|Year : 2022 | Volume
| Issue : 3 | Page : 140-150
Prevalence of physical and psychological impacts of wearing personal protective equipment on health care workers during COVID-19: A systematic review and meta-analysis
K Radha1, Gigini George1, Abin Varghese2, Jaison Joseph3, N Vijayanarayanan4
1 Faculty, College of Nursing, Bhopal Memorial Hospital and Research Centre, ICMR, Bhopal, Madhya Pradesh, India
2 Faculty, College of Nursing, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
3 Department of Psychiatric Nursing, College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
4 Department of Medical Surgical Nursing, RD Memorial College of Nursing, Bhopal, Madhya Pradesh, India
|Date of Submission||24-Jan-2022|
|Date of Decision||12-Feb-2022|
|Date of Acceptance||12-Mar-2022|
|Date of Web Publication||26-Sep-2022|
Faculty, College of Nursing, All India Institute of Medical Sciences, Nagpur - 441 108, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic has necessitated the use of personal protective equipment (PPE) among the frontline health care workers (HCWs). Even though PPE helps in preventing infection, it poses significant physical and psychological impacts at varying levels. Correspondingly, multiple independent studies have brought out the PPE-associated problems. However, there exists a lacuna on comprehensive information of global prevalence related to the same. Aim: To estimate the prevalence and risk factors of PPE among HCWs during COVID-19 across the globe. Design: Systematic review and meta-analysis. Method: The review was undertaken as per the protocol registered in PROSPERO CRD42021272216 following Preferred Reporting Items for Systematic Reviews and Meta-Analysis(PRISMA) guidelines. Two independent reviewers have undertaken the search strategy, study selection, and methodological quality assessment. Discrepancies were addressed by the third reviewer. Heterogeneity was addressed through I2 statistics and forest plots generated by open meta-software. Results: A total of 16 articles conducted across 6 different countries among 10,182 HCWs were included in the review. The pooled prevalence of skin lesions, headache, sweating, breathing difficulty, vision difficulty, thirst/dry mouth, fatigue, and communication difficulty, anxiety, fear were 57 (47–66%), 51 (37–64%), 75 (56–90%), 44 (23–68%), 61 (21–94%), 54 (30–77%), 67 (58–76%), 74 (47–94%), 28 (24–33%), 14 (10–17%), respectively. Moreover, the various risk factors included are the use of PPE for >6 h and young females. In addition, the medical management of new-onset problems created an additional burden on the frontline health care personnel (HCP). Conclusion: The frontline HCWs encountered physical and psychological problems at varying levels as a result of wearing PPE which needs to be addressed to prevent the inadequate use of PPE leading to infections.
Keywords: Consensus, COVID-19, drug-related side effects and adverse reactions, fatigue, headache, health personnel, humans, pandemics, personal protective equipment, prevalence, risk factors, sweating, thirst
|How to cite this article:|
Radha K, George G, Varghese A, Joseph J, Vijayanarayanan N. Prevalence of physical and psychological impacts of wearing personal protective equipment on health care workers during COVID-19: A systematic review and meta-analysis. Indian J Occup Environ Med 2022;26:140-50
|How to cite this URL:|
Radha K, George G, Varghese A, Joseph J, Vijayanarayanan N. Prevalence of physical and psychological impacts of wearing personal protective equipment on health care workers during COVID-19: A systematic review and meta-analysis. Indian J Occup Environ Med [serial online] 2022 [cited 2022 Dec 3];26:140-50. Available from: https://www.ijoem.com/text.asp?2022/26/3/140/357026
| Introduction|| |
The ongoing COVID-19 pandemic has resulted in a tremendous increase in the usage of personal protective equipments (PPE) by health care workers (HCWs) to avert the transmission of SARS-CoV-2. The World Health Organization (WHO) defined PPE as a gown, non-sterile gloves, goggles, and respirator mask. Although the PPE is designed to protect HCWs from the infection, the literature has reported multiple adverse effects due to its usage. The poor ergonomics of the respirator mask leads to pressure damage and infection since majority of them comes with restricted range of size and geometry. Likewise, a vast majority (87%) of the HCWs have reported skin damage as a result of respirator mask use especially over the cheeks and the bridge of the nose. In addition, alarmingly higher rates (97%) of skin damage are reported by first-line HCWs. Scarcity in the supply and availability of PPE across various countries has constrained the HCWs to utilize the available PPE for a longer period of time which in turn contributed directly to skin damage. Extremes of temperature coupled with lack of air-conditioning have resulted in extreme sweating among HCW wearing PPE. Ultimately multiple recusant outcomes such as reduced tactile sensitivity, impaired vision, and difficult communication were encountered. Furthermore, physiological adverse events in the form of breathing difficulty were reported by HCWs using masks without valves. Similarly, headache was also reported as an adverse effect of N95 mask during earlier SARS pandemic. COVID-19 has been reported to be transmitted through contact, so hand protection is one of the most important ways to avoid COVID-19 infection. Wearing latex gloves effectively reduces the risk of contact infection among HCWs. However, the usage of gloves posed numerous unfortunate events such as dry skin, itching, and rash. Surprisingly mental health impact in the form of somnolence, anxiety, and depression are also being reported by HCWs wearing PPE. Consequent upon the multiple adverse outcomes, the PPE may not be used adequately leading to a higher chance of infection among HCWs. Absenteeism and shortage of HCWs can exhaust the already overwhelmed health care system. The aim of our systematic review and meta-analysis is to accrue the relevant literature and project a magnitude on the adverse effects of PPE for an enhanced level of understanding. Furthermore, no systematic reviews have so far addressed the current area of concern to the best of our knowledge. We believe the current review can aid the health care organizations to have an accurate insight on the physical as well as psychological problems faced by the HCWs due to the use of PPE. Eventually, this can assist the human resource team to allocate and rotate HCWs in an optimal manner between COVID and non-COVID areas.
| Aims|| |
The major focus of this systematic review was to meet the following objectives:
- The prevalence of physical impacts of wearing PPE on HCWs during COVID-19.
- The prevalence of psychological impacts of wearing PPE on HCWs during COVID-19.
- The risk factors contributing to the physical and psychological impact as a result of wearing PPE and the subsequent consequences.
| Methods|| |
Systematic review protocol registration
The protocol for this systematic review and meta-analysis has been registered at PROSPERO International Prospective Register of Systematic Reviews-CRD 42021272216.
Ethical approval was not obtained since the data used in the study was from individually published studies that were ethically approved.
The preferred reporting items for systematic review and meta-analysis were used to perform the systematic review [Supplementary Table 1]. Original articles published from January 01, 2020 were searched in the databases; PubMed, MEDLINE, Science Direct, ProQuest Central, Corona Virus Research Database, and Google Scholar. Furthermore, we screened the footnote citations from potentially relevant articles to retrieve more articles. The entire databases search was completed on October 8, 2021. Multiple keywords that were used individually or in combination with Boolean operators (AND, OR) in the title/abstract were; “difficulties on wearing PPE,” “experience with PPE,” “compliance of PPE,” “physical and psychological effects,” “problems in the use of PPE,” “influences of PPE,” “self-reported issues on the use of PPE,” “health care workers,” “health care personnel,” “health care persons,” “health workers,” “workforce,” and “health personnel” [Supplementary File 1].
The following inclusion and exclusion criteria were applied for the study: Inclusion criteria includes (a) assessed HCL working with PPE (mainly respirator mask) in hospitals; (b) analyzed the prevalence of physical and psychological outcomes due to the usage of PPE; (c) measured the prevalence of physical and psychological outcomes using validated instruments and questionnaires; (d) published articles in English language. We excluded studies with the following characteristics (a) studies not reporting the aggregate prevalence of physical and psychological outcomes even after contacting the corresponding author, (b) qualitative studies, systematic review, meta-analysis, case reports, case series, and non-accessible full-text articles; (b) studies with small sample size (N < 60).
Study selection and data extraction
Three authors (RK,GG,AV) independently reviewed the title, abstracts of the retrieved articles across different databases for eligibility. Eligible full-texts studies were reviewed after removing the duplicates manually by each reviewer. Eventually, the full-text studies were included after a mutual discussion between the reviewers. The following information was extracted from all included studies: author, month and year of publication, country, population, age and gender, tools used, design, setting, sample size, the prevalence of physical and psychological problems, duration of PPE, and risk factors or consequences.
Appraisal of study quality
Loney criteria were used to evaluate the methodological quality of the included studies. The criteria evaluate studies using eight criteria: (1) random sample or whole population (2) unbiased sampling frame (3) adequate sample size (4) standard measures (5) outcomes measured by unbiased assessors (6) adequate response rate and refusers described (7) confidence intervals (CI) and subgroups analysis and (8) study subjects described. Each item in the tool is assigned a score of one or zero with the total score ranging from 0 to 8, with more scores indicating a higher degree of quality. Eventually the scores were entered into Robvis tool to generate a risk of bias graph.
Open meta was used to analyze the data (Wallace et al. 2012). In all statistical analyzes, the significance level was considered as P < 0.05. The overall prevalence of physical and psychological outcomes among HCP was calculated using the random-effect model according to Der Simonian and Laird's approach with a 95% CI with Freeman turkey double arcsine transformation employed to stabilize the variance among the studies. Heterogeneity testing was performed using the I2 and the Cochran's Q test. Moreover, a leave one out sensitivity analysis was performed to address the potential sources of heterogeneity.
| Results|| |
The electronic search across various databases yielded 2403 citations. Among them, 1700 duplicates were removed by manual search and with the aid of software RAYAAN QCRI resulting in 703 articles that were further subjected to the title and abstract screening. A total of 170 full-text articles were exhaustively reviewed by two reviewers (RK,GG). Out of the 170 articles, 150 were excluded since primary outcome data was not reported (150) and incomplete studies where author was not reachable (4). Eventually 16 articles were included for the systematic review and meta-analysis [Figure 1].
|Figure 1: Preferred reporting items for systematic review and meta-analysis flow chart depicting the selection process of included studies|
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A comprehensive record from the studies is being depicted in [Table 1]. The studies included in the review utilized cross-sectional web-based surveys among frontline HCWs (doctors, nurses, paramedical professionals). The majority (62.5%) of the studies were conducted in a single-center or multicenter health facilities while 37.5% of studies were regional surveys. The total sample size was 10,182 ranging from 61 to 4306. As per the available data from the included studies, the majority of participants (72%) were females while 28% were males. Duration of PPE use varied from 4 to 12 h/day with the majority of the studies reporting >6 h/day.
The methodological quality of included studies was done by two reviewers (xxxx) using the Loney criteria. Discrepancies in the scoring were addressed by mutual discussion and consensus. The quality score varied from four to seven across the studies with six as the median (interquartile range: 5–6). Finally, the 16 studies with moderate and high-quality scoring were included for the estimation of pooled prevalence [Figure 2]; [Supplementary Table 2].
Prevalence of physical and psychological problems due to PPE use
Multiple physical and psychological problems such as skin lesions, headache, sweating, breathing difficulty, vision difficulties, fatigue, communication difficulties, thirst/dry mouth, fear, anxiety, and depression were reported in the included studies at varying rates due to the usage of PPE by frontline HCWs [Table 2]. (a) Skin lesions: Majority (75%) of the studies reported skin lesions in various forms. The pooled prevalence of skin lesions was 57% (47–66%) with significant heterogeneity (I2 = 98.51, P < 0.01) [Figure 3]a. (b) Headache was reported in 37.5% of the included studies with a pooled prevalence of 51% (37–64%) at significant heterogeneity (I2 = 95.37, P < 0.01) [Figure 3]b. (c) Sweating: Majority (56%) of the studies indicated sweating with a pooled prevalence of 75% (56–90%) at I2 = 99.53, P < 0.01 [Figure 3]c. (d) Breathing difficulty: Respiratory difficulty was also reported as a problem with PPE by 31% of the studies with a pooled prevalence of 44% (23–68%) at I2 = 98.28, P < 0.01 [Figure 3]d. (e) Vision difficulty: The use of goggle while wearing PPE caused vision difficulties as reported by 33.3% of studies with a pooled prevalence of 61% (21–94%) at I2 = 99.49, P < 0.01 [Figure 3]e. (f) Thirst/dry mouth, fatigue, and communication difficulties were reported by 19% of studies with a pooled prevalence 54% (30–77%), 67% (58–76%), 74% (47–94%), respectively [Figure 3]f,[Figure 3]g,[Figure 3]h.
|Figure 3: (a) Prevalence of skin-related problems due to PPE use. (b) Prevalence of headache due to PPE use. (c) Prevalence of sweating due to PPE use. (d) Prevalence of breathing difficulty due to PPE use. (e) Prevalence of vision difficulty due to PPE use. (f) Prevalence of fatigue due to PPE use. (g) Prevalence of thirst/dry mouth due to PPE use. (h)Prevalence of communication difficulty due to PPE use|
Click here to view
Psychological problems such as anxiety and fear were reported only by two studies so a fixed effect model was used resulting in a pooled prevalence of 28% (24–33%) and 14% (10–17%), respectively.
Risk factors and consequences
The duration of PPE use was a significant risk factor for many of the ailments. In particular, the use of PPE >6, 8, and 12 h were more frequently reported to be associated with physical problems. Similarly, work shift exceeding 6 h was also a risk factor. Furthermore, young females reported more skin lesions with PPE use. Consequently, the physical and psychological problems had an impact on the work performance of HCP's which can compromise the already overwhelmed health care system. In addition, the medical management of new-onset problems created an additional burden on the frontline HCWs.
A leave-one-out sensitivity analysis was carried out for each of the outcomes in the study, such as skin lesions (n = 12), headache (n = 6), sweating (n = 9), breathing difficulty (n = 5), vision difficulties (n = 4), fatigue (n = 3), communication difficulties (n = 3), and thirst/dry mouth (n = 3). Accordingly, no individual studies in each of the specified outcomes had a considerable influence on the overall pooled prevalence [Supplementary Figure 1]a and [Supplementary Figure 1]b.
| Discussion|| |
The index study summarizes the overall physical and psychological impacts of PPE among HCP during the COVID-19 pandemic across the globe. Although multiple physical and psychological problems were reported, skin lesions in various forms were the commonly reported adverse effects in the majority of studies with a pooled estimate of 57% (47–66%; n = 12 studies). Approximately 75% of the frontline workers had excessive sweating and communication difficulties with PPE along with their assumed responsibilities during the pandemic. The pooled prevalence of breathing difficulties, headache, and unusual fatigue related to PPE were 44%, 51% and 72%, respectively. There are some possible explanations for our findings. Our findings need to take with caution as there was significant heterogeneity among the studies. This was mainly due to the inconsistencies in the included studies based on outcome measures, study period, and study contexts. The onset and impact of the pandemic were different across the world. Additionally, there is a countrywide difference in health care resources and disaster preparedness. Moreover, our results are purely based on the self-reported measurements which were collected amidst the restrictions associated with the COVID-19 pandemic. Further, our findings might not be generalized considering the methodological limitations such as respondent bias and sampling bias during the global epidemic. Certainly, all these lacunae might have influenced our findings but the present study opens an area of debate regarding the magnitude of problems related to PPE during COVID-19.
PPE use and prevalence of physical problems
Our findings revealed that skin problems were the most common side effects of PPE in the majority of the studies with an aggregate estimate of 57%. The most common skin problems were a form of skin lesions, acne, and itching and were directly related to prolonged use of masks and gloves. We also noted that wearing PPE for >6–8 h is the possible explanation for the skin adverse reactions. A recent systematic review reported the rate of skin side effects related to PPE to be 75.13%. This study also pointed out that these adverse events related to mask was 57.71%, and those associated with gloves and hand hygiene products was 49.16%. In a systematic review, Keng et al. identified that the most common skin problems related to PPE were in the form of xerosis, pressure-related erythema, and contact dermatitis, mainly affecting the face and hands. It is well known from the literature that wearing PPE for longer periods will result in pressure-related injuries leading to erythema and skin indentation at the initial stage which might progress to fissures, ulcers, and secondary infections.,
The possible solutions to manage these skin problems are consistent use of emollients and selecting the less irritating hand hygiene products. Nine studies in our review reported that sweating was a major side effect related to the consistent use of PPE with a pooled prevalence of 75%. Sweating is a pertinent skin adverse effect related to PPE use especially in countries with tropical climates. Apart from the prolonged use of PPE in such climates and its longer use tends to mechanical trauma due to increased heat and humidity. Additionally, the use of goggles while wearing PPE caused vision difficulties reported by four studies included in this review with a pooled estimate of 61%. We, therefore, recommend that health care institutions consider providing well-ventilated areas and sufficient manpower especially for those who are in anticipation of prolonged working hours in PPE. Strikingly, three studies included in our review pointed out the experience of 67% of unusual fatigue among HCWs due to PPE use. Minimizing the duration of time in PPE and allowing sufficient rest are the only possible solutions to manage these occupational hazards. It is worth noting that the adverse events of PPE are directly related to long working hours which further call for intensifying organizational policies to manage the crisis. Five studies in our review reported that 44% of the HCWs had breathing difficulties. There is a wide variation in the prevalence of breathing difficulties associated with PPE use ranging from 12.2% to 65.5%., This surprising wide range of the rate of breathing difficulties might be attributed to the type of masks and the pre-existing respiratory difficulties. The available empirical data suggest an N95 mask for causing significant breathing problems as compared to surgical masks.
In this meta-analysis, we investigated PPE-associated symptoms among HCWs during the COVID-19 pandemic. Majority of the included studies attributed that many of the physical ailments were directly related to the duration of wearing PPE. Taken together our findings open a common consensus of limiting the work shifts to at least 6 h or fewer for maximizing the health and minimizing the side-effects of PPE among the frontline HCWs.
PPE use and prevalence of psychological problems
The fear and anxiety of wearing PPE during COVID-19 were reported to be 14–28% among the HCWs. Similar to the various uncertainties of the global pandemic, possible side effects of PPE were a significant burden as it was novel to the frontline workers. The existing studies suggest increasing stress and psychological morbidity among the HCWs during the pandemic., This increased psychological distress may contribute to various psychiatric and medical illnesses. Apart from the assumed health care responsibilities, there was a significant work pressure in HCWs due to shortage of manpower, frequent and prolonged work shifts, lack of resources, etc. Further, the COVID-19 imposed lockdown and overload information in the media was a predisposing factor for mental morbidity among the HCWs.,
There is a need for innovative strategies systematized to address these emerging challenges and to reinforce the effective pathways to manage the crisis. To protect the psychological health of HCWs there must be specialized need-based interventions such as ongoing surveillance systems, web-based counseling, etc., The appropriate utilization of social media platforms is very helpful to reduce the mental distress during and aftermath of the Covid-19 pandemic crisis.
Strength and Limitations
The study has been carried out as per the PRISMA guidelines with utmost scientific rigor. A comprehensive analysis of the pooled prevalence of various physical and psychological problems due to PPE use especially with the use of respirator mask across the world has been done. The limitations are also being addressed. The heterogeneity that existed across the studies needs to be taken into account while interpreting the results. Also the analysis was not possible for the individual type of PPE such as respirator mask, gloves, gown, and goggles separately since majority of the studies focused on respirator mask.
| Conclusion|| |
The current review has addressed the prevalence of physical and psychological impacts of wearing PPE. A total of 16 studies conducted across European, Asian, and Pacific regions among 10,182 HCWs were included in the review. Even though multiple physical problems were reported, the most prominent among them were skin lesions in the form of xerosis, pressure-related erythema, contact dermatitis, and difficulties encountered in vision and communication. In addition, psychological problems such as anxiety and fear were reported at modest levels. Most of the studies have attributed the duration of PPE use as a significant risk factor for many of the ailments which can be effectively tackled by limiting the work shifts to a shorter duration.
| Relevance to Clinical Practice|| |
The findings have reported the existence and prevalence of physical as well as psychological problems associated with PPE use at a higher level. Appropriate interventional strategies need to be tailored at the organizational level to combat the impact of PPE use. The review sheds light on the following: shortened shift duty hours for HCWs, planned rotation of HCWs alternating with infectious and noninfectious wards, web-based counselling to monitor the psychological health and to assess the felt needs, allowing sufficient rest (in between duty as well as after a stretch of duty days) for HCWs working with PPE, providing optimal workforce, well-ventilated areas, and appropriate nonverbal training to deal with communication difficulties (while in PPE).
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors agree with the manuscript.
- Radha K: Conceptualization, methodology, formal analysis, data curation, writing-original draft
- Gigini George: Conceptualization, data curation, visualization, investigation, methodology, writing-original draft
- Abin Varghese: Review and editing, methodology, supervision, data curation
- Jaison Joseph: Conceptualization, data curation, visualization, methodology, writing-original draft
- N. Vijayanarayanan: Data curation, methodology, supervision
The authors acknowledge the assistance offered by the chief librarian-Mr. Vijay Singh Chauhan in retrieving potential articles.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Summary Box|| |
What this paper contributes to the wider global community?
- A higher prevalence of physical as well as psychological problems due to PPE use among HCW has been reported by the review.
- Appropriate organizational policies should be constituted to prevent the impact of PPE on HCW as the pandemic is still unpredictably haunting the entire world.
- The policies should address short shift duty hours for HCWs, planned rotation of HCWs between infectious and noninfectious wards, web-based counseling, optimal workforce, well-ventilated areas, and appropriate nonverbal training to deal with communication difficulties.
| Supplementary File 1|| |
Search strategy across databases
1. MEDLINE (search hits = 1851)
((Difficulties wearing personal protective equipment's) OR (experience personal protective equipment's) OR (compliance personal protective equipment's) OR (physical psychological effects) OR (problems use personal protective equipment's) OR (influences of personal protective equipment's)) AND ((health care workers) OR (health care personnel) OR (health care persons) OR (health workers))
Filters: Full text, journal article, English, MEDLINE, from January 1, 2020 to August 31, 2021
2. Science Direct (search hits = 6)
Personal protective equipment physical effects or psychological effects
3. Coronavirus Research Database (search hits = 162)
Problems in the use of personal protective equipment AND health care workers OR health care personnel OR health care persons OR health workers OR work force OR health personnel
Narrowed by: entered date: 2020-12-01 to 2021-08-31
Source type: Scholarly journals
4. ProQuest Central (search hits = 191)
Keywords: problems in use of personal protective equipment, HCW, physical, psychological effects
Narrowed by: entered date December 01, 2020 to August 31, 2021
Full text: Full text
Source type: Scholarly journals
5. APA PsychInfo (Search hits = 8)
Keywords: problems in use of personal protective equipment, HCW, physical, psychological effects
Narrowed by: entered date December 01, 2020 to August 31, 2021
5. Google Scholar (search hits = 185)
The first 50 pages have been searched Narrowed by: entered date: 2020–2021; Source type: Scholarly Journals, Journal of Clinical Nursing (71), Journal of Advanced Nursing (32), International Journal of Mental Health Nursing (31), International Nursing Review (21), Asian Journal of Psychiatry (30)
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]