to work.” (Southeast Asian female working at a long-term care facility)
2	Anxiety about contracting COVID-19	Quote 2: “I have this feeling that when I, every time I go to the resident’s room I was crying because I am just thinking about my family. What if I get sick? If I get that, you know and I bring it home and give it to my kids.” (Southeast Asian female working at a long-term care facility)
3	Contracting COVID-19	Quote 3: “Yeah, we have enough PPE but you know if you had, you work, because during that time there, we have a short staff, right, so they ask, the managers ask if we could do double; double shift so during that time we work like 16 hours because nobody, because nobody come, want to work in our floor…So, yeah, so, that's why I think that's the one, I got tested (positive) because of we are very tired.” (Southeast Asian female working at a long-term care facility)
Theme 2: The pandemic significantly impacted the job security of PSWs
No.	Sub-themes	Representative quotes
1	Reduced hours	Quote 4: “At the beginning some of my clients they refused service.” (White female working at private homes in the community)
2	Lost employment	Quote 5: “…because when there wasn't COVID I worked two, three places so if this one doesn't come, I call another agency. I, but now you can't. Especially now that I'm working on, in long-term so you can't go other places and you know more work, more money you know.” (Black female working at a long-term care facility)
Theme 3: Despite some improvements brought about by the pandemic policies, PSWs still experienced largely poor working conditions
No	Sub-themes	Representative quotes
1	Personal protective equipment impacts	Quote 6: “…we don't even allow to use the masks because they want to save the masks because they don't have many masks in the system so we don't have the PPE.” (Latino male working at a reactivation centre) Quote 7: “At the very start we're just like the, you know it's like short or they're just minimizing them because of the, they call it the shortage you know but now as the pandemic goes it's like we have enough now.” (Southeast Asian male working at private homes in the community) Quote 8: “You have a mask on and you have a face shield and you have a gown on. It's a bit of problem, a serious problem you know in terms to breathing you know.” (Black female working at a group home)
2	Lack of paid sick days offered by employers	Quote 9: Well, because I was casual so I don't get any paid sick day for that and a temporary full-time, same thing. So now that I'm a full-time, like I said, they said I have to be, I have to complete my three months’ probation but for my other colleagues I am sure they have, I think 12 days sick, sick days or so. (Black female working at a long-term care facility) Quote 10: Participant [P]: “… my HR told me okay, we already did everything; all the papers. Because I thought we're using our benefits… So I asked them. I said how am I going to get paid for 14 days plus? They said oh, we already, we already applied you for the WSIB so I was assuming that WSIB will do their job, their role but no, I have to call them to find out where is my cheque?” Interviewer [I]: “How much did they pay?” P: “No, because they pay 85%.” (Southeast Asian female working at a supportive housing) Quote 11: “I called them (the government) to report that it was the COVID and the benefits …so they give me $450.00 and that was the only thing I receive, yeah. My office didn't send me anything and stuff like that. So, I had to go back. I was praying, yeah, imagine for two weeks you have $450.00 for two weeks.” (Southeast Asian female working at a long-term care facility)
3	Delayed or inadequate temporary wage increase	Quote 12: I: “-do you think that amount (temporary wage increase) is sufficient? P: “Not really.” I: “No?” P: “Honestly, because before we can still work at other places, right. We can do part-time, we can do babysitting, we can do, we can do part-time to other home but now, none. Right, so it's just like the $250.00 is a help which we are so very thankful but compared to what we are earning when we do our part-time it's not like that. If we get $250.00 from the government, we can get $500.00 from other, you know from other job.” (Southeast Asian female working at a long-term care facility)
4	Lost childcare	Quote 13: “… just to be around for my kids too and just that's why I just have to reduce the hours too because you know they are doing their online stuff too and everything.” (Black female working at private homes in the community)
5	Increased workload and extra tasks	Quote 14: “I am doing double shift cause we’re in outbreak and we're short of staff and I have to pick up extra shifts you know.” (Black female working at a long-term care facility) Quote 15: “Because they don't have enough PSW they bring people from agency who make $25.00 an hour. Most of them they don't know what they doing…They make $25.00 an hour and we run this place and we making $16.00…That's not right.” (Latino male working at a reactivation centre) Quote 16: “I mean we do like, we have bedmaking day so I mean that's kind of a challenge because we have to make all the beds in and still go and attend to the clients; right, so when we have admissions that same day and then we have protocols sometimes like if they have bedbug history there is a big protocol we have to do there too to make sure the client is not bringing in bedbugs you know and yeah, so that's basically more of the challenging part and when they, you know they, like I said the last minute thing they come in and just throw things on us like okay, well we have now a meeting and you kind of have to just attend to it you know.” (White female working in institution for people living with disabilities) Quote 17: “…he needs somebody because sometimes he wants to go out, kind of aggressive, yeah, so-But you know they, because…. because of the situation he was, he, the residents, most of the residents weren’t allowed to go out so you know they want, he wants to go out, he wants to go out, he wants to go down, he wants to go to the you know because before the COVID he is doing that; going, go to the go outside to the park and have some coffee there and now when the COVID comes they are stuck. They are stuck inside their room.” (Southeast Asian female working at a retirement home)
6	Challenges with management	Quote 18: “…so I mean even one day we had concerns about when the first COVID came and we heard about the case and were just asking like you know well we heard it was somebody on our floor who had it? (The manager said) Well, it doesn't matter who had it, we don’t, we can't tell you who it was you know. And we're just like well we were in contact with like any client that was on the floor and she goes you know, even if I had the COVID, I don’t have to tell you about it and I can stand right in front of you. And I’m like really, that’s not appropriate because technically that’s not allowed you know, cause if you have COVID you're supposed to isolate yourself right. So, what you're saying is not appropriate response to say to your staff right now you know because we're worried about our first outbreak. Every day like you know it was very new to everybody, everybody is now scared, everybody is like oh, my God if I get COVID am I going to die? What's going to happen like you know and for her response it was very inappropriate you know.” (White female working at an institution for people with disabilities) Quote 19: P: “Some of them (management staff) are missing in action those days. We can see them they often go upstairs to you know to check us so it's just like during outbreak it's the, only the nurses that we see, only our- I: “The direct supervisor?” P: “-nurses, yeah, direct supervisor is there for us. Some of the DOCs (Director of Care), EDOC (Executive Director of Care), some of them are, we cannot find them. I don't know where are they so it's really hard to reach out for them those days.” (Southeast Asian female working at a long-term care facility)
7	Benefits of the pandemic policies	Quote 20: “I was having. Yeah, that's what I was telling you about that's the only thing I earned. My salary now that is making me happy because it's now raised to $20.00. It used to be $17.00 so add that $3.00 it raised to $20.00.” (Southeast Asian female working at a long-term care facility) Quote 21: “Because it's believed that's why you use mask and you are taking, that it's, how do they say like? It's not dignifying to the person you are taking care of like they are saying the person is smelly or the person you know, so we're not allowed to use mask initially.” (Black female working at a long-term care facility) Quote 22: The only changes are from now we move from floor-to-floor as part-timers you work everywhere but since the pandemic it’s like it has stopped a little bit so we're not moving from one floor to another… It’s good, it’s good because you, well you kind of know whom you are working with, you know your residents.” (Black female working at a long-term care facility)
Theme 4: PSWs demonstrated resilience by employing several coping mechanisms during difficult circumstances
No.	Sub-themes	Representative quotes
1	Reliance on family and friends for both emotional and logistical supports	Quote 23: “I, when I am working because of the school so I, they had to do online school I left them home. I had a friend who had no job because of COVID so she was kind of coming in to help, yeah.” (Black female working at a group home)
2	Drawing strength from faith and spirituality	Quote 24: “There is always a way out when you have uncertainty. There's some plans that we put in place, but when you are not sure you are not going to deceive yourself. You plan on what you have so at times like that one it doesn't come I lean on my husband and cause luckily for me I am here with my family and I believe God is all we get so was that not be done at the same time so that is how I survive.” (Black female working at long-term care facility)
3	Reflection on passion for the profession	Quote 25: “…when I give care to the resident and I feel I have done my best in taking care of them when I see that smile on their faces and when they tell you thank you for what you doing to me so I feel very fulfilled.” (Black female working at long-term care facility)

Interview participants also reported experiencing anxiety about contracting COVID-19 at work and during their commute to work using public transportation. As an example, when asked about how COVID-19 has affected their work, one participant working in a long-term care facility noted the risk they were taking by going to work (Table 2, Quote 2).

Aligned with the interview results, most survey respondents (66.6%) were worried about contracting COVID-19 at work, and 75% were worried about transmitting it to people at home. Finally, from 70.4% of survey participants who were tested for COVID-19, 4.7% received a positive result (Table 3). Some interview participants pointed to fatigue due to increased workload and understaffing as risk factors for COVID-19 exposure (Table 2, Quote 3).

Table 3.

Impacts of COVID-19 pandemic experienced by survey participants

Work experience variables	Unweighted counts	Unadjusted estimates, %	RDS-II adjusted estimatesa (95% CI), %
Concern about contracting COVID-19 at work
Extremely worried	417	65.8	66.6 (57.7–75.5)
Not at all worried – moderately worried	176	27.8	33.4 (24.5–42.3)
Missing	41	6.5	-
Concern about transmitting COVID-19 to people at home
Extremely worried	457	72.1	74.8 (66.8–82.8)
Not at all worried – moderately worried	136	21.5	25.2 (17.2–33.2)
Missing	41	6.5	-
COVID-19 test
Tested for COVID-19	431	68.0	70.4 (60.8–80.0)
Did not get tested for COVID-19	162	25.6	29.6 (20.0–39.2)
Missing	41	6.5	-
COVID-19 test results (N = 431)
Negative	403	93.5	93.7 (90.0–97.5)
Positive	19	4.4	4.7 (1.2–8.2)
Result pending	7	1.6	1.6 (0.3–2.9)
Missing	2	0.5	-
Impacted during the pandemic?
Yes	382	60.3	63.2 (55.3–71.2)
No	252	39.7	36.8 (28.8–44.7)
Specific impact of the pandemicb
Fired	10	1.6	0.9 (0.0–1.8)
Laid off	26	4.1	6.1 (0.0–12.3)
Hours reduced significantly (i.e., more than 25%)	133	21.0	22.9 (15.6–30.1)
Hours become uncertain	150	23.7	25.7 (18.2–33.1)
Pay was delayed	10	1.6	2.1 (0.0–4.6)
Took a leave of absence	89	14.0	14.9 (10.1–19.7)
Other	52	8.2	8.1 (4.8–11.3)
Concerns about job security
Much more concerns	317	53.6	54.6 (46.1–63.0)
Much less concerned – slightly more concerned	274	46.4	45.4 (37.0–53.9)
Missing	43	6.78	-
Difficulty in arranging childcarec
Much more difficult	242	41.4	40.7 (32.1–49.3)
Much more easy – slightly more difficult	343	58.6	59.3 (50.7–67.9)

^aThe percentage distribution for each variable excluded the missing data and any negative values in the lower limit of the 95% confidence interval (CI) were curtailed at 0.0

^bParticipants were able to select all options. As a result, each specific impact was treated as a variable with dichotomized responses (e.g., was fired or not; experienced payment delay or not) and the sum of positive responses across the different impacts exceeded the total number of participants (N = 634)

^cThis question was only applicable to individuals with child dependants (N = 585)

Theme 2: The pandemic significantly impacted the job security of PSWs

Reduced hours and lost employment were noted as major contributors to job insecurity during the pandemic. First, PSWs who worked mainly in home care experienced a reduction in their work hours due to a reduced number of clients as some became sick and others were afraid of being exposed to COVID-19. For example, some home care clients refused PSW service in their private homes (Table 2, Quote 4). Second, PSWs who mainly worked in long-term care facilities reported losing employment due to COVID-19 and consequently lost important sources of income. The Ontario government’s mandate that PSWs working in long-term care facilities only work in one home resulted in reduced income: PSWs who either worked as part-time staff at multiple facilities or worked for multiple staffing agencies were no longer able to do so following the mandate (Table 2, Quote 5).

In keeping with the interview results, over 60% of the survey participants also reported some form of work-related impacts (Table 3). More than 20% had their work hours significantly reduced, while over a quarter (25.7%) reported uncertain work hours. Some survey participants had to take a leave of absence (14.9%) for a number of reasons, such as difficulty arranging childcare, being worried about contracting COVID-19 and/or transmitting it to their family, having an underlying condition, and being required to self-isolate due to potential or confirmed diagnosis of COVID-19. In addition, a small proportion of the survey participants was laid off (6.1%), fired (0.9%), or had their wages delayed (2.1%). Over half (54.6%) of the survey participants also expressed having much more concern about their job security than they did prior to the pandemic (Table 3), which may be explained by the loss of income sources described in the interview.

Theme 3: Despite some improvements brought about by the pandemic policies, PSWs still experienced largely poor working conditions

The interviews also illuminated how the pandemic exacerbated pre-existing workplace challenges, such as inadequate paid sick days, staff shortages, and inadequate hours, in addition to new challenges, such as increased tasks and issues related to PPE. In summary, PSWs’ comments focused on six areas: (1) PPE impacts, (2) lack of paid sick days offered by employers, (3) delayed or inadequate temporary wage increase, (4) lost childcare, (5) increased workload and extra tasks, and (6) challenges with management.

Some interview participants reported scarce supplies of PPE at the beginning of the pandemic, including masks, gloves, gowns, and face shields (Table 2, Quote 6). However, the supply of PPE increased over time and there was generally a sufficient supply of PPE later on in the pandemic (Table 2, Quote 7). The improved supply of PPE was reflected in the survey, where only less than 5% of participants reported rarely or never having gloves, masks, hand sanitizers, and access to hand-washing station to use between clients (Table 4). Approximately one in ten survey participants reported rarely or never having gowns and face shields to use between clients. Most participants (81.4–87.4%, depending on the type of PPE) also reported receiving training to safely put on and take off different PPE (gloves, masks, gowns, face shield) (Table 4). Among those who received training, about 90% found it helpful.

Table 4.

PPE and trainings received by survey participants during the COVID-19 pandemic

Work experience variables	Unweighted counts	Unadjusted estimates, %	RDS-II adjusted estimatesa (95% CI), %
Frequency of having access to use the following between each patient
Gloves
Sometimes/often/always	560	88.3	97.5 (94.9–100)
Rarely/never	15	2.4	2.5 (0.1–5.1)
Missing	59	9.3	-
Masks
Sometimes/often/always	546	86.1	96 (93.5–99.2)
Rarely/never	21	3.3	3.7 (0.8–6.5)
Missing	67	10.6	-
Gowns
Sometimes/often/always	505	79.7	87.2 (78.6–95.7)
Rarely/never	59	9.3	12.8 (4.3–21.4)
Missing	70	11.0	-
Face shields
Sometimes/often/always	480	75.7	84.8 (77.3–92.4)
Rarely/never	82	12.9	15.2 (7.6–22.7)
Missing	72	11.4	-
Hand sanitizers
Sometimes/often/always	554	87.4	97.2 (95.3–99.1)
Rarely/never	21	3.3	2.8 (0.9–4.7)
Missing	59	9.3	-
Running water and soap
Sometimes/often/always	566	89.3	97.6 (95.3–99.9)
Rarely/never	12	1.9	2.4 (0.1–4.7)
Missing	56	8.8	-
Training for putting on and taking off the following PPE
Gloves
Received training	518	81.7	86.9 (78.9–94.8)
Did not receive training	71	11.2	13.1 (5.2–21.1)
Missing	45	7.1	-
Reported helpfulness of the training on gloves use (N = 518)
Helpful	479	92.5	89.9 (80.9–99.0)
Not helpful	38	7.3	10.1 (1.0–19.1)
Missing	1	0.2	-
Masks
Received training	517	81.6	87.4 (79.5–95.3)
Did not receive training	71	11.2	12.6 (4.7–20.5)
Missing	46	7.3	-
Reported helpfulness of the training on mask use (N = 517)
Helpful	475	91.9	89.0 (80.3–97.6)
Not helpful	41	7.9	11.0 (2.4–19.7)
Missing	1	0.2	-
Gowns
Received training	498	78.6	84.4 (76.2–92.5)
Did not receive training	84	13.3	15.6 (7.5–23.8)
Missing	52	8.2	-
Reported helpfulness of the training on gown use (N = 498)
Helpful	456	91.6	89.2 (80.0–98.4)
Not helpful	42	8.4	10.8 (1.6–20.00)
Missing	0	0	-
Face shields
Received training	487	76.8	81.4 (72.8–90.1)
Did not receive training	97	15.3	18.6 (9.9–27.2)
Missing	50	7.9	-
Reported helpfulness of the training on face shield use (N = 487)
Helpful	446	91.6	90.2 (83.5–96.9)
Not helpful	40	8.2	9.8 (3.1–16.5)
Missing	1	0.2	-
Training for protecting themselves from contracting COVID-19
Received training	445	70.2	73.1 (63.6–82.6)
Did not receive training	150	23.7	26.9 (17.4–36.4)
Missing	39	6.2	-
Reported helpfulness of the training for protecting themselves (N = 445)
Helpful	392	88.1	87.4 (81.2–93.6)
Not helpful	53	11.9	12.6 (6.4–18.8)
Missing	0	0	-
Training for protecting their patients from contracting COVID-19
Received training	443	69.9	74.6 (66.4–82.9)
Did not receive training	150	23.7	25.4 (17.1–33.6)
Missing	41	6.5	-
Reported helpfulness of the training for protecting their patients (N = 443)
Helpful	394	88.9	87.3 (77.3–97.3)
Not helpful	48	10.8	12.7 (2.7–22.7)
Missing	1	0.2	-

^aThe RDS-II adjusted percentage distribution for each variable excluded the missing data. Any negative values in the lower limit of the 95% confidence interval (CI) were curtailed at 0.0

Wearing PPE for extended periods of time was challenging for many PSWs who were interviewed. For example, a PSW described their difficulty with breathing (Table 2, Quote 8). PSWs also experienced headaches due to wearing face shields. Additionally, it was challenging for PSWs to take breaks because doing so required doffing and donning PPE.

Some PSWs noted the persistent absence of paid sick days from their employers as an important issue. Many agencies did not offer paid sick days or they were only available to permanent, full-time employees in some workplaces (Table 2, Quote 9). Thus, PSWs who contracted COVID-19 and were unable to work were not paid by their employers for the time off to recover and isolate. PSWs described the only benefit they could access was through Ontario’s Workplace Safety and Insurance Board (WSIB). Some PSWs described how they had to go through the WSIB claims process themselves and they were unable to recoup their full pay (Table 2, Quotes 10 and 11).

In October 2020, the Ontario government instated a temporary wage increase for PSWs of up to $3/h. Four PSWs stated that they did not receive the wage increase, and five others reported a delay in receiving their pay increase. One PSW did not receive their wage increase until February 2021, 5 months after the start of the mandated increase. Many PSWs also described the amount of pay increase as insufficient or indicated that more compensation should be given for their work, particularly when they were not given full-time hours (Table 2, Quote 12).

Some of the PSWs with children described losing childcare during the pandemic and, as a result, they were forced to reduce their work hours or not work at all. For example, one PSW with school-aged children had to reduce her work hours so she could care for her children and help them with virtual learning during closure of in-person learning (Table 2, Quote 13). Similarly, among survey participants with child dependents, about 40% found it much more difficult to arrange for childcare during the pandemic (Table 3).

Some interviewees also described an increase in their workload due to colleagues contracting COVID-19. For example, when long-term care facilities experienced staff shortages, PSWs were forced to pick up extra shifts (Table 2, Quote 14). In response to the staff shortage, some long-term care facilities used staffing agencies, and some PSWs noted the stark differences in compensation and quality of work between the facility staff and the agency staff (Table 2, Quote 15). The staff shortage also resulted in a larger and unmanageable ratio of clients to PSW (Table 2, Quote 16), which could go as high as 16 clients per PSW compared to the average of 8–10 clients prior to the pandemic.

The challenge posed by the staffing shortage was exacerbated by the increased burden and extra tasks at work due to the pandemic. For example, PSWs in long-term care had to apply strict infection control protocols, including confining long-term care residents to their rooms. In some cases, patients became aggressive because they could not leave the facility (Table 2, Quote 17).

In addition to staffing policy issues, PSWs in long-term care experienced other challenges related to management policies. For example, some PSWs perceived management as not prioritizing their well-being (Table 2, Quote 18). When PSWs made complaints to management, their complaints were either not addressed at all or were not resolved in a timely manner. At times, the importance of their complaints was minimized. Some PSWs also reported having difficulties contacting managers to discuss problems (Table 2, Quote 19).

Despite the challenges, however, the participants were able to draw on some benefits of the policies that were implemented in response to the pandemic. Benefits and pay raises given during the pandemic were a welcome change for PSWs who had struggled with inadequate wages (Table 2, Quote 20). Some PSWs also reported that wearing PPE gave them a sense of better infection control than during pre-pandemic times. As face masks had to be worn by everyone during the pandemic, PSWs could wear them without offending their clients (Table 2, Quote 21). The policy of working in one long-term care facility also promoted a sense of security from COVID-19 exposure. For PSWs working in long-term care facilities, they were assigned to work with the same residents for infection control purposes. One positive aspect of this change was that they got to know the same group of residents better, whereas in pre-pandemic times, they shifted frequently between different clients (Table 2, Quote 22).

Theme 4: PSWs demonstrated resilience by employing several coping mechanisms during difficult circumstances

We found that PSWs applied several strategies to cope with the pandemic and the challenges it posed for their work and personal life, which include (1) relying on their family and friends for both emotional and logistical supports, (2) drawing strength from their faith and spirituality, and (3) reflecting on their passion for the profession.

Many interviewees credited their spouses, children, and friends for supporting them both emotionally and physically during the pandemic. Some PSWs who lost childcare described that their neighbours or their older children helped look after younger children during school closures (Table 2, Quote 23). In other instances, participants received encouragement from their spouses or children when they were overwhelmed by their work and relied on their spirituality and faith during uncertain times (Table 2, Quote 24).

Moreover, PSWs drew on their passion for the profession to cope during challenging times. Generally, PSWs find their work personally rewarding because they are able to make a positive impact on their clients’ lives. Some PSWs said they consider their clients like family members while others described the feeling of personal fulfillment from their work with clients (Table 2, Quote 25).

Discussion

We found that the COVID-19 pandemic significantly impacted the work conditions, job security, and well-being of PSWs. Pre-existing poor work conditions, such as insecure jobs with no benefits, absence of paid sick days from employers for non-permanent and agency staff, and lack of full-time hours, contributed to COVID-19–related challenges. Part-time PSWs in long-term care facilities could not work in other locations, and PSWs working in home care experienced a reduction in their work hours that resulted in reduced income and concerns around job security.

These poor working conditions were compounded by issues related to PPE scarcity at the beginning of the pandemic, staff shortages and increased work burden in long-term care settings, difficult relationships with management, and loss of childcare for PSWs with young children. Furthermore, job insecurity and social isolation stemming from pandemic policies significantly impacted the mental health of PSWs. A sizable proportion of PSWs also expressed anxiety about contracting COVID-19 and transmitting it to their family, while some were infected with COVID-19. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

Our findings are consistent with previous work on PSWs in Ontario, which demonstrated the precarious work conditions and significant stress that they experience (Zagrodney & Saks, 2017; Zeytinoglu et al., 2017). In addition, our study was able to highlight any changes in PSW work conditions during the early stage of the pandemic, based on the perspective of PSWs. One notable finding is the benefits of the pandemic policies, which may be considered in future policy reforms. For example, the temporary wage increase provided by the Ontario government was a welcome change that could be made permanent as an incentive to retain PSWs. As PSW staffing shortage had been associated with severe COVID-19 outbreaks across Canada (Marrocco et al., 2021), effective retention strategies will be needed to avoid similar issues in future pandemics.

Along with job insecurity, negative work relationships have also been linked to adverse health outcomes, such as chronic health conditions and mental health problems among workers (de Castro et al., 2008; Kim et al., 2013). Unmanageable workload and job stress have also been associated with suboptimal care by healthcare workers (Ruotsalainen et al., 2020). With many PSWs struggling to manage the increasing workload during the pandemic while also experiencing anxiety about contracting and transmitting COVID-19, it is pertinent for employers to be transparent about their decision-making process and provide adequate support to PSWs to prevent rapid turnover due to burnout and health issues. Efforts to provide a better sense of security, such as providing adequate COVID-19 testing and supply of PPE, can help alleviate anxiety among PSWs. Indeed, the PSWs in our study described better infection control as a positive implication of the pandemic policy.

Paid sick days have been consistently shown to offer benefits to employers and improve public health, such as improving workers’ productivity and reducing the spread of virus, respectively (Scheil-Adlung & Sandner, 2010; Zhai et al., 2018). Nevertheless, our findings suggest that many PSWs with non-permanent contracts in both long-term care and home care rarely received paid sick days from their employers. Combined with insufficient wages, lack of paid sick days placed PSWs in the difficult position of having to choose between financial obligations and their health. This could potentially lead to adverse public health outcomes, especially since PSWs work with individuals who are susceptible to worse outcomes from infectious diseases such as COVID-19. To help limit COVID-19 and in anticipation of future public health emergencies, the federal government and the province of British Columbia have legislated permanent paid sick days for employees (Government of British Columbia, 2021; Government of Canada, 2021c). However, other provinces such as Ontario only offered temporary paid sick days for reasons related to COVID-19 (Government of Ontario, 2021b).

The mandate limiting long-term care workers to one facility also revealed the negative implications of casualization of PSWs, who struggled with unpredictable work hours and loss of income sources during the pandemic. The trend towards casualization has also been seen in other Canadian provinces and in the United States, and has been described as negatively impacting caregiver–client relationships and contributing to high turn-over rates and lower quality of care (Ranucci & Berry, 2021; Sharman et al., 2008). Similarly, our interview participants described continuous relationships with long-term care residents as a positive outcome of the new workplace policy that assigned the PSWs to work with the same residents during the pandemic. Therefore, future policy may consider incentivizing employers to offer more permanent, full-time positions for PSWs in all settings to improve the job security of PSWs, strengthen the relationship between clients and PSWs, and help improve the quality of care. Future models could consider the strategy adopted by the British Columbia government, which took over as the employer for all long-term care workers in the province and hired the workers full-time at a stage of the pandemic when workers were barred from working in multiple settings (Moist, 2020).

The COVID-19 pandemic has exacerbated and brought to the forefront workplace challenges faced by PSWs. The aging Canadian population, coupled with the growing preference towards home care over hospital care, will continue to raise the demand for PSWs (Canadian Healthcare Association, 2009; Saari et al., 2018). While initiatives such as providing training funding and incentives for recent PSW graduates can help attract new workers into the PSW profession (Government of Ontario, 2020), a more sustainable solution is to improve the work conditions for workers already in the field.

Limitations

Our survey sampling method (RDS) should produce more reliable estimates than convenience sampling; however, it might not be able to capture the full diversity of the PSW population in our geographical area of interest. The large proportion of Black participants in the survey may be attributed to the disproportionate number of Black participants in the ‘seeds’. The collective experiences of PSWs of different ethnic backgrounds may differ from those who identified as Black. Our study is also limited to the experience of PSWs in the Greater Toronto Area, which may not be generalizable to other jurisdictions with different population densities, socioeconomic characteristics, ethnic diversities, and health-related policies.

While this study was focused on understanding PSW working conditions during COVID-19 from the perspectives of PSWs, there are other perspectives that could be examined for a more fulsome picture of PSW working conditions. We did not survey or interview other key stakeholders, such as employer organizations, policy makers, and clients and family members to garner their perspectives. Further research could focus on these important stakeholders.

Finally, despite emerging themes specific to a certain work setting, such as staffing shortages in long-term care facilities, or refusal of service by clients in private homes, our study did not have adequate sample to conduct in-depth comparative analysis across the different work settings. Future research can therefore focus on the commonalities and differences in PSW work conditions across different settings to inform strategies for human resource planning that consider the specific needs and challenges of each setting.

Conclusion

As we recover from the COVID-19 pandemic and reflect on strategies to improve our public health response to future threats, it is imperative that we consider decent work for personal support workers who provide care for our most vulnerable. Our findings highlight potential areas for labour policy reforms related to the PSW workforce. First, PSWs need to be better compensated for their work. While the Ontario government’s temporary wage increase prompted by the pandemic was a welcomed improvement, PSWs need this wage increase to be made permanent. Second, PSWs need full-time, permanent jobs with benefits. Our study indicated that the COVID-19 pandemic significantly impacted PSWs who worked part-time, casual, and short-term contract jobs. Their precarious work arrangements create the conditions whereby PSWs needed to cobble together multiple jobs and work long hours to make a living and support their families. Income loss due to limiting PSWs to work in one healthcare setting had significant impacts on their livelihood. In the absence of permanent position, many of them also did not have paid sick days or health benefits. Third, PSWs were subjected to difficult working conditions, such as large client loads and challenging clients, which were worsened by staffing shortages. We recommend that PSW workload be evaluated to allow for high-quality care provision to clients in more ideal conditions (e.g., a smaller client to PSW ratio). In conclusion, policy changes that improve the working conditions for PSWs are urgently needed to retain these professionals as Canada’s population ages and healthcare needs continue to grow.

Contributions to knowledge

What does this study add to existing knowledge?

• Pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19–related challenges for PSWs.

• During the height of the COVID-19 pandemic, PSWs were subjected to significant stress; however, they exhibited great mental resilience and dedication to their work.

• PSWs want to be better compensated for their work and COVID-19’s restrictions on multiple work settings significantly impacted PSW incomes.

• There are positive implications of pandemic policies, including a temporary wage increase, better infection controls, and consistent assignments of staff to clients, which may be considered for future workplace standards.

• What are the key implications for public health interventions, practice or policy?

• Temporary wage increases need to be made permanent to sustain the PSW workforce and ensure workers receive fair compensation.

• There needs to be a shift in improving working conditions by ensuring more full-time, permanent jobs with benefits.

• Stressful working conditions, such as large client loads in long-term care due to staffing shortages, need to be addressed to provide high-quality care as well as to improve working conditions for PSWs.

Author contributions

All the authors contributed to the study conception and design. Data collection and analysis were performed by APH, CM, JWH, and AP. The first draft of the manuscript was written by APH and JWH. All the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.

Funding

This research was made possible through funding from the Metcalf Foundation. The funder did not have any involvement in the collection, analysis, and interpretation of data, nor did they have any involvement in the writing of the report and in the decision to submit. Dr. Andrew Pinto is supported as a Clinician-Scientist by the Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, the Department of Family and Community Medicine, St. Michael’s Hospital, and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital. Dr. Pinto is also supported by a fellowship from the Physicians’ Services Incorporated Foundation and as the Associate Director for Clinical Research at the University of Toronto Practice-Based Research Network (UTOPIAN).

Data availability

Not applicable

Declarations

Conflict of interest

The authors declare no competing interests.

Ethics approval

This study was approved by the St. Michael’s Hospital Research Ethics Board (#18-103), Toronto, Canada.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable