|Year : 2021 | Volume
| Issue : 4 | Page : 59-64
Knowledge, attitude, and practices regarding the use of mask among healthcare workers during coronavirus disease 2019 pandemic: A questionnaire-based survey
Heena Garg, Shailendra Kumar, Yudhyavir Singh, Puneet Khanna, Anjan Trikha, Rajeshwari Subramaniam
Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi, India
|Date of Submission||25-Jun-2021|
|Date of Decision||30-Aug-2021|
|Date of Acceptance||19-Sep-2021|
|Date of Web Publication||29-Nov-2021|
Assistant Professor, Anesthesiology, Critical Care and Pain Medicine. Room No-322a, JPNATC, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Background and Aims: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a large number of healthcare workers (HCW) getting infected, making it difficult to sustain uninterrupted and quality healthcare services. Using a mask is the minimum standard of care to prevent the spread of infection. Recently, the World Health Organization (WHO) has added airborne spread as an important mode of spread of COVID-19. The aim of this survey study was to assess the awareness about the use and reuse of masks for infection control practices among HCWs during the ongoing pandemic. Materials and Methods: A questionnaire-based survey on the awareness, knowledge, and practices related to the use of masks in COVID-19 infection in the healthcare setting was circulated through E-mail to medical and paramedical staff. A convenient sampling method was used for data collection, and the distribution of responses was presented as frequencies and percentages. Descriptive statistics were performed for all groups and subgroups based on the responses. Results: The survey sent to 1000 HCWs but only 394 responses (response rate 39.4%) were obtained. N95 was used by 282 (71.57%) personnel, surgical mask in 99 (25.12%) workers, cloth mask 11 (2.79%), and no mask in 2 (0.05%) HCW. Two hundred and eighty (71.07%) HCWs were reusing the mask. However, only 150 out of 280 subjects (53.57%) were correctly reusing the mask. Conclusion: Although universal masking was present in our study population, the awareness about the correct practice of reuse was limited. Since the pandemic is not going to settle any time soon and we might get short on existing supplies, it is vital that the HCWs need to be trained for the correct reuse and more efficient ways of reuse need to be explored.
Keywords: Coronavirus, coronavirus disease 2019, mask, N95, protection, reuse
|How to cite this article:|
Garg H, Kumar S, Singh Y, Khanna P, Trikha A, Subramaniam R. Knowledge, attitude, and practices regarding the use of mask among healthcare workers during coronavirus disease 2019 pandemic: A questionnaire-based survey. Saudi Crit Care J 2021;5:59-64
|How to cite this URL:|
Garg H, Kumar S, Singh Y, Khanna P, Trikha A, Subramaniam R. Knowledge, attitude, and practices regarding the use of mask among healthcare workers during coronavirus disease 2019 pandemic: A questionnaire-based survey. Saudi Crit Care J [serial online] 2021 [cited 2022 May 19];5:59-64. Available from: https://www.sccj-sa.org/text.asp?2021/5/4/59/331513
| Introduction|| |
Coronavirus disease 2019 (COVID-19) has affected millions of people around the globe, and the health care resources and workers have been overwhelmed by the influx of patients. After affecting numerous other countries, the virus is now tightening its grip in India as well. The number of COVID-19 cases in India has reached up to 5 million with more than 75,000 deaths. As the pandemic has progressed, a large number of healthcare workers (HCWs) are getting infected as well as succumbing to COVID-19. The World Health Organization (WHO) in its media briefing stated that 10% of global infections account for those in HCWs.
As we are learning more and more about the modes of spread, it is becoming evident that checking the spread of droplet infection is important in containing the viral transmission. While the use of personal protective equipment and hand washing cannot be overemphasized, the minimum basic protection with a mask is imperative.
While some HCWs are involved in direct care and contact of COVID-positive patients in designated centers, others are catering to the other essential services in non-COVID areas. The type of mask that needs to be used is different in different areas. The debate about which mask to use and when to use has been going on since a long time now.
The aim of this study was to assess the knowledge, attitude, and practices related to the use of masks during this COVID-19 pandemic in doctors and paramedical fraternity in the Indian health care settings.
| Materials and Methods|| |
This prospective cross-sectional survey study was conducted by the team of doctors of AIIMS, New Delhi, after approval by the Institute Ethics Committee, AIIMS, New Delhi (IES-368/08.05.2020) in the month of June 2020 (over 1-month period). The study participants included doctors, nurses, health technical staff, and medical students.
A questionnaire-based survey was taken up on the awareness, knowledge, and use of masks related to COVID-19 infection in the healthcare settings. The questionnaire was developed according to the guidelines of the WHO, Indian Council of Medical Research, and the Centre of Disease Control and consisted of two parts: (1) Basic demographic characteristics (age, gender, job designation, workplace), and (2) knowledge, attitude, and practices regarding the use of mask to limit COVID-19 exposure. A consent was added to the survey as an additional question before starting the survey.
The electronic mail database was obtained from the association and organizations of our institute (doctors, nurses, technical staff, and student's body) with the assurance of using the database solely for the intended survey and keeping the private information confidential. An E-mail invitation was sent to complete an electronic form of the survey (http://www.docs.google.com) to various HCWs in India. The responses were collected by a person designated to collect the responses and check the completion of the form.
Sample size and statistical analysis
According to a report by the WHO in 2016, the total health workforce of India comprises of 2,069,540 HCWs, based on the census of 2011. Therefore, for accurately estimating the study population needed for this survey, a convenient sampling method was used to derive the sample size. Ho reported 52% correct use of mask in a primary care outpatients' setting. Thus, assuming 50% awareness regarding correct use of mask among HCWs, a sample size of 384 was calculated with 95% confidence interval and 5% margin of error. For an expected response rate of 40%, the number of individuals that need to be invited to participate in the survey comes out to be 960. Therefore, a total of 1000 HCW were invited for the survey after selecting E-mail by computer generated sequence.
The distribution of responses is presented as frequencies and percentages. Descriptive statistics were performed for all groups and subgroups. The data were analyzed using SPSS software (Texas 77845, USA, version 14.0) and Microsoft Excel. The proportions were compared using the Chi-square test. A P < 0.05 with confidence interval of 95% was considered statistically significant.
| Results|| |
Descriptions and demographics
The survey sent to 1000 HCWs through E-mail, of which a total of 405 responses were obtained. The overall response rate was 40.5%. Out of these, 11 incomplete entries were removed, and the total surveys for statistical analysis were 394 (total response rate 39.4%). Out of the total 394 respondents, 222 (56.34%) were males and 172 (43.65%) were females. The major response contribution was from 299 doctors (75.8%) followed by 37 technical staff (9.39%), 36 medical students (9.13%) and 22 nursing officers (5.58%). The results are tabulated in [Table 1]. The age group of 20–35 years included 297 responders (75.38%), 35–50 years had 81 responders (20.56%), 50–65 years had 14 responses (3.55%) and 2 responses were received from the age group of >65 years (0.51%).
Two hundred and ninety-five (74.87%) responders were working in a government institute out of which 2 were working in a primary health care setting, 24 in community health center and 269 in a tertiary care institute. Out of the total, the health personnel working in a private sector were 99 (25.12%). The maximum response was elicited from 140 (35.53%) of HCW who were working in operation theater (OT) complex. This was followed by 64 (16.24%) respondents who were working in non-COVID intensive care units (ICU). Around 50 (12.69%) HCW were working in COVID suspect or positive areas, 52 (13.19%) in non-COVID wards and 41 (10.4%) in outpatient clinics (outpatient department [OPD]).
Type of mask use
The primary masks used were N95 by 282 (71.57%) personnel, followed by surgical masks in 99 (25.12%) workers. Cloth mask was used by 11 (2.79%) responders. Two (0.05%) people responded as to not wearing a mask. One personnel was using an N99 mask, and one was using an filtering face-piece (FFP) 1 mask [Figure 1]. On subgroup analysis, it was found that the maximum use of N95 was in COVID suspect area (45/50; 90%). One person was using an N99 mask in COVID area. The next higher use was found in the OT area, where 116 out of 140 respondents used N95 masks (82.85%). This was followed by ICU (49/64; 75.56%), emergency area (16/28; 57.14%), and ward (25/52; 48.07%).
Mask use in government and private sector is depicted in [Table 2]. Surgical masks were used in 64 individuals (21.69%) and 33 individuals (47.82%) in government and private sector, respectively. N95 use constituted 220 (74.57%) respondents in government and 62 (62.62%) individuals in the private sector. Cloth mask was used by 8 (2.7%) individuals in government health care settings and by 3 (3.03%) in private hospitals.
Out of the total 394 responders, 280 (71.07%) were reusing the mask. The workplace distribution of reusing the mask is depicted in [Figure 2]. The reusing methods included reusing after 4–5 days in 150 subjects (53.57%). 32 (11.43%) subjects reused the mask after air-drying and 47 (16.78%) after sun drying. Other methods included cleaning with 70% ethanol for 16 (5.71%) responders, washing with soap and water for 30 (10.71%) of the total. Three personnel (1.07%) were sterilizing the mask using ethylene oxide (ETO). One was using plasma therapy and one microwave sterilization (0.35%) [Figure 3].
|Figure 3: Methods used for reusing the mask in government and private hospitals. Calculated using chi-square test. *Z- test used for variables having “zero” variables|
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The reuse of masks was compared in males and females. A total of 151 males out of 222 (68.1%) reused the masks. In females, 129 out of 172 (75%) reused the masks (Chi-square = 2.297; P = 0.129). The use of masks was compared in the private and government sector. The different masks used in both the sectors are compared in [Table 2]. It was found that 62 out of 99 (62.62%) in the private sector and 218 out of 295 (73.89%) in the government sector were reusing the mask (Pearson Chi-square value = 4.5803; P = 0.032) [Table 2].
| Discussion|| |
The novel COVID-19 initially emerged during December 2019 in Wuhan, China, and was declared a pandemic by the WHO on March 11, 2020. The virus has crusaded the entire world and has infected over 30 million people and 9,00,000 fatalities in over 200 countries. In India itself, the disease is spreading at an alarming rate with the confirmed cases crossing 5 million mark, and the number of deaths has edged to around more than 75,000. As more and more HCWs are getting infected with coronavirus, the use of masks has become a necessity in these times of COVID-19 pandemic.
Our study aimed to assess the use of masks in the HCWs and evaluate the type of mask used in different health care settings. We also aimed to assess the reuse practices of the mask and its disinfection. The survey was completed by a total of 394 responders. This satisfied the sample size criteria. This was an E-mail-based survey study due to the ongoing COVID pandemic. Our survey achieved a response rate of 39.4% through an electronic mail platform. The published literature for the observed response rate with web-based surveys is approximately 25%–30% response. Another study observed the response rate among physicians for web-based surveys to be around 35%.
Various possible mechanisms have been postulated for person-to-person transmission of coronavirus. The major mechanism implicated is atomization of virus-bearing particles due to coughing or sneezing. Atomization can also occur during normal respiration or talking by an infected person. Virus transmission occurs via airborne route as well as through fomites. Inhaled virus-bearing aerosols deposit directly along the human respiratory tract.,
Masks are meant to not only protect the wearer it also helps in protecting the environment from the wearer. The use of masks in a densely populated country like ours cannot be overemphasized. In HCWs, masks play a pivotal role in protection from infection. The WHO has, in a recent scientific brief, acknowledged the airborne transmission of the virus in indoor crowded spaces have suggested the possibility of aerosol transmission, combined with droplet transmission. The WHO has advocated the use of fabric mask for the general public and continuous use of a medical/surgical mask by health workers and caregivers working in all clinical areas during all routine activities throughout the entire shift.
Medical masks are defined as surgical or procedure masks that are flat or pleated. Universal masking in health facilities is defined as the requirement to wear a mask by all HCWs and anyone entering the facility regardless of the activities undertaken. Targeted continuous medical mask use is the practice of wearing a medical mask by all HCWs and caregivers working in clinical areas during all routine activities throughout the entire shift. Masks are only changed if they become soiled, wet, or damaged or if removed for eating or drinking.
Universal masking was found in our respondents where 392 out of 394 persons (99.5%) were adhering to the mask guidelines. The two persons not wearing a mask were working in OPD and laboratory areas. This included one medical student in OPD and one laboratory technician. However, 11 of our respondents, despite working in the hospital premises were using cloth masks (2.8%). These included four each in OPD and laboratory, two in ward, and one in emergency. The subgroups constituted nine doctors and two medical students, three in the private sector and eight in the government sector. This can be attributed to nonavailability or being uncomfortable to adjust to the routine use of a surgical mask or respirators. Moreover, though a cloth mask is better than no mask at all, it is not recommended in health care settings.
A higher response rate was elicited from the age group of 20 to 35 years (75.38%). This could be due to more familiarity with the online digital platforms. Chu et al. in a meta-analysis of 44 studies found that the use of masks protects both HCWs and the general public against infection by these coronaviruses. The use of both N95 or similar respirators or face masks by those exposed to infected individuals was associated with a large reduction in risk of infection (AR 3·1% with face mask vs. 17·4% with no face mask) across 29 studies. The association with protection from infection was more pronounced with N95 or similar respirators (adjusted odds ratio [aOR] 0·04, 95% confidence of interval [CI] 0.004–0.30) compared with other masks in HCWs (aOR 0·33, 95% CI 0.17–0.61) especially with aerosol-generating procedures (AGP). While N95 had a stronger protective association compared with surgical masks or 12–16-layer cotton masks, both N95 and surgical masks also had a stronger association with protection versus single-layer masks. This is consistent with our study where the use of N95 was associated maximum with OTs and ICU where the incidence of AGP is high.
When distribution in the government and private sector was compared, it was found that the use of surgical masks was higher in the private sector (47.82% vs. 21.69% P = 0.03). The use of N95 was found to be higher in the government sector (74.57% vs. 62.62% P = 0.02). There was no statistically significant difference in the use of cloth masks (2.7% vs. 3.03% P = 0.08) in government and private sector, respectively. The difference in the use of N95 and surgical mask could be due to decreased theater and ICU load in the private sector. Furthermore, the majority COVID suspects were being catered by the government hospitals mandating the use of N95 initially.
In times of pandemic, when a significant crunch can occur on the already exhausted medical system, it is mandatory to understand the importance of use of correct masks in the workplace setting and the reuse of masks. On March 19, 2020, the WHO confirmed that “The current global stockpile of personnel protective equipment (PPE) is insufficient, particularly for medical masks and respirators.” Going by the technical standards, the N95 respirators or medical face masks are single-use since they are heat sensitive and are not designed to undergo sterilization processes and manufacturers initially advised against the sterilization process. However, due to the shortage of these masks caused by the COVID-19 crisis, manufacturers, governments, and related agencies and institutions began to analyze the reuse, disinfection, or sterilization of PPE. We analyzed the incidence of reuse of masks in our survey responders. It was found that 280 out of 394 (71.06%) respondents were reusing the mask. This is crucial in these times when the number of cases has begun to escalate. Reusing the mask is a beneficial exercise creating a positive economic impact and helping us avert the scenario of shortage of PPE.
It was found that the incidence of reuse was higher in the government sector when compared to the private sector (73.89% vs. 62.62%; P = 0.032). This can be due to the disparity between the availability of funds and cost bearing transferred to the patient in the private sector. The reuse was higher in smaller hospitals (<100 bedded) as compared to the bigger hospitals in the private sector (100–300 and >300 bedded) (24/33; 72.72% vs. 38/66; 57.58%). This, however, did not achieve a statistically significant value (Chi-square = 2.157; P = 0.14). This can again be attributed to the disparity in the resource availability.
To reuse the FFP respirators, the US government recommended that each HCW receives five FFP respirators and uses one per day in a specific order. The FFP respirator must be kept in a breathable paper bag and stored by order of use. In our survey, the reusing method after 4–5 days was used by 150 subjects (53.57%). When compared the reuse in government and private sector, 119 out of 218 (54.58%) and 31 out of 62 (50%) were reusing the mask with the same technique. This, however, did not achieve a statistically significant difference (P = 0.52).
However, if there is a shortage, five FFP respirators may not be available per HCW. Therefore, it is necessary to study disinfection or sterilization methods for extended use of the masks. We asked our respondents about the different methods they used for reusing the mask. This included sun drying (16.78%), air-drying (11.43%), use of ethanol (5.71%), washing with soap and water (10.71%), ETO (1.07%), and microwave and plasma irradiation (0.35% each). The methods used were commonly household measures on an individual basis. Only four respondents were using hospital based sterilization procedures which included ETO and plasma sterilization (2.19%).
Decontamination might cause poorer fit, filtration efficiency, and breathability of disposable FFP respirators as a result of changes to the filtering material, straps, nose bridge material, or strap attachments of the FFP respirators. While decontamination and reuse are not consistent with approved usage, this option may need to be considered when shortages exist.
While washing with soap and detergent and sun drying are suitable methods for cloth masks, these are not the recommended methods for medical masks and respirators. The use of 70% ethanol is also not recommended since it eliminates the electrostatic retention of the mask fibers, reducing filtration capacity by 95%. In addition, washing with soapy water can also affect the electrostatic properties of the fibers or even deform the mask.
ETO, ionizing radiation, microwave, high-temperature air drying, autoclave, or steam have also not been recommended for the respirators since they can significantly degrade the filter, either because they alter the electrostatic properties of the filter fibers, affect particle penetration levels, or deform the FFP respirator leading to FFP respirator degradation. The use of ETO, which is widespread in hospitals, is less safe than hydrogen peroxide vaporization and less environmentally friendly., Sunlight, though carrying ultraviolet (UV) light effective against many microbes, it does not carry a sufficient amount of UV-C light which can be effective against the severe acute respiratory syndrome coronavirus 2 virus, as it is blocked by the ozone layer.
We found that the awareness about the reuse of masks was low in HCWs with many of them resorting to methods which were not standardized or even decreased the efficacy of mask manifolds. The sensitization was even lower in the private sector, where there was statistically significant higher use of 70% ethanol (P = 0.03) and washing with soap and water (P = 0.04) of the N95 masks.
Other methods which can be used include H2O2 hydrogen peroxide, chlorine dioxide, bleach, ozone decontamination, UV rays, and gamma irradiation. These were not used by our respondents and the use of these have still not reached widespread levels at a national level and have not been approved. More efficient and viable methods need to be explored for reusing the masks considering the coronavirus is going to linger on, and more masks will be needed by the workforce in the near future.
The survey study has its own limitations. In such a pandemic time, it was difficult to go for traditional methods of survey such as paper surveys and face-to-face interviews which resulted in a low response rate. The authenticity of the respondent answering the question remains. There was limited response from the private sector. This can be due to the limited functioning and dramatically decreased patient load in the private sector due to the pandemic. Furthermore, the response was lesser from paramedical staff. This may be due to nonfamiliarity of the respondents to using the Google forms to fill the survey, which indicated lack of digital knowledge.
| Conclusion|| |
Universal masking though adhered to in our study population; the knowledge and resources for reuse need to be upgraded. It is vital in these times to use masks correctly and emphasize on their reuse in health care settings given that the pandemic is not going to settle any time soon, and we might get short on existing supplies of PPE. The medical workers need to be trained not only for using the mask correctly but also for the correct reuse. Policies and ways to effectively reuse the masks need to be worked on by the health agencies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM 2020;113:707-12.
Mhango M, Dzo bo M, Chitungo I, Dzinamarira T. COVID-19 risk factors among health workers: A rapid review. Saf Health Work 2020;11:262-5.
Lewis D. Is the coronavirus airborne? Experts can't agree. Nature 2020;580:175.
Esposito S, Principi N, Leung CC, Migliori GB. Universal use of face masks for success against COVID-19: evidence and implications for prevention policies. European Respiratory Journal. 2020;55.
Ho HS. Use of face masks in a primary care outpatient setting in Hong Kong: Knowledge, attitudes and practices. Public Health 2012;126:1001-6.
Yun GW, Trumbo CW. Comparative response to a survey executed by post, e-mail, & web form. Journal of computer-mediated communication. 2000;6:JCMC613.
Cunningham CT, Quan H, Hemmelgarn B, Noseworthy T, Beck CA, Dixon E, et al
. Exploring physician specialist response rates to web-based surveys. BMC Med Res Methodol 2015;15:32.
Morawska L, Cao J. Airborne transmission of SARS-CoV-2: The world should face the reality. Environ Int 2020;139:105730.
Zhang R, Li Y, Zhang AL, Wang Y, Molina MJ. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proc Natl Acad Sci U S A 2020;117:14857-63.
Lai AC, Poon CK, Cheung AC. Effectiveness of facemasks to reduce exposure hazards for airborne infections among general populations. J R Soc Interface 2012;9:938-48.
World Health Organization. Transmission of SARS-CoV-2: implications for infection prevention precautions: scientific brief, 09 July 2020. World Health Organization; 2020.
World Health Organization. Advice on the use of masks in the context of COVID-19: interim guidance, 5 June 2020. World Health Organization; 2020.
MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai AA, et al
. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577.
Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, et al
. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. Lancet 2020;395:1973-87.
Nilakantam S, Kishor M, Dayananda M, Shree A. Novel coronavirus-19 pandemic impact on private health-care services with special focus on factors determining its utilization: Indian scenario. Int J Health Allied Sci 2020;9:77-80. [Full text]
World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages: interim guidance, 6 April 2020. World Health Organization; 2020.
Bhattacharya S, Hossain MM, Singh A. Addressing the shortage of personal protective equipment during the COVID-19 pandemic in India-A public health perspective. AIMS Public Health 2020;7:223-7.
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review. PLoS Med 2012;9:e1001244.
Rubio-Romero JC, Pardo-Ferreira MD, Torrecilla-García JA, Calero-Castro S. Disposable masks: Disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the COVID-19 pandemic. Saf Sci 2020;129:104830.
Liao L, Xiao W, Zhao M, Yu X, Wang H, Wang Q, et al
. Can N95 respirators be reused after Disinfection? How many times? ACS Nano 2020;14:6348-56.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]