Access and Use Experience of Personal Protective Equipment Among Frontline Healthcare Workers in Pakistan During the COVID-19 Emergency: A Cross-Sectional Study

Introduction

The novel coronavirus diseases 2019 (COVID-19) pandemic is thought to be the most challenging global health calamity of the century after World War II. ¹ First originating in Wuhan, China, it took only few months for the disease to spread to almost all countries and territories around the world and infect millions of people. ² Compared with the general population, the risk of contracting COVID-19 is particularly high among frontline healthcare workers who have the highest probability of direct or indirect exposure to patients and infectious material. ³ Although the exact number of healthcare workers affected by COVID-19 is not available, some estimates suggest that as of September 1 they make up about 1 in 7 of all COVID-19 cases ⁴ and more than 7,000 deaths. ⁵ A shortage of personal protective equipment (PPE) for healthcare workers ⁶ has been cited as the most common reason for the high rate of infection among healthcare workers and resultant mortality. ⁷ Lack of personal protective measures coupled with prolonged exposure to infected patients is directly linked to the high risk of infection among healthcare workers. ⁸

Since the start of the pandemic, guidance on the usage and supply of PPE has continued to develop, however, it has emphasized managing resources rather than optimizing protection of healthcare workers. ⁹ The shortage of PPE among healthcare workers at the beginning of the pandemic led to an increase in the demand for PPE. ¹⁰ The problem was further complicated by the lack of awareness among healthcare workers about the use of PPE. ¹¹ Similarly, due to the lack of training, they were unaware of the basic concept of PPE and knowledge about the use of it. ¹² A study at Hubei Province, China, identified use of PPE as one of the biggest physical and psychological challenges experienced by the physicians while responding to COVID-19. Physical challenges included correctly putting on (donning) and taking off (doffing) equipment; wearing a mask for long periods of time; and handling the psychological burdens of patient management, including communication with patient and peers. ¹³ These challenges pose a serious threat to lower- and middle-income countries like Pakistan where the coping capacity of a health system for any outbreak is already fragile. ¹⁴

Pakistan is among several countries with insufficient human resources in their health systems. In 2013, Pakistan's doctor-to-patient ratio of 1:1,127 was below and doctor-to-nurse ratio of 1:2.7 was just above the World Health Organization (WHO)-recommend doctor-to-patient (1:1,000) and doctor-to-nurse (1:4) ratios. ¹⁵ The lack of human resources, combined with financial and management issues, has led to Pakistan's failure to achieve health-related targets. ¹⁶ Furthermore, a uniform policy on the supply of PPE and related training and development activities for healthcare professionals does not exist; the majority of healthcare workers are not trained on the use of PPE, especially during a rapidly evolving situation such as the COVID-19 pandemic. The aim of the present study was to assess self-reported access to PPE, whether adequate information was provided about the use of PPE, COVID-19 risk perceptions, and the ability to perform donning and doffing of PPE to inform Pakistan's strategies to protect its frontline healthcare workers.

Methods

The study was designed as a cross-sectional, self-reported survey administered to frontline healthcare workers in Pakistan during the response to COVID-19. The study protocol was approved by the Khyber Medical University Ethics Review Board (Dir/Ethics/KMU/2020/17). Due to the countrywide lockdown to restrict the spread of COVID-19, data were collected online using a structured questionnaire developed by the University of Bologna (Italy) and Harvard University and used in Italy. ¹⁷ The original questionnaire was translated from Italian to English. Before implementation, the questionnaire was sent to infection control in charge of 5 tertiary care hospitals dealing with COVID-19 for expert review and feedback. The revised final questionnaire (www.liebertpub.com/doi/suppl/10.1089/hs.2020.0142) was shared on all known social media groups (ie, Facebook and WhatsApp) already created by the healthcare workforce. The survey was conducted from May 9 to June 5, 2020. Inclusion criteria included healthcare workers (doctors, nurses, and paramedical staff) ages 21 years and older with a valid medical license/registration number and working in Pakistan during the COVID-19 emergency.

The questionnaire included questions about demographic information, access to different types of PPE, and strategies adopted during PPE shortages. Respondents were asked if they had adequate access to required PPE (ie, surgical masks, N95 masks, N99 masks, surgical gloves, disposable gowns, coverall suits, protective goggles, disposable shoe covers) during their professional duties. Responses were recorded as never, sometimes, or always. Respondents were further asked if they had received adequate information (eg, names of pieces and parts of PPE and their intended use and setting) about the use of individual PPE and whether the information was clear, complete, and useful. Information about donning and doffing of individual PPE was also obtained. Finally, the study assessed the risk perception of contracting the disease during professional duty and daily life, the use of prophylactic self-medication, and the COVID-19 testing status of respondents.

Categorical and continuous variables were presented as number (n), percentage (%), and mean (standard deviation [SD]). Chi-square testing was applied to explore the differences between the groups of healthcare workers (P ≤ .05). We used Stata version 15 (StataCorp, College Station, TX) to analyze the data.

Results

In total, 453 healthcare workers responded to our survey. Of these, 218 (48.12%) were doctors, 183 (40.40%) were nurses, and 52 (11.48%) were paramedical staff (Table 1). The respondents belong to all provinces and regions of Pakistan and were mainly male (n = 373, 82.34%). Two-thirds of the respondents were in the 21 to 34 age category (n = 302, 66.67%). Of all the respondents, 223 (49.23%) worked in tertiary care hospitals, 108 (23.84%) in secondary care hospitals, 35 (7.73%) in primary care hospitals, and 60 (13.24%) in emergency operation centers. The most frequently reported category for years of experience was 0 to 5 years, reported by 194 (42.83%) respondents. Further details on the respondent's characteristics are provided in Table 1.

When asked if they had access to PPE when needed, 156 (34.44%) respondents reported never having any access to PPE, 168 (37.09%) had access to PPE only occasionally, and 129 (28.48%) always had access (Table 2). Masks (ie, surgical, N95, and N99 masks) were the most commonly missing pieces of PPE as reported by 255 (56.29%) healthcare workers. Over one-quarter (n = 124, 27.37%) of respondents also reported missing either coverall suits, disposable gowns, protective goggles, or disposable shoe covers. The lack of PPE resulted in 71.74% of the healthcare workers to use coping strategies, with the most common strategies being the reuse of N95 masks (n = 137, 30.24%), reuse of surgical masks (n = 67, 14.79%), reuse of protective goggles (n = 56, 12.36%), and washing or chlorination of disposable gowns (n = 45, 9.93%). When asked whether they had received adequate information regarding the use of PPE to protect themselves from contracting COVID-19, only 29.80% of the healthcare workers reported that they have always received adequate information. The remaining respondents either never or only rarely received such information. Half of the respondents (n = 229, 50.55%) agreed that the information received to date about the use of PPE was clear and complete (42.16%). When asked if the information received was useful, responses were split between those who agreed it was useful (n = 263, 58.06%) and those who either disagreed (n = 97, 21.41%) or were not sure about its usefulness (n = 93, 20.53%). When asked whether they could correctly perform donning and doffing procedures for specific pieces of PPE, 75 (16.56%) of the respondents did not know how to correctly wear and remove N99 masks. Responses to donning and doffing of PPE are summarized in Table 3.

On a scale of 0 to 10, the perceived mean risk of contracting COVID-19 in the healthcare setting among healthcare workers was 7.4 ± 2. The majority (n = 312, 68.87%) of respondents perceived it as a high risk, and only 7 (1.55%) believed they were at no risk at all. The same perceived mean risk of COVID-19 outside the work environment was 6.0 ± 2.9, and 215 (47.46%) of the respondents believe it was a high risk and 11 (2.43%) perceived there was no risk. Although the perceived risk of contracting COVID-19 outside the work environment was lower, respondents were still concerned about their family members. Of the total respondents, 284 (62.69%) reported to have taken precautionary measures at home, whereas 169 (37.31%) did not taken any measures. The most common precautionary measure was to quarantine at home (n = 204, 45.03%). In an attempt to protect themselves from contracting COVID-19, a significant (P = .003) number of respondents (n = 233, 51.43%) reported to have taken prophylactic self-medication, despite a lack of evidence. The most common self-medication was the use of multivitamin supplements (20.97%) and antimalarial drugs (6.62%). Respondents were further asked if they had tested for COVID-19. Of the 453 respondents, only 136 (30.02%) tested at least once for COVID-19 and 32 (23.53%) ever tested positive. These data are summarized in Table 4.

Discussion

Ensuring a continuous supply of PPE and providing adequate training on its proper use are critical to protect healthcare workers from COVID-19. In this study we reported some of the first evidence on access and use of PPE and COVID-19 risk perception among frontline healthcare workers in Pakistan. Our results show that every third healthcare worker in Pakistan has no PPE at all, which is alarming but not uncommon in the context of COVID-19. Due to the rapidly evolving pandemic, demand for PPE surged very quickly and when combined with panic buying, hoarding, and misuse, the global stockpiles of PPE were depleted in no time. The situation has prompted most countries to impose a temporary ban on export of PPE, leading to price hikes and backlogs to meet demand. As a result, even higher-income countries such as the United States and Australia have reported shortages of PPE in healthcare settings, especially at the start of the pandemic. In April 2020, in the United States, 36% of healthcare workers had no remaining supply of face shields and nearly all had no remaining supply of at least 1 type of PPE. ¹⁸ Similarly, half of the doctors, nurses, and paramedics in Australia had at one time no access to 1 or more type of PPE. ¹⁹ To cope with shortages, healthcare workers reused PPE many times, especially N95 and N99 masks, and washed or chlorinated coverall suits and disposable gowns. Furthermore, in a bid to optimize the PPE supply, WHO has advised the healthcare authorities to establish telehealth clinics, limit the number of patients going to the hospitals, and cancel elective and nonurgent clinical procedures. ²⁰ These strategies were also adopted in Pakistan.

It is pertinent to mention that in addition to availability of PPE, access to information about the use of PPE and correct donning and doffing procedures is also crucial. Our study reports that only half of the healthcare workforce in Pakistan considered the information they received about the use of PPE to be clear. These results are consistent with findings from an April 2020 systematic review suggesting the main reasons for such ambiguities are frequent changes in national and international guidelines about the use of PPE during the course of pandemic and lack of clarity in information. ²¹ Similarly, proper donning and doffing of PPE is vital in limiting exposure to pathogens and protecting healthcare workers. ²² We found that 16.56% of the Pakistani healthcare workers did not know how to correctly doff surgical, N95, or N99 masks. A hospital base observational study carried out by the University of Illinois also showed that 90% of observed doffing was incorrect, with respect to the doffing sequence, doffing technique, or use of appropriate PPE. ²³

The first case of COVID-19 in Pakistan was reported in February 2020, and since then the risk perception of COVID-19 among the general public and healthcare workers has changed. Previously, studies have shown a link between population risk perception of a disease and protective behaviors. ²⁴ A 2011 systematic review by Koh et al ²⁵ showed that healthcare workers' risk perception can be influenced by their behaviors and that they accepted the risk as part of their job. In the current study, we found that healthcare workers had a higher perceived risk of contracting COVID-19 in the workplace than in their homes or communities. As a result, the majority adopted protective measures such as quarantining at home and the workplace. Some of them even resorted to using prophylactic medicine such as multivitamin supplements and prophylactic antibiotics. Although risk perception was high, only 30.02% of the frontline healthcare workers in Pakistan had tested for COVID-19, of whom 23.53% ever tested positive. These results are in concordance with a recent study from the United Kingdom and United States showing that healthcare workers are at significantly higher risk of contracting COVID-19 compared with the general population. ³ It is further important that all healthcare workers, especially those who do not have adequate access to PPE or who are frequently reusing PPE, should be tested regularly for COVID-19.

Although we have reported some of the first evidence of PPE access, use, and risk perceptions among frontline healthcare workers in Pakistan during the COVID-19 crisis, this study carries some limitations. The sample size was not large enough to capture the actual requirements of PPE in Pakistan. The results are not generalizable to all healthcare workers in Pakistan as the study was conducted only in a subset of healthcare workers involved in the COVID-19 response. The study was conducted in the early stages of the pandemic for a short period of time and the parameters observed might not be the actual representation of the COVID-19 response over time. Because we used an online survey tool, the possible effects of self-selection (ie, participants who selected themselves for the survey) bias, ²⁶ coverage bias (ie, internet access and timing), ²⁷ and participant characteristics (ie, age and familiarization with the internet) ²⁸ on sample size and findings cannot be ignored. Self-selection and coverage bias are particularly important in the context of health surveys, wherein the researchers have no control on selection of the participants or internet coverage, and as a result, many participants who met the eligibility criteria may have not responded to the survey.

Conclusion

Results from this online survey indicate that frontline healthcare workers in Pakistan have limited access to PPE or adequate training related to PPE. As a result, they are at high risk of contracting COVID-19. We, therefore, recommend that governments, ministries, and health system managers not only to enhance the supply of PPE but also to provide adequate training opportunities for healthcare workers to protect themselves and their families during the response to pandemic. In the long run, infection control including the use of PPE should be taught at all levels in the healthcare worker curriculum.