Knowledge and awareness regarding facemasks among medical professionals in a COVID dedicated hospital – Time for introspection and system strengthening


 Background- There is a limited literature especially in India on the awareness regarding facemasks among medical professionals. Therefore the aim of the study is to assess the awareness, practices followed and problems faced in using different types of facemasks among medical professionals in a COVID dedicated hospital.Methodology- An e-survey via was conducted among medical professionals working in a tertiary care (COVID dedicated) hospital of North-India. The survey asked for the general demographic details, knowledge and awareness on facemask use, quality and various problems faced on regular or prolonged use, sanitization / disposal and recommendations to infected and non- infected people in community. Results- Survey was sent to around 368 medical professionals out of which a total of 150 participants completed the survey giving an overall response rate of 40.8%. The mean score was 9.8 +/- 2.375 out of 21 giving an overall correct rate of 46.67%. 38% and 31.33% participants knew the correct recommendations of facemasks to infected and non-infected people in the community respectively, Only 4.67% knew the correct sanitization procedures, 84% and 69.33% participants reported problems of discomfort on face and sweat issues respectively while 48.7% of the population felt some amount of breathlessness within 1-3 hours with N-95/FFP2 masks. Discussion- Awareness in this part of the world was low as compared to the western compared to countries (46.67%) which increases significantly with years of experience(p<0.001), however no such correlation of knowledge score with discipline of medical professionals was found. Since, it is the young medical force which is at the forefront to tackle the menace, therefore, institute should provide regular training and knowledge up gradation about the facemasks and adequate and accurate information needs to be disseminated to younger medical professionals via social media to prevent them from the risk of infection.

recommendations of facemasks to infected and non-infected people in the community respectively, Only 4.67% knew the correct sanitization procedures, 84% and 69.33% participants reported problems of discomfort on face and sweat issues respectively while 48.7% of the population felt some amount of breathlessness within 1-3 hours with N-95/FFP2 masks.
Discussion-Awareness in this part of the world was low as compared to the western compared to countries (46.67%) which increases signi cantly with years of experience(p<0.001), however no such correlation of knowledge score with discipline of medical professionals was found. Since, it is the young medical force which is at the forefront to tackle the menace, therefore, institute should provide regular training and knowledge up gradation about the facemasks and adequate and accurate information needs to be disseminated to younger medical professionals via social media to prevent them from the risk of infection.

Background
It is known that person to person transmission is the route for spread of COVID-19 through transmission of droplets by coughing or sneezing of an infected individual. [1,2,3] WHO has highlighted the role of nonpharmaceutical interventions such as facemasks and hand hygiene as measures to prevent the droplet transmission since in uenza pandemic in 2009 till an effective antiviral medication or vaccine comes. [4] Meta-analysis studies showed that use of facemasks among healthcare workers and non-healthcare workers can reduce the transmission of infection by 80% and 47% respectively. [5,6] Thereafter it has been stressed to make effective guidelines [7,8] for the proper selection and use of facemasks. Guidelines regarding reuse and sanitization of facemasks have also been issued by Centre for disease control (CDC). [9,10] Few studies are published in India so as to assess the awareness of COVID 19 among healthcare workers. [11,12] However, there is a wide lacuna in literature on the awareness on use of different types of facemasks among medical professionals. Medical professionals are the frontline workers in this deadly situation of pandemic, therefore, accurate knowledge regarding quality and features of facemasks and the correct practices followed by them in using different types of facemasks is of paramount importance so as to prevent transmission and hence reduce people suffering from the infection and keep the country safe.
Therefore, we conducted this study to assess the knowledge, practices followed and problems faced in using different types of facemasks among medical professionals in a COVID-19 dedicated hospital.

Methodology
This cross-sectional survey was conducted among medical professionals working in a tertiary care hospital of North-India. The ethical clearance for the study was obtained from institutional ethics committee. An e-survey was conducted in the month of July and August, when the COVID-19 situation was at the peak in the country. An online questionnaire on Google forms was created. The e-survey URL was circulated via Email and WhatsApp to the medical professionals working in the hospital and 2 reminders were sent at an interval of 2 weeks via Email and WhatsApp. The sample size came out to be 151 in a nite population of 500 upon using the formula SS[1+(1-SS/pop)]. Where SS is the sample size in in nite population which was 216 assuming the prevalence for correct rate of knowledge test among medical professionals 90% [13] and margin of error of 4% and con dence interval of 95%,

Questionnaire
The study questionnaire was divided into 3 sections, the rst section asked about the personal information such as designation, discipline, years of experience, level of triage in which they work in the hospital, type of facemask they use etc. The second section consisted of questions which assessed them on the problems they face in using different types of facemasks. The third sections consisted of questions which assessed them on the awareness they have and the right practices followed by them while using different types of facemasks. The correct answers in the questionnaire were allotted points and hence the participants were assessed from a total score of 21 points. The results were calculated and compiled using Microsoft Excel and statistical analysis was done using SPSS (IBM) version 23software.
The correlation between the personal details and the score of awareness and right practices followed was done using one-way ANOVA test.

Results
The questionnaire was sent to 368 doctors working in the hospital. Out of which 150 participants lled the questionnaire so the response rate was 40.8%. Their demographic details are given in table 1, highest mean score by 6-10 years of experience (12.09 +/-1.758). 12% (18) 19.1% (29) 12% (18) 14.7% (22) The whole survey was allotted maximum points of 21 out of which medical professionals scored a mean score of 9.8 with a standard deviation of 2.375 and hence an overall correct rate of 46.67%. On applying one way ANOVA test, association of score with discipline and years of experience was found. There is a signi cant relation between the knowledge score and years of experience of the medical professionals.
The mean score increases with years of experience(p < 0.001) (Fig-1).No signi cant relation between the knowledge score and discipline of the medical professionals was found suggesting that the awareness regarding correct practices does not depend on the discipline or specialty (p = 0.34). (Fig-2)It was found that 74% of the population uses N-95, 22.7% uses 3-ply, 2 % use clothed and some use N-99/100, FFP1, FFP2/FFP3 etc. (Fig-3) A vast majority of the population (greater than 50%) faces the problem of humidity, pressure on nose and ears, sweaty, di culty in tying and around 50% of the population thinks that facemasks are costly. (Fig-4)Also 17.8% of the population feels short of breath in less than 1 hour, 48.7% of the population in 1-3 hours, 23% in 4 or more than 4 hours and 10.5% don't feel short of breath at all. (Fig-5) Discussion 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 signi cant 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 signi cantly with increase in years of experience; however, no such correlation was found between the awareness score and the discipline of the medical professionals. These ndings were corroborated by a similar study in which knowledge score varied signi cantly with educational status with postgraduates having a higher mean knowledge score than undergraduates. [14] However, Ehladi's study [19] showed no signi cant correlation between the years of experience and knowledge, but the knowledge varied signi cantly 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 noninfected 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 t-test should be carried out before people wear respiratory protective equipment for the rst time.
Inadequate t-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 t 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 t test, this is in accordance with the study in Sydney, Australia, [26] in which majority of the population are not t 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 di culty in tying followed by pressure on their face and ears, humidity, not liked by children, sweat and dirt. Around 50% of the population nds them costly ( g-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 in uenza 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 ow 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 di cult 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. 2) More focus on prevention of COVID must be put apart from dissemination of information on symptoms, diagnosis, treatment, prevalence, vaccine etc.

3)
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 nd it easy to learn.

4)
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.

5)
More discussion on prevention should be encouraged among friends and colleagues.

6)
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

7)
Practices such as disposing the facemask after do ng or when duty is over and not to bring them at home or resting places need to be encouraged The strength of this study lies in that, rst, this is contributing signi cantly 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 identi ed area via those portals of information which can affect signi cantly 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 o cers and other staff is also a major limitation as they also contribute signi cantly to the management of COVID patients.

Conclusion
Page 9/17 The awareness among medical professionals is low (46.67%). Experienced doctors have a higher mean score, asit increases signi cantly with years of experience. The frontline workforce comprises of residents and young workforce, their knowledge regarding face-masks is of paramount importance as in the absence of any proven drug or vaccine, it is the measure to prevent any further spread of infection. This young medical force should update them regularly regarding various facemasks through the guideline's competent authorities and professional bodies. The institute should also provide regular training and knowledge up gradation about the facemasks. A proper t-test and its importance must be realized among medical professionals. Adequate knowledge among young workforce will also promote them in dissemination correct recommendations to community thus overall prevention the spread of infection. 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.
Availability of data and materials Not available.
Competing interest Figure 1 Association of knowledge score with experience (in years)

Figure 2
Page 14/17 Association of knowledge score with discipline   Problems faced in using facemasks.

Figure 5
Duration after which participants feel short of breath.