COVID-19 spreads mainly via droplet transmission. [1]Masks act as a simple barrier that prevents respiratory droplets from reaching others. According to a recent study, use of facemasks by healthcare workers and non- healthcare workers can reduce the risk of respiratory virus infection by 80% and 47% respectively. [5]WHO also promotes the use of facemasks to prevent the spread of infection till a suitable vaccine or drug comes.[4] Therefore masks can act as a significant non- pharmaceutical intervention to prevent infection and break the chain of transmission.Since the menace of the respiratory viral infection was not much due to milder diseases and presence of effective anti-viral drugs and vaccines in pre-COVID times, facemasks and their use was not as popular as during present COVID pandemic due to its deadly nature and lack of anti-viral drugs and vaccines against it, therefore use of facemasks and correct knowledge regarding its use has suddenly became a necessity especially among medical professionals.
The overall correct rate for the medical professionals was 46.67% which indicates an overall poor awareness amongst medical professionals working in a COVID dedicated hospital of India. This is in accordance with the study done in India in which an overall moderate to poor level of knowledge and practices regarding the use of facemasks was found among medical professionals.[12] Similarly, another study among dental health professionals in India showed that less than one third of the participants recorded high overall score for COVID-19.[14] However, this is in contrast with the study conducted in Mumbai to assess the awareness among healthcare students and professionals on SARS-COV-2 for which the overall correct rate came out to be 71.2%. [15] This might be due to the fact that the above mentioned studies assessed the knowledge on SARS- COV-2 as a whole whereas our study assessed the awareness on only prevention aspect of corona virus disease. This is also in contrast with the study on dentist’s awareness and knowledge levels on the novel coronavirus-19 in Istanbul [16] Turkey and a similar study conducted by Tripathi R et al [17] in Saudi Arabia which showed an overall correct rate of 89%. Also a study done in China by showed an overall correct rate on COVID-19 of 89% [18]. Therefore, it can be inferred that there is a strong need to increase awareness among medical professionals especially regarding the use of facemasks because as compared to other countries, the awareness here is pretty low.
On further analysis of this data, it was found that the mean score increases significantly with increase in years of experience; however, no such correlation was found between the awareness score and the discipline of the medical professionals. These findings were corroborated by a similar study in which knowledge score varied significantly with educational status with postgraduates having a higher mean knowledge score than undergraduates. [14]However, Ehladi’s study [19] showed no significant correlation between the years of experience and knowledge, but the knowledge varied significantly with the department. This might be because of the differences in the sources of information. The main source of information used in Libya according to the study was TV and social media, however, the main sources of information in our country according to this study is CDC and WHO guidelines. (Fig-6)It might be possible that doctors with more experience are more comfortable and approach more to these guidelines as compared to younger doctors whereas everyone accesses TV and social media on the same rate.
According to table 2, majority of the medical professionals showed a good knowledge on how to keep facemasks when not in use,[20]reuse practices,[21] and life of N-95 in COVID dedicated conditions.[9]Whereas, very few medical professionals showed a good knowledge on disposal practices,[22](only 31.33% participants followed the correct practice of treating the mask with the hypochlorite solution before disposing in the dustbin),portals of entry of COVID-19,[23]recommendations of facemasks to non-infected as well as infected population, [24]and the difference between 3-ply and N-95 in clinical settings. [24]Only 23.7% participants were aware of the correct practice of reusing the facemask after 3 or more than 3 days but as a policy matter of the hospital, it is disposed off. A few (4.6%) participants follow the correct practice of sanitizing the facemask with steam or hydrogen peroxide solution.(Table − 2)
A face fit-test should be carried out before people wear respiratory protective equipment for the first time. Inadequate fit-test can reduce the protection provided and exposes the person to the risk of infection and lead to immediate or long-term ill health or can even put the wearer’s life in danger. [25]For the proper fit of the respirator, one must need to shave of the facial hair and put the respirator at the correct place on face and press the nose clip so as to ensure no leakage from the respirator, Respirators should have no leaks, however, should be comfortably put and not over tightened. Only 27.4% of the population undergo fit test, this is in accordance with the study in Sydney, Australia, [26] in which majority of the population are not fit tested properly and are not aware of the hospital policy for the use of facemasks. As medical professionals are the frontline warriors to tackle the menace of this disease, it is clearly the need of the hour to increase the awareness (especially among younger professionals) regarding prevention techniques, therefore more and more information needs to be disseminated to them regarding prevention.
A vast majority of the population faces the problem of difficulty in tying followed by pressure on their face and ears, humidity, not liked by children, sweat and dirt. Around 50% of the population finds them costly (fig-4). Participants also reported other problems such as acne, skin rash, odor even after brushing well, spectacles become foggy, doesn’t provide enough protection over beard, itchy, contact dermatitis, headache speech becomes incoherent etc. This is in accordance with the studies done in Sydney, Australia,[27] Germany[28] and by Letita et al, France [29] during influenza pandemic in which they mentioned several problems faced by general population in using facemasks such as pain, shortness of breath, discomfort, heat and humidity, etc., However, no study was found which assessed problems faced by medical professionals in using facemasks in COVID pandemic till now.
The extent of breathing problems associated with facemasks was determined in a Heowpeuh’s study. [30] They assessed objectively the impact of wearing simple and N95 face masks 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 with the use of N95 respirators.[31]Participants also reported that around 49% of them feel short of breath in 1–3 hours followed by 4 or more than 4 hours (23%). (Fig-5) Since, the symptoms start coming within 1–3 hours, it can be projected how difficult would it be for them to wear facemasks for 6–8 hours at a stretch. Some suggestions on the solutions for various problems mentioned are listed in table-3.
Table-3 Suggestion for better knowledge dissemination and increasing awareness.
Suggestions
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1)
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Adequate training and education must be provided to younger medical professionals regarding adequate use of facemasks.
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2)
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More focus on prevention of COVID must be put apart from dissemination of information on symptoms, diagnosis, treatment, prevalence, vaccine etc.
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3)
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More and more activities around facemasks should be encouraged such as making interesting and easy to learn videos or presentations from the guidelines so that right information reaches mass population and also young doctors find it easy to learn.
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4)
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Necessary steps should be taken to encourage media (TV news) and social media to disseminate adequate and correct information regarding preventive strategies of COVID − 19.
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5)
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More discussion on prevention should be encouraged among friends and colleagues.
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6)
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Experiments and innovations need to be encouraged in order to reduce the various problems in using facemasks without compromising with their effectiveness and make them more comfortable
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7)
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Practices such as disposing the facemask after doffing or when duty is over and not to bring them at home or resting places need to be encouraged
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The strength of this study lies in that, first, this is contributing significantly to the wide lacuna of existing knowledge regarding awareness and problems faced in using different types of facemask among medical professionals. This might give the direction in disseminating adequate knowledge in the identified area via those portals of information which can affect significantly to the awareness to the effected population and help in making the country more aware. Second, medical professionals are regularly dealing with the COVID-19 patients, therefore, their correct awareness is of the foremost importance as it may not only prevent them from infection but also motivate them to disseminate correct guidelines into the community as well thus breaking the chain of transmission. Third, this study was conducted in the biggest Covid-19 dedicated hospital of India which treated more COVID-19 patients than any other hospital in the country. Fourth, this study was conducted in the month of July and August when the menace of COVID − 19 was at its peak in the country.
However, this study has few limitations. First, the sample size was moderate with the response rate of 40.8% which is comparable to the study done in an Italian teaching hospital where response rate was 25% [31] and a study done on emergency medical service worker where response rate was 68.8%[32] but less than 85%[33] and 92%, [34]which might be due to time constraints. Secondly, participants found the questionnaire very lengthy. Thirdly, non-participation of nursing officers and other staff is also a major limitation as they also contribute significantly to the management of COVID patients.