The COVID-19 pandemic has profoundly affected the lives of almost every individual in every nation, with numbers of infections continuing to grow. Across these nations, first responders are essential in their roles addressing emergencies, despite their risk of exposure to COVID-19 in the course of their work. We sought to understand the impacts of the COVID-19 pandemic on the lives of volunteer firefighters in the United States, an understudied group of these first responders. Interviews were conducted with volunteer firefighters between September and November 2021. Interviews were analyzed using deductive dominant thematic analysis. Thirty-three firefighters were interviewed who had an average of 22 years of service and a mean age of 52 years. Interviewees described pandemic-related challenges including the fear of COVID exposure and frustrations with work and personal relationships. They also identified unexpected work-related benefits including a deepened commitment to serve and improvements to training and safety. Further, some volunteers noted personal benefits such as developing stronger connections with others, having a new outlook on life, and observing goodwill. Our findings provide insight into the multifaceted and complex impact of the COVID-19 pandemic on volunteer firefighters. To date, the negative impacts of COVID-19 have been examined in racial and ethnic minority groups , US immiFirst responders play an essential role in society by responding to fire, medical, hazardous material, or other similar emergencies. Less is known about the impact of COVID-19 on first responders despite their risk of exposure performing their work duties. One recent study estimated that more than half of the workers in protective services, which includes firefighters, were exposed to COVID-19 at least once a month, and nearly one-third of these workers would be exposed at least once a week . StudiesCOVID-19 stress and anxiety experienced by first responders may not be remedied by the availability of vaccines against COVID-19 if the vaccines are not widely accepted among these groups. Prior to vaccine availability, a survey of firefighters and emergency medical services (EMS) personnel showed that fewer than half of respondents (48.2%) indicated high acceptability of a COVID-19 vaccine if it were to become available . More reOf note, there are approximately 745,000 volunteer firefighters in the US . In the The stress of being on the front lines delivering emergency services combined with the potential for exposure to COVID-19 in chaotic situations may place volunteer firefighters at high risk for adverse physical and psychological effects resulting from the COVID-19 pandemic. We designed this study to improve our understanding of the impacts of this pandemic on volunteer firefighters in relation to both their volunteer service roles and as members of their local communities.2.2.1.We conducted a qualitative study comprised of interviews with members of the National Volunteer Fire Council (NVFC), a nonprofit membership association for volunteer fire, EMS, and rescue services. Interviews were held between September and November 2021 and aimed to understand how NVFC members were both professionally and personally impacted by the COVID-19 pandemic.2.2.NVFC members, including volunteer firefighters and emergency medical technicians (EMTs), were recruited to participate in study interviews with the help of NVFC leadership. All NVFC members  received a recruitment email from their organization with information about the study and how to participate. Interested members contacted the study team to participate in the study and were scheduled for interviews in the order they expressed interest. Although many NVFC members expressed interest in participation, interviews ceased once we reached saturation in data collection; this gives us confidence about the salience of the results we present .All interviewees provided informed consent to participate in the study. Interviews were conducted by phone using a semi-structured interview guide that asked questions about the impact of COVID-19 on NFVC members. Interviews lasted approximately 40 min and were audio-recorded, transcribed verbatim, and de-identified.2.3.Interview transcripts were coded and analyzed using deductive dominant thematic analysis –25, allo3.3.1.We interviewed a total of 33 NVFC members across 24 states. On average, interviewees had volunteered for their local fire services for 22 years and were 52 years of age . Most interviewees were male (73%), nearly half had completed EMS/EMT medical training (45%), and about one-third achieved the rank of lieutenant or higher (33%). 3.2.Data collected from our study interviews revealed that the COVID-19 pandemic posed important challenges for volunteer firefighters in their roles as first responders. Interviewees discussed work challenges including: (1) fear of COVID exposure and transmission during emergency response; (2) frustration with emergency responders not following public health measures; and (3) difficulty fostering camaraderie. We describe these themes in further detail next, and present additional verbatim quotations in “The pandemic has increased stress levels. So now there’s even times when I go on what we call a speed call. In other words, I’m not on duty, but they need somebody to respond. I’ll respond, and I don’t always have all my protective gear with me. So, yesterday I was on a call for a guy laying on the side of the road, and all I had was gloves. Okay so this guy is vomiting. Does he have COVID? I don’t know. Just don’t let them breathe on me”. This fear of COVID-19 exposure also reportedly discouraged some volunteers from responding to emergency calls. As one firefighter explained, “Some people will really decrease their [emergency] responses because they just, you know, they may have somebody at home with a weakened immune system or something. So, they’ve decided that they’re not going to participate and risk bringing that back home to their family”.First, volunteer firefighters acknowledged fear about COVID-19 exposures during emergency responses. As one EMT highlighted, “I was shocked. It wasn’t the general public. These are firefighters … it’s disappointing. I guess in many ways it’s heartbreaking. You know, it’s, I have the same kind of feelings about people who work in the healthcare field resisting vaccination. I’m like, how can you ethically say that you want to care for people, help people, protect people, and not do something that is so simple to try to keep the health of others in your community safeguarded? It just seems to go against everything that we’re supposed to stand for”. An EMT firefighter expressed similar frustrations by sharing, “Not everybody following the guidelines and documents, you know, that’s the hard part, you know, that’s most frustrating”.Second, volunteer firefighters expressed disappointment with some of their coworkers who did not follow public health measures against COVID-19. As one firefighter reflected about his coworkers refusing to get vaccinated, “We used to look forward to seeing each other, hanging out after calls, talking, catching up with everybody and now it’s like, go do the call, and let’s get everybody out of here. So, it’s changed the camaraderie a lot”. Similarly, another firefighter explained “Well, I think we’ve lost a lot of connection to one another. That [socializing and cooking at the firehouse] is really when, you know, a lot of the camaraderie and the trust building, and the connection happens. Certainly, it happens during training. Certainly, it happens during calls. But it’s all that soft stuff that happens in addition to what you have to do, where you really start to get connection and a feeling of tightness with your department. And that was being impeded for many months”.Volunteer firefighters’ responses also suggested that connecting and building trust with coworkers was much more difficult during the COVID-19 pandemic. They commented on how the changes during the pandemic resulted in less camaraderie among the firefighters. As one firefighter reflecting on the changes during the pandemic shared, 3.3.Volunteer firefighters also described the negative impacts the COVID-19 pandemic was having on their personal lives such as: (1) fracturing of relationships; (2) disruptions to their social support system; (3) chronic stress and negative impacts on mental health; and (4) feeling frustrated that people are not taking the pandemic seriously. We describe these themes in further detail next and present additional verbatim quotations in “I lost a few friends, because of this. We don’t talk to each other anymore. Their belief system is so opposite of each other that we can’t talk to each other because they become angry. Well, hopefully in a few years they’ll come back. We’ll have a nice beer together and slap each other and say how in the heck did we get this way? That means we were true friends to begin with”. Another interviewee shared, “So, we now, unfortunately, know who in our previous group of friends did not want to get a vaccine or had some weird out-of-left-field thoughts. And so, moving forward, that’s just going to be an issue that we’re going to have to encounter. And either find a way to look past that with people, or our social group is just going to become smaller and smaller with people who think more like us”.Interviewees’ responses suggested they noted a fracturing of some relationships that was related to issues surrounding the COVID-19 pandemic. As one firefighter reflected, “Yes, I think that the inability to responsibly be social with a large group of people has impacted us. It was initially very stressful to not be able to be out with a larger group of friends, but we have learned to cope with that enclosed social group and now it’s okay. But at the beginning it was very stressful”. Another firefighter described additional impacts on the social relationships of children, “What it’s going to do to our young children that have seen that have been through this… They are stuck at home for school for a whole year or something. How are these kids going to handle being socially out in public?”.Volunteer firefighters’ responses also suggested negative effects for themselves and others caused by disruptions to their social support system. One firefighter reflected on how a lack of social gatherings impacted her and her spouse, “I have a tendency to be a whole lot more angry. Yeah, I mean when I go home and my husband is watching the news, I’m like, ‘Turn that crap off!’ And the anger comes to the surface”. Another interviewee reflected similarly, “We’re just over it, ready for it to be done. You can only stay super vigilant for so long”.Further, many volunteer firefighters expressed concern about chronic stress and the negative mental health impacts of the COVID-19 pandemic. One interviewee shared, “I think there’s a frustration just, you know, just kind of how, as a community, and, including the wider community, how we’re dealing with it, and not dealing with it at times. It’s a little frustrating when some folks are kind of cavalier about it. And I’ve had, you know, I have relatives that have a relative who passed away. I understand it’s their choice, but it is a little frustrating when some of the choices that they make impact others unnecessarily”. Another interviewee shared similar frustrations in reflecting, “I’m a little more frustrated that people are still thinking that this is just a light case of the flu, or, you know, that the people who are denying that this is an epidemic, pandemic. I get frustrated with that, you know, they’re not taking steps to protect themselves or others”.Finally, volunteer firefighters commented they were frustrated by people not taking COVID-19 seriously. They shared their frustrations about people in the community who were against wearing masks and increasing risk to others. One interviewee commented, 3.4.Despite the devastating impacts of COVID-19 on society, volunteer firefighters also reported finding “silver linings” that they associated with their experiences during the pandemic. Specifically, they mentioned unexpected benefits related to their work including: (1) a reinforcement of commitment to serve as a volunteer firefighter, and (2) an opportunity to improve training and work safety. We describe these themes in further detail next and present additional verbatim quotations in “We are one of the few volunteer departments in the area that actually has a waiting list of people to get on. We just have a lot of new younger guys and girls in the community that just want to step up and serve. And maybe this COVID’s actually helped because they see the need for it”. Another interviewee shared, “So, there’s another thing that pops up with COVID, it says, ‘Oh, this is a life event where you should reconsider whether you’re a firefighter.’ The benefit of providing service to the community outweighs the personal risk that I’m going to accept”.First, responses from volunteer firefighters suggested they experienced a renewed commitment in themselves and others to serve as emergency responders. As one interviewee reflected, “I think it’s done a number of things, obviously it’s, you know, changed our work environment. A lot more stuff has gone remote. I think it’s opened our eyes to some things that we were doing in the past that probably weren’t the most efficient ways that we could be doing things. I think we’re foolish not to look at some of the things and say has this, corrected maybe, some things that could have used some correction for a long period of time”. Another volunteer firefighter shared, “Firefighters think they’re invincible and firefighters sometimes get a little too relaxed when it comes to taking in all aspects of safety. But, even safety in the medical sense. And I think this has caused us just to kind of reevaluate some of the unnecessary risks that we’ve taken and to be more cognizant of the safety measures that we’ve been taught and take them a little more seriously. Unfortunately, it took some people we know dying in order for that to happen”.Interviewees additionally suggested that the COVID-19 pandemic provided a benefit for emergency responders by enabling improvements to volunteer firefighter training and safety. One volunteer firefighter commented, 3.5.Volunteer firefighters also mentioned personal benefits resulting from the pandemic, such as (1) developing stronger connections with others; (2) having a new outlook on life; and (3) observing the best of our society. We describe these themes in further detail next and present additional verbatim quotations in “The social family, the people in your household, relationships have gotten stronger because people are forced to spend more time together”. Similarly, another interviewee explained, “So, it’s opened up some beautiful ways of building connections with people, sharing stuff”.Volunteer firefighters commented about how they perceived a “silver lining” in their ability to develop stronger connections with others during the pandemic. One interviewee shared, “I think it’s turned out to be a very positive year, year and a half, whatever, for us to just kind of relax, enjoy life more. I got a new position at work and have been able to focus more on that. And, we don’t have the stress of going into our jobs. We don’t have to stress about going out on weekends. And, I think it’s just an overall positive. It was hard at first, but we got past that pretty quickly”. Another volunteer firefighter pointed out, “I think it’s just made me more appreciative of life, of the people around me and understanding life can be short”.Interviewees also reported having a new outlook on life in response to the COVID-19 pandemic. Several volunteer firefighters shared decisions they made in their personal lives. For example, one volunteer firefighter said, “A lot of people in this business have done extraordinary things in life or in face of the threats of this pandemic, and much like what happened on 9/11 in our business, they’ve really come through. They’ve shown the best of our society, and I hope that our communities are as proud of their volunteer firefighters as I am, because what they have done has been nothing short of amazing”. Similarly, a volunteer firefighter EMT explained, “I took good care of myself to make sure I didn’t get it so I could still help other people”.Last, interviewees shared that their experience during the pandemic involved seeing some of the best of our society. Many volunteer firefighters felt proud about their role in helping community members during the crises. A fire chief noted, 4.Our study shows the broad impact of COVID-19 on both the professional and personal lives of volunteer firefighters who have been working throughout this pandemic. In spite of ongoing burdens from the pandemic and added danger to themselves and their coworkers from potential occupational exposure to COVID-19, many study participants noted that they had also seen some benefits from this experience. Of note, we did not ask participants directly whether they had observed anything positive during this time frame; rather, they spontaneously provided examples of good things that had occurred because of the emergence of COVID-19. Interestingly, several of the stumbling blocks and silver linings that we identified represented opposing views of similar topics: some relationships were lost while others were strengthened; chronic stress negatively impacted mental health yet brought a new outlook on life; frustration was felt for those not acting responsibly during the pandemic while inspiration was felt for those who stepped up to help in this time of need.Recently, DePierro, et al. wrote about the mental health consequences such as the post-traumatic stress disorder (PTSD) and depression that first responders and medical personnel developed following the attacks of 11 September 2001 and have suggested that frontline workers and essential personnel may experience similar effects from the COVID-19 pandemic . Our stuThere is ample evidence suggesting that strong social connections in the firehouse contribute significantly to resilience, work performance –32, and The perspectives of our study participants also suggest possibilities for post-traumatic growth, described as positive change experienced due to a traumatic experience . In pracThe volunteer firefighters in our study had, on average, volunteered for a long period of time. They expressed pride and enthusiasm for their role in serving the public. These extraordinary individuals routinely confront environmental, biological, and physical dangers. We found that the added risks of COVID-19 infection along with the social turbulence that has characterized the pandemic has placed additional strain on both the professional and personal lives of these individuals. The salience of these findings suggests the important role of leaders who can proactively address mental health challenges, reinforce healthy coping strategies, and encourage resilience among these volunteers.One unique finding in this study is the impact of the pandemic on deepening the commitment to serve. In the firefighter and EMS communities, significant workforce turnover has led to communities being concerned about staffing of their emergency services. While staffing shortages were a concern prior to the emergence of COVID-19 , these hSeveral limitations should be considered when interpreting our study findings. First, our respondents were, on average, slightly older than the typical volunteer firefighter, thus their experiences and concerns may be somewhat different than those of younger volunteers. Second, about one-third of our respondents had a rank of lieutenant or higher, and therefore senior-level volunteers may be somewhat over-represented in our data. Nonetheless, we feel that the perspectives provided by this experienced group are important for understanding the broad impact of the pandemic on the lives and livelihoods of volunteer firefighters. Future work studying a different population of volunteer firefighters may provide additional insight about these issues.5.The impacts of COVID-19 and the ongoing pandemic on the infrastructure of emergency services, particularly in environments that rely on volunteers for these services, have been profound, including in areas such as the safety, mental health, and resilience of first responders. Recognizing the challenges as well as unexpected benefits experienced by these volunteers throughout the pandemic can inform efforts to support these groups and the important work they do for our society.


In recent years, there has been a renewed interest in using virtual reality (VR) to (re)create different scenarios and environments with interactive and immersive experiences. Although VR has been popular in the tourism sector to reconfigure tourists’ relationships with places and overcome mobility restrictions, its usage in senior cyclotourism has been understudied. VR is suggested to positively impact tourism promotion, cycling simulation, and active and healthy ageing due to physical and mental rehabilitation. The purpose of this study is to assess the senior citizens’ perceived experience and attitudes toward a designed 360° VR cyclotouristic experiment, using a head-mounted display (HMD) setting within a laboratory context. A total of 76 participants aged between 50 and 97 years old were involved in convergent parallel mixed-method research, and data were collected using a questionnaire based on the technology acceptance model, as well as the researchers’ field notes. Findings suggest that 360° VR with HMD can be an effective assistive technology to foster senior cyclotourism by promoting tourism sites, simulating the cycling pedaling effect, and improving senior citizens’ general wellbeing and independence with physical and mental rehabilitation. Possible age-associated impairments  , alongsiIndeed, the COVID-19 outbreak affected various sectors with health spending and employment , and traAlthough several studies on immersive reality technologies have demonstrated to be successful in promoting tourism ,13 and fVR can be described as an immersive and interactive digital experience, aiming to simulate the physical or fictional contexts  in diverThe purpose of this study is to assess senior citizens’ perceived experience and attitudes toward a designed 360° VR cyclotouristic experience, using a head-mounted display (HMD) setting within a laboratory context, by answering the research question: “How can 360° VR foster senior citizens’ cyclotourism experience?”. The following hypotheses were anticipated: (a) there are differences in younger and older senior citizens concerning the promotion of the touristic experience; (b) social interaction and safety confidence in VR activities are key for senior citizens to have fun. This confidence is often encouraged by family, friends, and caregivers. These hypotheses are supported in (i) Moniz and colleagues’ study , in whicThis paper is structured as follows: VR is often associated with sensory immersion , interaction, and a sense of ‘being there’ , in whicAccording to LaViola and colleagues , consideIn terms of output devices, these have the following parameters: (i) field of view (environment’s angular extent observed in a certain time); (ii) field of regard (a measure of the view angle); (iii) resolution ; (iv) screen geometry, i.e., rectangular, hemispherical, or hybrid; (v) light transfer by front and rear projection , or laser projected onto retina; (vi) update rate ; and (v) ergonomics .Output devices can be divided into three groups. The first group is visual devices  , which aFurthermore, VR can englobe three factors: the virtual space, presence, and entertainment . FollowiVR often uses virtual scenarios that enable the user to move freely in the virtual world, whereas 360° VR emerges by offering spherical panoramic experiences. Spherical/immersive 360° video  has beenFollowing this analysis, HMDs are VR output devices considered entirely immersive wearable instruments that provide a full field of view that enables complete isolation of the user from the physical world . An HMD, or real 3D immersive VR, is composed of a modulated light source visualized through an optical system  which is worn on the user’s head through a band, helmet, or around an eyeglass frame. Immersive HMDs are systems in which the optics are positioned in front of the eyes, blocking most of the visual field . In shorHowever, it is important to recognize the limitations of VR and HMD, such as discomfort, nausea, cost of equipment, and unfamiliarity. In fact, two components are essential to apply VR and overcome the mentioned limitations. These are: (i) creating a virtual world through the video capturing or 3D modeling; and (ii) experimenting with it using a device in which users can immerse themselves in the virtual environment.In the context of this research, a 360° VR cyclotourism experience was developed with the target audience of senior citizens. In this section, a brief overview of the related research on VR applied to tourism, cycling, and senior citizens is provided.The tourism industry has been undergoing significant changes resulting from technological advances and increases in the production of online content, which tends to influence consumer behavior . ContempSustainability and heritage preservation to diminish overtourism and act as an alternative to visiting protected/preserved natural sites , or evenTravel planning and management , becauseMarketing promotion and sales , which cEnhanced experiences , given tImmersion, entertainment, and engagement ,54, becaSocial interactions and connectivity, through the possibility to encounter or meet users and interact with them , among oWhether in a pandemic context or not, VR in tourism has benefited both the business and destination spectrum and customers . For exaAccording to Beck and colleagues , a virtuAlthough VR in tourism contexts may be widely available, some barriers in terms of access  may compromise its usage and popularity . Although VR tourism does not replace physical travel, it democratizes an activity that overcomes spatial and temporal barriers, extending the traveling experience regardless of financial, physical, and psychological conditions.2 emissions, avoiding greenhouse gas and other fossil fuel components. Riding a bicycle also reduces traffic jams and noise pollution [Riding a bicycle may bring several benefits concerning health and environmental sustainability , but alsollution ,61.https://www.zwift.com/eu, accessed on 16 March 2022). Cycling indoors offers several advantages such as safety and control of training, regardless of weather conditions, representing a viable and realistic alternative for amateurs and professionals.Cycling is not always possible in the conventional way , and indoor virtual cycling is, therefore, a solution to this necessity. Virtual cycling or cycling simulation has reached its popularity boom with the emergence of ‘smart’ training rollers and programs such as Zwift  a simpler way, with the use of stationary bicycles or bikes mounted in rollers, and VR equipment; or in (ii) a complex way, by using high-end hardware and software engine and coding. Regarding hardware, it is common to use bicycle simulators with stands or motion platforms to mimic physical forces , trepidation , freedom of movement , and slope. Through software, it is possible to provide a visually appealing graphic scenario, calibration, and its validity .Similarly to other applications of VR, using it in cycling may also have some limitations, e.g., the distant relation to the actual outdoor cycling feeling in terms of physical effort, surroundings, and landscape.The exponential growth in the ageing population paralleled to other age groups is noticeable through the inverted demographic pyramid. In fact, senior citizens often represent a susceptible group at risk of social and digital marginalization , sedentaSuch impairments give rise to the possibility of intervention, assessment, and planning of projects and activities for senior citizens, aimed at preventing difficulties related to cognitive decline, as well as therapy. Assistive technologies rely on resources  and services  used with the aim of increasing, maintaining, or improving the functional capabilities of people with disabilities . MoreoveIn the same logic, the use of VR with wearable devices, such as HMD, is suggested to be quite effective in the rehabilitation of senior citizens with physical or cognitive disabilities . VR can create a motivating environment for learning and understanding a user’s perceptual and motor skills’ characteristics ,78. FurtAccording to Campelo and colleagues , one of Campelo and colleagues also developed a model entitled VRehab , for theHowever, there are some limitations given that this audience tends to be unfamiliar with the technology and may be hesitant in accepting its usage, because sometimes they may not comprehend its possible contributions. Thus, a technology acceptance model  was usedThe purpose of this research was to assess the senior citizens’ perceived experience and attitudes toward a designed 360° VR cyclotouristic experiment, using the HMD setting within a laboratory context, by answering the research question “How can 360° VR foster cyclotourism experience?”. Additionally, the following hypotheses were anticipated: (a) there are differences in younger and older senior citizens concerning the promotion of the touristic experience; (b) social interaction and safety confidence in VR activities are key for senior citizens to have fun, being encouraged by family, friends, and caregivers. With this experiment, it is also intended that participants evaluate the experience, giving their perceptions and opinions about using VR in a cyclotourism context.The use of qualitative and quantitative methods was needed; thus, a convergent parallel mixed-method approach was followed within a laboratory setting, as depicted in A virtual cyclotourism activity, entitled “Senior Virtual Reality Meeting: A Trip to Paris” was conducted from 20 October to 17 November 2021, with 14 sessions of about one and a half hour each, in the Department of Communication and Art at the University of Aveiro, Portugal. This activity was conducted due to the request of institutions of the Third Age to provide an experience with VR technology for senior citizens. Subsequently, the researchers planned and developed a cyclotouristic trip to Paris, because it appealed to the participants. Such choice was based on the city’s fame and its monuments, but also the pandemic situation that inhibited the participants from traveling (due to the restrictions imposed) and from having moments of conviviality and sharing.The following sections clarify the experimental process, the technology acceptance- based questionnaire, unstructured interview and data analysis questions, the participants’ recruitment and characterization, and the data collection and analysis procedures, ending with ethical concerns involving the target audience. The virtual cyclotourism activity was divided into two phases , and eacWhile preparing for the activity, a questionnaire about the experience was elaborated, proceeding with a selection of 360° videos and background music, and participants informed consent. The questionnaire was based on the survey from Barsasella and colleagues  groundedhttps://www.youtube.com/watch?v=HNApxhvK1Hg, accessed on 18 October 2021), whereas the second one was a cycling trip by the Parisian suburbs.  Background music based on Parisienne instrumental jazz  was also added to build an immersive environment. Finally, the informed consent safeguarded the participants and/or their caregivers’ acknowledgment of the study, instruments used for data collection, and publication of results.Two 360° 4K videos were selected and downloaded from YouTube. The first was a visit to the Eiffel Tower  Smart TV, with HDMI connection to the computer, so that the remaining, generally, five participants  could comprehend what the person testing  was seeing; two cameras for audio and video recording; chairs for the senior citizens that were observing; an armchair for the participant who was testing; a stationary bicycle; and a fan. The setup was arranged so that one researcher could conduct the experiment, while another could observe and take notes of the participants’ reactions. Nevertheless, the two cameras, located at strategic points, collected the audio and video of senior citizens who watched the experience and those who were experiencing it. One of the goals was also the senior citizens’ observation–participation in the whole activity , not only to prevent them from being afraid of testing, but also to encourage social interaction. In detail, the participants arrived in a group of approximately six, and while one participant at a time performed the experiments, the others watched on the Smart TV.The first phase of the experiment was based on the primary contact with VR, i.e., the adaptation to the use of HMD  in termsThe second phase was based on the cyclotourism experience  and lastSimilar to the first phase, a video of Paris’ suburbs was playing alongside the background music; however, a fan was included for air circulation because participants were putting on effort while pedaling. During this phase of the experiment, most of the participants shared their memories of the streets of Paris (those who had been there), similar cities, and their wishes to visit other places with VR technology. Moreover, they also encouraged each other before and throughout the experiment. Afterwards, all the participants filled out the questionnaire and suggested places for a future experiment.A questionnaire , based oThe questionnaire sections included sample characterization (containing questions about age and gender); whether participants ever visited Paris; and satisfaction of use related to the 360° VR experience, as demonstrated in the Data Collection column of The virtual reality experience was comfortable ’ adapted from ‘VR was comfortable to use’; (ii) Q3. ‘I enjoyed using virtual reality technology’ adapted from ‘I enjoy using VR’; (iii) Q4. ‘I had fun using virtual reality technology’ adapted from ‘I have fun when I use VR’; (iv) Q5. ‘My family and friends influenced me to use virtual reality’ adapted from ‘My family members think I should use VR and People who are friends and acquaintances have influence on my intention to use VR’; (v) Q6. ‘My caregivers encouraged me to use virtual reality’ adapted from ‘People who take care of me encourage me to use VR’; (vi) Q7. ‘Virtual reality can be a technology capable of improving my state of mind’ adapted from ‘VR is an efficient tool to raise my mood,’ and (vii) Q8. ‘In the future, I would like to use virtual reality to relax my mind’ adapted from ‘In the future, I intend to use the device for mental relaxation.’ Data collection items were simplified so that all participants could understand and respond. Seven out of the thirteen items were adapted from the Barsasella and colleagues’ questionnaire , and an The additional questions  complemented the study insofar as it was important to analyze the ease of being able to see the experience using the HMD (having the point of comparison of what was seen on the Smart TV), if these activities may foster social interactions, as well as if all the data referring to cyclotourism have pertinence in the combination of VR technology with this subject and target audience. Additionally, the participants’ caregivers (when applied) were interviewed—following an unstructured interview—to manifest their opinions not only on the overall experiment as assistive technology, but also on the immediate effects on the target audience. In detail, two central guiding questions were asked to all the caregivers based on: (i) “What is your opinion on the 360° VR cyclotouristic experience?” and (ii) “What were the immediate effects of this assistive technology on the participants’  wellbeing?”, both followed by prompts and probing questions for further elaboration and exposition on the responses. This unstructured interview lasted between 5 and 10 min and allowed the caregivers’ feedback. Moreover, data were collected through field notes, and data analysis resulted in two themes: (i) use of the technology , and (ii) effects of the experiment. Data collection questions were tested to measure internal consistency and correlation based on the hypothesis of a relation between each item. The data analysis questions were answered with the support of the questionnaire, participant observation, field notes, caregivers’ opinions, and the literature.A convenience sample was recruited by invitation email . n = 59) and 22% males (n = 17), as illustrated in n = 30) were institutionalized and it was their first outing since the beginning of the pandemic; 7% (n = 5) were illiterate; 8% (n = 6) had never ridden a bicycle or were afraid of riding one; 51% (n = 39) had physical impairments ; and finally, 72% (n = 55) had never been in Paris.The sample consisted of 76 senior citizens, with an average age of approximately 74 years old , 78% females  the outcomes. However, there was not such an influence on the experiment. Although gender may not be adequately represented in this study and there may be some member and gender bias, because some groups of participants were from the same institution, the researchers ensured that all participants expressed their opinions with the data collected from the questionnaire, the interaction between participants, researchers, and caregivers. In detail, the importance of ensuring individual opinions is because opinions may be influenced by the group, not reflecting what each participant felt about the experiment.Additionally, 15 caregivers  were interviewed (following a non-structured interview). Data were collected from 20 October to 17 November 2021 in 14 experiment sessions that were conducted with an average of 5 to 6 participants and at least 1 caregiver per session, as previously explained. Data triangulation from the different data sources  was performed to assure the validity of the research. After collecting the data, the participants’ perspectives and caregivers’ feedback gathered from the ongoing experiment  were divided into words, phrases, or sentences using open coding to be compiled in different categories according to the context and number of occurrences. Furthermore, the participants’ questionnaire responses were divided into variables. https://www.ibm.com/analytics/spss-statistics-software (15 January 2022).) and NVivo 1.5.1 ). To ensure code reliability, coding in each software was reviewed by the researchers of this study, so that the results could be more accurate. Regarding the quantitative approach, every statement value was coded . Furthermore, SPSS tests  were performed to safeguard the data collection consistency.Data analysis was performed using IBM SPSS Statistics 28.0.1.0  and doctoral program in Information and Communication in Digital Platforms (University of Aveiro and University of Porto) under the FCT (Fundação para a Ciência e Tecnologia) grant nr. 2020.04815.BD. Furthermore, it safeguarded: (a) the informed consent of the participants and their caregivers; (b) voluntary participation; (c) involvement of the research team in the process; (d) that the risks of participating in the study did not outweigh the risks associated with the participants’ wellbeing, and authorization of the recording and capture of images and audio for research purposes.To reassure voluntary participation, participants and/or their caregivers were given an informed consent form, which communicated the circumstances under which the study was carried out, the purpose of the research, potential risks and benefits, and the right to withdraw at any time and to refuse to answer any question. Researchers assured that all participants and/or their caregivers understood the terms of any agreement before taking part in the research project.Furthermore, the risks of participating in the study did not outweigh the risks associated with the participants’ daily lives, and the experimental procedures were closely followed and supervised by the research team and participants’ caregivers (when applied). Researchers also assured the confidentiality and the privacy of the data, because all participants were randomly identified with a P and a number, as well as ensured that the private information was not released elsewhere. When reporting the results, only the relevant information to the purpose of the study was written.Crossing data obtained from the results of each method had the purpose of answering the data analysis questions  to evaluMy family and friends influenced me to use virtual reality, and Q6, My caregivers encouraged me to use virtual reality, did not account many answers because these either did not apply to all the participants or the participants refused to answer. More specifically, 4% (n = 3) did not answer Q5, and 9% (n = 7) did not answer Q6. The percentages estimated for the total of participants were registered (n = 76), and the levels of completeness and internal consistency were measured using Cronbach’s alfa test with the level of completeness of 87% and reliability of 0.553. When performing the same test without the most unanswered item, Q6, mismatching participant’s context, the completeness raised to 95% and the reliability increased to 0.822.It is worth mentioning that Q5, n = 70) totally agreed that the virtual reality experience was easy to see (Q1), and only 4% (n = 3) considered it somewhat difficult or very difficult. These results answer the question What are the main aspects that affect participants’ condition of vision?, because visual impairments and lens fogging were an observed cause that interfered, mostly due to the use of masks for COVID-19 protection. Nevertheless, the HMD seems to be a wearable device capable of providing ‘easy-to-see’ images and video for most participants .Findings suggest that 92% of the participants (n = 71) agreed or totally agreed that the experience was comfortable with no nausea . Nevertheless, the remaining 7% (n = 5) did not find it natural, causing sickness or dizziness. Answers to the question What are the main aspects that influence participants’ discomfort and/or sickness? were found to be, essentially, the smothering sensation when using the HMD with a mask, vertigo syndrome (identified in some participants), and differences in light intensity.Regarding Q2, 93% (n = 71) totally agreed that it was a fun technology (Q4). The remaining 7% (n = 5) agreed that it was fun. According to the participants’ responses on the questionnaire, it was possible to consider VR an entertainment tool (answer to Is VR a useful tool for entertainment?), also being grounded with the following opinions:Although all the participants enjoyed using the VR technology (Q3), 93%  I really felt like I was there.”—P39“I’m ready for many more experiences like this.”—P72n = 67) and/or their caregivers  to participate in the VR experiment (Q5 and Q6). Participants reckoned on the ability of VR to their self-wellbeing state, because 6% (n = 4) would not like to use it to improve their state of mind (Q8), and 8% (n = 6) did not think the technology was capable of it (Q7).Moreover, it was possible to show that most of the participants were influenced by their family and friends  found VR to be a good way of doing tourism (Q9), because it was closely linked to their real tourist experience, as stated in the following sentences: Regarding “When I left I was even surprised to be in the room, it felt like I was there.”—P2“That’s exactly how you see the tower when you’re there. I want to go back there.”—P27“Just now I was in Paris and I’m already here.”—P54What are the main factors of using VR in cyclotourism that contribute to active and healthy ageing?, participants’ opinions on VR and cyclotourism to experience places in a safe way (Q10) and exercise (Q11), were gathered. Most (95%) of the participants (n = 72) agreed or totally agreed that combining VR with cyclotourism is safer than the actual cyclotourism activity; however, 3% (n = 2) stated that it was not a good form of exercise. Nevertheless, most of the participants’ opinions were similar to the following quotes:To answer “Oh cool… and I take the opportunity to exercise.”—P10“I don’t even like riding a bike, but this one is much more interesting.”—P16“It would be nice to have this at my home, it would be the perfect way to do some gymnastics. What a spin!”—P21“Being able to do this is very good for self-esteem.”—P45“I haven’t ridden a bike for 3 years. Really enjoyed.”—P61“This is good for exercising and physical therapy, it’s good for the legs.”—P62“I used to ride my bicycle a lot, it was good.”—P75Can VR enhance social interactions?, all the participants considered the whole experience to be a good way of fostering social interactions (Q12), whereas 7% (n = 5) did not feel that they wanted to share it with their family and friends (Q13). Most senior citizens had an encouraging attitude towards their group by sharing their experience when using the HMD and cheering while watching what others were seeing with the HMD on the Smart TV. Additionally, the majority of the participants tended to narrate or tell stories while they were experimenting.Regarding Overall, the experiment has benefited both the research and senior citizens’ wellbeing. Using 360° VR to perform cyclotourism was found to be suitable, because participants considered it easy and comfortable to see, closely linked to the tourism environment, and a secure way to visit places and exercise as a form of physical therapy or physical maintenance. Furthermore, the experiment contributed to social interactions, namely, through encouragement, sharing of the experience with friends and family, and storytelling.Based on the participants’ opinion of the global experience—collected with field notes—the NVivo word frequency tool was utilized to determine whether it was a positive experience. As p < 0.05 and ** p < 0.01. Interestingly, no relationship between having visited Paris and the questions of the VR experience was found. In contrast to possible speculation ascertaining that having been to Paris and already knowing the city could either negatively influence—because the participants could consider the experience far from reality—or positively influence—because they had the opportunity to revisit something they already knew, no relationship was verified. A Pearson’s correlation test was performed to observe if there was any linear relationship between the items from the questionnaire. Moreover, some differences concerning some items were found, with particular emphasis on the influence of family and friends in convincing older participants to try VR (Q5), as well as the older senior citizens feeling that the VR activities were an experience to share (Q13).r = 1.000) was found with the influence of family and friends on senior citizens’ participation in the activity (Q5) and the encouragement of their caregivers (Q6). Even though Regarding the correlation between the questionnaire’s items, a perfect positive relationship  shared their personal opinion on the overall experiment and its effects on the participants. When surveyed about the theme of technology use, they were impressed with the acceptance of the experiment by those psychologically affected , the more sedentary participants, and those with physical limitations. Such may be justified by the participation and encouragement of the group, but also by being able to watch what the participants were experiencing. Secondly, in the scope of the effects of the experiment, the caregivers reported that the whole activity was a boost to their self-esteem because participants were not only part of something that was a manifestation of interest by some, but also because their opinion was valued. Accordingly, they considered the experience a well-established assistive technology for senior citizens.Following such statements, in addition to camera recordings and field notes, it was possible to demonstrate that participants had a positive experience with 360° VR as assistive technology. Overall, their comments show enjoyment, nostalgia, and appreciation.This paper has presented contextual research on the applicability of VR with HMD as an assistive technology for tourism, cycling, and senior citizens’ usage. It proceeded with the complete process of structuring and performing a 360° VR cyclotouristic experience, and the main results and findings. In accordance with the initial expectation of the possibility that 360° VR could be a solution for assisting senior cyclotourism, it was possible to answer the research question “How can 360° VR foster senior citizens’ cyclotourism experience?”. By cross-referencing the literature with the participants’ opinions, it was found that the experiment was a reliable tool to promote an active lifestyle while encouraging a safe way to perform (cyclo) tourism and increase social behaviors.Based on the literature review, 360° VR tourism has the potential to be a resource to represent and immerse participants into real environments, whilst stimulating entertainment and engagement, sustainability, low-cost solutions, and information sharing. Such reports were noticeable in this study’s experiment because it enabled senior citizens to impersonate cyclotourists that travel and experience some of Paris, without physically leaving the laboratory site. Indeed, participants faced not only a sense of independence, but also engagement and immersion that intensified the credibility of the scenario . With thRegarding the simulation of cyclotourism with a stationary bicycle, it is a simpler form of conducting the experiment and it represents advantages in terms of independence, safety, and control of exercise, without having to be concerned about overcrowded locations, poor pavement conditions, and weather conditions. In fact, it was possible not only to replicate some of the cyclotourist movements within the research experience, such as the pedaling effect generated through the dynamics of the bicycle , and to As for the use of VR by senior citizens, it is alleged that it can promote general wellbeing by benefiting physical, cognitive, and psychosocial functions ,78, whicIn terms of results, it was possible to corroborate both hypotheses: (a) there are differences in younger and older senior citizens concerning the promotion of the touristic experience; and (b) social interaction and safety confidence in VR activities are key for senior citizens to have fun. In detail, even if, broadly, the experiment was considered good to foster senior cyclotourism, older participants tended to give greater importance to the fact that their friends, family, and caregivers encouraged them to use 360° VR, which contributed to the way they feel about the suitability of it to perform (cyclo) tourism to know places and exercise, share the experience, and use it in the future. Additionally, such encouragement may be seen as a strategy for social interactions and a sense of assuredness in using the technology and having fun with it.A stronger correlation of Q1 and Q2 with any other variables was expected, because it was easy to assume that visibility and comfort would affect—positively if visible and comfortable and negatively if not—the experience significantly; however, it did not occur. A positive correlation between Q3 and Q4 was expected; however, participants tended to find the experiment more enjoyable than fun. It was not anticipated that fun would have an association with VR being good to conduct tourism instead of correlating with sharing the activity. It was also predicted that if family and friends influenced participants, they would like to share with them (Q5 and Q13), but it was not anticipated that influence was so positive in the participants’ perception of VR being good (cyclo)tourism and safe exercise. In the same vein, it was considered that Q7 and Q8 would be correlated; however, this was not demonstrated. Q9 had the most correlations, which was also expected because VR seems to be a suitable tool to perform tourism. Nonetheless, the several positive correlations on the use of technology in cyclotourism safeness to know places, exercise, and socialize surpass the expectations.Thereby, the study reported in this paper corroborates the literature and related studies on VR tourism, cycling, and usage by senior citizens, having expected and unexpected results and findings. It set out to overcome the fact that 360° VR with HMD as an assistive technology applied to senior cyclotourism may not be deeply studied in academia, and it could be a valuable contribution to social science studies within wellbeing and behavior change towards an active and healthy ageing promotion. Furthermore, this research addresses the effectiveness of 360° VR with HMD and a simple setup to adhere to cyclotourism and foster safe conviviality between different profiles of senior citizens . Thus, it is possible to assume that 360° VR can foster cyclotourism due to its proximity to reality, its tendency to be an enjoyable and a fun technology, and its comfort when used in short periods . It also may serve as an assistive technology for senior citizens and disabled people not only to carry out tourism, but also as a rehabilitation and social interaction tool.The background research about VR evidences the potential of improving senior citizens’ wellbeing by promoting socially engaged states. However, even if VR studies have been progressively gaining interest and awareness—because it demonstrates possibilities for impacting human behavior, contributing to cognitive health, and for rehabilitation by simulating reality situations and/or tasks by providing greater motivation—assisting senior citizens’ independence, rehabilitating functional capabilities, and improving emotional and social wellbeing remain areas to be explored.In a nutshell, this study further extends the current knowledge on VR research by applying it to a new subject (assisting senior cyclotourism), providing positive affective-motivational states and satisfaction in 360° VR with HMD assistive experiment. It counts not only on the participants’ feedback, but also on their caregivers’ (when applied) opinions on the use of this experiment as an assistive technology, which seems able to aid cognitive, social, emotional, and physical improvement. It also contributes to tourism and active and healthy ageing research by empirically showing the reactions of senior citizens using VR technology, emphasizing their enjoyment, engagement and social interactions, and interest in cyclotourism. Additionally, the empirical methodology may allow a reliable and simple setup for different application subjects , decreasing the possible limitations related to experience customization, and surpassing the constraints of previous studies of VR and 360° VR.It is important to acknowledge the consideration of a few limitations for this research; therefore, the results must be interpreted with caution. Firstly, the subject of VR and 360° VR in the context of assistive technology in cyclotourism for active and healthy ageing is an unexplored topic, with the experience performed in this study being pioneering research. Secondly, a convenience sample was recruited; hence, attempts to generalize beyond these participants are not justified because the outcomes are not warranted. Thirdly, there may be some respondents’ bias in the results obtained, because each group of participants was from the same institute or were acquaintances. However, the researchers tried to ensure that all participants expressed their opinions of the experience, interpreting the outcomes based on the questionnaire’s responses and camera records. Finally, this study was performed during the COVID-19 outbreak, having the need to shorten the activity to comply with all safety and hygiene measures. This fact may have influenced the pragmatism of the experience, not allowing for greater social moments that could have improved its results.Regarding future work, a longitudinal study with longer periods of testing would be beneficial to sustain the obtained results; however, it is important to gather the conditions that allow the research to be carried out safely (concerning the pandemic and the target audience). Supplementary research needs to be carried out in the psychology field, to understand the use of VR as an assistive tool with other motivational technologies, such as gamification, while analyzing whether there is an impact on behavior change towards active and healthy ageing, as well as in the use and frequency of cyclotourism indoors and outdoors. Moreover, adding the VR component to exergames  or current cyclotourism and cycling apps would be beneficial to this research and probably a significant contribution to senior citizens, disabled and institutionalized people, and/or people incapable of riding a bicycle outside due to the pandemic, or psychological and/or physical limitations. Lastly, it is intended to improve the experience and incorporate gamification elements to foster storytelling, competition, and cooperation behaviors, as well as explore and analyze the immersion of senses in a profound way.


Police officers, firefighters, and paramedics are on the front lines of crises and emergencies, placing them at high risk of COVID-19 infection. A deeper understanding of the challenges facing first responders during the COVID-19 pandemic is necessary to better support this important workforce. We conducted semi-structured interviews with 21 first responders during the COVID-19 pandemic, asking about the impact of COVID-19. Data collected from our study interviews revealed that, despite large numbers of COVID-19 infections among the staff of police and fire departments, some—but not all—first responders were concerned about COVID-19. A similar divide existed within this group regarding whether or not to receive a COVID-19 vaccination. Many first responders reported frustration over COVID-19 information because of inconsistencies across sources, misinformation on social media, and the impact of politics. In addition, first responders described increased stress due to the COVID-19 pandemic caused by factors such as the fear of COVID exposure during emergency responses, concerns about infecting family members, and frustration surrounding new work policies. Our findings provide insight into the impact of COVID-19 on first responders and highlight the importance of providing resources for education about COVID-19 risks and vaccination, as well as for addressing first responders’ mental health and well-being. First responders, including police officers, firefighters, and emergency medical services (EMS) personnel, are essential workers required to interact with the public, and in the midst of the Coronavirus disease 2019 (COVID-19) pandemic, their work has become particularly visible. Often at the forefront of the pandemic, these first responders have a high risk of exposure to COVID-19-positive individuals in the course of their job duties. Due to this increased risk of exposure, research has shown that first responders have a three-fold higher rate of COVID-19 infection compared to members of the general population  going on and something that you know, we’ve never seen. I’ve never seen in my life before and it’s scary.”  Others, including some department leaders, stated they were unconcerned and noted that they did not think of COVID-19 as a public health crisis. A department leader with this contrasting view reflected, “I don’t know if I’m quite the right person to interview because I’m not worried about it one bit.I’m not really buying into it. And I kind of do my thing and if I get it, I get it.”  Additional representative quotations showing this variability in perspectives are listed in Despite the major impact of COVID-19 on their departments described by many PD and FD leaders, other interviewees had varied perspectives about COVID-19. Some first responders reported being very concerned about COVID-19. One police officer, for instance, expressed fear stating, “So, I think when you, when you look at the data, when you truly understand how the vaccine is made and what it does, I really, I had no issues, no hesitation of getting it.”  Others noted that they were not interested in getting the vaccine for reasons such as not trusting vaccine development and being afraid of side effects. A resistant police officer explained, “We are not planning on getting one.Well, I feel like it came out too fast. And there’s not enough known about it. I don’t get the flu shot either. I just don’t feel comfortable getting it. I don’t trust it. I’m not letting my kid get it.”  One police officer similarly expressed apprehension about the vaccine’s development by reflecting, “Mostly because it seemed like the process occurred pretty quickly.”  Another resistant police officer explained, “I had the whole COVID once and that was bad enough. And I’m like, the side effects I heard are pretty bad, but I just, I want more information before I get the vaccine.”  Additional representative quotations are presented in Similarly divided perspectives were found when interviewees were asked about COVID-19 vaccination. In this case, some interviewees clearly supported vaccination, such as a firefighter who shared, When first responders were asked about where they get information on or hear about COVID-19, the great majority of our interviewees expressed frustration about three things: (1) COVID-19 information was reportedly confusing and inconsistent; (2) misinformation was pervasive on social media; and (3) politics appeared to have an impact on the information that was being shared. Examples of these areas of frustration are discussed next, with additional representative quotations presented in “There’s so much information out there, you didn’t know what to believe. So, at that point, I literally had to quit watching the TV and quit reading stuff and just go with it.” Similarly, another police officer expressed confusion stating, “The inconsistency that you get from different entities, you know, you have Fauci saying one thing, the CDC saying another, and you know, doctors all over the place saying a myriad of different things.” First, interviewees expressed frustration around inconsistencies in information that was being shared about COVID-19. One police officer explained that they felt that COVID-19 information was difficult to understand because, “It’s easy for somebody to put something on the Internet, somebody to read it, and share it, and it gets shared 10,000 times. If that’s your social group, that’s all you’re going to see. I think social media, it is what it is. It’s a demon.”  A department leader similarly noted:“You get these conspiracy theorists, like I’ll give you a conspiracy theory. Somebody out on social media. It happened pretty early on and it was shared by a bunch of people mostly people that are extreme right. …It was just way out there, just kind of really, really out there, conspiracy theory… I saw that one a couple different times from people and it was just like ‘What are you people believing?’”First responders also emphasized their frustration about COVID-19 misinformation found on social media. A police officer explained, “I think that it’s hard, what you would deem genuine or real data or real information, because obviously it’s become politicized.”  Similarly, a paramedic commented, “So, I’ll be honest. I don’t give a damn what Dr. Fauci says. I don’t care what the Democrats say. I don’t care what the Republicans say. I just don’t give a [expletive] I am sick and tired of them all. It almost seems like every single one of them has got an agenda and I just don’t give a damn what it is.” The impact of politics on COVID-19 information being shared was a third source of frustration reported by first responders. One police officer explained, “I think the level of stress that healthcare workers, frontline, you know out in the community like me, as well as in the hospital, has gone up, oh man, hundreds of percentages. It’s taking its toll on a lot of people.”  Another paramedic reflected,“Our run volumes increased, the number of patients at the hospital has increased, the number of mental health patients that we run on at the fire department and at the hospital have significantly increased. And those are always stressful runs, right? You’ve got someone losing their mind but at the same time you don’t want them to hurt you. And it’s just the level of stress has significantly gone up.”Across interviews, a great majority of first responders acknowledged how the emergence of COVID-19 had increased their stress levels. Paramedics were particularly focused on the stress being faced by healthcare professionals. As one paramedic noted, Beyond the general increase in stress caused by performing their job duties during the COVID-19 pandemic, first responders across all roles also described three specific types of work-related stressors: (1) the risk of COVID-19 exposure during emergency responses; (2) concerns about passing a COVID-19 infection to family members; and (3) adapting to new work policies and procedures. More detailed examples of these sources of stress are discussed next, with additional representative quotations presented in “We can’t not go to something [an emergency call]. We have to go. So, it’s just an extra thing to put ourselves in the line of knowing we’re going out and dealing with people who potentially have COVID or are positive. It’s just an extra layer of stress on us.”  Similarly, a paramedic explained:“I have a job to do. Right? So, I just can’t stare at my patient and say I can’t help you because I’m afraid you’re going to give me COVID-19. That just, so I guess, I guess it’s kind of a risk-reward analysis that I take every time I’ve got a patient in the back of my squad. How big of a risk am I willing to take and what kind of a reward am I going to get? The reward is whether or not my patient gets better or gets worse.”First, comments made by interviewees underscored that many first responders were afraid of getting infected with COVID-19 while performing their job duties. One police officer noted, “I think the biggest thing is I’m just always worried about it. I was worried taking it home to my family members like some of the more high-risk people in my family or the baby at home.” Similarly, a paramedic commented, “Stress. You know, being worried about taking it home.”  Finally, a PD staff member reflected: “I think there’s been stress too for the people who have to be at work all the time. Am I going to get this and what’s it going to do to me and my family?” .Fear of passing COVID-19 to family members was also highlighted as a stressor for first responders. One police officer reflected, “The difficulty lies in the way we approach runs now, is especially if it’s a run that has some fever issues or some respiratory issues, we go in without our partner the first whoever is completely dressed goes in and kind of talks to the person initially by yourself. So, I think things slow down a little bit, that makes it more difficult because you know, we’re problem solvers and we like to solve things fast in the fire department world. So, we walk up, and I start talking to you, my partner starts checking vital signs and you know, we have a flow that we have, and it’s definitely slowed the flow of our work down. So, you know, that’s certainly a difficulty that we experience.”Third, many first responders emphasized that they experienced stress around adapting to new work policies and procedures during the pandemic. A paramedic explained:“We have to, you know, check our temperatures daily. There’s all the bull we have to go through daily, before we come to work. And then, when someone tests positive, then number one, there’s a whole trace, like going back on the trace and saying, ‘Were you in contact with them,’ and then that person has to get checked out for so long. Limiting the vacation times, so people, they’re getting kind of frustrated with that, and not being able to travel because if we go to a state where it’s over 15% [positivity rate] we are mandated to quarantine. And, we were having to use our own sick time for it. It’s just, you know, a lot of things going on with that aspect.” Similarly, a PD officer shared:The first responders we interviewed had varied perspectives about the COVID-19 pandemic, with some appearing to express little fear about the virus while others were quite concerned about both the possibility of becoming infected and exposing their family to the virus. Interestingly, first responder interviewees who did not perceive themselves to be personally at risk for COVID-19 spanned all age groups. This differs from the perspectives of the general public, where younger individuals perceive the risks of COVID-19 to be lower compared to older individuals .Our study also identified several barriers to first responders’ willingness to get a COVID-19 vaccine: the personal belief that COVID-19 infection does not pose a significant threat to oneself and/or others, mistrust of the vaccine development process, and fear of vaccine side effects. Of note, the innovative messenger ribonucleic acid (mRNA) technology used to make the first two available vaccines is one factor that allowed the COVID-19 vaccines to be developed and deployed in clinical trials so quickly, but it has also been a subject of misunderstanding and a target of conspiracy theories on social media . MoreoveThe context of the COVID-19 pandemic has also contributed to challenges in understanding and adapting to evolving COVID-19 messaging, concerns which were noted by the first responders we interviewed. In addition to confusion about the messaging from information sources such as the federal government around COVID-19 , inconsiThe pandemic-related fear, frustration, and stress expressed by first responders in our study is aligned with previous work that identified occupational issues of concern  ,3,9. OurOur study was limited to first responders working in one midwestern city; thus, the influence of any local, regional, and state health mandates and politics could not be considered. In addition, our study was not designed to explore potential differences related to role, age, or gender; thus, additional research to further understand the influences of these parameters on perceptions of first responders is warranted. Furthermore, this study did not include first responders who perform emergency services as volunteers in their communities. Additional research can be conducted to better inform our understanding of the perspectives of different types of first responders in the context of the COVID-19 pandemic.Our study shows that, not surprisingly, the COVID-19 pandemic has significantly impacted first responders. First responders we interviewed expressed varied views about COVID-19 infection and vaccination, and described fear about ongoing risk of exposure, frustration about COVID-19 misinformation, and added stress due to the ongoing pandemic. These results highlight the importance of providing education on the safety and efficacy of COVID-19 vaccines (including mRNA technology), clarification and consistency around COVID-19 guidance and prevention strategies, and resources to address chronic stress and mental health issues for first responders working throughout the COVID-19 pandemic, as well as of continuing study to inform our understanding of how to best help first responders perform their critical roles in our emergency response system.


Regarding intersex/DSD as a community sphere, there is a clear need of promoting education on sex and body diversity. With respect to the health sphere, it is mentioned the inadequacy of services and how this has a negative impact on the health of intersex/DSD people. Regarding the law sphere, it is highlighted the need of designing legislations at a national level which protect and defend the rights of intersex/DSD people. Regarding the psychosocial sphere, these people suffer from social isolation, secrecy, shame, self-identity questioning, and mental disorders that negatively impact their quality of life.Intersex/differences of sex development (DSD) conditions are divergences among genitalia, gonads, and chromosome patterns. These variances have been present for millennia and socially defined according to the cultural system established. The aim of this study is to describe the perspectives of adult intersex/DSD people, their relatives, and intersex/DSD expert professionals in Spain. A descriptive qualitative study design was adopted. The study was carried out in several locations in Spain. Individual in-depth interviews were conducted and addressed to 12 participants . A total of 4 spheres, 10 categories, and 26 subcategories were obtained. The number of verbatims obtained in each of the spheres described were intersex/DSD as a community ( Intersex/differences of sex development (DSD) variations involve the presence of discordances among the chromosomal, gonadal, and phenotypic sex determination criteria. These are originated during the process of sex determination in the foetal life, and involves multiple factors such as genetic variance, or secondary factors related to maternal or environmental influence, affecting both gonadal and genital development and originating ambiguity in sex genitalia ,2. InterAlthough the management of DSD remains controversial, as many experts consider bodily variations a manifestation of the diversity of the human being individualized and multidisciplinary care is necessary ,6.In relation to the incidence of intersex/DSD conditions, there can be observed a great complexity and discrepancy among the number of cases. According to Woodward and Burns , this raIn the international sphere, different legislations related to legal recognition of intersex people, as it is the case of Australia in March 2010, and Germany in 2013, allow the selection of a third choice for gender on birth certificates and passports. However, Spanish law requires the registration of newborns in one of the two sexes in the Civil Registry  ,10.Regarding international policies, several countries have different laws which prohibit, restrict, or condemn non-consensual surgeries and treatments to intersex/DSD minors, as it is the case of Malta and Chile, which passed these legislations in 2015, and Portugal in 2018. However, in Spain there are no laws for the time being in force relating to the rights of intersex/DSD people, but there are regional policies in 7 of the 17 autonomous communities in the country ,11. In tMental healthcare for children and parents can be highly helpful but may also be interpreted by a child as a message that something is wrong with them . BenneckRegarding intersexuality as part of the LGBT community, we must point out that in 2009, it was accepted to incorporate intersexuality, adopting the LGBTI sequence. However, not all intersex people agreed with that inclusion .The objective of the study is to describe the perceptions of intersex/DSD people, their relatives, and professional experts.A descriptive qualitative research design was used, and data were collected from February 2020 to November 2020. Such an approach can offer a rich description of a phenomenon about which little is known . FurtherA convenience sampling strategy was used to recruit 12 participants from several locations in Spain. Such a sampling strategy allows researchers to identify information-rich individuals within the phenomenon of interest by the virtue of their knowledge and experience . This stThe inclusion criteria were: In profile 1, intersex/DSD people: (a) age 18 or older, and (b) in one of the intersex/DSD categories according to the 2006 Chicago declaration  My compulsive drive was to have constant sexual intercourse, nymphomaniac? No, I didn’t feel pleasure, I just needed to reaffirm my feminine self”.Several of the intersex/DSD people participating in this study underwent genital surgical procedure, either gonadal or vaginoplasty. It is also observed that there are discrepancies in this profile and their relatives towards the defence or criminalization of these procedures in intersex/DSD minors. Detractors of surgical interventions point out the different negative consequences these procedures cause at physical and psychological levels. However, there is agreement among expert professionals, who strongly disapprove of minors undergoing surgical procedures without their own consent, as well as of the social implication in determining the application of these procedures.A_SIA: “[…] The question of gonadectomy is really serious, as well… at least in my case, because, of course, it has huge physical and psychological consequences”.F_HSC: “[…] I am positive I would do the same over and over, it is fantastic”.E_A: “[…] If it not consented to, when you are a baby and the like, I’m fully against. To me that is maiming and abuse. A total neglection of this person’s rights”.Regarding treatments and examinations in the health process, it is observed how the different profiles of participants denounce the degrading and humiliating treatment on the part of health professionals and indicate the infringement of fundamental right to privacy as well as the lack of medical monitoring during examinations.A_SIA: “[…] from examinations in which all the health professionals, all the gy-naecologists had to be there… students, rights? It’s outrageously humiliating and abusive […]”.F_SIA2: “[…] They wanted to experiment with our daughter, because the options we were given, they were all awful”.There is unanimity in the discourse of the different profiles when denouncing the lack of information among health professionals in relation to the intersex/DSD conditions, as well as the lack of updated treatments and discrimination in healthcare.A_SK: “[…] Most of the times, when I went to a doctor, I swear, they literally told me: “I studied this on my first year”. And then they googled it, right in front of me! Then is when you feel absolutely abandoned, like very… very… untended […]”.F_HSC: “[…] lack of knowledge on the part of nurses, on the part of those who keep medical histories… in this sense… feh… [sighs] really, really, really forsaken […] drug coverage, in the case of chronic patients… it should be covered by the hospital and not a magistral medicine which I have to order at the pharmacy and therefore subject to withholding taxes applied to me […]”.E_A: “[…] The biggest problem area professionals find in these cases is lack of knowledge […]”.Some discrepancies are observed in the participants’ discourses. Some of them denounce the immobility and non-compliance of the Spanish government with regards to surgeries performed on minors, whereas other participants reject those legislations.A_SIA: “[…] Why forcing a surgery on a child when there is nothing wrong to fix? You know what I mean? When there is no health issue and even when this health issues are going to appear precisely after the intervention, right? Affecting both physical and psychological health. Of course, this should be regulated because who if not is protecting them?”.F_HSC: “[…] I think it is an abomination to ban surgeries until adult stages and of course that these procedures are eliminated from the healthcare system […]”.Regarding the policies on the existence of a third gender category on health and law records besides man and woman, intersex/DSD people do not endorse the initiative, as they consider it a new way of classifying and discriminating their realities. However, among expert professionals, some discrepancies are observed in terms of the adequacy of implementing this category, as some professionals advocate for its erasure and others consider it a useful tool.A_SIA: “[…] There is a lot of social pressure and law urge to register a baby, when this is totally unnecessary”.E_E: “[…] Societies in which this is so well done, in which they have designed or included other checkboxes […] people who are other thing, nor men or women, and they are called something different… and there some others can fit, people who in a natural, nor artificial way, are born with a given sex but they do not feel comfortable with the gender in which that sex normally develops in our society […]”.It can be observed that there are different synergies among the discourses of intersex/DSD people, who declare to have found difficulties in establishing social relations, or even that they experimented different types of bullying, discrimination, or abuse.A_SK: “[…] Yes, I spent 14 years without a single friend, and that caused me… well… not a single friend because I was bullied at school […]”.A_SIA: “But the first years were of complete isolation, it is exactly that, isolation […]”.Intersex/DSD people declare to currently have or have had periods of difficult relations with their relatives. This is due to the stress situation within the family.A_SIA: “It affected us all very deeply. I think any of us couldn’t cope or manage. My mother didn’t know how… and… well, I think that my family used to stuck away all what was overwhelming, to make as if something didn’t exist, so maybe it would go away […]”.A_HSC: “[…] the relationship with your parents, well I speak for myself, in my own experience, it was awful, really, one of the biggest problems I’m facing now is to forgive [quotation marks] what I blame them for, because, on top of that, we had family conflicts when living together”.Regarding sex life and relationships, it is observed that it is one of intersex/DSD people’s major concerns. The rejection of their condition and low self-esteem, produce difficulties in establishing couple relationships.A_SK: “[…] But I have experienced that before getting married and being with girls… Having a coffee or whatever, telling any girl my story… and they simply dis-appeared, just like that. It’s hard… really… really hard […]”.F_SIA2: “[…] Then we clashed sometimes… there were frictions when I started to get angry with my doctor and I didn’t want him anymore”.Some synergies can be observed among the discourses of the different participant profiles, which indicate how intersex/DSD involves limitations in the work dynamics.A_HSC: “[…] I was making some slips in the professional field, I started to have problems, became a recluse sort of woman”.F_HSC: “[…] It means a lot of boundaries in your life, your work, I had to schedule and organize drug intakes… I travel a lot… I lead a department… so, at a professional level… phew… that’s crazy”.Similar discourses are identified among the different profiles of participants, expressing how intersexuality/DSD creates a climate of secrecy that prevents sharing their condition with relatives, which affects family dynamics.F_HSC: “[…] It was extremely hard, a lot of money, dedication and struggling… Hmm… I don’t know how to explain it… a lot of effort”.Similar feelings are identified among the different participant profiles. It is observed disbelief and even difficulties in processing the information. With respect to their relatives, they experience shock situations and even rejection of this reality.F_HSC: “[…] Everything fell apart […] it was horrible, the first days were a huge shock […] at the beginning, I don’t know… even rejected the girl, a little”.F_SIA2: “[…] It was a tremendous blow […] Then, damn… it was like beating one’s head against the wall […]”.All intersex/DSD people interviewed showed a similar discourse and indicated to have experienced low self-esteem, rejection, and shame towards their own bodies and may suffer from dissociative disorders to cope with the stress of having to fit into the man/woman dichotomy culturally imposed.A_SK: “[…] it was… a really hard process, really, a process… of learning and acceptance in the first place […]”.A_SIA: “[…] there were like two versions of myself, an external one who pretended to be happy, as I was a normal woman, right? As it should be, and then, internally, I was someone who trusted no one, feeling ashamed of myself, and feeling deeply rejected […]”.It is observed how the discourses of both intersex/DSD people and their families denounce the lack of knowledge and visibility of these conditions in society, the latter sometimes encouraged by health professionals who argue that the outreach could also prompt a backlash against the emotional stability of people with these conditions. However, this scenario creates situations of social isolation.A_HSC: “[…] 98% of the population is completely unaware or they have no idea of it”.E_PSIA: “[…] I have a strong phobia of someone finding out that”.FAMSIA2: “[…] The first thing the doctor said was that we have to hide it and not telling family or friends about it, not telling anyone because it may cause harm. Every-thing was about hiding and hiding […] We’ve been hiding it all this time”.In the discourses of intersex/DSD people, it can be also identified how they suffer besides symptomatology and pathologies associated to their conditions—a denial of their masculinity and femininity.A_SIA: “[…] what I felt is that, if I revealed my secret, it would be impossible for me to be with a man, because I considered myself heterosexual, ok? … so, accepting me without having a functional vagina, mmh… I lived like that and that was the only option I had all those years […] but it seems to me that what women’s pleasure or desire don’t matter, right? The only thing that matters is to be normal and able to satisfy… to be a penetrable body […]”.A_SK: “[…] Immediately, most of the population links inability to reproduce with sexual incapacity or non-performance. So, in the end they say: “This guy is a eunuch”, and it has happened to me, they have said that to my face and it is very hard […]”.From different profiles, the suggested improvements in the care approach include the urgency of having multidisciplinary teams, educational campaigns for health professionals, and larger number of services.It is observed in the different discourses the need of promoting measures to foster social visibility and enlarging the presence of psychologists and mental health professionals in the health approach.Participants declare their need and aspiration to implement legislation in Spain related to the rights of intersex people, with the aim of guaranteeing sanctions for actions that violate the rights of people, such as surgical interventions on intersex/DSD minors.A_ST: “[…] It will be very interesting to have a multidisciplinary team which included a mental health team […]”.E_A: “[…] In my opinion there is a huge lack of health protocols after diagnosis and a lot to be done about terminology for each specific case […]”.E_E: “[…] It is necessary to train… nurses, doctors… in the treatment, in concepts that, after all, are social constructs, so we can dispel prejudices, right? Also, regarding patient care […]”.A_SK: “[…] Everything should be more supportive… culturally, socially, educationally, and from a health perspective so… so we can be part of society […]”.F_SIA1: “Social and educational visibility of the existence of body/genital sex characteristics different from the extreme masculine-feminine”.E_J: “[…] Hence the importance of providing visibilization of intersex people, pointing out that still today we are consenting to serious violations of human rights in the case of intersex people […]”.F_SIA1: “The reality of intersex people does not exist in the national registers by law […] it must exist in the register law of this reality”.This study detects a lack of information in the different groups. In this sense, García-Dauder et al.  stated tThere are some synergies with the study by Machado et al. , which iThere is a social and family secrecy about intersex/DSD people, which causes late diagnosis detection. With respect to healthcare, it is highlighted the lack of sensitivity and empathy on the part of health professionals in the communication of diagnosis, their lack of knowledge regarding these realities, the scarce number of multidisciplinary teams, and the absence of an adequate healthcare process, which is currently marked by lack of intimacy and exhibitions during medical examinations and other considered of interest in terms of psychological health. These findings are consistent with the results obtained in the studies by Gregori  and GregIn addition, some intersex/DSD people relatives express regret after applying surgical procedures, which coincides with other studies such as those by Lorenzo et al.  and RoenAfter birth, families of babies with ambiguous genitalia experience stress towards the obligation of registering the baby within the dichotomous classification of sex in the Spanish Civil Registry. However, as the studies by Gregori  and LaurRegarding the social sphere, it is revealed how the need of hiding and the feeling of guilt on the part of relatives towards intersex/DSD people produce a negative impact on family relations. In addition, intersex/DSD people may suffer from different forms of bullying, discrimination, or abuse, as well as difficulties to establish social or partner relationships. This is mainly due to the fear intersex/DSD people experience towards the rejection of their condition and the presence of low self-esteem, body shame, and rejection, and even dissociative disorders when facing the need of belonging to the woman/man dichotomy established by rigid, heteronormative systems that reject body diversity and constantly depreciate intersex/DSD people’s femininity/masculinity. All this pressure leads to the need of constantly pursuing the established standards of what is considered man or woman ,32,33.Additionally, it is observed how the presence of isolation behaviours and mental disorders associated to the different syndromes may cause alterations in the work dynamics of intersex/DSD people ,34.With respect to their families, their members may present a major psychological impact after the diagnosis of the intersex/DSD condition, resulting in the lack of free time and disruption in family and work dynamics .The need of providing psychological support to build self-esteem, eliminate stigmatizing images, and redefine the notion of normality is observed ,15,28.Phenomenology intrudes on people’s private worlds, so trust can be a limiting factor, especially if participants are talking about sensitive information .As a result of the COVID-19 pandemic, interviews were conducted online and over the phone, making it difficult to interact with the other person, which would be more possible in a face-to-face interview.Regarding intersex/DSD as a community field, there is a clear need to promote information and education on sexual and bodily diversity. The inclusion of intersex/DSD people within the LGBT community presents some discrepancies among the participants, since not all are represented in it.With respect to the health sphere, there is a late detection of the diagnosis due to family secrecy. Professionals are required to have adequate training and awareness to care for intersex/DSD people. A holistic, patient-centered approach is needed to decrease health risk behaviors. Discrepancies are detected regarding the suitability of surgical procedures.In the law sphere, the need to design legislation in Spain that protects and defends the rights of intersex/DSD people are highlighted, thus complying with the criteria established by international organizations.Regarding the psychosocial sphere, family relationships are affected by the feeling of guilt of relatives. Likewise, couple, work, and social relationships are affected by the harassment, discrimination, or abuse that these people may suffer. The strict social norms related to male/female stereotypes have a negative influence. Intersex/DSD people experience social isolation, secrecy, shame, questioning of their own identity, and mental disorders that diminish their quality of life. It is necessary to provide adequate psychological support. This study has contributed to identify relevant aspects about the approach and influence of intersex/DSD in the different profiles involved. These findings can be used as a foundation in future studies which may establish prospective research areas while visibilizing the realities and demands of intersex/DSD people among health professionals, with the aim of improving the healthcare provided to these people and their families.