At the beginning of the COVID-19 pandemic, health workers must deal with the minimal information on COVID-19 as a new disease and its dynamic handling policies, which create anxiety and additional workload (4). The increasing workload also increased role conflict between health workers' work and personal lives (9). Health workers with complex adaptation skills toward these rapid changes are having risk for higher stress (15). Our study was conducted in the third year of the pandemic and contributed to our understanding of how the pandemic impacted primary health workers' work-life balance and stress.
Most importantly, our study found that the stress level among our respondents was low, but their work-life dimensions were high, showing significant work/family interference or enhancement. These findings verify the imbalance between the primary healthcare worker's work and personal lives due to the pandemic, increasing their stress. As the health workers who became the frontline of the testing-tracing-treatment strategy and the COVID-19 mass vaccination, primary health workers were assigned more extra work during the pandemic. Even before the pandemic started, primary health workers in this study had been loaded with extra tasks outside their primary job; our study found that these extra tasks did not associate with their stress. In contrast, the multiple extra tasks related to the COVID-19 control measures become a protective factor against stress among primary health workers. This finding is different from other studies, which reported that the increased workload due to the pandemic increased the health workers' stress levels (13, 15). Considering the data collection period of our study conducted in mid-2022, in the third year of the COVID-19 pandemic, the primary healthcare workers may have become more resilient. A cohort study in three waves of the COVID-19 pandemic shows that health professionals developed a stronger resiliency during the pandemic and actuated their coping strategies (20). Resilient health workers during the pandemic can cope with their stress, preserve their difficulties and mobilize a response to always focus on their achievement (20). The resilience of health workers also explains our other findings that the health workers burdened with multiple tasks related to COVID-19 are likely more fruitful for primary health workers rather than only working monotonously on COVID-19 handling. With resiliency, multiple tasks provide more variation and challenge in daily work for health workers, reducing boredom and increasing their performance (21, 22).
In addition, our study found that gender, age, and marital status did not determine stress levels. This finding is in contrast with previous studies in the first wave of the pandemic, which found that gender commonly determined the stress level among healthcare workers, with female health workers having higher stress levels (14, 16, 23, 24). The ability to develop resiliency is not different between gender, age, and marital status but is based on the experience of health workers (25). It explains our findings that those social demographic variables did not determine health workers' stress in this third pandemic, but the experience years did. In our study, primary health workers with shorter working years have less stress since they can create coping strategies that effectively decrease stress. It is different from a study that explained that older health workers have better ability to create coping strategies during their challenging times which can prevent them from stress (16). Work stress is a common issue that enhances at higher ages due to older adults' work, health, and socioeconomic vulnerability (26). Frontline health workers working in high-risk COVID-19 transmission developed a perceived threat of COVID-19, increasing their burnout degree and resulting in higher stress levels (4).
Furthermore, we found that work-life balance affects primary healthcare workers' stress levels. This work balance is manifested in two different conditions. First, the interference between work and personal life increases health workers' stress. This condition indicated any conflict between health workers' personal and work lives. Other studies fully support this finding, which found that role conflicts among health workers reportedly increase their stress levels (9, 15). Health workers are vulnerable to mental health because of their overwhelming workload and high demand for personal accomplishment during the COVID-19 pandemic (27). Second, the enhancement between work and personal life decreases the stress level. Social supports received by primary health workers reportedly decrease their stress (9). The personal relationships of health workers with their family members and spouse enhanced their work-life balance during the pandemic (14). Work support from their working circles significantly minimizes the interference between work and personal life (28).