Knowledge and Practices Regarding Risk-Based Mask Use Among Healthcare Workers During the COVID-19 Pandemic: A Cross-Sectional Study

Introduction

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), posed substantial occupational risks to healthcare workers (HCWs), particularly those involved in direct patient care. Transmission of SARS-CoV-2 occurs predominantly through respiratory particles and close contact, while airborne transmission is of particular concern in enclosed and healthcare environments, especially during situations associated with increased generation of respiratory aerosols [1][2]. Consequently, appropriate infection-prevention measures, including the rational use of respiratory protective equipment, became an essential component of protecting HCWs during the COVID-19 pandemic.

Healthcare workers represented one of the occupational groups with repeated and prolonged exposure to potentially infected individuals. In India, SARS-CoV-2 infection among HCWs was documented early in the pandemic, and COVID-19-related mortality among doctors was also reported [3][4]. These circumstances highlighted the need for appropriate personal protective measures and greater awareness among HCWs regarding the level of exposure risk associated with different clinical activities.

Medical masks and respirators constitute an important component of infection-prevention strategies in healthcare settings. N95 respirators provide greater respiratory protection against airborne particles than conventional surgical masks, particularly when appropriately fitted [5][6]. However, during the initial phase of the pandemic, unprecedented global demand for N95 respirators and other personal protective equipment resulted in substantial supply constraints [7]. Appropriate allocation and rational use of available respiratory protective equipment therefore became particularly important to ensure that higher-level protection remained available for healthcare personnel working in settings with greater occupational exposure risk.

To address these concerns, the Ministry of Health and Family Welfare (MoH&FW), Government of India, issued guidelines on the rational use of personal protective equipment during the clinical care of patients with COVID-19 [8]. These recommendations categorized different activities and healthcare settings according to the anticipated risk of SARS-CoV-2 exposure and recommended respiratory protection according to the level of risk [8]. Such a risk-based approach was intended to protect healthcare personnel while simultaneously promoting optimal utilization of limited protective resources.

The effectiveness of these recommendations depends not only on the availability of appropriate respiratory protective equipment but also on HCWs' awareness of occupational exposure risk, their knowledge of the recommended type of mask and their adherence to these recommendations in routine clinical practice. Identifying gaps between recommended practices and actual mask use can help guide targeted infection-prevention training and strengthen preparedness for future respiratory infectious disease outbreaks.

Therefore, the present study was undertaken to assess the knowledge of healthcare workers regarding the risk of acquiring SARS-CoV-2 infection in different clinical care settings of the hospital, evaluate their knowledge of risk-appropriate mask use according to MoH&FW recommendations and assess their actual mask-wearing practices during the COVID-19 pandemic.

Aim and Objectives

Aim: To assess knowledge and practices regarding risk-based mask use among healthcare workers during the COVID-19 pandemic.

1. To assess HCWs' knowledge regarding the risk of SARS-CoV-2 exposure in different clinical care settings of the hospital.

2. To assess their knowledge of appropriate mask use according to MoH&FW recommendations.

3. To evaluate actual mask-wearing practices among HCWs.

Materials and Methods

Study Design and Setting

A cross-sectional study was conducted during September 2020 at Pt. Jawaharlal Nehru Government Medical College and Hospital, Chamba, Himachal Pradesh.

Study Population and Sample Size

The institutional healthcare workforce included 132 doctors, 147 nurses and 112 paramedical staff. Healthcare workers who met the availability criteria were approached during the study period. Approximately 238 HCWs were approached, of whom 204 participated, giving a response rate of 85.7%. The final study sample comprised 64 doctors, 42 nurses and 98 paramedical staff.

Inclusion Criterion

HCWs who were available for data collection during daytime working hours, between 9:00 AM and 4:00 PM, at the time of the study were included.

Exclusion Criteria

1. HCWs with fever, cough or breathlessness at the time of data collection.

2. HCWs who were under quarantine or working in an isolation ward.

3. HCWs working night shifts and unavailable during the designated daytime data-collection period.

Data Collection

Data were collected using a pretested, semi-structured, self-administered questionnaire based on the MoH&FW guidelines for rational use of personal protective equipment during COVID-19. The questionnaire was pilot-tested on 40 HCWs before the main study.

Assessment of Knowledge and Mask-Wearing Practices

Knowledge was assessed for 11 healthcare activities, covering both the risk of SARS-CoV-2 exposure and the appropriate mask recommended for each setting, giving a maximum knowledge score of 22. Higher scores represented greater knowledge of MoH&FW recommendations. Mask-wearing practices were assessed through interview as well as direct observation in the respective working areas.

Statistical Analysis

Data were entered and analyzed using SPSS version 20. Categorical variables were presented as frequencies and percentages and compared using the Chi-square test or Fisher's exact test, as appropriate. Mean knowledge scores among pre-clinical, para-clinical and clinical doctors were compared using one-way analysis of variance (ANOVA). A p-value <0.05 was considered statistically significant.

Ethical Considerations

The study was approved by the Institutional Ethics Committee of Pt. Jawaharlal Nehru Government Medical College, Chamba (Approval No. SPRC/GMC-CBA/20/08/01-(a)). Written informed consent was obtained from all participants, and confidentiality was maintained.

Results

A total of 204 healthcare workers participated in the study, including 64 (31.4%) doctors, 42 (20.6%) nurses and 98 (48.0%) paramedical staff. Among the doctors, 12 (18.8%) belonged to pre-clinical, 18 (28.1%) to para-clinical and 34 (53.1%) to clinical departments.

Knowledge regarding the risk of SARS-CoV-2 exposure varied considerably across different clinical care settings of the hospital. Correct responses were generally low in several routine patient-contact areas. Significant differences among doctors, nurses and paramedical staff were observed for several settings, including triage, temperature recording, the doctor's chamber, emergency care, SARI care and laboratory sample collection.

Values represent HCWs who correctly identified the guideline-defined risk category, n (%).

MoH&FW risk categories were added from the 2020 guideline on rational use of PPE. NA: not applicable because no participant gave a correct response in any group.

Knowledge regarding the recommended mask also differed among professional groups. Overall, 54.4% of HCWs correctly identified the recommended mask for the doctor's chamber in OPD, while 47.1% correctly identified the appropriate respiratory protection during care of severely ill SARI patients. No participant correctly identified the recommendation for visitors accompanying children or elderly patients.

Values represent HCWs who correctly identified the recommended respiratory protection, n (%).

For high-risk activities, the MoH&FW guideline recommends a full complement of PPE; the N95 respirator is the respiratory-protection component.

Actual mask-wearing practices also varied across different clinical care settings of the hospital. In the doctor's chamber in OPD, 23/64 (35.9%) doctors used the recommended respiratory protection. During emergency care, 2/6 (33.3%) doctors, 2/6 (33.3%) nurses and 1/8 (12.5%) paramedical staff used the recommended respiratory protection. During care of severely ill SARI patients, all HCWs assessed in the respective professional categories used the recommended respiratory protection. All ambulance drivers and laboratory staff assessed for sample collection and transportation also used the recommended protection.

n/N represents the number using the recommended respiratory protection among the number assessed in the respective setting; N therefore varies by setting.

Practice assessment combined interview and direct workplace observation. A dash indicates that the category was not assessed/applicable. For registration/help desk and sanitary staff, zero use was recorded but the denominator was not documented; a percentage is therefore not presented.

The mean knowledge score differed significantly among the three groups of doctors. Clinical doctors had the highest mean score, followed by pre-clinical and para-clinical doctors. The overall difference was statistically significant (F=6.25, p=0.003).

Discussion

The present study assessed knowledge regarding risk-based mask use and actual mask-wearing practices among healthcare workers during the COVID-19 pandemic. The findings demonstrated considerable gaps in both knowledge of occupational exposure risk and selection of appropriate respiratory protection according to MoH&FW recommendations. These gaps varied across different clinical care settings of the hospital and professional categories, with paramedical staff generally showing lower levels of knowledge than doctors and nurses.

Knowledge regarding the risk of SARS-CoV-2 exposure was low in several routine clinical care settings of the hospital. Only 15.2% of HCWs correctly identified the risk at the screening/help desk or registration counter, 21.6% at the triage area and 23.0% in the holding or waiting area. Knowledge was relatively better for the doctor's chamber in OPD (43.1%), laboratory sample collection and transportation (39.2%) and care of severely ill SARI patients (37.7%). These findings indicate that HCWs were relatively more aware of exposure risk in areas perceived as directly related to clinical care, while knowledge regarding risk in routine patient-contact areas remained inadequate.

A similar pattern was observed for knowledge regarding the appropriate type of respiratory protection. Only 12.7% of HCWs correctly identified the recommendation for the screening/help desk or registration counter, 17.2% for the triage area and 23.5% for attending emergency cases. In comparison, 54.4% correctly identified the recommendation for the doctor's chamber in OPD, 47.1% for severely ill SARI patients and 43.1% for laboratory sample collection and transportation. No participant correctly identified the recommendation applicable to visitors accompanying children or elderly patients. These findings suggest that awareness of risk-based mask recommendations was inconsistent and depended considerably on the clinical care setting of the hospital.

The present findings differ to some extent from those reported by Bala and Arora, who studied 546 HCWs from different hospitals in India and found generally good knowledge regarding hand hygiene, personal protective equipment and mask use, although gaps in infection-control practices were identified [9]. The difference may be explained by the nature of the assessment. The present study did not merely assess general awareness regarding masks but specifically evaluated whether HCWs could identify the appropriate respiratory protection according to the level of occupational exposure risk defined in MoH&FW guidelines.

Jindal et al. studied 956 healthcare students and professionals in North India and reported deficiencies in PPE-related knowledge; less than half of respondents had knowledge regarding the correct sequence of doffing PPE and the use of an N95 mask [10]. These findings are broadly consistent with the present study and indicate that general awareness of COVID-19 preventive measures does not necessarily translate into adequate knowledge regarding selection and use of respiratory protective equipment.

Professional-category differences were particularly evident in the present study. Among doctors, 56.2% correctly identified the recommended mask while attending emergency cases and 71.9% during care of severely ill SARI patients. Among nurses, the corresponding proportions were 19.0% and 76.2%, respectively, whereas knowledge among paramedical staff was considerably lower in several settings. These differences may reflect variations in clinical exposure, access to infection-control information and frequency of participation in COVID-19-related training activities.

Specialty-wise analysis among doctors also showed a significant difference in knowledge scores. Clinical doctors had the highest mean score of 9.0 ± 3.3, followed by pre-clinical doctors with 7.0 ± 2.3 and para-clinical doctors with 6.0 ± 2.9. The overall difference was statistically significant (F=6.25, p=0.003). Although no predefined cut-off was used to categorize knowledge as good or poor, all three mean scores were below the maximum possible score of 22. Greater involvement of clinical doctors in direct patient care during the pandemic may have contributed to their relatively higher knowledge; however, the cross-sectional design does not allow causal interpretation.

An important finding of the present study was the gap between knowledge and actual mask-wearing practices. In the doctor's chamber in OPD, only 23/64 (35.9%) doctors used the recommended respiratory protection. During emergency care, only 2/6 (33.3%) doctors, 2/6 (33.3%) nurses and 1/8 (12.5%) paramedical staff used the recommended protection. In contrast, compliance was better during management of severely ill SARI patients, where all HCWs assessed in the respective professional categories used the recommended protection. Similarly, all ambulance drivers and laboratory staff assessed for sample collection and transportation used the recommended protection. The very small denominators in some of these settings should be considered when interpreting the corresponding percentages.

Agarwal et al., in a cross-sectional survey of 956 HCWs from India, demonstrated suboptimal adherence to several COVID-19 preventive practices. They identified inadequate knowledge, long duty hours, shortage of PPE, high patient workload and behavioural factors as important barriers to appropriate preventive practices [11]. Their observations support the present finding that availability of guidelines alone may not ensure adequate compliance and that knowledge, workplace conditions and availability of protective equipment can influence actual practices.

The particularly low awareness regarding sanitary staff deserves attention. Only 5.4% of HCWs correctly identified the exposure-risk category applicable to sanitary staff and only 4.4% correctly identified the recommended mask. Sanitary workers are involved in environmental cleaning, handling contaminated materials and biomedical waste and may therefore experience occupational exposure. Infection-prevention training should consequently include all categories of hospital personnel rather than focusing predominantly on doctors and nurses.

The discrepancy between knowledge and practice observed in the present study should also be considered in the context of the early phase of the pandemic. Global shortages of N95 respirators and other personal protective equipment were widely reported during this period [7]. The MoH&FW guidelines therefore recommended rational allocation of respiratory protection according to the anticipated level of occupational exposure [8]. Appropriate implementation of such risk-based recommendations requires not only adequate supplies but also repeated communication of guidelines, training and supervision.

The importance of appropriate respiratory protection is further supported by evidence that SARS-CoV-2 transmission may occur from presymptomatic and asymptomatic individuals [12][13]. HCWs working in apparently lower-risk or routine clinical areas may therefore encounter infectious individuals before COVID-19 is clinically suspected. This reinforces the need for awareness of risk-appropriate infection-prevention measures across all patient-contact areas.

Although several studies from India have assessed general knowledge, attitudes, PPE use and preventive practices among HCWs, the specific combination of knowledge regarding MoH&FW-defined risk categories, selection of the corresponding recommended respiratory protection and assessment of actual workplace mask-wearing practices has been less frequently evaluated. To the best of our knowledge, no published study from Chamba district has specifically assessed both risk-based mask knowledge and actual mask-wearing practices among different categories of HCWs across different clinical care settings of the hospital according to MoH&FW recommendations. The present study therefore provides useful region-specific evidence regarding gaps between recommended and actual respiratory protection practices.

The findings emphasize the need for regular and role-specific training of doctors, nurses, paramedical personnel and support staff regarding occupational exposure risk and appropriate respiratory protection. Guidelines should be communicated in a simple and practical manner, supplemented by periodic demonstrations, workplace monitoring and reinforcement. Lessons from the COVID-19 pandemic may help healthcare institutions strengthen infection-prevention preparedness and improve protection of HCWs during future outbreaks of respiratory infectious diseases.

Limitations

This study has certain limitations. It was a single-centre, cross-sectional study conducted over a short period and therefore may not represent practices in other healthcare settings. Only HCWs available during daytime working hours were included, which may have introduced selection bias by excluding night-shift workers. Mask-wearing practices were assessed through both interview and workplace observation; therefore, self-reporting and awareness of being observed may have influenced participant behaviour. In some clinical areas, the number of HCWs available for direct assessment was small, limiting the precision and generalizability of practice-related percentages. Denominator information for a few support-service practice categories was not documented, so those findings could not be expressed as valid proportions. In addition, the study was conducted during the early phase of the COVID-19 pandemic, when availability of N95 respirators and PPE was variable and recommendations were evolving.

Conclusion

The study identified important gaps in healthcare workers' knowledge regarding risk-based mask use according to MoH&FW recommendations. Knowledge and actual mask-wearing practices varied across professional categories and different clinical care settings of the hospital, with relatively better awareness and compliance in clearly perceived high-risk areas such as the care of severely ill SARI patients. Clinical doctors had comparatively higher knowledge scores than pre-clinical and para-clinical doctors. Regular role-specific training, periodic reinforcement of infection-prevention guidelines and monitoring of workplace practices are required to improve appropriate use of respiratory protection and preparedness for future respiratory infectious disease outbreaks.

Declaration

Sources of Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Conflict of Interest

The author declares no conflict of interest.

Acknowledgments

The author gratefully acknowledges all healthcare workers who participated in the study.

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