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 Table of Contents  
Year : 2022  |  Volume : 29  |  Issue : 2  |  Page : 110-115

‘Shifting from anxiety to the new normal’: A qualitative exploration on personal protective equipment use by otorhinolaryngology health-care professionals during COVID-19 pandemic

1 Department of ENT, JIPMER, Puducherry, India
2 Department of Diversity in Public Health, Institute for Health Research, University of Bedfordshire, Luton, United Kingdom
3 Department of Preventive and Social Medicine, JIPMER, Puducherry, India

Date of Submission11-Jan-2022
Date of Decision19-Feb-2022
Date of Acceptance08-Mar-2022
Date of Web Publication23-Apr-2022

Correspondence Address:
Mahalakshmy Thulasingam
Department of Preventive and Social Medicine, JIPMER, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_10_22

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Background: The novel coronavirus pandemic has influenced the working practice of health-care professionals who come across symptomatic and asymptomatic COVID patients in their day-to-day practice. Especially, among HCWs in otorhinolaryngology, with the risk of exposure being high, hence were mandated to use personal protective equipment (PPE). Materials and Methods: The change in perceptions and patterns of PPE use throughout the COVID-19 pandemic was studied in detail through interviews conducted among 15 key informants, and the data were analyzed using health belief model in our study. Results: A health belief model explains the trajectory of PPE use by otorhinolaryngology health care providers during the COVID-19 pandemic. The course of usage of PPE by otorhinolaryngology health-care professionals during the COVID-19 pandemic was explained through the health belief model. During the initial days of the COVID-19 pandemic, intense perceived severity and susceptibility to COVID infection led to PPE use, and otorhinolaryngology HCWs resorted to higher grade PPEs which gave optimal protection; but in course of time with a better understanding of the natural course of illness, minimal PPEs without compromising HCW safety were used with minimal discomfort. Perceived severity of COVID infection on self and family, health knowledge, influence of peers, and support from the institution encouraged them in using PPEs. Conclusion: We found that various aspects of health belief model such as the perceived susceptibility, perceived severity of the disease, perceived barriers and benefits in PPE use, self-efficacy, health-related knowledge, and the cues to action influence PPE use among otorhinolaryngology HCWs. The key findings can be applied in behavior change models to promote the use of PPE in the hospitals, especially during the time of pandemic.

Keywords: COVID-19, health belief model, pandemic, personal protective equipment, practise

How to cite this article:
Sivaraman G, Lakshmanan J, Paul B, Thulasingam M, Raghavan B, Raghu N, Raja K, Saxena SK. ‘Shifting from anxiety to the new normal’: A qualitative exploration on personal protective equipment use by otorhinolaryngology health-care professionals during COVID-19 pandemic. Niger Postgrad Med J 2022;29:110-5

How to cite this URL:
Sivaraman G, Lakshmanan J, Paul B, Thulasingam M, Raghavan B, Raghu N, Raja K, Saxena SK. ‘Shifting from anxiety to the new normal’: A qualitative exploration on personal protective equipment use by otorhinolaryngology health-care professionals during COVID-19 pandemic. Niger Postgrad Med J [serial online] 2022 [cited 2023 Feb 6];29:110-5. Available from: https://www.npmj.org/text.asp?2022/29/2/110/343729

  Introduction Top

Health-care professionals (HCPs) were at risk for COVID infection.[1] Infection in HCPs would largely amplify the outbreak within their health-care facility.[2] COVID-19 is a new workplace hazard, especially for the HCPs.[3] Using personal protective equipment (PPE) and following COVID appropriate behavior is essential.[3] During the initial phases and peak of the pandemic, there was a demand and supply mismatch of PPE.[4] According to the World Health Organization guidelines in March 2020, HCPs involved in aerosol-generating procedures are recommended to use respirators, eye protection, gloves, and aprons.[5] Otorhinolaryngologists during surgery and other aerosol-generating procedures are closer to the source of the aerosol, with the particle's density increasing exponentially as per the principle of diffusion.[6] A recent systematic study also confirmed the evidence that HCPs in the department of otorhinolaryngology high risk for infection.[7]

Although studies including a systematic review emphasize the need for PPE use among the HCPs involved in otorhinolaryngology procedures,[7] there is less attention on their health behavioral intention to practice their profession with PPE. Of the theories that are used to understand the behavioral intention such as the Health Belief Model, Theory of Planned Behaviour, Precaution Adoption Process Model, we adopted the Health Belief Model for this study as health motivation was the central focus of it.[8] Other studies have also adopted the HBM to understand the use of PPE.[9],[10] The HBM deals with threat perception and the risk and benefit evaluation.[11],[12] The threat perception includes the perceived susceptibility, perceived severity and cues to action. The latter includes perceived benefits and perceived barriers.[13] This study was conducted with the background understanding that HCPs working in otorhinolaryngology are at a higher risk and the gap to recognize their motivational influences on the behavioural intention to use PPE.[7] This study, therefore, adopts the HBM to understand the behavioural intention to use PPE among the HCPs working in otorhinolaryngology patient care areas.

  Materials and Methods Top

Study setting

This study was undertaken at the department of otorhinolaryngology, at a tertiary care teaching hospital from the southern part of India with 2,100 inpatient beds. This is a COVID-designated centre. This department cares for 350–400 patients (outpatient and emergency) daily, with 40 inpatients (including 8 ICU beds) and human resources composed of 5 faculty, 21 residents and around 10 nurses and support staff.

Sample size

Key-informant sampling technique was used to purposively select 15 key informants from the department of otorhinolaryngology, who were vocal and willing to spend at least 1 h for the interview: Faculty (n = 2), junior/senior residents (n = 5), nursing officers (n = 3), and ward/OPD/OT attendants (n = 3) and audiologist (n = 2). With these interviews, data saturation was attained. They worked in the department during the pandemic and for at least months before the pandemic.

Research approach

A qualitative phenomenological approach was adopted as it aims to study the lived experiences of the participants and allows them to explore their meaning.[6]

Data collection

The interview guide was based on a literature review and the gaps identified. The interview guide along with prompts was prepared based on the health belief model. The interviews were conducted in English or the local language (Tamil) based on the participant's choice by two different researchers (MT and GS) who are from the same institute, formally trained and had experience in qualitative research. Since the interviewers were from the same institute, their area of expertise was known to the participants. During the interview, the interviewee, interviewer, and a note-taker only were present and followed COVID appropriate behavior. The note-taker did not interrupt the interview.

The duration of the interviews varied between 30 and 60 min. Interviews were audio-recorded using voice changer software to ensure confidentially and give the participants a safe sense. Toward the end of each section of the discussion, key points of the interview were summarised to the participant for participant validation. The recordings were stored in a password-protected computer and were transcribed into English within 2 days of the interview. The transcripts were de-identified to maintain anonymity.

Data analysis

Manual thematic analysis was done.[6] Both inductive and deductive coding was used.[7] The constructs of the HBM informed the global themes, the sub-themes and codes were actively generated by the researcher. The data analysis was done by two investigators MT and LJ for 4 months. The analysis was then reviewed by SG, and any discrepancies were discussed to improve the correct conceptualisation of the data. Minor modifications in the statements quoted in the results section were done for clarity in English.

Ethical clearance

This study was approved by the Scientific and Ethics committee of the Institute (JIP/IEC/2020/298). Written informed consent was taken from the participants.

  Results Top

We interviewed 15 participants, 9 were male and 6 were female and their ages ranged from 26 to 50 years. Three of them were staying in a hostel and the rest stayed with their family. The transcripts were subjected to qualitative analysis focusing on individual perceptions on disease susceptibility and severity, perceived benefits, and barriers of PPE usage, health-care-related knowledge, health care practices and the cues to action during the COVID-19 pandemic. [Table 1] summarises the categories, sub-categories and codes under which the results were analysed as per the health belief model.
Table 1: Categories, sub categories and codes from the results of our study in health belief model

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Perceived susceptibility

During the initial phase of the pandemic, perceived susceptibility to COVID was high among the participants, due to the uncertainty in epidemiology and restricted availability of PPE. The high chance of COVID suspects presenting to the otorhinolaryngology outpatient department, proximity during clinical examination, and the possibility of aerosol generation were the factors that lead to higher perceived susceptibility among otorhinolaryngology HCP. This concern was expressed by a senior resident doctor: '…when we examine patient's throat, if the patient coughs, there will be more saliva, splashed over the face. It is better to wear face shields when examining the oral cavity for all patients.. I'd choose equipment that provides 100% coverage'.

Otorhinolaryngology specialists always had the query “Is this COVID?” as they usually address patients whose symptomatology is identical to that of COVID ('Identical symptomatology'). While this was specific to otorhinolaryngology, the general fear while dealing with COVID-positive patients was reflected as: 'When I began working with COVID patients, I was frightened of coming into contact with them. However, knowing that my PPE covered my entire body provided me peace of mind that I was not in direct contact…' (a Nursing Officer), overtime they adopted practices that decreased the risk of transmission, like the one described below 'We should ask the anaesthetist to stop ventilating the patient because we have opened the trachea and that patient is already COVID-19 positive patient' (Senior Resident doctor).

Perceived severity

In this category, we took into account the apprehensions of participants regarding the physical, emotional, and social adversities of COVID-19 disease. The participants were anxious about long-term sequelae, the course of the disease, and being in isolation/quarantine. The witnessed, unanticipated disease progression and mortality accelerated the fear concerning severity ('uncertain consequences of COVID illness'). One Junior resident Doctor said: '… Patients have been known to be asymptomatic over long before suddenly deteriorating and dying, including doctors and medical professionals in their early careers' (A doctor who is a Junior Resident).

Apprehension of developing the disease and being separated from family during quarantine/isolation added to the perceived severity of the disease. 'I was afraid of being isolated from my family. If I tested positive, as per the institute protocol, I would have been kept in COVID ward for 1 or 2 weeks' (Assistant Professor). 'Fear of transmitting illness to vulnerable family members' is clear from the following quotes. 'My parents were old. If they get sick, it would be difficult to take care of them. So, I followed all the necessary precautions (Audiologist)'.

Perceived barriers

Health care workers commented on the thermal discomfort, excessive sweating, dehydration, suffocation, facial pain, headache, adverse skin reactions, and the need to withhold their basic needs. 'These N95 masks are too tight, they make me breathless…' (A Junior Resident doctor). These barriers were highly reported in the initial phase when water-resistant coveralls were used because of anxiety and poor knowledge on the transmission of COVID-19. With time, health-care workers used the PPE that was essential.

With the initial coverall use, a staff nurse commented 'There was a lot of sweating and suffocation… Doffing was so relieving, it felt like I was going to Heaven' '…. also, I should add that the issue varies from person to person, such as diabetics and female nurses who are menstruating at that time… I can tell that it was very difficult' (staff nurse). These words conveyed the 'discomforts of PPE use'. They overcame these barriers by switching over to comfortable PPEs without compromising on personal protection. 'We started using, HIV kits along with N95 masks and goggles. I've seen several residents follow this only, and they didn't contract the infection after using them. Hence, we decided to continue this practice'.

At times doctors are faced with the dilemma regarding 'patient care first or personal safety first?' 'Donning of the PPE takes time. So, if a patient requires emergency care, there would be no time to put the PPE on.

Should we prioritize the safety of the patient over our own safety?' And this time barrier led to concern for both the patient and the healthcare personal safety. 'Non-availability of PPE' was an issue in the initial COVID period, and many spent their money to purchase N95 masks. Later, the institute compensated and provided an adequate number of N95 masks.

The challenges in interpersonal communication with the PPE especially in the operation theatre were narrated by a faculty as: '… not with an N95 mask, but with respirator 300 there was an extra effort for the people to understand what I was trying to say. The difficulty in routine conversation was brought up by an OPD assistant who said; 'When I talk, with mask and at a distance, they (patients) would not fully understand what I am speaking, and this led to misunderstandings and arguments'.

'Challenges during otorhinolaryngology procedures' were commented as below by a senior resident doctor. '……we can't see through the microscope or do proper syringing. We can't see anything with the bull's eye lamp. So, with time we started using only goggles (instead of face shields)… vision was poor, and goggles fogged. I discovered this trick: Dipping my goggles in spirit or savlon, helped a bit to avoid fogging. We were also limited in our mobility; we weren't as comfortable as we had been without PPE…' (Senior Resident doctor). Gradually they had to adapt themselves to PPE use.

Perceived benefits

One of the major drivers for use of PPE is the positive perception of participants about the protection from COVID-19 offered by the PPE. Participants felt that they are better protected with the N95 masks and used them more often than surgical masks. 'I don't think three-ply masks will be sufficient… The number of patients becoming positive is increasing day by day. So, it's better to use N95 mask with face shield when we examine patients and changing our gloves between patients' (junior resident). Even during shortage of N95 mask they adopted method to safely reuse the N95 mask. A comment by a junior resident highlighted: '…, I will put my N95 mask in a paper cover. And I put it aside without touching, to do anything else. And once the 1 week is over, I'll use it. I'll mention the date. The 1st day, I use it as number one, and so on so date from the time I calculate 7 days' (Junior Resident).

The use of PPE gave a sense of protection to self, family, co-workers, and patients. Adherence to PPEs gave the HCP the emotional satisfaction of protecting themselves and their vulnerable family member. 'I didn't want to infect my family. I was cautious at work and used masks, gloves, and aprons as instructed by the sister (which means Nursing Officer). At home, I also stayed in a separate room (Ward Assistant)'. This also shows that all cadres of staff were motivated and utilized PPE.

The concern of the HCP to be available to care for non-COVID patients was narrated by a junior resident doctor '… We might get infected when we see patients in the COVID ward. I felt like I needed to stay away from COVID so I am available for other patients (patients with non-COVID illness'. The need to deliver optimal patient care' stood above all constraints of PPE usage. Some also believed that regular mask use protected them from respiratory infections and allergies ('non-COVID benefits'). The perceived benefits outweighed the perceived barriers, and health care workers adhered to PPE use.


The 'familiarity with PPE use' during the pre-COVID times especially during tracheostomy made the otorhinolaryngology HCPs self-efficient and they quickly adjusted to regular use of PPE. '… since we were already using surgical masks, we became comfortable with its daily usage very easily…'.

Moreover, the use of HIV kits in the pre-COVID era, while operating patients with blood-borne infections, facilitated easy switch over and comfortable use of HIV kits instead of full coverall PPE. 'HIV kit (HIV kit is well organized set of equipment that contains safety goggles, gloves, double mask, surgical gown and leg cover) is a routine thing for us which we were using in our day-to-day practice also. So, it is not very uncomfortable. It's very easy to wear… we needed no other person to help us as for donning, doffing process'.

During the pre-COVID era, PPE were use while operating blood borne infections like HIV. This facilitated easy switch over and comfortable use of PPE during COVID-19. HIV kit is a routine thing for us which we were using in our day-to-day practice also. So, it is not very uncomfortable. It's very easy to wear…we needed no other person to help us as for donning, doffing process.

Health-related knowledge

Health care practices changed with the acquirement of knowledge about COVID and it assisted them to choose the right PPE. The knowledge was acquired via self-reading, training conducted by the institute, and informal discussions among colleagues/seniors. One Junior Resident doctor commented: '… every day we have discussions about the pandemic, what is happening around… always we discussed about PPE' (junior resident doctor).

Cues to action

The timely, regular release of updated guidelines by the institute that were aligned with the global scenario encouraged the HCP to abide by the PPE usage. 'Regular supply of PPEs' was ensured by the institute and it motivated the HCP. In addition, regular 'supervision' by senior doctors promoted PPE use. A junior resident told, 'the faculty were doing it and I did see them'. 'Role modeling' (my seniors do; hence I should do) worked here.

  Discussion Top

This phenomenological study helped to understand the motivational influences to use PPE. There were seven categories described in the health belief model: Perceived susceptibility, perceived severity, perceived barriers, perceived benefits, self-efficacy, health-related knowledge, cues to action.

The self-defined susceptibility to the COVID-19 pandemic affected PPE use. Droplet and fomite, being the main modes of transmission of COVID-19,[10],[11] HCP in Otorhinolaryngology rightly perceived that they were highly susceptible to the infection. They believed they were 'always at risk' and had a query 'Can this be COVID?' as their patient had similar symptomatology as COVID-19.[13] These factors made them adhere to PPE use. Despite uncertainty on the role of tracheostomy for weaning of mechanically ventilated patients with COVID-19,[14],[15] several tracheostomies were performed by our study participants for patients with COVID-19. In addition, during the early stages of COVID, there was no specific treatment or vaccination for COVID-19.[16] All these factors contributed to a perception of increased disease vulnerability, leading to a favorable attitude toward PPE use.[17]

In the health belief model, perceived severity refers to an individual's subjective perception of a disease's serious state, which is influenced by the current existing reality and the anticipated future events.[18] Weinstein demonstrated that a high perceived severity of disease causes proactive health-protection behaviors.[19] In our study, along with the severity of the disease per se, the social issues connected with isolation and quarantine were highlighted. As our study participants were health care workers who had no significant co-morbidities, they were mainly worried about transmitting the disease, and its severity, to vulnerable family members. Some HCP were also worried, after hearing from the media about the deaths of young medical professionals as a result of COVID.[20] Furthermore, the fact that 'not everyone has symptoms' and 'too many instances, too rapidly' raised a red flag about the seriousness of COVID-19. These perspectives on illness severity and vulnerability helped to maintain a constant level of awareness to prevent COVID, which encouraged apt use of PPE. This was emphasized by Prasetyo et al., who stated that perceived vulnerability and perceived severity had substantial indirect effects on intention to follow, as well as significant direct effects on actual and adapted behaviors, resulting in perceived efficacy.[17]

Amidst the varying perceptions on disease susceptibility and severity, the benefits offered by PPE were unquestionable, offering both direct protection to the HCPs and indirect protection to patients presenting with non-COVID illness. As frontline warriors in the fight against the COVID-19 pandemic, personal safety was crucial, as the depletion of the human resource may bring the campaign to a halt. They had to take care of themselves, and PPEs gave them the psychological comfort of complete protection, allowing them to focus on patient care. The intention to 'never go wrong' in the protection of self and others made them grab the benefits of available PPE and make the best use of it.

'Complete PPE' refers to the full coverall PPE, with goggles or face shields and leg covers and double gloves.[21] This created the satisfaction of complete protection of skin and mucosa. Concerns were also expressed by diabetic individuals and menstruating women staff during the initial COVID period when they had to work for 6–8 h in full PPE without break. Additionally, otorhinolaryngology HCPs struggled with visibility due to fogging, overall mobility, instrument handling, and proprioception, and the thought that PPE never gave the clinician 'the feel of patient.' Despite the multiple discomforts participants felt PPEs gave them more confidence to spend more time with the patient and thus better care. As the pandemic progressed to its peak, health care workers got adjusted to the discomforts of the PPE. Beyond the discomforts, stood their patient concern and the thought of providing optimal care to the patient; 'my patient should not suffer.'

Unlike in other specialties, otorhinolaryngology professionals were used to masks and gloves in their routine practice even before the COVID pandemic. The familiarity with PPE enabled them to quickly adjust to its regular use. Only, there was a need to change from an ordinary three-ply mask to an N95 mask.[22] Being in a surgical specialty, they were used to operating with PPE.[23] This self-efficacy; the thought that 'this is not something new,' ensured better adherence to PPE use in the Otorhinolaryngology Department.

Fear and concerns drove rigorous adherence to PPE use in the early days of the pandemic. Subsequently, it became an informed decision based on evidence. This understanding was gained through sharing personal experiences and observing the health care practices of colleagues/seniors who had remained disease-free, as well as learning lessons from those who were affected by the disease. The regular capacity-building sessions by the institute, timely release of guidelines, and supervision of the health care practices added to adherence to PPE use. Chris Carter et al. also highlights those integrated efforts, a coherent policy with guidelines for practice enabled better control over the pandemic with available limited resources.[24]

Our participants made a special mention of N95 masks. In the beginning, the transition from surgical mask to N95 mask was difficult. Unlike surgical masks, N95 masks caused discomfort and suffocation as they are tight-fitting, as stated by some participants. But with the psychological satisfaction that N95 masks offer better protection encouraged better compliance. Even during shortage of N95 mask, participants used methods to reuse the mask as per the guidelines.[25],[26]

Guidelines/recommendations kept aside;[27] it is the health beliefs/intentions that determine the adherence to PPE. Proper adherence to available resources was noted. This infers that not only the resource setting but also the right perceptions of the disease make the difference and encourages the use of 'right PPE at the right time'.

From our study is factors that assisted them like perceived severity to self and family, health knowledge, influence of peers and support from the institution encouraged them in using PPEs are discussed in detail; highlighting the importance of N95 mask use. This finding can shed lights on why the healthcare worker are reluctant to use PPE though they are at high risk of being infected. It is recommended that in future the key findings can be applied in behavior change models to promote the use of PPE in the hospitals during the time of pandemic.

The strengths of our study were that it captured the existing practices with PPE and strengthened the understanding of individual perceptions about PPE among HCPs working in otorhinolaryngology. The study included all cadre of staff working in a relatively low-resource setting.

  Conclusion Top

During the initial days of the COVID pandemic, intense perceived severity and susceptibility to COVID infection led to PPE use, and otorhinolaryngology HCWs resorted to higher grade PPEs which gave optimal protection; but in course of time with a better understanding of the natural course of illness, minimal PPEs without compromising HCW safety were used with minimal discomfort. The factors that assisted them like perceived severity to self and family, health knowledge, influence of peers and support from the institution encouraged them in using PPEs are discussed in detail; highlighting the importance of N95 mask use.

It is recommended that the key findings can be applied in behavior change models to promote the use of PPE in the hospitals especially during the time of pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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