Abstract

Introduction

Since early 2020, the coronavirus (COVID-19) pandemic has caused major disruptions to industries and workplaces, with costs to the economy and individual incomes (Ingram et al., 2021). Workplaces have been a major source of COVID-19 transmission and subsequently been subject to closures, limits on number of employees on site, and other operating restrictions (Lei et al., 2020). Restrictions on industry were particularly tight in Australia, where government lockdowns in the state of Victoria prohibited all but a few essential services and their employees to work onsite, with all other individuals required to work or stay at home (Stobart and Duckett, 2021). Globally, such restrictions, although effective in limiting COVID-19 transmission, created tensions with industry and the public, lessening the sustainability of such measures (Wood et al., 2022).

The emergence of rapid antigen tests (RATs) for COVID-19 provided a potential tool for systematic surveillance workplace testing. COVID-19 surveillance initially focused on laboratory-based polymerase chain reaction (PCR) testing, which although accurate, requires a day or more for laboratories to process high test volumes (Ingram et al., 2021). RATs are diagnostic tests that detect the presence of viral disease through nasopharyngeal or saliva samples (Augustine et al., 2020). Compared to PCR COVID-19 testing which requires samples to be collected by trained individuals followed by laboratory testing, RATs can be self-administered, performed on site, and generally produce a result in 15 min (Augustine et al., 2020). The trade-off is their lower sensitivity compared to PCR testing (Augustine et al., 2020). RATs have been evaluated primarily within healthcare settings, where medical staff administered the tests to workers with high fidelity to the manufacturer’s protocols (Bond et al., 2022; Muhi et al., 2021; Ventura et al., 2022). However, interest in using RATs quickly emerged in other sectors with high COVID-19 exposure, including education, supermarket supply chains, and the construction industry. However, in Australia and elsewhere, there was little policy guidance or evidence on how to effectively manage the implementation of RATs in the workplace including logistical requirements (e.g., space, infrastructure, regular supply), quality control (e.g., monitoring of adherence to test protocol, data collection, worker education), and strategies to reduce worker resistance.

While studies point to the effectiveness of RATs in detecting positive cases in non-medical settings (Iddins et al., 2021; Orlandi et al., 2021; Papenburg et al., 2022; Rosella et al., 2022; Schulte et al., 2021; Tulloch et al., 2021), the literature offers few lessons regarding how to create enabling conditions for effective and sustainable implementation. Using a case study from Victoria, Australia—where the construction industry was one of the few industries allowed to operate during lockdowns and a key source of COVID-19 transmission (SBS News, 2021)—this study examines the experience of the first large-scale infrastructure project in the state to implement mandatory workplace RAT. Applying the RE-AIM framework, our mixed methods study examined factors associated with the adoption, implementation, and maintenance of this intervention.

Methods

Results

Over the seven-week mandatory RAT period, 37,720 RATs were conducted on site [67 non-negatives identified (0.18%)]. Only one ‘non-negative’ RAT result was confirmed PCR positive. In total, 40 construction workers, six health staff, and five managers and administrators were interviewed, 30 workers completed surveys and nine workers were directly observed completing a RAT. Brief participant characteristics are provided in Table ​Table2,2, noting that characteristics of workers are not available for direct observations. Of those surveyed, over three-quarters (77%) reported that they had conducted between 6 and 10 RATs at the time of survey completion.

Table 2

Characteristics of interviewees and survey respondents

Participant characteristics	Interview	Survey
	n (%)	n (%)
Total	51	30
Gender#
Male	41 (80.4)	21 (70.0)
Female	7 (13.7)	9 (30.0)
Age group in years#
18–29	12 (23.5)	8 (26.7)
30–39	7 (13.7)	10 (33.3)
40+	5 (9.8)	12 (40.0)
Role at construction site
Construction	38 (63)	7 (23.3)
Administration	3 (6)	11 (36.7)
Health staff	6 (12)	–
Management	5 (10)	7 (23.3)
Other+	–	5 (16.7)

Open in a separate window

Different symbol indicates communications, engineering, procurement, warehouse management

^#Not all demographic characteristics were reported by participants

Adoption

Viewed as a time-limited mandate, there was a high degree of acceptance for RAT as a condition of worksite entry by managers and the workforce, with little pushback observed. Key reasons for high acceptability included the desire to keep jobs going, ease of test-taking, and, for some, increased safety and the peace of mind afforded by RATs. Workforce quotations underscoring themes elaborated below are presented in Table ​Table33 and survey responses in Fig. 1.

Table 3

Illustrative Quotes Related to Adoption

Sub-theme	No	Illustrative quotation
Minimizing site closures and keeping jobs going	1.1.1	Interviewer: And what's your understanding of why people at your workplace are being tested regularly at work? Respondent: So we can remain open. Yeah (Worker)
	1.1.2	So we had a couple of cases before the lockdown…there were a couple of guys on site that had COVID at different times and because of that, a lot of people lost work, like we had to go back home, get tested and isolate (Worker)
Simple testing procedure	1.2.1	Yeah, pretty easy. Yeah. Straight in the mouth…Sort of sucking on a lollipop and then straight on to the test (Worker)
	1.2.2	When we saw or when we discovered the saliva testing kit, it lent itself to be more efficient method of mass testing before work and essentially able to be administered by the workers (Manager)
Safety and test accuracy	1.3.1	Interviewer: And do you think that it [RATs] does make the site safer? Respondent: I don't know. I'm assuming it does. Yeah. But I don't know. Because they were saying that they're [the RAT tests] only 50% accurate. So that is a 50% chance…That leaves a bit of room for error (Worker)
	1.3.2	you've got to make sure the quality issue is there. If the test has to be in your mouth for two minutes, you hear different people and interpretations about whether it's 90 s, 60 s too much fluid, not enough. If you've had protein, if you've had a coffee, if you've done this… (Worker)
	1.3.3	[RAT] is a good investment, but yes, for us as an alliance and as a business, it’s just thinking outside the box, being ahead of the game, looking at ways to maintain peoples’ health and safety when they come to work. So it’s all part of the health and safety…to provide a safe workplace (Worker)

Open in a separate window

Open in a separate window

Fig. 1

Survey respondents’ attitude towards the RAT protocol

Minimizing Site Closures and Keeping Jobs Going

The workforce clearly understood that RAT was a requirement of going back to work (Quote_1.1.1), voicing that RAT was a way to ‘just to be able to get back to work’’ and workers felt ‘pretty well excited’’ to be back. Workers gave examples of having to miss shifts in the past due to positive cases in their team and government policy requiring all contacts to isolate (Quote_1.1.2). Given that it was a critical infrastructure project with strict deadlines, it was considered a ‘good investment’ by management. From the managers’ perspective, high acceptability of RATs was influenced by the fact that after implementation, the construction project did not experience any COVID-19-related disruptions by way of site shutdown or large numbers of staff being furloughed as close contacts. Other factors which may have supported workforce acceptance of RATs included the backing by their union, as noted by 67% (n=25) of survey respondents.

Simple Testing Procedure

The ease of taking the RAT contributed to the test’s acceptability. Among interviewees, the saliva-based RAT was seen as simple, non-invasive, and reasonably easy to incorporate into daily workflows (Quote_1.2.1). Managers viewed the selection of a saliva-based versus a nasal-based test as important for implementation feasibility (ability of workers to self-administer) and worker acceptability (Quote_1.2.2). All survey respondents similarly reported that doing the RAT was easy and expressed minimal challenges. Remembering to pick up the test (13%, n=4), waiting the recommended amount of time for test results (6.7%, n=2), and extra shift time to do the RAT (6.7%, n=2) were the most commonly reported challenges among survey respondents.

Safety and Test Accuracy

From a management perspective, implementing RATs was considered an appropriate workplace measure that helped to contribute to a safe working environment and a return of their workforce (Quote_1.3.3). However, interviewees and survey respondents held mixed perceptions about the degree to which RATs improved workplace safety. Many interviewees indicated that the RATs provided ‘peace of mind’’ for themselves and their family. At the same time, there was considerable uncertainty around the extent to which the tests truly made them safer; among some, the RATs were believed to be only 50% accurate, leaving considerable ‘room for error’ (Quote_1.3.1). Workers believed that test results could be affected by many variables, including amount of saliva and what they had to eat or drink prior to the test, which in turn contributed to a high number of false positives (Quote_1.3.2). These mixed sentiments were echoed among survey respondents: more than 90% indicated that they would prefer to work in settings where RATs are used, felt this preference was supported by their co-workers, and believed most workers complied with RAT protocols. Nearly all survey respondents believed the tests made them and their families feel safer (80%), yet half (50%) held doubts about the test’s accuracy.

Implementation

Communication and Worker Knowledge

Interviewees and survey respondents indicated that the source and quality of information received varied among workers. According to interviewees, some received information in pre-shift meetings, others received links to informational videos and some only received information upon first entry. Among survey respondents, instructional information was mostly received verbally (91.3%, n=21) alongside video (52.6%, n=10) and written (47.7%, n=10) instruction. Instructional information was received from onsite health staff (35%, n=8), onsite COVID-19 marshals or safety team (26%, n=6) co-workers (17%, n=4), and from their manager or administrator (17%, n=4). Most survey respondents (92%, n=23) correctly identified a negative RAT result.

Intervention Fidelity

The interviews, observations, and surveys all revealed gaps in adherence to testing protocols. Misconceptions and logistical constraints were key factors that influenced adherence. Workforce quotations underscoring themes related to intervention fidelity are presented in Table ​Table44.

Table 4

Illustrative quotes related to Implementation

Sub-theme	Ref	Illustrative Quotation
Adherence to protocols	2.2.1	It's been a journey. Certainly in the early days of the commencement of the testing regime, worker education was an area for improvement so that every time we had new workers or even just existing workers, first few days, was a learning process … Using the test kits incorrectly e.g., not removing the protective cap from the swab, or even returning the protective cap from the swab and then proceeding to try and join the swab with chemical reservoir. So we have seen, certainly an improved user skill. But always, you know, first time users, its worth taking the time and that's the benefit of having the life aid paramedics on site at those control points to provide instruction for first time users (Manager)
Monitoring entry	2.3.1	The early phase planning was going to try to see how we can manage the large number of four groups, we're talking about 600 people almost on average per shift, and we run day and night shift. The main idea was to make sure that we control the mass (Manager)
	2.3.2	Probably a more effective method would be to have the workers conducting the tests in a controlled environment at our pre-start, that would give us high efficiency and competence that tests are being conducted correctly and for the right duration, etc. But that would expose us to being a close contact site if we had a positive worker in the pre-start compound or in the pre site area. So we looked at… we had to assess the benefits and risks of allowing workers to test outside of the worksite. So essentially, take a test home every day, and tests on the way to work, but no later than before the entry to the worksite (Manager)

Open in a separate window

Despite general perceptions among workers that the test protocol was straightforward and relatively easy to comply with, managers and health and safety staff held mixed views regarding workers’ compliance. Some managers reported several challenges in the ‘early days’ related to ‘user skill’ and failure to follow the instructions, while other managers felt that worker compliance was generally high (Quote_2.2.1, Table ​Table4).4). In the context of significant workforce turnover, several managers and health and safety staff raised compliance issues related to the quality and consistency of information for onboarding new workers.

Actions Following Non-negative Results

A health worker noted that diversity of professionals (nurses, paramedics) and non-professionals (COVID-19 marshals) employed to assist with the testing, and differences in their level of training, knowledge, and time on site, led to different interpretation of the protocols following a non-negative result. Numerous interviewees believed that they should re-test following a non-negative result because of faulty kits and false positives due to consumption of certain foods and drinks (e.g., coffee). Some confusion was similarly echoed in survey respondents. Five survey respondents reported non-negative or invalid results. Actions following these results included performing another RAT, completing a PCR test, and contacting their manager. Most survey respondents were aware of the correct actions following a non-negative result, indicating they would stay in their car and call someone (70%, n=16) and/or do a PCR test (57%, n=13). However, one survey respondent with an invalid result indicated that they were “not entirely sure if my single line tests were invalid” and “never made aware there was a difference in single line results” (Worker).

Time to Results

Interviews revealed several misconceptions. Regarding time-in-mouth, it was commonly believed that 30 seconds was sufficient to get enough saliva and that waiting longer would produce false results. For time-to-results, workers generally perceived that the test was readable after the control line appeared in the first couple of minutes (even among those who recalled the instructions to wait 15 min). Further, some perceived the 15-min wait as ‘annoying.’ Over a quarter of survey respondents (n=7) indicated they did not hold the test in the mouth for the full 2 min and few waited the full 15 min for test results according to the manufacturer’s instructions (Table ​(Table5).5). Our observations further noted that eight of nine (89%) of those observed did not follow the prescribed waiting time to result. Variables, such as the diversity of staff involved in implementation and differences in the level of training and information provided to workers, influenced implementation fidelity (i.e., the degree to which strategies that support the implementation of an intervention were used as intended). Inconsistencies in implementation fidelity likely impacted intervention fidelity (i.e., the degree to which the innovation was implemented as intended) as shown by the variations in actions taken following non-negative results and differences in the way tests were taken relative to the manufacturer’s instructions.

Table 5

Adherence to testing protocols at the most recent rapid antigen test among survey respondents

Survey question	Response	n (%)#
Total		30
Last rapid antigen test was conducted	In the car	17 (68.0)
	Worksite entry	1 (4.0)
	At home	7 (28.0)
Last rapid antigen test was conducted alone	Yes	20 (80.0)
	No	5 (20.0)
Last rapid antigen test; time to hold pen in mouth	<30 s	1 (4.0)
	One minute	4 (16.0)
	Two minutes	18 (72.0)
	3 to 5 min	2 (8.0)
Last rapid antigen test; time to wait for test to finish	Until the control line appeared	6 (24.0)
	<5 min	5 (20.0)
	5 to 10 min	7 (28.0)
	15 min	4 (16.0)
	>15 min	3 (12.0)
Last rapid antigen test; used timer when doing the test	Yes	9 (36.0)
	No	16 (64.0)

Open in a separate window

^#Denominator is not always the same because of missing data (25 respondents completed the questions about protocol adherence at their last rapid antigen test)

Monitoring Entry

Given the hundreds of workers entering the site each shift, a major preoccupation by managers and health workers was the challenge of limiting large numbers of workers from congregating at the front entrance while awaiting test results which would create a potential COVID-19 transmission risk (Quote_2.3.1, Table ​Table4).4). Our observation found that workers seeking to collect tests contributed to crowding at the entry gate alongside workers waiting for test results. Reasons for testing at the front gate included new workers who had not received any test kits, workers who had not received a kit to take home after their previous shift due to stockouts or had forgotten them, and preference to not wait in the car. Health workers indicated they had varying success in requesting workers to move away (e.g., take a walk). In response to crowding at the entrance, site management adapted the protocol, advising workers to conduct the test while driving to work so that the result was ready upon arrival. This was done to improve feasibility while acknowledging the limitations on quality assurance (Quote_2.3.2, Table ​Table4).4). Managers expressed a high degree of trust in their workforce to appropriately take the test on route without direct supervision. Workers interviewed indicated that testing while traveling on route to the site was convenient and did not waste their time. Overall, 68% (n=17) of survey respondents reported conducting their most recent RAT in their car.

Discussion

In the context of rapid approval of and implementation of RATs as a COVID-19 risk mitigation measure in Australia and globally, this study provides important implementation lessons on factors affecting the adoption, implementation, and maintenance of mandatory RAT in a large workplace within a low prevalence setting. In the Australian context, following months of significant disruptions to industry operations due to COVID-19-related lockdowns, our study found high acceptance among workers and managers for mandatory RAT in the short term. Factors which supported adoption by workers included the desire to stay in work, the perception that the testing procedure was easy and non-invasive, and a sense of workplace safety. These factors are consistent with other evaluations of RAT usage in the workplace (Doron et al., 2021; Nguyen et al., 2022). For managers, economic considerations were forefront in supporting adoption. Mandatory use of RATs made sense economically, preventing closures and disruptions. However, in implementing the testing regime, implementation and sustainability challenges emerged related to knowledge and adherence to testing protocols; managing crowding among workers; and maintaining worker acceptance in the context of high population vaccination rates.

The policy environment around COVID-19 testing in Australia shortly before and around the time of this study was rapidly changing. In August 2021, the Therapeutic Goods Administration first approved COVID-19 RATs for use only under the supervision of a trained healthcare provider (Therapeutic Goods Administration, 2022a). Prior to this, Australia had solely relied on PCR-based COVID-19 testing, meaning there was minimal community literacy or experience with RATs at the time of implementation. This may have contributed to the varied adherence to RAT protocols observed within this study. Consequently, all education on rapid antigen testing was reliant on worksite-provided education. Other studies have identified similar challenges related to poor adherence. A UK study found that only 8.6% and 25.3% of staff achieved a protocol adherence rate of>75% and>50%, respectively, leading to no reduction of COVID-19 outbreaks (Tulloch et al., 2021). Poor adherence to testing procedures may lead to increased frequency of false negatives with the potential for workplace outbreaks, ultimately undermining costly investments in mandatory surveillance RAT regimes (Paltiel et al., 2021). To promote stronger intervention fidelity, our study suggests that strategies to improve implementation fidelity—such as provision of consistent messaging to promote compliance to testing protocols—is important. Attention to consistent and effective implementation strategies is especially important in workplaces with high staff turnover.

While insufficient intervention fidelity (adherence to protocols) can diminish effectiveness, the implementation literature also shows that insufficient room for adaptation can hinder uptake, sustainability, and effective implementation (Hawe et al., 2004; Pinnock et al., 2017). Unlike many health interventions which are designed and optimized in a research setting, the construction project had a significant role in determining the intervention design and implementation strategies, and by extension, significant autonomy around adaptation. Limited space and the requirement to have trained health personnel monitor worker testing also emerged as a significant logistical challenge. In our study site, managers responded by adapting the testing protocol and encouraging workers to take the test in their cars enroute to work. This adaption may be insightful for other workplaces considering validating RATs upon an employee’s arrival on site, which are likely to contend with similar constraints. While this adaptation diverged from government policy around health worker-observed RAT, it improved feasibility; thus, highlighting tensions between best practice (government and manufacturer guidelines) and implementability. Similar challenges were observed in a large-scale implementation of RAT in the workplace in Canada, where the implementation approach was also adapted to allow home-based testing (permissible according to Canadian guidelines (Rosella et al., 2022). Site adaptability to the implementation of surveillance testing is critical to implementation success, and has been shown in the implementation literature to be essential for making new ways of working part of regular practice and supporting sustainability in the longer run (Chambers et al., 2013). The agility of the United Kingdom logistics sector in implementing measures to protect their staff and business, often in a context of limited Government and policy guidance, was an important component of their response to COVID-19 (Wei et al., 2022). There needs to be flexibility in systems to allow for modifications and adaptions to enable implementation success of surveillance testing, particularly, in rapidly evolving health and policy landscapes. Importantly, adaptations also need to be quality assured and monitored to ensure that changes made on the fly improve the fit and/or effectiveness while also complying with the current policy environment. In assessing interventions, the use of an implementation framework to guide the approach where adaptations are applied can help to both strengthen the intervention fidelity (the degree to which the intervention is implemented as intended) and implementation fidelity (the degree to which strategies that support the implementation of an intervention were used as intended). This, in turn, is likely to lead to better outcomes and the sustainability of implementation (Albrecht et al, 2022).

While rapid testing was supported by the workforce to keep the worksite open and safe, our findings foreshadowed significant challenges in maintaining ongoing support in the long term with implications for the sustainability of mandatory testing as a condition of work. This study was conducted during a unique timepoint when the Australian state of Victoria was nearing pre-determined COVID-19 vaccination targets and still had low community prevalence. Under the national plan, lockdown restrictions would be eased progressively when 70% and then 80% of people over 16 years of age were double vaccinated (The Australian Government, 2021). The vaccination policy, coupled with rising population vaccination rates, created a sense of optimism that vaccination would allow for the safe opening of society. This likely influenced workers’ acceptability of mandatory testing as a time-limited measure. As seen in Australia and internationally, there has been a generalized decrease in support for ongoing mask, vaccination, and testing mandates, with many governments subsequently lessening and/or abandoning these requisites (International Monetary Fund, 2021). While many countries, including Australia, have now approved home-based testing, voluntary testing requires public willingness, access to tests, and tracking systems to support surveillance efforts—features with which many countries and organizations are struggling (Nguyen et al., 2022). Greater guidance from policy makers about how to adapt testing protocols to be appropriate for the background COVID-19 prevalence may help maintain levels of acceptability among staff, as has been noted elsewhere (Nguyen et al., 2022).

Limitations

Given the limited focus on the implementation experience of RATs, compared to studies reporting on RAT effectiveness in case detection, this study provides important findings regarding adoption and implementation. Our use of direct observation combined with interviews provided value in confirming reported practice with actual practice. However, the low number of responses to our survey is a major limitation to our quantitative data, particularly that only seven surveys were completed by construction workers. Several factors may have contributed to this. The interviews were conducted at a similar time to when the survey was open, with all interviewees receiving a $20 voucher compared with an opportunity to win one of three $100 vouchers for survey completion. Possibly, workers preferred the certainty of a $20 voucher. Furthermore, the interviews were conducted face-to-face. It is possible that workers were more likely to participate in an interview when approached directly rather than remembering to complete a survey. While our study was conducted in a single, for-profit worksite, observed technical challenges (e.g., protocol adherence, managing logistics) are likely salient to other workplaces. However, the impetus for adoption may be highest in for-profit industry contexts, where delays and shutdowns due to workers contracting COVID-19 creates immense cost in lost work and challenges in managing on-time project completion. Supplying daily tests to workers may be prohibitively expensive in non-for-profit and public sectors, and in low-income country settings. Further, the high level of worker acceptability that was observed may have been influenced by the particularly restrictive lockdowns in Australia. This study was performed in a setting with a relatively low prevalence of COVID-19 and high vaccination coverage. Future studies should investigate how implementation and sustainability may differ in contexts of high compared to low COVID-19 prevalence and how testing regimes could be adapted for implementation in other industries and public sectors where budgets and tight deadlines may be less salient.

Conclusion

Achieving intervention fidelity and implementation fidelity in a rapidly changing context is difficult, particularly so during a pandemic. Using implementation tools, such as the Plan, Do, Study, Act Cycles (PDSA), can create space for adaptations to be considered as part and parcel of implementation and provide for systematic assessment of these adaptations (Institute for Healthcare Improvement, n.d.; Gilbert et al, 2020). While these tools are more commonly used in health and academic settings, they may be less familiar to commercial and non-profit enterprises—supporting their use in these settings may be beneficial to the sustainability of new interventions implemented in fast-moving environments.

With COVID-19 likely to continue to circulate for years to come, finding ways to keep workplaces open while keeping workers safe will be a priority for countries and businesses. The implementation of RATs on a large-scale construction site in the State of Victoria, Australia was an acceptable and feasible short-term measure to keep worksites open by minimizing COVID-19 transmission, while acknowledging issues with adherence to the testing protocol. As use of RATs becomes normalized and increasingly non-mandatory, new strategies will be needed to maintain worker willingness and quality control over results. Further, developing centralized systems for recording both home and workplace testing results will be important for surveillance and vigilance among the population.

Supplementary Information

Acknowledgements

Author Contributions

AF and CN: conceptualized the study, contributed to the methodology, supervised the data collection, analysis, interpretation, and contributed to writing and editing the manuscript. TL and NSC: contributed to the methodology and data collection, led the analysis and undertook the main contribution to writing and editing the manuscript. JG: contributed to the methodology, analysis, and writing the manuscript.

Funding

Open Access funding enabled and organized by CAUL and its Member Institutions. This work was funded by the Victorian Department of Health but had no role in the study design, data collection, analysis, or interpretation of results.

Declarations

Footnotes

References