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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 202-207

Use of mask at public places among health care professionals following COVID-19 postquarantine period in Southern Haryana, India


1 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
2 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India

Date of Submission23-Jul-2020
Date of Acceptance19-Aug-2020
Date of Web Publication05-Oct-2020

Correspondence Address:
Dr. Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_245_20

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  Abstract 

Introduction: The instances of social stigma and violence against health care worker was already prevalent but during COVID-19, such instances have reached its peak. So, this global health crisis of COVID-19 pandemic offers a unique opportunity to investigate the level of perceptions and practices regarding use of mask or personnel protective equipment (PPE) in public places amongst health care professionals following COVID-19 postquarantine period.
Materials and Methods: The study included 100 health care personnel working in COVID-19 outpatient and wards as participants who have completed their quarantine period after being sent on quarantine at home/hostels or state-run facilities during the 3rd week of June 2020. After obtaining informed consent from participants, a structured questionnaire was used to collect the data. All the tests were performed at significance level of 5%.
Results: More than two third of the participants (69.0%) were using mask/PPE at all in public places. Around two third of participants were willing to wear mask/PPE in public places like local markets/street (64.0%); bus/train/flight (74.0%); institution/college (61.0%) and malls/shopping complex (73.0%). Only 58.0% of study participants were having overall good perception score for wearing mask/PPE.
Conclusions: The present study made an attempt to find out the perceptions and practices of health care personnel regarding mask/PPE use while they are in public place and it was observed that perception and practices were not satisfactory in this regard. The need of hour is psychological support for health care workers to overcome such stigma fear and the findings might help local administration to enhance that support.

Keywords: COVID-19 pandemic, healthcare worker, perception, stigma


How to cite this article:
Singh A, Panika RK, Gupta V, Goel PK. Use of mask at public places among health care professionals following COVID-19 postquarantine period in Southern Haryana, India. Indian J Health Sci Biomed Res 2020;13:202-7

How to cite this URL:
Singh A, Panika RK, Gupta V, Goel PK. Use of mask at public places among health care professionals following COVID-19 postquarantine period in Southern Haryana, India. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2020 Oct 28];13:202-7. Available from: https://www.ijournalhs.org/text.asp?2020/13/3/202/297190


  Introduction Top


The COVID-19 has emerged from Wuhan province of China and took the form of pandemic affecting all the continents including most of the countries.[1] As of now worldwide there are total 11,591,595 confirmed COVID-19 cases and 537,859 deaths from COVID-19 and in India count is raising in exponential manner with total confirmed cases counting to 721,774 and deaths are 20,642.[2],[3] Though the case fatality rates of COVID-19 (2.3%) are lower as compared to severe acute respiratory syndrome (9.5%) and Middle East respiratory sydrome (34.4%) infection but transmission rates are far higher when compared to those diseases.[4],[5],[6]

The pandemic has also resulted in an overwhelming and unprecedented workload on healthcare systems across the world and till date, no validated vaccination or specific antiviral drugs has been extensively suggested for COVID-19. Therefore, as per guidelines from World Health Organization (WHO) and Ministry of Health and Family Welfare (MoHFW, India) applying preventive measures to control COVID-19 infection is the most crucial intervention.[7],[8],[9],[10]

There have been various incidences of misunderstandings between health care workers (HCWs) and patients which have led to violence against HCWs. Also, during COVID-19 pandemic there well observed and documented stigma prevailed in the societies all over the India against HCWs.[11] Stigma can undermine social cohesion and prompt possible social isolation of groups, which might contribute to a situation where the virus is more, not less, likely to spread. This can result in more severe health problems and difficulties controlling a disease outbreak. Stigma can drive people to hide the illness to avoid discrimination, prevent people from seeking health care immediately, and discourage them from adopting healthy behaviors such use of mask in the public place.

So, this global health crisis of COVID-19 pandemic offers a unique opportunity to investigate the perception and practices regarding use of mask or personal protective equipment (PPE) in public places level amongst health care professionals following COVID-19 postquarantine period and also exploring the various factors in shaping perceptions which will be overall the first step in identifying the potential areas for developing a structured training program in order to be prepared for the future such instances.


  Materials and Methods Top


Study setting and design

This present cross-sectional study was conducted at tertiary health care center situated in district Nuh, Haryana during the 3rd week of June 2020. Nuh was among worst affected district among all 22 districts of Haryana state with maximum number of positive cases. A large number of persons were sent on quarantine including health care personnel.

Study population and sample size

The study subjects was selected using purposive sampling method and included health care personnel who have completed the duration of quarantine period as being sent on quarantine at home/hostels or in state-run facilities after discharging duties in close contact with COVID-19 positive patients; and it counted to around 137 eligible participants.

The minimum required sample size was calculated (n = 97) considering the proportion of health care professions having practice of using mask in public place as 50% (studies not found in Haryana) with confidence level of 95% and 10% absolute allowable error by applying the following formula: n = (Z 1 − a/2)2 × p (1 − p)/d 2; where Z = Standard normal variate for level of significance (at 5% type I error [P < 0.05], Z = 1.96 for 2-sided test), a = Level of significance (0.05), P = Prevalence (proportion-50%), d = Absolute Allowable error (4%), n = Sample Size, so all eligible study participants which counted to be 137 were included in the study.

Study tool

A 16-elements structured questionnaire with close ended responses was developed which covered the domains of participant's characteristics, mask/PPE practices in public places and perception towards mask/PPE usage in public places during COVID-19 postquarantine period. A pilot study was done among ten health care personnel and it took on an average 20 min for completing questionnaire. The questionnaire was made precise, relevant, valid and acceptable by presenting it among 15 randomly selected faculty members. Prior to distributing the questionnaire to the study participants further refining and organizing of the same was done to make it more comprehensive.

The questionnaire had of 4 divisions and consisted of total 16 elements. Division one consisted of two elements and gathered information regarding participants characteristics such as current age in years and sex. Division two comprised of one element and aimed to gather practices for mask/PPE usage in public places. Division three comprised of 8 elements and aimed to reveal the attitude towards mask/PPE usage in public places such markets/streets, bus/train/flight, malls/shopping complex and institution/college. Division four comprise of 5 elements and aimed to obtain the participants perception/beliefs when mask/PPE is used either by him/herself or by somebody else in public places; and preventive perceptions of mask/PPE. The responses for the division three and four were based on 4-or 5-point Likert scale pattern and the participants were suggested to respond to each elements of that division based on it. Positive statements were scored on a 5 or 4–1 or 0 scale with 'most positive' responses yielding 5 or 4 points whereas negative statements were scored on a 0 or 1–4 or 5 scale. A combined score was obtained on the basis of response to each of the elements of division three and four which ranged between 5 and 47. Equal or more than median of the attained score was considered good whereas less than median of the attained score was considered poor.

Data collection

The list of health care personnel, placed under quarantine at home/hostel or in state-run facilities was obtained from Office of Medical Superintendent along with their contact details. A few days after completion of their quarantine period (14 days), they were contacted telephonically for their availability to conduct this study. They were explained about purpose of this study and were requested to participate. Out of 137 participants, only 100 subjects provided their written consent after understanding the study objectives and were included in the study. The questionnaire for participants was administered by the investigator himself by face to face interview technique. During interview investigator took all necessary precautions to prevent the COVID-19 transmission such maintaining social distance, using N-95 mask and using hand sanitizer 70% isopropyl alcohol based. Also, the filled questionnaires were then checked for the completeness. Being elective and not requite were the properties for participating in study. The study was initiated after obtaining the ethical approval from IEC, SHKM GMC, Nalhar Letter No. SHKM/IEC/2020/40, Date: 24 April, 2020.

Data analysis

Collected data were entered in the MS Excel spreadsheet, coded appropriately and later cleaned for any possible errors. Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, more variables were created so as to facilitate association of variables. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%) and quantitative data were presented as mean (standard deviation). Bivariable logistic regression had been done to find out the strength of association between perception score and independent variables. All tests were performed at a 5% level of significance; thus, an association was significant if the P < 0.05.


  Results Top


A total of 100 participants were assessed in the study. The mean age (in years) of the study participants was 27.21 ± 1.63 and there was nearly equal representation from each gender (54.0% males and 46.0% females). Surprisingly [Figure 1]. showed that more than two third of the participants (69.0%) were using mask/PPE at all while in public place or home and nonuse of mask/PPE was prevalent among male participants (37.0%) when compared to female participants (23.9%).
Figure 1: Distribution of mask/personnel protective equipment use among study participants in public places/home (n = 100)

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Around two third of participants were willing to wear mask/PPE in public places like local markets/street (64.0%); bus/train/flight (74.0%); institution/college (61.0%) and malls/shopping complex (73.0%). However, when participants were enquired in-depth if there is strict law for wearing mask in public places then also there was no change in attitude and less than four fifth of participants were willing to wear the mask/PPE [Figure 2].
Figure 2: Distribution of willingness responses of participants towards wearing of mask/personnel protective equipment in public place (n = 100)

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When participants perception of strangeness towards wearing of mask/PPE by either him/herself or somebody else was assessed it was observed that about one third of participants (27.0%) disagreed on the fact that “when I wear mask/PPE in public place it makes others to think strange about me” and more than two third participants (68.0%) disagreed on the fact they “it looks strange when somebody wears mask/PPE in public place” and in fact responses from male and female participants were nearly coherent [Figure 3].
Figure 3: Distribution of perceptions regarding strangeness on wearing mask/personnel protective equipment among participants (n = 100)

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It was noticed in the [Figure 4]. that more than two third of participants strongly agreed on the fact of perceived benefits of wearing mask/PPE i.e., self-protection (65.0%) and protects others (72.0%). The overall mean perception score for wearing mask/PPE among participants was 40.1 ± 5.1 whereas mean score among male and female participants it was 39.3 ± 4.9 and 40.9 ± 5.1. The median perception score for wearing mask/PPE in public places was 41.5 with interquartile range between 37.3 and 44.0. The median score was higher among females when compared to males [Figure 5].
Figure 4: Distribution of participants responses for perceived benefits of wearing mask/personnel protective equipment and learning from western countries (n = 100)

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Figure 5: Distribution of perception score using box and plot (median and interquartile range) among participants (n = 100)

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Out of 100 study participants, 58 participants (58.0%) had median score for wearing mask/PPE more than 41.5, which means that only 58.0% were having overall good perception for wearing mask/PPE. Stepwise bivariate logistic regression analysis in [Table 1], revealed that the poor perception score for wearing mask/PPE was significantly associated with daily mask/PPE usage.
Table 1: Independent association of variables and mask/personnel protective equipment perception score among study participants (logistic regression analysis) (n=100)

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  Discussion Top


Currently, COVID-19 is a global topic of discussion in the media and among the public, especially among HCWs and patients and; since widespread public measures are key to a timely control the infection, the good perceptions and practices amongst health care personnel regarding COVID-19 is vital and at present there is no study being conducted to assess the same. Through this study, the investigator gained a deeper understanding into participant perceptions and practices that are necessary for protection against infection. The study revealed that only half of HCWs had both good perception score and practices for prevention of COVID-19 transmission in public places.

In present study around more than two third of the participants (69.0%) were using mask/PPE when they are in public place and it was in coherence with study done by Nepal et al. where the good practice score was observed among more than 80.0% of study participants. Such difference in practices might be due to different settings of using mask/PPE by HCWs.[12] Apart from this Ng et al. emphasized that these are challenging times for HCWs, particularly those directly caring for COVID-19 patients. They are likely to be overworked, which makes them vulnerable to errors and possibly increases their risk of getting infected.[13]

In present study around two third of participants were willing to wear mask/PPE in public places like local markets/street; bus/train/flight; institution/college and malls/shopping complex and was in coherence with the studies done by Asaad et al., and Alsahafi and Cheng where positive attitude towards usage of mask/PPE was observed among more than 70.0% of participants.[14],[15]

Even though there are guidelines for use of mask in public places introduced by MoHFW, India and also, rational use of mask/PPE was advocated by Christopher et al., and Feng et al., then also only two third of participants were willing to wear mask/PPE in public place supposing that if there is strict law for the same.[16],[17],[18]

The WHO has raised concern regarding shortage of PPE endangering health workers worldwide.[19] To overcome such shortage retailers have shifted production to make masks, gowns for health-care workers in coronavirus pandemic.[20]

The effectiveness of mask/PPE in preventing the COVID-19 infection have been documented in studies done by Brainard et al. and Leung et al. demonstrated that surgical face masks significantly reduced detection of influenza virus RNA in respiratory droplets and coronavirus RNA in aerosols, with a trend toward reduced detection of coronavirus RNA in respiratory droplets.[21],[22] But in a study by Xiao et al. and Jefferson et al., it was stated that although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from several randomized controlled trials of these measures did not support a substantial effect on transmission of laboratory-confirmed influenza.[23],[24]

In a study done by Cowling et al., which comprised of two surveys and it was observed that 74.5% and 97.5% of the general adult population wore masks when going out, whereas in present study only 58% of HCWs had good perception score for wearing mask/PPE.[25] The reason might be the stigma being commonly faced by HCWs and it was clear from the present study observation as only one third of participants disagreed with the strangeness towards wearing of mask/PPE by either him/herself. Instances of stigma among HCWs was elaborated Ramaci et al., and findings suggested that stigma has a high impact on HCWs outcomes.[26] Due to the such increased instances the Indian government has given an ordinance that makes violence against healthcare workers a nonbailable offence, punishable by up to 7 years imprisonment, amid concerns that the COVID-19 pandemic has stirred an upsurge of such targeted violence.[27] Also studies by Bavel et al. Chen and Huang and Hussain et al., have suggested use social and behavioral science to support COVID-19 pandemic response and prevent threats in addition to mask/PPE usage.[28],[29],[30]


  Conclusions Top


So, the present study made an attempt to find out the perceptions and practices of health care personnel regarding mask/PPE use while they are in public place and it was observed that perception and practices were not satisfactory in this regard. The major cause might be increased stigma and violence, which might have created hesitation among them for using mask in public places. Although the Government of India as amended the laws for violence against health care personnel, but along with it there is need of psychological and social support for them too. The study findings might help local administration to enhance that psychological and social support.

This study was novel in concept and attempted to reveal the perceptions of health care personnel regarding use of mask/PPE in public places. The limitation of study is that due to novel in nature, comparable studies were not available, so comparison of perception scores was not highlighted to that extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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