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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 1 | Page : 40-50 |
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Knowledge and Awareness Regarding Facemasks among Medical Professionals in a COVID-Dedicated Hospital – A Cross-sectional Study
Sulakshna Aggarwal1, Lovenish Bains2, Anurag Mishra2, Aashima Dabas3, Madhav Goel1, Aiman Perween Afsar1
1 Maulana Azad Medical College, New Delhi, India
2 Department of Surgery, Maulana Azad Medical College, New Delhi, India
3 Department of Paediatrics, Maulana Azad Medical College, New Delhi, India
| Date of Submission | 15-Sep-2021 |
| Date of Decision | 03-Oct-2021 |
| Date of Acceptance | 02-Jan-2022 |
| Date of Web Publication | 29-Apr-2022 |
Correspondence Address:
Dr. Lovenish Bains
Department of Surgery, Maulana Azad Medical College, New Delhi, Postal Code: 110002
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mamcjms.mamcjms_102_21
Background: Severe acute respiratory syndrome coronavirus 2 is a severe respiratory infection that spreads through infected droplets. Facemasks have been mandated by the World Health Organization and Centers for Disease Control as the cornerstone for preventing the spread of infection among healthcare workers. However, despite the ubiquitous use of masks, many healthcare professionals are unaware of their properties and proper use. Therefore, the study aims to assess the awareness, practices followed, and problems faced in the use of facemasks among medical professionals in a coronavirus disease (COVID)-dedicated hospital. Methodology: An e-questionnaire-based survey was conducted among medical professionals working in a tertiary care (COVID-dedicated) hospital in North India. The questionnaire tested for the knowledge and awareness on properties of facemasks, problems faced on regular or prolonged use, and removal, storage, and disposal practices among professionals. Results: The survey was sent to 368 medical professionals with a response rate of 45.65%. About 43.3% of the participants were aware of the properties of the N95 facemask, and 26% of the health professionals checked for the proper fit of the mask after putting it on. Discomfort and sweat issues were the most common problems reported by 84% and 69.33% of participants, respectively. About 86% of the participants had the knowledge of appropriate removal of the mask, but only one-third were aware of the proper mask disposal practices. Conclusion: Knowledge about the properties of facemasks, their use, and disposal practices among the North Indian healthcare professionals was found to be significantly lower than in western countries; however, the awareness increased with experience in the participants studied (P < 0.001). As it is the young medical force at the forefront to tackle the menace, regular training and accurate information on facemask usage must be disseminated via institutional training programs to prevent the risk of infection and equip the frontline workers to share this knowledge with the community further.
Keywords: COVID-19, facemasks, infection, knowledge, medical professionals, prevention
How to cite this article:
Aggarwal S, Bains L, Mishra A, Dabas A, Goel M, Afsar A. Knowledge and Awareness Regarding Facemasks among Medical Professionals in a COVID-Dedicated Hospital – A Cross-sectional Study. MAMC J Med Sci 2022;8:40-50 |
How to cite this URL:
Aggarwal S, Bains L, Mishra A, Dabas A, Goel M, Afsar A. Knowledge and Awareness Regarding Facemasks among Medical Professionals in a COVID-Dedicated Hospital – A Cross-sectional Study. MAMC J Med Sci [serial online] 2022 [cited 2023 Jun 5];8:40-50. Available from: https://www.mamcjms.in/text.asp?2022/8/1/40/344347 |
| Introduction | |  |
The transmission of coronavirus disease 2019 (COVID-19) was earlier thought to occur via droplets, but recent evidence has strongly pointed toward the airborne transmission of the virus-infected respiratory excretions. [1] The virus enters the human body through the nose, mouth, and eyes due to direct inhalation, contact with infected surfaces, and extended stay in closed or crowded environments.[2] Centers for Disease Control (CDC) guidelines emphasize that facemasks must be used to mitigate the risk of infection even after an individual is fully vaccinated.[3] There is ample evidence to support the effectiveness of N95 and surgical masks in reducing the risk of spread of COVID-19 infection.[4],[5] A prospective cohort study reported that the risk of COVID-19 infection in healthcare workers is 12 times that in the general population. Furthermore, it said that the healthcare workers who have inadequate access to facemasks were 31% more likely to be infected with COVID-19 than those who had adequate access.[4] Another study reported a direct reduction in COVID-19 infections among healthcare professionals using N95 and surgical facemasks by 50%.[5]
The life-saving role of facemasks in the current pandemic makes it essential to estimate the knowledge healthcare professionals have about the properties and correct usage of facemasks. Only a handful of questionnaire-based studies in India assessed the awareness about COVID-19 among Indian healthcare professionals; however, they did not include questions on the features and the properties of facemasks in their assessment.[6],[7] There is a paucity of knowledge about the proper use and properties of facemasks among medical professionals, which is an important determinant of their health, especially when dealing with COVID-19-infected patients. This study was undertaken with the aim of assessing the knowledge, practices, and problems faced in the use of facemasks among medical professionals in a COVID-19-dedicated hospital.
| Materials and Methods | | |
This cross-sectional survey was conducted among medical professionals working in a tertiary care hospital in North India. The ethical clearance for the study was obtained from the institutional ethics committee. An e-survey was conducted via an online questionnaire created using Google forms. The e-survey URL was circulated via e-mail and WhatsApp to the medical professionals, and two reminders were sent at an interval of 2 weeks. The sample size was calculated using Open epi software as 139 in an infinite population, assuming the prevalence of the correct rate of a knowledge test among medical professionals 90%[8] with a design effect of 1 and confidence limits 5%.
Questionnaire
The study questionnaire was created with Google forms and consisted of three sections: the first section asked about anonymized demographic details. The second section assessed them on the filtration efficacy, life of the mask, and problems they face when using facemasks, and the third section assessed the knowledge and awareness on N95 and its properties, and practices regarding fit, removal, and disposal of the mask. Each correct response was scored as one point without any negative marks for an incorrect response for a range of scores from 0 to 21 as maximum. The questionnaire was pretested and validated in 15 respondents who were not enrolled in the study [Appendix, https://forms.gle/TpwqChKtGfnMpPxr5].
Statistical analysis
The results were calculated and compiled using Microsoft Excel and statistical analysis was performed using SPSS (IBM) (IBM© SPSS) version 23 software. Proportions were represented as a number (%). The mean/standard deviation (SD) scores were calculated. The association between the personal details and the score of awareness was carried out using a one-way analysis of variance (ANOVA) test. P-value <0.05 was taken as significant.
| Results | | |
We sent the questionnaire to 368 doctors working in the hospital, out of which 168 participants responded; hence, the response rate was 45.65%. Around half of the participants were students, interns (14.3%) or junior residents (32.2%). The majority worked for more than 4 hours (82.5%), where 35.6% worked for more than 8 hours in a COVID-dedicated hospital. Approximately one-third worked at level 2 of the triage, followed by 21.4%, who worked at level 1. In addition, 73% of the participants reported that they use N95 masks during hospital hours. Approximately one-fourth of the participants wear a mask for more than 8 hours, and 61.7% wear a mask for 3 to 8 hours [Table 1]. | Table 1 Descriptive characteristics of the medical professionals with experience (in years)
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Approximately 43.3% of the professionals were aware of the properties of the N95 facemask. About 47.5% and 42% mentioned the filtration efficacy and the meaning of N in N95 correctly, respectively. Only 26.7% performed a fit test before wearing the mask. The most common problems faced by professionals were humidity (78.6%), pressure on the nose and ears (84%), and sweat (69.3%) [Figure 1]. Also, 17.8%, 48.7%, and 23% of the population experienced shortness of breath in less than 1 hour, 1 to 3 hours, and ≥4 hours, respectively, whereas 10.5% of them do not feel short of breath at all [Figure 2]. As good numbers of the professionals were aware of the proper removal (86.3%), only 31.5% knew the correct disposal practices [Table 2].
A total of 21 questions were asked in section 3, each of which had a right and a wrong answer. One mark was allotted for each correct answer, making the total score 21. The overall mean score was 9.8 (SD ± 2.375), making the overall correct rate 46.67%. One-way ANOVA test was used to test the association of knowledge score with discipline and years of experience. We found a significant relationship between the knowledge score and years of experience among the medical professionals (P < 0.001) [Figure 3]. Knowledge score did not vary significantly with the discipline of the medical professionals, suggesting that the awareness regarding correct practices does not depend on the discipline or specialty (P = 0.34) [Figure 4], [Table 3].
| Discussion | | |
An effective facemask covering the nose and mouth is an important preventive measure against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); therefore, World Health Organization (WHO) recommends facemasks as a preventive measure against SARS-CoV-2.[9] CDC recommends N95 masks for healthcare workers when caring for either confirmed or suspected patients with COVID-19 due to its airborne transmission.[10] A recent meta-analysis study suggests that N95 facemasks significantly reduce the risk of infection among healthcare workers by 80%. These results are consistent with both Asian and western populations.[11]
We found that 43% of the professionals were aware of the properties of N95. N95 bars 95% of the particles of size 300 nm,[12] which were known to less than half of the participants in the study. Although COVID-19 has a diameter of approximately 60 to 140 nm which is smaller than the filterable capacity of N95 masks; however, it is the property of Brownian motion More Details of particles of size <300 nm which prevents them from passing through the mask making N95 masks an important equipment in personal protection armamentarium.[13] Furthermore, 42% of the participants responded correctly on the meaning of N in N95. N refers to “Not-oil,”[13] which means these masks are effective only in the absence of oil-based particles. About half of the participants knew the life of N95 in COVID-dedicated conditions. Improper extended use of a mask decreases its effectiveness and may compromise the safety of the wearer.[14] An Irish study conducted in 2021 found that only one-third of the healthcare workers showed concern about the quality and properties of a mask.[15] Adequate knowledge on protective equipment is essential, as it was associated with increased confidence in personal protective equipment (PPE) among healthcare workers, potentially promoting a sense of efficacy in coping with the pandemic.[16]
Medical professionals should carry out the fit test before wearing respiratory protective equipment for the first time.[17] Poor fit can lead to leakage, thus compromising the protection of the wearer.[18] For the proper fit of the respirator, one needs to shave off the facial hair and put the respirator at the correct place on the face[19]; press the nose clip to ensure no leakage from the respirator when preventing over-tightening and being comfortable.[18] In our study, 26.7% of the professionals underwent the fit test, which is in agreement with the findings reported by an Australian survey in which 27% of the healthcare workers checked for fitness.[20] The filtration efficiency and the fit are the two significant factors that determine the effectiveness of the facemasks.[21] As medical masks often have a drawback of loose fit, CDC has recently recommended double masking, that is, wearing a cloth mask over a surgical three-ply mask to ensure snug fit over a high filter capacity medical mask. The outer mask straps can be crossed to ensure a better and tighter fit of the masks over the face.[22] Another CDC-recommended procedure to ensure tight fit of masks is called knotting. In this procedure, the end of the straps near the mask are knotted and pushed under the mask to flatten the excess material near the face.[23]
Though masks offer many advantages, a few issues have been reported related to the prolonged use of masks. A vast majority of the professionals felt pressure on their faces and ears, humidity, and sweat [Figure 1]. Participants also reported other problems such as spectacles being foggy, reduced efficacy over the beard, itchy, contact dermatitis, headache, and speech becoming incoherent. Purushothaman et al. corroborated similar findings as 52% of healthcare workers (who wore either surgical or N95 facemask for a minimum of 4 hours) developed itchy nose, 56% developed acne on the face, 39% experienced redness on the face, and 67.6% experienced excessive sweating around the mouth. In addition, pain in the nose was reported by 30%, and behind the ears, by 54.2% of the participants probably due to tight fitting of masks.[24] In Germany, the majority of the participants among general population did not report any problem when wearing the mask. Nevertheless, around half of children (53%) and one-third of the adults (35%) (out of those who agreed that mask causes problems) reported heat and humidity followed by pain and shortness of breath.[25] Canini et al. reported warmth (46%), respiratory difficulties (39%), humidity (36%), irritation (13%), and pain (2.6%) as problems faced by adults while wearing facemasks in France.[26] A survey study conducted in Singapore found prolonged use of N95 masks in healthcare workers to precipitate headaches. Pressure from the mask strap, hypoxemia, and hypercapnia was considered the underlying factor for the headache in participants who wore N95 masks for more than 4 hours.[27] Lee et al’s study determined the extent of breathing problems associated with facemasks. It assessed the impact of wearing medical and N95 facemasks on breathing resistance. The results showed a mean increment of 126% and 192% in inspiratory and expiratory flow rates, respectively. There was also an average reduction of 37% in air exchange volume using N95 respirators.[28] Nevertheless; it did not seem to impact tidal volume or the frequency of breath. Additionally, the reported changes in breathing resistance are small enough to have minimal clinical implications in healthy adults.[29] Participants also reported; around 49% of them felt shortness of breath in 1 to 3 hours, followed by 4 or more than 4 hours (23%) [Figure 2]. Since the symptoms start coming within 1 to 3 hours, we can project how difficult it would be for them to wear facemasks for 6 to 8 hours at a stretch.
Most professionals (84%) were aware that virus remains on the outer surface of the mask; therefore, they either never touched the outer surface of the mask when wearing it or touched it once or twice in an hour. On the contrary, Agarwal et al’s study found that a significant proportion (36%) of the healthcare workers touched the anterior surface of their facemasks while wearing them.[30] Touching the mask holds a serious risk for transmission of infection if other surfaces or body parts such as eyes, nose, or mouth are touched with infected hands. The correct method of mask removal is by pulling strings out of the ears and not touching the portion of the mask covering the face,[21] which was used by 86.3% of the participants. The same percentage of participants also reported washing their hands with soap water for 20 seconds or 60% alcohol solution before touching the mask for removal.[31] Disinfecting hands before and after mask removal is a must to reduce the risk of contamination of hands. Reszke and colleagues reported that only 43.4% take off their mask correctly without touching the anterior surface and about half (49%) wash their hands after taking off their mask in Poland.[32] Only 31.5% of the professionals follow the correct practice to discard the mask in a closed yellow bin and perform hand hygiene with the alcohol-based rub afterward.[33] Consistently, another study reported that only 15 out of 79 healthcare workers dispose of their masks in the yellow bin.[34] About 57% of the 956 Indian healthcare workers surveyed online followed donning and doffing properly for facemasks.[30] In addition, Phan et al. in Chicago observed that 90% of PPE doffing practices were incorrect concerning doffing sequence and doffing techniques.[35] Suboptimal practices associated with usage and disposal of facemasks do not only pose a considerable risk of contamination of healthcare workers but also to the community at large.
Overall, medical professionals showed poor awareness regarding facemasks (46.67%). Despite the benefits of masks, complete knowledge about masks is lacking. Kumar et al. found that only 35.2% of the healthcare workers scored >80% (high score), and 45.4% of them scored in between 60% and 80% (moderate score) in their knowledge and awareness regarding the use of surgical facemask.[36] Lack of adherence to the PPE had been a major obstacle to the safety of the healthcare workers since influenza pandemic.[37] In Poland, healthcare workers showed very poor adherence to all the WHO recommendations concerning mask wearing regardless of the profession, medical specialty, or specific workplace.[32] Similarly in Germany, healthcare workers did not show 100% adherence to the use of facemasks before donning and after doffing PPE when working in COVID wards.[38] In a meta-analysis conducted in 2020, the researchers examined the barriers faced by healthcare workers to adhere to infection control guidelines. They reported that healthcare workers were doubtful of the vague local guidelines, which were needlessly lengthy and contradicted the national and international guidelines. Other barriers were increased workload arising due to the infection control protocols without the support from management which caused fatigue, lack of protective equipment, poor communication about the institutional guidelines, and lack of training about the infection and PPE.[39]
We found that the mean score increases significantly with an increase in years of experience (P < 0.001); however, the awareness score and discipline of the medical professionals did not show any significant association (P = 0.34). Participants with less experience (<3 years) had a significantly lower knowledge score than those with experience of ≥10 years. Another Indian study reported similar findings in which resident doctors and paramedical staff in the age group of 18 to 30 years adhered less to the preventive practices.[30] Libya reported similar results, in which knowledge and awareness did not vary significantly with the department. About 73.5% of participants in Libya showed inadequate knowledge regarding facemask.[40] As medical professionals are the frontline warriors to tackle the menace of this disease, it is the need of the hour to increase the awareness (especially among younger professionals) regarding the proper application of facemask and detailed information about facemask properties. Some suggestions on the solutions for various problems mentioned are summarized in [Table 4].[41] | Table 4 Suggestions for appropriate facemasks usage (based on World Health Organization multimodal strategy)
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The strength of this study lies in: First, this study contributes significantly to the vast lacuna of existing knowledge regarding awareness and problems faced in using different types of facemask among medical professionals. Therefore, it might give the direction in disseminating adequate knowledge in the identified area via those portals of information which can affect significantly to the awareness of the affected population and help in making the country more aware; second, we conducted our study in the largest only COVID-dedicated hospital of India. Thirdly, it has greater participation of young medical force who will be working now in COVID wards and intensive care units, their knowledge about proper mask usage must be adequate. Lastly, this study is one its kind, as it assesses the awareness on preventive measures against COVID-19, which can significantly contribute in reducing infection rates.
Nevertheless, this study has few limitations. First, the response rate was 45.65%, moderate but comparable between an Italian survey with a response rate of 25%[42] and the Brazilian study with a response rate was 68.8%. Secondly, many participants found the questionnaire very lengthy. Thirdly, the participation of nursing officers was limited; as part of the workforce, they should also have adequate knowledge for their safety. As this is a questionnaire-based online survey with voluntary participation and those who did not participate may be systematically different from those who participated, the possibility of respondent bias cannot be ruled out.
| Conclusion | | |
The awareness among Indian medical professionals about the properties and usage of facemasks is inadequate. Less than one-third of the healthcare professionals checked the fitting of their masks. As proper removal of a facemask was known to most participants, its proper disposal was not known to two-thirds of the participants. Such inadequate knowledge about the properties and usage of facemasks seriously undermines their protective function predisposing the healthcare workers, their families, and the community to the risk of life-threatening infection. Experienced doctors are significantly more aware of proper facemask usage than younger ones. As the frontline workforce comprises mainly residents and the young workforce, their knowledge regarding facemasks is of the utmost importance. In the face of the current pandemic, this young medical force should update them regularly regarding various facemasks through the guideline’s competent authorities and professional bodies. Furthermore, the institute should provide regular training and knowledge upgradation about facemasks to its employees in compliance with international guidelines to ensure the safety of the workers as well the community.
Ethics approval and consent to participation
The ethical approval was obtained from the institutional ethics committee of Maulana Azad Medical College. Consent for the participation was incorporated in the survey questionnaire, only those who consented were eligible to participate.
Consent for publication
Consent for the publication was incorporated in the survey questionnaire, only those who consented were eligible to participate.
Authors’ contributions
LB conceptualized the manuscript. SA designed the study, co-ordinated the execution of the study. SA, LB, and MG reviewed the literature, analyzed data, and made major contribution to the writing of the manuscript. LB, AM, and AD supervised the execution and provided important intellectual contributions to design, co-ordination and analysis of the study. SA, LB, AM, AD, MG, and AAP performed final review and editing of the manuscript. All authors have read and approved the final version of the manuscript.
Acknowledgments
The authors thank the institution, Maulana Azad Medical College and Lok Nayak Hospital and Gurukool for providing us a great opportunity to conduct this study. The medical students sincerely thank the mentors Lovenish Bains, Anurag Mishra, and Aashima Dabaas for pursuing them to take this study and guiding at each step.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]
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