Assessment of Health Workers’ Knowledge, Beliefs, Attitudes, and Use of Personal Protective Equipment for Prevention of COVID-19 Infection in Low-Resource Settings
Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious disease with a potential for healthcare workers (HCWs) getting infected due to inadequate protection while attending to patients. Effective use of personal protective equipment (PPE) is key to mitigating the spread of SARS-CoV-2 infection in healthcare settings. Hence, there is a need to understand HCWs’ use of PPE in resource-limited settings and how closely the currently recommended guidelines for PPE are followed. This study assessed the HCWs’ knowledge about, attitudes towards, beliefs on, and use of PPE to prevent SARS-CoV-2 infection in a resource-limited setting. Methods. This cross-sectional study was conducted in April 2020 in Southwest and Northwest Nigeria. The selection of participants was performed via the snowball sampling technique using a 33-item, web-based, self-administered questionnaire via a social media network. We obtained relevant sociodemographic data and information on participants’ occupations and knowledge about, attitudes towards, beliefs on, and use of PPE. We analysed the data using SPSS version 23.0 for Windows (IBM, Armonk, New York, USA). A values <0.05 were considered statistically significant. Results. A total of 290 subjects responded to the questionnaire, and 18 (6.2%) were excluded because of incomplete data. The mean age of the respondents was 32.3 ± 9.9 years. There were 116 males (42.6%). The majority of the respondents were medical doctors (114, 41.9%), followed by nurses and clinical students. Of the 272 respondents in this survey, only 70 (25.7%) had adequate knowledge about PPE. Of the respondents who presumed they had adequate knowledge about donning and doffing PPE, 94 (56%) were incorrect. The predictors of good knowledge were ages younger than 45 years () and practice location (). Conclusion. This study showed that HCWs’ knowledge about, attitudes towards, and beliefs on PPE and their PPE skill in practice in Nigeria were remarkably poor. There is an urgent need for nationwide practical training on PPE use to curtail the spread of SARS-CoV-2 infection among HCWs.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen that causes coronavirus disease 2019 (COVID-19), is one of the most contagious viruses in human history . Following the declaration by the World Health Organization (WHO) on 11 March that COVID-19 is a pandemic disease, COVID-19 has rapidly spread across 212 countries with an estimated 4,248,389 cases and 294,046 mortalities within the five months from the start of the outbreak to 14 May 2020 [2, 3]. Over a period of five weeks, the number of COVID-19 cases in Nigeria rose from 38 cases on 24 March to 4,791 cases by 14 May 2020 . This ravaging infection has spread beyond boundaries and race and has a predilection for senior citizens.
Containment of this disease has been a major problem despite the numerous protocols advanced by various regulatory bodies. These guidelines and protocols include those by the WHO, the Centers for Disease Control, the International Labour Organization, and the European Agency for Safety and Health to prevent infections among healthcare and nonhealthcare workers [3–6]. They include facility cleaning, regular and proper handwashing, respiratory hygiene and etiquette, advice on national travel, emphasis on staying at home for infection containment, events and meeting arrangement rules, case notification and management, and proper use of face masks [3–7]. Among the critical components of infection and prevention control (IPC) during the management of COVID-19 is the mandatory use of PPE by healthcare workers (HCWs) . This component is a safeguard, as HCWs are at greater risk of contracting the disease [9, 10]. In Nigeria as on the 1st of May, approximately 113 HCWs have been infected with SARS-CoV-2 during their duties [11, 12].
PPE is a physical barrier worn by HCWs to prevent spreading of a pathogen from either a suspected or confirmed case or a pathologic specimen. It serves the dual role of preventing disease spread from patients to HCWs and vice versa. These physical barriers include goggles, face shields, fluid-resistant medical or surgical masks, particulate respirators (e.g., powered air-purifying and N95 respirators), gloves, disposable gowns, disposable coveralls, waterproof or heavy duty aprons, waterproof boots, and hoods or headcovers in conjunction with other IPC methods [9, 13, 14].
Wu et al.  and the National Hospital Infection Management and Quality Control Centre recently reported a large-scale infection of HCWs from the Hubei province in China that was mainly due to underutilisation of PPE [8, 15]. Similarly, the Henry Ford Health System recently confirmed that 46.6% of its workers had been infected with SARS-CoV-2 . The consequence of these reports [15, 16] is fear among HCWs in the setting of a lack of definitive treatment or a vaccine for SARS-CoV-2. This situation necessitates critical observation of occupational hazards and workplace safety during the COVID-19 pandemic. HCWs in low-resource settings need adequate PPE skill (including appropriately selection, donning, removal, decontamination, and disposal of PPE) at the backdrop of good theoretical knowledge of the indications and procedures, for effective protection in clinical areas. They should also have the right attitudes towards, training on, approaches to, and beliefs on and the requisite skills for PPE in practice in addition to other interventions to successfully fight and win the battle against SARS-CoV-2.
The need, therefore, to evaluate HCWs’ knowledge about, attitudes towards, beliefs on, and use of PPE become imperative to identifying gaps and facilitating prompt intervention during the COVID-19 pandemic.
2. Subjects and Methods
This cross-sectional study took place in April 2020 in two purposively selected geopolitical zones in the country (Southwest and Northwest Nigeria) as a nationwide survey may not be a true representation in view of the sampling technique.
The Institutional Research Ethics Review Committee approved the research with the reference number BUTH/REC/-055.
As a result of nationwide mandatory lockdown and the concern for interviewers’ safety, the researcher opted for an online survey using a Google form administered via the WhatsApp platform , the most widely used social media platform in Nigeria . At the beginning of the questionnaire, each respondent was introduced to the survey. Their voluntary participation was sought, and an electronic consent was obtained. Potential participants who declined to click on the “yes” option for consent cannot proceed to access the survey.
The sample size was estimated using a 43.4% PPE utilization rate in a similar study in Cyprus due to limited local data on the level of utilization of PPE among HCWs in Nigeria. A sample of 262 was obtained at 95% confidence interval and 6% margin of error. However, 290 responded to the survey, but 18 were excluded in the final data analysis due to incomplete data.
We included health workers who are in active service in any of the Nigerian hospitals and have access to the Internet. Responses with incomplete information were excluded from the data analysis.
We obtained the list of HCWs’ groups and associations of state chapters in Nigeria to form the sample frame. Thirty percent of the number on the list of associations and groups (assumed to be adequate) were selected by simple random selection to form the snowball seeds for the study .
A semistructured questionnaire  was synthesised from the WHO training manual for PPE and from the existing literature (summarized in Table 1) to obtain relevant sociodemographic data, knowledge about PPE, attitude towards PPE, beliefs, and level of PPE skill of each participant.
Prior to commencement of the study, a pilot study was carried out to validate the questionnaire. The Google form questionnaire was also peer-reviewed by faculty members of the Department of Public Health, Bowen University Teaching Hospital, the Paediatric Department, University College Hospital Ibadan, and the Infectious Disease Unit, Federal Medical Centre Kastina, Kastina State, Northwest Nigeria.
A Google form questionnaire link was sent to the various HCWs’ close user WhatsApp groups and associations which included the nurses, the medical doctors, the physiotherapists, and the laboratory scientists across the selected geopolitical zones in the country. The heads of the groups and associations were contacted to encourage participation of members in the survey. Each respondent was encouraged to send the link to other HCWs’ close user groups for participation (chain-referral sampling technique).
Seven questions assess the knowledge of the participants. Each question has an option of “either yes, no, or not sure as the most appropriate response.” A correct response to the question scores one mark, while a wrong answer attracts zero . The mean score of the seven items was determined. Scores ≥the mean score were credited as good knowledge score and poor if otherwise.
The HCWs’ PPE skill in practice was assessed with a set of 10 questions. The mean score was obtained. Subjects with scores ≥the mean score were also deemed to have adequate skill [21, 22]. The Likert scale consisting of five grades of responses was used to assess attitudes and beliefs. Similar estimates as described above for knowledge and skill were used for attitude and belief scores. In addition to the above, the questionnaire also inquired about participants’ view on locally made PPE which includes sewn face masks made of fabric material, coverall gown made of waterproof synthetic materials, and face shield produced from plastic bags as shown in the image on the questionnaire from one of the centers in Northwestern Nigeria as opposed to imported supplies from Europe, China, USA, and Germany.
Data were entered into a password-encrypted computer and subsequently analysed using IBM Statistical Package for Social Sciences (SPSS) version 23.0 for Windows (IBM, Armonk, New York, USA). values of <0.05 were considered significant. Categorical variables were summarized using frequencies, ratios, and proportions, while the chi-square or Fisher’s exact test was used to determine the association between the variables. We assessed the variables that were statistically significant on bivariate analysis for predictors of good knowledge and good PPE skill in practice using multivariate logistic regression.
A total of 290 subjects responded to the questionnaire, and 18 (6.2%) were excluded because of incomplete data. The mean age of the study population was 32.3 ± 9.9 years. One hundred and sixteen were males (42.6%), giving a M : F ratio of 1 : 1.3. The majority of the respondents were medical doctors 114 (41.9%), followed by nurses and clinical students as shown in Table 2. The larger proportions of the respondents were from tertiary health facilities (206 (75.6%)).
Table 3 shows the responses of the participants to questions on general knowledge of PPE. Although 270 (99.3%) of the respondents were aware of PPE, only 38 (14.0%) know that the standard PPE list extends to 8–11 items. About half (134 (49.3%)) of the respondents correctly admitted that there were 4 levels of PPE utilization. When the picture of a level A PPE suit was shown, only a third (74 (27.2%)) could identify the image correctly.
Table 4 shows training of human capacity on PPE: 130 (47.8%) HCWs had training on PPE and half (64 (23.5%)) had the training for more than six months prior to the outbreak of SARS-CoV-2 infection. The main source of training was via in-person seminars (68 (25.0%)), followed by the social media networks such as Facebook, Twitter, and WhatsApp.
Of note is the fact that younger subjects (≤45 years), both the nurses (44 (16.2%)) and medical students (44 (16.2%)), were more knowledgeable about PPE among the various cadre of HCWs compared with the residents (26 (9.6%)) and medical consultants (28 (10.3%)) () as shown in Table 5. Regarding having the essential knowledge for selection and safe use of gloves, only 38/272 (14.0%) know the recommended glove for PPE and the need to read the biohazard safety instruction on the glove’s packs for optimal use.
With respect to HCWs’ PPE skill in practice (Table 6), 174 (64.0%) admitted to have used PPE before but less than half 80/174 (46.0%) knows how to correctly select appropriate PPE for use. When asked questions about wearing and removing PPE, of the 108 (39.7%) who assumed they had the requisite knowledge of these procedures, only 18 (6.6%) and 34 (12.5%) know the correct sequence for donning and removal of PPE, respectively. Better PPE skills were demonstrated by the younger nurses 32 (11.8%) compared to other members of the health team () as shown in Table 7. Two hundred and fourteen (78.7%) admitted that they will definitely use PPE if available. Using the Likert scale, twelve (4.4%) of the study participants always use PPE in the course of attending to patients.
Sixty-six (24.2%) of the respondents believe that the available PPE is of good quality at most. Eighty six (31.6%) believe that the quality of locally made PPE such as face masks, face shield, and coverall gowns compares favourably well with the imported brands from USA, Europe, China, and Germany as shown in Table 8. Other details are shown in Table 8.
The only predictors of good knowledge of PPE was age. The unadjusted odds were β = 1.32, OR = 3.8 (95% CI: 1.4–10.0), . When adjusted for age younger than 45 years, the odds were β = 1.137, OR = 3.1 (95% CI: 1.0–9.7).
The predictors for good PPE practice skill were age and place of practice. The unadjusted and adjusted odds for age younger than 45 years for good PPE practice skill were β = 1.689, OR = 5.4 (95% CI: 2.1–13.9), and β = 0.903, OR = 2.5 (95% CI: 1.0–6.0), , respectively. In terms of HCWs’ practice location, the unadjusted odds for Southwest and Northwest Nigeria and the adjusted odds for Southwest Nigeria were β = 1.516, OR = 4.6 (95% CI: 1.5–14.2), and β = 1.227, OR = 3.4 (95% CI: 1.3–9.3), respectively.
In the prevention of workplace hazards, HCWs’ knowledge, attitudes, and beliefs are paramount if any success in containment is to be achieved. Our study showed that HCWs had poor knowledge about PPE. Only 14.0% of the respondents knew what constituted standard PPE. The observed low knowledge about PPE among HCWs in this study is similar to that in a report by Wang et al.  in the Hubei province of China and the previously reported knowledge of HCWs among individuals who cared for patients with Ebola infection in Southeast Nigeria . The finding of nurses and medical students being more knowledgeable about PPE than the older senior colleagues although unexpected corroborates the inverse relationship of increasing years of experience and HCWs knowledge of PPE reported by authors [24, 25]. The suggested reasons for HCWs’ poor knowledge about PPE included a lack of HCW training and paucity of retraining of HCWs on PPE, lack of expertise to conduct this training, and a false assumption that epidemics of contagious diseases are rare and acquiring related knowledge may be a futile effort. Perhaps the findings could also represent a higher visibility of younger digital native HCWs to access readily available up-to-date information on PPE compared with the older digital native colleagues who use a more rigorous process to access information from textbooks and journal articles. Perhaps, the disproportionate involvement of older colleagues with nonclinical responsibility such as managerial duties in addition to the aforementioned reason may also be suggested for the disparity observed among the age groups.
In the containment of contagious diseases, the consequences of HCWs having poor knowledge are multifaceted. The workers are not only at risk of contracting infections but also serve as hosts to rapidly spread the disease within a short period. This study’s findings of HCWs’ poor knowledge about the indications for and selection of appropriate PPE are consistent with the observations by Chia et al.  in Singapore during the SARS-CoV outbreak in 2003 in which more than half of the nurses and clerical staff agreed that paper face masks serve a similar function to surgical masks.
Despite the fact that approximately half of the respondents had some form of training on PPE, only 6.6% and 12.5% knew the correct procedure to don and remove PPE, respectively. A study in the United States assessed the doffing practices of HCWs and found that in 90% of cases, the selection and/or the sequence of doffing PPE was incorrect . Another study in the United States found that 100% and 27% of HCWs at least breached the protocol for Ebola for donning and doffing PPE, respectively . The high levels of breaches of the protocol in wearing and removal of PPE could be attributed to the complexity of the protocols and the need for training and retraining. Following the appropriate steps is important to avoiding self-contamination when utilizing PPE. Perhaps, the poor skill about and practice of donning and removing PPE may partly explain the high rate of HCW infections in Nigeria during the COVID-19 outbreak .
Concerning is the level PPE skill observed among the medical doctors as compared to the nurses. Nurses were observed to have better performance than the other HCWs in utilizing PPE in tandem with the reports in the literature [24, 25]. The reason for this disparity is not very clear; however, it is possible that a higher proportion of specialist nurses who work in the theatre and intensive care unit participated in the survey. They are regularly exposed to using PPE as a routine in the course of their clinical duty. It is also plausible to suggest that lack of immediate health consequences from previous accidental exposure to unsafe practices by older HCWs could have given a false confidence of not requiring PPE skill in practice.
Institution and execution of countermeasures for infection control and prevention (ICP) measures should include continual medical education of HCWs on ICP with emphasis on the participation of HCWs older than 45 years. Constitution of an effective safety committee, organization of scheduled and impromptu performance-based evaluation, and addressing the perceived barrier in compliance with these guidelines such as perceived difficulty with communication particularly with elderly patients and addressing the perceived discomfort associated with wearing the PPE such as maintaining cool ambient temperature in healthcare settings are paramount .
Our study also shows poor attitudes towards the use of PPE, as less than 5.0% admitted using PPE when required. This rate is lower than the 55.0% compliance found among Chinese HCWs during the 2009 pandemic, the 52% compliance reported by McGaw et al.  among physicians, and the 65% compliance among nurses in Jamaica . The poor attitudes towards using PPE are concerning, as nosocomial COVID-19 infections among HCWs will have negative consequences in low-middle-income countries like Nigeria, where there is already an inadequate supply of healthcare personnel. The poor attitudes towards PPE use may be due to nonavailability, increased pressure on merger consumables, or global shortage of PPE, as approximately three-quarters of the respondents were willing to use PPE if it was made available by the facility.
The finding that only one-third of the respondents’ believe that the available PPE were adequate for infection prevention calls for an audit and a review of the quality/specifications and suitability of PPE in the current use in the healthcare setting in the study locations.
This study also showed that 6 out of 10 HCWs believed that the quality of PPE available in the market was of fair quality. This observation could encourage the use of PPE, with HCWs having confidence in the protection offered during usage. PPE is meant to protect HCWs from infection during the course of their work .
The present survey is not without its limitations. The feasible web-based online nature of the survey and the purposive sampling techniques could have excluded individuals from the study.
In the course of the survey, an intense apathy of the HCWs to participate in the survey was observed either consequent to increased work load/stress level, additional cost of mobile data utilized in accessing the survey, overt lack of interest, or multiple survey fatigue at the time of the study which could have excluded some of the HCWs from participating. All of these limits the generalisability of the result and calls for careful interpretation. It is also reasonable to suspect that the responses from the self-administered questionnaire may not always represent the true/honest position of the respondents. However, respondents were encouraged to be honest and assured their responses were anonymous.
This study showed that HCWs’ knowledge about, attitudes towards, beliefs on, and use of PPE in Nigeria were remarkably poor. There is an urgent need for nationwide practical training on PPE to curtail the spread of SARS-CoV-2 infection among HCWs.
All data are fully available to all interested researchers upon request without restrictions from the corresponding author or from the Director of Clinical Services, Bowen University Teaching Hospital, Ogbomosho ([email protected]).
Ethical approval was obtained from the Health Research Ethical Committee of the Bowen University Teaching Hospital with the approval number BUTH/REC/-055.
Informed consent was obtained from all participants for this study.
Conflicts of Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
MAA substantially contributed to conception or design; contributed to acquisition, analysis, or interpretation of data; drafted the manuscript; critically revised the manuscript for important intellectual content; gave final approval; and agrees to be accountable for all aspects of the work in ensuring that questions relating to the accuracy or integrity of any part of the work are appropriately investigated and resolved. AOD contributed to conception or design; critically revised manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy. ROI substantially contributed to the design, acquisition, analysis, or interpretation of data; critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy. AOA contributed to design and acquisition; critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy.
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