Advertisement

Determinants of nurse's and personal support worker's adherence to facial protective equipment in a community setting during the COVID-19 pandemic in Ontario, Canada: A pilot study

  • Emily C King
    Correspondence
    Correspondence Author: Emily C King, PhD, VHA Home HealthCare, 30 Soudan Ave – Suite 600, Toronto ON Canada M4S 1V6
    Affiliations
    VHA Home HealthCare, 30 Soudan Ave – Suite 600, Toronto, ON, Canada M4S 1V6

    Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada M5T 3M7
    Search for articles by this author
  • Katherine AP Zagrodney
    Affiliations
    VHA Home HealthCare, 30 Soudan Ave – Suite 600, Toronto, ON, Canada M4S 1V6

    Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada M5T 3M7
    Search for articles by this author
  • Sandra M McKay
    Affiliations
    VHA Home HealthCare, 30 Soudan Ave – Suite 600, Toronto, ON, Canada M4S 1V6

    Department of Physical Therapy, University of Toronto, 500 University Ave, Toronto, ON, Canada M5G 1V7

    Ted Rogers School of Management, Ryerson University, 55 Dundas St W, Toronto, ON, Canada M5G 2C3

    The Institute for Education Research (TEIR), University Health Network, 222 St. Patrick St., Toronto, ON, Canada M5T 1V4

    Michael Garron Hospital, Toronto East Health Network, 825 Coxwell Ave, East York, ON, M4C 3E7
    Search for articles by this author
  • D Linn Holness
    Affiliations
    Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada M5T 3M7

    Temerty Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, Canada M5S 3H2

    Department of Medicine and MAP Centre for Urban Health Solutions, St Michael's Hospital, Unity Health Toronto, 36 Queen St E, Toronto, ON, Canada M5B 1W8
    Search for articles by this author
  • Kathryn A Nichol
    Affiliations
    VHA Home HealthCare, 30 Soudan Ave – Suite 600, Toronto, ON, Canada M4S 1V6

    Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada M5T 3M7
    Search for articles by this author

      ABSTRACT

      Background

      Appropriate and consistent facial protective equipment (FPE) use is critical for preventing respiratory illness transmission. Little is known about FPE adherence by home care providers. The purpose of this study is to adapt an existing facial protection questionnaire and use it to develop an initial understanding of factors influencing home care providers’ adherence to FPE during the COVID-19 pandemic.

      Methods

      A survey was shared with home care providers during Wave 2 of the COVID-19 pandemic in Ontario. Descriptive statistics and logistic regression by FPE adherence were conducted across individual, organizational, and environmental factors.

      Results

      Of the 199 respondents (140 personal support workers; 59 nurses), 71% reported that they always used FPE as required, with greater adherence to masks (89%) than eye protection (73%). The always-adherent reported greater perceived FPE efficacy, knowledge of recommended use and perceived occupational risk, lower education, and not experiencing personal barriers (including difficulty seeing, discomfort, communication challenges).

      Discussion

      Adherence rates were relatively high. In this context, with participants reporting high levels of organizational support, individual-level factors were the significant predictors of adherence.

      Conclusions

      Initiatives addressing perceived FPE efficacy, knowledge of recommended use, perception of at-work risk, and personal barriers to use may improve FPE adherence.

      Keywords

      INTRODUCTION

      The COVID-19 pandemic has highlighted the importance of home care within the broader healthcare system and the tremendous value that home care providers offer by enabling clients to live and receive care safely at home, rather than in institutions. This value is directly related to the necessary focus on interrupting or stopping the transmission of infection, as evidenced by the much lower infection rates amongst both workers and care recipients in this sector
      • West E.A.
      • Kotoun O.J.
      • Schori L.J.
      • Kopp J.
      • Kaufmann M.
      • Rasi M.
      • Fehr J.
      • Puhan M.A.
      • Frei A.
      Corona Immunitas Research, G.
      Seroprevalence of SARS-CoV-2 antibodies, associated factors, experiences and attitudes of nursing home and home healthcare employees in Switzerland.
      . This sector, like others in global health care systems, faced extreme challenges early in the pandemic related to securing adequate supplies of facial protective equipment (FPE) and other necessary infection prevention and control (IPAC) supplies. These shortages were managed through extraordinary measures including rationing, extended use and limited reuse of these scarce resources
      • Shang J.
      • Chastain A.M.
      • Perera U.G.E.
      • Quigley D.D.
      • Fu C.J.
      • Dick A.W.
      • Pogorzelska-Maziarz M.
      • Stone P.W.
      COVID-19 Preparedness in US Home Health Care Agencies.
      ;
      • van den Bulck A.O.E.
      • de Korte M.H.
      • Metzelthin S.F.
      • Elissen A.M.J.
      • Everink I.H.J.
      • Ruwaard D.
      • Mikkers M.C.
      In the Eye of the Storm: A Quantitative and Qualitative Account of the Impact of the COVID-19 Pandemic on Dutch Home Healthcare.
      .
      Home-based health care has important differences from institution-based health care (whether in hospitals or long-term care facilities) that impact infection prevention and control including differences in workforce composition, less convenient access to colleagues and supplies, and differences in pre-pandemicIPAC practices. The home care workforce is composed predominantly of unregulated ‘paraprofessional’ workers (known as personal support workers (PSWs), home care aides, home health aides, personal care aides) who provide 70-80% of paid home care (Home Care Sector Study
      Home Care Sector Study Corporation
      Canadian home care human resources study.
      . Nurses in home care may hold either a Registered Practical Nurse designation, which requires a 2-year diploma program, or a Registered Nurse designation, which requires a Bachelor's degree. Home care workers typically work alone in clients’ homes, with relatively limited contact with colleagues
      • Lang A.
      • Edwards N.
      • Fleiszer A.
      Safety in home care: a broadened perspective of patient safety.
      access only to the personal protective equipment that they carry or have pre-delivered to the client's home, and little opportunity for just-in-time education on its use. Furthermore, while hand hygiene and gloves are commonly used in home care and homecare providers are educated and trained in the appropriate use of facial protective equipment, regular use of face masks and eye protection was previously relatively uncommon, as these precautions were necessary in only a small proportion of client visits.
      Facial protective equipment is a critical barrier to reduce the transmission of COVID-19 and other respiratory infections
      • McMichael T.M.
      • Duca L.M.
      • Lewis J.
      • Riedo F.X.
      • Wilde N.
      • McDonald M.
      • Spitters C.
      • Wechkin H.A.
      Use of standard, contact, and droplet precautions with eye protection for the prevention of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission among home healthcare personnel in hospice and home healthcare settings-King and Snohomish counties, Washington, February-October 2020.
      but adherence with recommended usage has historically been relatively low, even amongst health care workers. Although little work has focused on the home care setting
      • Houghton C.
      • Meskell P.
      • Delaney H.
      • Smalle M.
      • Glenton C.
      • Booth A.
      • Chan X.H.S.
      • Devane D.
      • Biesty L.M.
      Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis.
      , studies that have examined FPE adherence by nurses in hospital and clinic settings have found that adherence rates are typically relatively low, at 22% - 44%
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      ;
      • Turnberg W.
      • Daniell W.
      • Seixas N.
      • Simpson T.
      • Van Buren J.
      • Lipkin E.
      • Duchin J.
      Appraisal of recommended respiratory infection control practices in primary care and emergency department settings.
      ; the only study to have reported data separately for nursing assistants (another term for PSWs that is typically used in hospital settings) found adherence rates comparable to those for nurses in the same study (20% adherence to eye protection; 34% adherence to masks)
      • Turnberg W.
      • Daniell W.
      • Seixas N.
      • Simpson T.
      • Van Buren J.
      • Lipkin E.
      • Duchin J.
      Appraisal of recommended respiratory infection control practices in primary care and emergency department settings.
      . The sole published study focused on home care was a survey of 353 US nurses in a non-epidemic/pandemic context that found a self-reported rate of eye protection use to be 69%; rates of mask use were not reported
      • Adams V.
      • Song J.
      • Shang J.
      • McDonald M.
      • Dowding D.
      • Ojo M.
      • Russell D.
      Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
      .
      Unsurprisingly, higher adherence rates are typically found in facilities and units specialized to care for patients with infectious diseases. Higher adherence rates have been found in Canadian hospitals caring for patients with SARS CoV-1 (77%) (with higher adherence to respiratory protection (94%) than to eye protection (74%))
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . High adherence has also been found to respirators and eye protection in Thai hospitals caring for patients with MERS (100%)
      • Wiboonchutikul S.
      • Manosuthi W.
      • Likanonsakul S.
      • Sangsajja C.
      • Kongsanan P.
      • Nitiyanontakij R.
      • Thientong V.
      • Lerdsamran H.
      • Puthavathana P.
      Lack of transmission among healthcare workers in contact with a case of Middle East respiratory syndrome coronavirus infection in Thailand.
      , and to masks in hospitals caring for patients with pandemic H1N1 in Thailand (74%), China (55%), Hong Kong (70-96%) and Singapore (82-88%) and the United Kingdom (25-62%)
      • Chokephaibulkit K.
      • Assanasen S.
      • Apisarnthanarak A.
      • Rongrungruang Y.
      • Kachintorn K.
      • Tuntiwattanapibul Y.
      • Judaeng T.
      • Puthavathana P.
      Seroprevalence of 2009 H1N1 virus infection and self-reported infection control practices among healthcare professionals following the first outbreak in Bangkok, Thailand.
      ;
      • Chor J.S.
      • Pada S.K.
      • Stephenson I.
      • Goggins W.B.
      • Tambyah P.A.
      • Medina M.
      • Lee N.
      • Leung T.F.
      • Ngai K.L.
      • Law S.K.
      • Rainer T.H.
      • Griffiths S.
      • Chan P.K.
      Differences in the compliance with hospital infection control practices during the 2009 influenza H1N1 pandemic in three countries.
      ;
      • Hu X.
      • Zhang Z.
      • Li N.
      • Liu D.
      • Zhang L.
      • He W.
      • Zhang W.
      • Li Y.
      • Zhu C.
      • Zhu G.
      • Zhang L.
      • Xu F.
      • Wang S.
      • Cao X.
      • Zhao H.
      • Li Q.
      • Zhang X.
      • Lin J.
      • Zhao S.
      • Li C.
      • Du B.
      China Critical Care Clinical Trial, G.
      Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
      . Adherence can also change over time: Canadian health care providers caring for SARS CoV-1 patients had low adherence at the beginning of the epidemic (35% of shifts) in March 2003 but very high adherence (97% of shifts) only three months later
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . Studies to date that have focused on the COVID-19 pandemic have reported mixed results. Studies conducted in some hospital and primary care settings have found near-perfect adherence to respiratory and/or eye protection (e.g. in Hong Kong, Oman and Italy) (Al
      • Al Abri Z.G.H.
      • Al Zeedi M.
      • Al Lawati A.A.
      Risk Factors Associated with COVID-19 Infected Healthcare Workers in Muscat Governorate, Oman.
      ;
      • Ippolito M.
      • Ramanan M.
      • Bellina D.
      • Catalisano G.
      • Iozzo P.
      • Di Guardo A.
      • Moscarelli A.
      • Grasselli G.
      • Giarratano A.
      • Bassetti M.
      • Tabah A.
      • Cortegiani A.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ;
      • Wong S.C.
      • Lam G.K.
      • AuYeung C.H.
      • Chan V.W.
      • Wong N.L.
      • So S.Y.
      • Chen J.H.
      • Hung I.F.
      • Chan J.F.
      • Yuen K.Y.
      • Cheng V.C.
      Absence of nosocomial influenza and respiratory syncytial virus infection in the coronavirus disease 2019 (COVID-19) era: Implication of universal masking in hospitals.
      , while others have reported lower rates (e.g. hospitals in the UAE (78% mask adherence, 51% eye protection), the US (42-86%) and Ethiopia (35% masks adherence, 15% for eye protection)
      • Atnafie S.A.
      • Anteneh D.A.
      • Yimenu D.K.
      • Kifle Z.D.
      Assessment of exposure risks to COVID-19 among frontline health care workers in Amhara Region, Ethiopia: A cross-sectional survey.
      ;
      • Bani-Issa W.A.
      • Al Nusair H.
      • Altamimi A.
      • Hatahet S.
      • Deyab F.
      • Fakhry R.
      • Saqan R.
      • Ahmad S.
      • Almazem F
      Self-Report Assessment of Nurses' Risk for Infection After Exposure to Patients With Coronavirus Disease (COVID-19) in the United Arab Emirates.
      ;
      • Darwish O.A.
      • Aggarwal A.
      • Karvar M.
      • Ma C.
      • Haug V.
      • Wu M.
      • Orgill D.P.
      • Panayi A.C.
      Adherence to Personal Protective Equipment Guidelines During the COVID-19 Pandemic Among Health Care Personnel in the United States.
      ;
      • Sartori N.
      Evaluating Personal Protective Equipment Compliance in the Midst of a Pandemic.
      .
      To inform interventions to promote adherence, it is necessary to understand the predisposing, reinforcing, and enabling factors that influence health care workers’ choices regarding the use of FPE. At the individual level, previous work conducted in hospital and clinic settings has found adherence to be improved by having a longer tenure in a health care role, increased frequency of use, a higher perception of risk, positive attitudes toward FPE (including feeling protected by it), and an absence of personal barriers such as discomfort, visual clarity,interference of the FPE with care, and the impact on client relationships (e.g. communication difficulties or concern about offending clients)
      • Bani-Issa W.A.
      • Al Nusair H.
      • Altamimi A.
      • Hatahet S.
      • Deyab F.
      • Fakhry R.
      • Saqan R.
      • Ahmad S.
      • Almazem F
      Self-Report Assessment of Nurses' Risk for Infection After Exposure to Patients With Coronavirus Disease (COVID-19) in the United Arab Emirates.
      ;
      • Barratt R.
      • Gilbert G.L.
      • Shaban R.Z.
      • Wyer M.
      • Hor S.Y.
      Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians.
      ;
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      • Prakash G.
      • Shetty P.
      • Thiagarajan S.
      • Gulia A.
      • Pandrowala S.
      • Singh L.
      • Thorat V.
      • Patil V.
      • Divatia J.V.
      • Puri A.
      • Pramesh C.S.
      Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic.
      • Sartori N.
      Evaluating Personal Protective Equipment Compliance in the Midst of a Pandemic.
      ;
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . At the organizational and environmental levels, adherence has been found to be greater when FPE is readily available, workers have clear training and clarity on FPE usage policies, and workers perceive high organizational support – including organizational, supervisory and peer support, positive communication surrounding health and safety, role modeling and instructional feedback from supervisors and managers, and support for changing work practices
      • Adams V.
      • Song J.
      • Shang J.
      • McDonald M.
      • Dowding D.
      • Ojo M.
      • Russell D.
      Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
      ; Al
      • Al Abri Z.G.H.
      • Al Zeedi M.
      • Al Lawati A.A.
      Risk Factors Associated with COVID-19 Infected Healthcare Workers in Muscat Governorate, Oman.
      ;
      • Barratt R.
      • Gilbert G.L.
      • Shaban R.Z.
      • Wyer M.
      • Hor S.Y.
      Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians.
      ;
      • Chughtai A.A.
      • Seale H.
      • Rawlinson W.D.
      • Kunasekaran M.
      • Macintyre C.R.
      Selection and Use of Respiratory Protection by Healthcare Workers to Protect from Infectious Diseases in Hospital Settings.
      ;
      • Hu X.
      • Zhang Z.
      • Li N.
      • Liu D.
      • Zhang L.
      • He W.
      • Zhang W.
      • Li Y.
      • Zhu C.
      • Zhu G.
      • Zhang L.
      • Xu F.
      • Wang S.
      • Cao X.
      • Zhao H.
      • Li Q.
      • Zhang X.
      • Lin J.
      • Zhao S.
      • Li C.
      • Du B.
      China Critical Care Clinical Trial, G.
      Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
      ;
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . The environmental and organizational influences on home care workers, who typically work alone in settings that are neither designed for care nor controlled and resourced by the employer, differ greatly from those who work in acute, clinic and congregate settings. Furthermore, the use of FPE was not previously common in this context. The sole study of home care nurses found adherence to IPAC protocols (including FPE use) to be promoted by having a sufficient supply of equipment and lack of in-home barriers; investigation of most of the above-listed individual, organizational, and environmental factors was beyond its scope
      • Adams V.
      • Song J.
      • Shang J.
      • McDonald M.
      • Dowding D.
      • Ojo M.
      • Russell D.
      Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
      .
      Sector-specific research is needed to understand how nurses (both registered practical nurses and registered nurses) and PSWs in home care used FPE to limit the spread of respiratory illness during the COVID-19 pandemic. Such findings would provide employers with information on how to increase FPE adherence to safeguard the health of home care providers and their clients. To that end, the objectives of this study were to:
      • 1
        Adapt an existing Facial Protection Questionnaire (FPQ) instrument
        • Nichol K.
        • Bigelow P.
        • O'Brien-Pallas L.
        • McGeer A.
        • Manno M.
        • Holness D.L.
        The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals.
        ;
        • Nichol K.
        • McGeer A.
        • Bigelow P.
        • O'Brien-Pallas L.
        • Scott J.
        • Holness D.L.
        Behind the mask: Determinants of nurse's adherence to facial protective equipment.
        for use with nurses and PSWs in home care during the present COVID-19 pandemic.
      • 2
        Pilot-test the survey with a moderate sample of home care workers (PSWs and nurses) to develop an initial understanding of the individual, environmental and organizational factors influencing their use of FPE during the COVID-19 pandemic.

      METHODS

      Study design and study participants

      This study was designed as a pilot to inform a larger and more comprehensive multi-organizational project. It employed a cross-sectional survey design, with surveys administered at one large home care organization in the Greater Toronto Area of Ontario, Canada. Ethics approval was obtained from the University of Toronto's Research Ethics Board and the study purpose was shared with participants through the informed consent process.
      Nurses and PSWs employed by the organization were invited to participate in the online survey via an email from the research team, forwarded by their supervisors. Participants were offered a $20 gift card as compensation for their time. The survey was available to participants from January 27, 2021 – February 10, 2021, during the second wave of the pandemic in the region studied. A reminder email was sent to nurses only on January 29th, 2021 to support the recruitment of a sufficient sample of respondents from this group.

      Survey tool

      The questionnaire developed for use in this study is an adaptation of the Facial Protection Questionnaire used by Nichol et al
      • Nichol K.
      • Bigelow P.
      • O'Brien-Pallas L.
      • McGeer A.
      • Manno M.
      • Holness D.L.
      The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals.
      ,
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      with nurses working in the acute care sector, which follows the PRECEDE model to explore the Predisposing, Reinforcing, and Enabling Factors in Educational Diagnosis and Evaluation as adapted to understanding self-protective behaviour at work
      • Nichol K.
      • Bigelow P.
      • O'Brien-Pallas L.
      • McGeer A.
      • Manno M.
      • Holness D.L.
      The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals.
      . For the present study, the FPQ was adapted to reflect: (1) home care-specific language and working conditions; (2) the inclusion of unregulated healthcare providers (PSWs) as well as nurses (RPNs and RNs); (3) the circumstances of the ongoing COVID-19 pandemic, including changes to FPE usage guidelines resulting from supply shortages, and (4) a focus on droplet rather than airborne precautions to reflect contemporaneous local public health on preventing the transmission of COVID-19.
      The new home care-focused, COVID-19-specific version of the FPQ (FPQ-HC-C19) was a 5-part, 95-item questionnaire, measuring demographics and work patterns (Part 1), individual factors that may affect adherence (Part 2), adherence to recommended use of FPE (Part 3), environmental factors (Part 4) and organizational factors that may influence adherence (Part 5). The survey is available upon request.
      Part 1 included 15 items that measured demographic information, work patterns, and frequency of FPE use (daily, weekly, monthly, rarely, never) before and after the start of the COVID-19 pandemic. Participants responded using checkboxes or by filling in blanks.
      Part 2 explored individual factors which may have affected adherence including knowledge of how COVID-19 is transmitted (5 items), knowledge of facial protection use and the effectiveness of preventative actions (7 items), exposure history and personal impacts (6 items), perception of risk (3 items), and personal barriers to the use of FPE (18 items). Most questions used Likert scales (strongly agree/agree/neutral/disagree/strongly disagree), plus a ‘don't know’ option for the knowledge questions. The single exception was: “Do you know people who have been exposed to an infectious respiratory illness at work which resulted in a negative physical and/or mental health outcome?”, which used a yes/no response supplemented by checkboxes to specify the relationship to these individual(s) (family member/close friend/colleague/someone else I know).
      Part 3 examined adherence to recommended use of each surgical masks and eye protection within 2 meters of a client with a suspected or diagnosed droplet spread disease, both before (4 items) and since the start of the COVID-19 pandemic (6 items, including within 2 meters of any client, to reflect newly required IPAC practices). Responses for the time before the COVID-19 pandemic used a 5-point Likert scale (always/mostly/sometimes/rarely/never), while questions which asked about the participant's current practice used the same 5-point Likert scale, supplemented by a ‘not applicable’ option. For a respondent's current practice to be deemed ‘adherent’, they had to answer ‘always’ to all six of the current practice questions, thus reflecting adherence to the FPE use practices required at the time of the survey. This definition is stricter than was used in the original FPQ and reflects the heightened risk and demands for consistency during the COVID-19 pandemic.
      Part 4 of the survey asked about environmental factors that could influence adherence: the availability of (4 items) and convenience of access to (2 items) FPE, and media coverage of COVID-19 (2 items). 5-point Likert scales (strongly agree/agree/neutral/disagree/strongly disagree) were used for each item, except a question about training dates.
      Part 5 of the survey measured organizational factors, including organizational support for health and safety (6 items), absence of job hinderances (3 items), training (6 Likert-scale items plus a training date) and communication (7 items). All items are very similar to those from the original FPQ (which drew from established scales) and use 5-point Likert scales (strongly agree/agree/neutral/disagree/strongly disagree).
      Finally, at the end of the survey, respondents were encouraged to share any additional information regarding FPE.

      Pretesting of the survey tool

      The revised FPQ was pre-tested by three PSWs and three nurses from the host home care agency. Feedback from these testers was used to simplify the survey flow, remove questions about the organization of the care environment that were deemed non-relevant, and adapt the phrasing of some questions to make their intent easier to understand. It is the final/revised version of the survey tool that is described above. This final tool contained 95 items.

      Statistical Analysis

      This study used descriptive statistics consisting of frequency distributions (proportions) or means for each variable separated by FPE adherence (‘Always adherent’ versus ‘Not always adherent’). Additionally, tests of significance through chi-square for categorical and t-test for continuous explanatory variables against adherence were performed with a significance threshold of p≤0.05. Lastly, a logistic regression was utilized to test the relative statistical significance of multiple explanatory variables on FPE adherence. Adjusted odds ratios (OR) were used for interpretation, with a value of 1.0 signifying equal probability between outcome variable groups of always adherent versus not always adherent. All analyses utilized RStudio software (Version 1.4.1103). Supplementary analyses provided more detail about specific personal barriers to using FPE by providing proportions for each individual survey item as well as assessing combined personal barriers to each mask, face shield, and eye protection use.

      RESULTS

      Sample

      Complete surveys were submitted by 199 participants – 140 PSWs (70.4% of the sample) and 59 nurses. Participants took an average of 19 minutes to complete the survey. The majority of respondents were female (92.5%) and the average age was 44 years (Table 1). Most respondents had full-time employment status (83.9%); respondents had an average of 9.3 years of experience in their roles. Having obtained a Diploma/Certificate as their highest educational attainment was more common (83.4%) than Bachelors/Masters/Doctoral degrees (16.6%).
      Table 1Demographic characteristics of the sample
      VariableDescriptionn or Mean (% or SD)
      SexFemale184 (92.5%)
      Age (years)(continuous)44.1 (10.4)
      Highest Education
      Diploma/Certificate166 (83.4%)
      Bachelors/Masters/Doctoral33 (16.6%)
      Role
      PSW140 (70.4%)
      Nursing59 (29.6%)
      Tenure in role (years)(continuous)9.34 (7.72)
      Tenure in role within primary employment

      organization (years)
      (continuous)6.56 (5.85)
      Employment status
      Full-time167 (83.9%)
      Part-time/Casual32 (16.1%)
      Hours worked(continuous)34.2 (10.8)
      Leadership RoleYes59 (29.6%)
      More than one employerYes65 (32.7%)
      Employed in retirement or long-term care homeYes17 (8.5%)
      Client Location
      Private homes/apartments167 (83.9%)
      Congregate care24 (12.1%)
      Other8 (4.0%)
      Mode of travel to work includes drivingYes131 (65.8%)
      Mode of travel to work includes public transitYes86 (43.2%)
      Mode of travel to work includes walkingYes40 (20.1%)

      Adherence

      The majority responded as always adherent with FPE (n=141, 71%), while approximately one-third reported not always adherent with FPE (n=58, 29%: mostly (n=26, 13%), sometimes (n=24, 12%), rarely (n=3, 2%), or never(n=5, 3%)). Adherence rates were 71% for both PSWs and nurses. FPE adherence rates differed by type, with higher adherence to surgical masks (n=177, 89%) than eye protection (n=145, 73%).

      Univariate and bivariate analysis

      Table 2 reports proportions/means and statistical significance (chi-squared or t-test) for each explanatory variable by the outcome variable for FPE adherence. Multiple factors were significantly correlated with FPE adherence. Education was significantly correlated with overall FPE adherence, with higher proportions of more educated individuals (Bachelors or above) in the not always adherent group (28%) versus the always adherent group (12%). Perceived efficacy was significantly correlated with FPE adherence; low perceived efficacy was more prevalent for those that were not always adherent (19%) versus those that were always adherent (4%). Knowledge of FPE recommendations was significantly correlated with FPE adherence and the majority of the sub-sample that were not always FPE adherent demonstrated gaps in their knowledge of recommended use (64%). Perception of risk was significantly correlated with FPE adherence and perceived risk tended to be lower for those that were non-adherent (48%) versus those that were always adherent (32%). Use of surgical masks or eye protection prior to the COVID-19 pandemic was significantly correlated with FPE adherence during the pandemic.
      Table 2Relationship between adherence with the use of facial protection and each demographic, individual, environmental, and organization factor
      Always AdherentNot Always Adherentp-value
      VariableDescriptionLeveln or Mean (% or SD)n or Mean(% or SD)Chi-square or t-test
      DemographicGenderFemale130 (92.2%)54 (93.1%)1.00
      Male11 (7.80%)4 (6.90%)
      Age(continuous)45.0 (10.1)41.9 (11.0)0.07
      Highest Education**0.01
      Diploma/Certificate124 (87.9%)42 (72.4%)
      Bachelors/Masters/Doctoral17 (12.1%)16 (27.6%)
      EmploymentRole1.00
      PSW99 (70.2%)41 (70.7%)
      Nursing42 (29.8%)17 (29.3%)
      Tenure in role (years)(continuous)9.82 (7.75)8.18 (7.58)0.17


      Host organization as Primary Employer
      Yes118 (83.7%)49 (84.5%)1.00
      Tenure in role within primary employment organization (years)(continuous)6.84 (6.04)5.90 (5.35)0.28
      Employment statusFull-time117 (83.0%)50 (86.2%)0.73
      Part-time and Casual24 (17.0%)8 (13.8%)
      Hours worked(continuous)33.9 (11.1)34.9 (10.0)0.53
      Leadership RoleYes43 (30.5%)16 (27.6%)0.81
      More than one employerYes46 (32.6%)19 (32.8%)1.00
      Employed in retirement or long-term care homeYes13 (9.22%)4 (6.90%)0.78
      Client Location1.00
      Private homes/apartments118 (83.7%)49 (84.5%)
      Congregate care17 (12.1%)7 (12.1%)
      Other6 (4.26%)2 (3.45%)
      IndividualMode of travel to work includes0.82
      Driving94 (66.7%)37 (63.8%)
      Public Transit57 (40.4%)29 (50.0%)
      Walking27 (19.1%)13 (22.4%)
      PPE use prior to COVID-19 (March 2020)Frequent17 (12.1%)9 (15.5%)0.67
      PPE use since COVID-19 (March 2020)Frequent141 (100%)56 (96.6%)0.08
      Knowledge of transmissionHigh137 (97.2%)55 (94.8%)0.42
      Perceived efficacy**High135 (95.7%)47 (81.0%)0.00
      Knowledge of recommended FPE use*High78 (55.3%)21 (36.2%)0.02
      Exposure at work (self)Yes63 (44.7%)29 (50.0%)0.60
      Exposure at work (others)Yes43 (30.5%)18 (31.0%)1.00
      Relationship to known exposed individual
      Exposure of family12 (8.51%)6 (10.3%)0.89
      Exposure of friend15 (10.6%)5 (8.62%)0.86
      Exposure of colleague23 (16.3%)5 (8.62%)0.23
      Exposure of other (not family, friend, or colleague)22 (15.6%)9 (15.5%)1.00
      Perceived occupational risk*High96 (68.1%)30 (51.7%)0.04
      Personal barriers to using any FPEHigh128 (90.8%)53 (91.5%)1.00
      Personal barriers to using a maskHigh120 (85.1%)52 (89.7%)0.53
      Personal barriers to using eye protectionHigh85 (60.3%)39 (67.2%)0.45
      Personal barriers to using a face shieldHigh110 (78.0%)51 (87.9%)0.16
      Pre-COVID mask use with suspected or diagnosed client**Not always22 (15.6%)21 (36.2%)0.00
      Pre-COVID eye protection use (face shield, goggles, fitted eye protection) with suspected or diagnosed client**Not always30 (21.3%)25 (43.1%)0.00
      Environmental
      Media influenceYes124 (87.9%)47 (81.0%)0.29
      OrganizationalReceived trainingYes119 (84.4%)46 (79.3%)0.51
      Organizational support for health and safetyHigh102 (72.3%)40 (69.0%)0.76
      Absence of job hindrance due to FPEHigh29 (20.6%)14 (24.1%)0.71
      Access to FPE at workHigh129 (91.5%)52 (89.7%)0.89
      Convenience of FPE at workHigh123 (87.2%)48 (82.8%)0.55
      Communication + Support (peer, sup & org)High91 (64.5%)35 (60.3%)0.69
      *p<0.05, **p<0.01

      Multivariate analysis

      After accounting for other factors within a single model via logistic regression analysis, our findings showed that most variables that were significant when considered independently (through chi-square or t-test) remained significant to FPE adherence (Table 3). Compared to participants who were always adherent to FPE (the reference group used for the outcome variable in the regression), those who were not always adherent were significantly more likely to have higher education, low perceived efficacy of FPE, low knowledge of recommended use of FPE, and low perceived risk. Although pre-COVID FPE use was significant in bivariate analyses, it was non-significant in the regression model. Additionally, once considering other factors in the full regression model, an absence of personal barriers to using a face shield was positively and significantly associated with high adherence.
      Table 3Regression output for odds of not always adhering to FPE
      VariableDescriptionest.SEpadjusted Odds Ratio (95%CI)
      Gendermale vs. female0.290.770.711.09 (0.24, 4.92)
      Agecontinuous years-0.020.020.340.98 (0.94, 1.02)
      Highest Education**Bachelors/Masters/Doctorate vs. Diploma/Certificate1.410.540.014.37 (1.49, 12.82)
      RoleNursing vs. PSW-0.350.480.460.65 (0.24, 1.71)
      Hours Workedcontinuous hours0.000.020.791.01 (0.97, 1.05)
      Travel to work includes drivingYes vs. no0.460.620.461.78 (0.5, 6.32)
      Travel to work includes public transitYes vs. no0.390.300.191.53 (0.83, 2.8)
      PPE Use Prior to COVID-19Frequent (Daily/Weekly/Monthly) vs. Infrequent (Rarely/Never)0.760.600.211.91 (0.59, 6.19)
      Knowledge of transmissionLow (SA/A to less than 4/5 questions) vs. High (SA/A to at least 4/5 questions)0.561.010.581.66 (0.24, 11.54)
      Perceived FPE efficacy***Low (N/D/SD/DK to ANY variables) vs. High (SA/A to all variables)2.110.660.009.15 (2.39, 35.08)
      Knowledge of recommended FPE use**Low (N/A/SA/DK to ANY variables) vs. High (D/SD to all variables)1.010.410.012.7 (1.2, 6.11)
      Exposure at work (self)Yes (SA/A to all variables) vs. No (N/D/SD/DK to ANY variables)0.260.410.531.2 (0.53, 2.75)
      Exposure at work (others)Yes vs. no0.000.470.990.96 (0.37, 2.44)
      Perceived occupational risk**Low (N/D/SD/DK to ANY variables) vs. High (SA/A to all variables)1.430.470.004.12 (1.57, 10.77)
      Personal barriers to using a face shield*Low (SA/A to zero barriers) vs. High (SA/A to at least one variable)1.120.570.050.71 (0.27, 1.84)
      Pre-COVID mask use with suspected or diagnosed clientMostly/Sometimes/Rarely/Never (for either suspected and/or diagnosed client) vs. Always (with both suspected and diagnosed client)0.030.840.973.18 (1.08, 9.39)
      Pre-COVID eye protection use (face shield, goggles, fitted eye protection) with suspected or diagnosed clientMostly/Sometimes/Rarely/Never vs. Always-0.380.700.591.94 (0.7, 5.39)
      Access to FPE at workLow (N/D/SD/DK for ANY variables) vs. High (SA/A to ALL variables)0.550.580.351.21 (0.23, 6.32)
      Convenience of FPE at workLow (N/D/SD/DK for ANY variables) vs. High (SA/A to ALL variables)0.500.560.370.65 (0.17, 2.54)
      Received training: KN thesis definitionNo (N/D/SD/DK to 2+ variables) vs. Yes (SA/A to at least 5/6 variables)0.210.530.691.72 (0.55, 5.41)
      Media influenceReported media influenced risk perception and work practices: No (N/D/SD/DK to ALL items) vs. Yes (SA/A to ANY variables)-0.500.550.361.79 (0.6, 5.36)
      Perceived organizational supportLow (N/D/SD/DK to ANY variables) vs. High (SA/A to all variables)-0.080.460.871.17 (0.4, 3.45)
      Job hindrances to working safely due to FPEHigh (N/D/SD/DK to ANY variables) vs. Low (SA/A to ALL variables)-0.400.550.460.67 (0.23, 1.96)
      Organizational support/CommunicationLow (N/D/SD/DK to ANY variables) vs. High (SA/A to ALL variables)-0.160.470.740.85 (0.34, 2.14)
      *p<0.05, **p<0.01, ***p<0.001. N/D/SD/DK represents neutral/disagree/strongly disagree/don't know. SA/A represents strongly agree/agree.
      Footnote: Any survey variables excluded from the regression model were non-significant when included in the model and did not influence the significance of other variables when included. An exception was personal barrier variables for mask and eye use; when added to the model, personal barriers for face shields became non-significant. These three variables for personal barriers were highly correlated and personal barriers for face shields was most significant and therefore was retained in the model. In addition to meeting the criterion of non-significant when included and no impact on the trend in significance of other variables, reasons for exclusion were based on small sample size within a given category for that variable (N<10), high correlation with a similar variable wherein the other variable was more significant and therefore was retained in the model, and/or small proportional differences between outcome variable groups for that variable. More details are available upon request.

      Barriers to PPE Use

      Given the very high rates at which personal barriers to FPE use were reported, we further examined the specific barriers reported for each type of FPE. The most commonly-reported barriers to wearing FPE were visual (“glasses fogging”, “difficulty seeing”, and “face shield fogging”; 87% of respondents), difficulty communicating (65%), and physical discomfort (57%). The majority of participants reported that wearing a surgical mask made it harder to do their job due to their glasses/eye protection fogging up (74%) and difficulty communicating with clients, families, or colleagues (59%). Difficulty seeing was commonly reported as a personal barrier making it harder to do their job when wearing eye protection (56%). The majority of participants reported that wearing a face shield made it harder to do their job due to their face shield fogging up (71%) and difficulty seeing (57%). Participants who reported that wearing a surgical mask made it harder to do their job due to difficulty breathing were significantly more likely to not always be FPE adherent (X2 (1, n = 141) = 4.06, p = 0.043).

      DISCUSSION

      Demographics

      PSWs represented the majority of the sample (70%), consistent with the workforce composition at the participating care agency and proportions reported in the Canadian home care sector (Ontario Home Care Association, 2011). Demographic characteristics of gender, age, and education are comparable with previous findings for home/community-based PSWs
      • Sayin F.K.
      • Denton M.
      • Brookman C.
      • Davies S.
      • Chowhan J.
      • Zeytinoglu I.U.
      The role of work intensification in intention to stay: A study of personal support workers in home and community care in Ontario, Canada.
      ;
      • Zagrodney K.
      • Deber R.
      • Saks M.
      • Laporte A.
      and nurses
      Canadian Institute for Health Information
      Nursing in Canada, 2020 — Data Tables.
      ;
      College of Nurses of Ontario
      Membership Statistics Report 2021.
      . Compared to most samples, both PSWs and nurses in this study were more likely to be employed full-time, reflecting the unionized environment of the host agency.

      Adherence

      Self-reported adherence in this study was relatively high (71%), despite the strict definition used (always adherent to all elements of FPE). As in previous studies, adherence to surgical masks (89%) was higher than adherence to eye protection (73%)
      • Atnafie S.A.
      • Anteneh D.A.
      • Yimenu D.K.
      • Kifle Z.D.
      Assessment of exposure risks to COVID-19 among frontline health care workers in Amhara Region, Ethiopia: A cross-sectional survey.
      ;
      • Bani-Issa W.A.
      • Al Nusair H.
      • Altamimi A.
      • Hatahet S.
      • Deyab F.
      • Fakhry R.
      • Saqan R.
      • Ahmad S.
      • Almazem F
      Self-Report Assessment of Nurses' Risk for Infection After Exposure to Patients With Coronavirus Disease (COVID-19) in the United Arab Emirates.
      ;
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . Note that using a similar definition to previous work by Nichol et al
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      would have yielded a higher self-reported adherence rate (95%), which drastically exceeds the 44% found in hospital nurses in their study
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      and is comparable to the very high rate (97%) seen in Canadian hospitals during care for SARS CoV-1 patients by the end of the SARS CoV-1 epidemic
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      .
      Previous work by Nichol et al found that FPE adherence was significantly higher for nurses who used PPE routinely
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      . With the COVID-19 universal masking and eye protection guidelines requiring use with every client at the host organization since May 11, 2020, routine use by providers was normalized by the time this survey was conducted (January and February of 2021); as frequency of FPE use has been found to promote adherence, this likely contributed to the high rate of adherence reported in the present study
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      . Baseline (pre-pandemic) data are not available in a Canadian home care setting or for personal support workers, but a study of US home care nurses found a pre-pandemic adherence rate for eye protection of 69%
      • Adams V.
      • Song J.
      • Shang J.
      • McDonald M.
      • Dowding D.
      • Ojo M.
      • Russell D.
      Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
      .

      Organizational factors influencing adherence

      In previous literature, organizational factors have been identified as substantially driving adherence to infection prevention and control measures
      • Adams V.
      • Song J.
      • Shang J.
      • McDonald M.
      • Dowding D.
      • Ojo M.
      • Russell D.
      Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
      ;
      • Barratt R.
      • Gilbert G.L.
      • Shaban R.Z.
      • Wyer M.
      • Hor S.Y.
      Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians.
      ;
      • Chughtai A.A.
      • Seale H.
      • Rawlinson W.D.
      • Kunasekaran M.
      • Macintyre C.R.
      Selection and Use of Respiratory Protection by Healthcare Workers to Protect from Infectious Diseases in Hospital Settings.
      ;
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness D.L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      ;
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      ; however, they were not found to be significant predictors of FPE adherence in this study. Despite challenges related to global FPE shortages experienced throughout the health care sector
      • Shang J.
      • Chastain A.M.
      • Perera U.G.E.
      • Quigley D.D.
      • Fu C.J.
      • Dick A.W.
      • Pogorzelska-Maziarz M.
      • Stone P.W.
      COVID-19 Preparedness in US Home Health Care Agencies.
      ;
      • van den Bulck A.O.E.
      • de Korte M.H.
      • Metzelthin S.F.
      • Elissen A.M.J.
      • Everink I.H.J.
      • Ruwaard D.
      • Mikkers M.C.
      In the Eye of the Storm: A Quantitative and Qualitative Account of the Impact of the COVID-19 Pandemic on Dutch Home Healthcare.
      , the proportion of respondents who reported that their needs were well met at an organizational level was very high – FPE was available and conveniently accessible, the vast majority of staff reported receiving adequate training, and media attention regarding COVID-19 was high. While there was some diversity in perceptions of organizational support and communication related to health and safety, approximately two thirds of respondents in both the adherent and non-adherent groups reported high levels of support and communication. Although this study was carried out solely in the home care setting so direct comparison cannot be made, it is also possible that organizational factors play a lesser role in this sector, where providers typically work alone, compared to congregate settings such as hospitals, clinics and long-term care facilities. Another possibility is that under pandemic conditions with high levels of organizational support and FPE adherence, remaining barriers to adherence are found primarily at the individual level.

      Individual-level factors influencing adherence

      This study did find several individual-level factors which significantly influenced FPE adherence. Significant variables between bivariate and multivariate results remained consistent, suggesting a strong relationship between each of these variables and FPE adherence. In the full regression model, FPE adherence was significantly and positively related to lower education, higher perceived efficacy of FPE, higher knowledge of recommended use of FPE, and higher perceived risk of occupational illness. Although it is in some ways surprising that those with higher levels of education were significantly less likely to always adhere to recommended FPE use, there is a lack of clarity in the literature on the relationship between education and adherence, with some studies finding that professional staff demonstrate better adherence than those with less clinical training
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      and others finding that nurses demonstrate greater FPE adherence than physicians
      • Chor J.S.
      • Pada S.K.
      • Stephenson I.
      • Goggins W.B.
      • Tambyah P.A.
      • Medina M.
      • Lee N.
      • Leung T.F.
      • Ngai K.L.
      • Law S.K.
      • Rainer T.H.
      • Griffiths S.
      • Chan P.K.
      Differences in the compliance with hospital infection control practices during the 2009 influenza H1N1 pandemic in three countries.
      . A larger sample is required to understand whether level of education has the same impact on adherence for PSWs and nurses, and further research is warranted to understand why higher levels of education might correlate with lower levels of FPE adherence.
      Consistent with previous literature on FPE use, perceiving the efficacy of FPE as being low, having a lower level of knowledge about FPE, and low perceived risk of occupational transmission were correlated with lower adherence to FPE use
      • Chughtai A.A.
      • Seale H.
      • Rawlinson W.D.
      • Kunasekaran M.
      • Macintyre C.R.
      Selection and Use of Respiratory Protection by Healthcare Workers to Protect from Infectious Diseases in Hospital Settings.
      ;
      • Hu X.
      • Zhang Z.
      • Li N.
      • Liu D.
      • Zhang L.
      • He W.
      • Zhang W.
      • Li Y.
      • Zhu C.
      • Zhu G.
      • Zhang L.
      • Xu F.
      • Wang S.
      • Cao X.
      • Zhao H.
      • Li Q.
      • Zhang X.
      • Lin J.
      • Zhao S.
      • Li C.
      • Du B.
      China Critical Care Clinical Trial, G.
      Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
      ;
      • Sartori N.
      Evaluating Personal Protective Equipment Compliance in the Midst of a Pandemic.
      ;
      • Shigayeva A.
      • Green K.
      • Raboud J.M.
      • Henry B.
      • Simor A.E.
      • Vearncombe M.
      • Zoutman D.
      • Loeb M.
      • McGeer A.
      • Team S.H.I.
      Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
      . For each of these factors, this suggests an opportunity to improve usage rates by engaging with staff to increase awareness of the risk of occupational transmission of respiratory infection as well as knowledge about and confidence in the use of FPE as an effective means of preventing this transmission.
      Participants who experienced high personal barriers to using a face shield were significantly more likely to report non-adherence to FPE guidelines. Personal barriers to mask use were excluded from the regression model due to high correlation with personal barriers to face shield use, but full regression models incorporating either variable yielded similar outcomes. The most commonly-reported barriers to wearing masks, eye protection and face shields were visual (87% of respondents), difficulty communicating (65%), and physical discomfort (57%). These findings are consistent with previous literature which has reported personal barriers including visual clarity, interference with care, and comfort (e.g., fit, heat) as factors influencing non-adherence to FPE
      • Barratt R.
      • Gilbert G.L.
      • Shaban R.Z.
      • Wyer M.
      • Hor S.Y.
      Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians.
      ;
      • Chughtai A.A.
      • Seale H.
      • Rawlinson W.D.
      • Kunasekaran M.
      • Macintyre C.R.
      Selection and Use of Respiratory Protection by Healthcare Workers to Protect from Infectious Diseases in Hospital Settings.
      ;
      • Prakash G.
      • Shetty P.
      • Thiagarajan S.
      • Gulia A.
      • Pandrowala S.
      • Singh L.
      • Thorat V.
      • Patil V.
      • Divatia J.V.
      • Puri A.
      • Pramesh C.S.
      Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic.
      . These findings clearly indicate a need for improvements in fit and comfort to promote increased usage of FPE. As poor mask fit can also influence the degree to which glasses, goggles and face shields fog, fit may also impact this most common complaint. There is clearly a need for improvements in masks, goggles and shields to improve comfort and visual clarity and for these critical human factors to be taken into consideration in the design and selection of FPE.

      Study Limitations

      The study design used was cross-sectional, capturing behaviours and factors that influence them at only a single point in time. As participation was voluntary, those with strong views about FPE may have been more likely to respond. As with any survey study, bias due to recall and social desirability may be present. In the context of adherence, self-reported adherence rates may be higher than those observed in practice, making it likely that our data over-estimated true adherence rates to some extent.
      This study represented a pilot implementation of a newly-adapted survey. As such, it employed a relatively small sample size meaning that only large effects could be detected. In particular, the relatively low number of participating nurses meant that the study was not sufficiently powered to allow comparison of how given factors may have different influences on personal support workers versus nurses. Further study, with a larger sample size, will allow such factors to be explored and may allow for testing with a more diverse sample. The present sample was drawn from a single home care agency serving primarily urban and suburban environments; future work should incorporate perspectives from other home care agencies, including those serving rural and small-town settings.

      CONCLUSIONS

      The home care nurses and PSW participants in this survey reported very high levels of adherence to FPE, with 71% reporting that they always wear both masks and eye protection or a face shield with all clients as required by the universal masking and eye protection requirements in effect at the time of the study (Wave 2 of the COVID-19 pandemic in Ontario, Canada). In contrast to previous findings, organizational and environmental barriers did not emerge as significant predictors of FPE adherence in this study. Results suggested that when these organizational and environmental standards were largely met, as was the case with this sample, individual factors became the significant predictors of FPE compliance. Higher adherence was significantly related to greater perceived efficacy of FPE, greater knowledge of recommended use of FPE, higher perceived risk of occupational illness, and a lower level of education. Lower adherence was significantly correlated with reported personal barriers to face shield use (which was highly correlated with reporting of personal barriers to mask use). Very high levels of personal barriers to use were reported – most commonly visual barriers, difficulty communicating and physical discomfort. Policies, initiatives and education addressing perceived FPE efficacy, knowledge of recommended FPE use and perception of occupational risk would be expected to significantly effect FPE compliance in the home care sector. There may also be opportunities to improve adherence through reducing personal barriers through innovations to improve visual clarity, ease communication, and improve comfort.Fig. 1
      Figure 1:
      Figure 1Proportion of sample experiencing personal barriers to FPE use. Note that Visual barriers (black bars) were most prevalent for all types of FPE, followed by difficulty communicating when wearing masks or face shields (grey bars). Physical discomfort was also commonly reported with each type of FPE (white bars)

      ACKNOWLEDGEMENTS

      This study was funded by the Centre for Research Expertise in Occupational Disease, which is funded by the Ontario Ministry of Labour, Training and Skills Development.

      REFERENCES

        • Adams V.
        • Song J.
        • Shang J.
        • McDonald M.
        • Dowding D.
        • Ojo M.
        • Russell D.
        Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses.
        Am J Infect Control. 2021; 49: 721-726https://doi.org/10.1016/j.ajic.2020.10.021
        • Al Abri Z.G.H.
        • Al Zeedi M.
        • Al Lawati A.A.
        Risk Factors Associated with COVID-19 Infected Healthcare Workers in Muscat Governorate, Oman.
        J Prim Care Community Health. 2021; 122150132721995454https://doi.org/10.1177/2150132721995454
        • Atnafie S.A.
        • Anteneh D.A.
        • Yimenu D.K.
        • Kifle Z.D.
        Assessment of exposure risks to COVID-19 among frontline health care workers in Amhara Region, Ethiopia: A cross-sectional survey.
        PLoS One. 2021; 16e0251000
        • Bani-Issa W.A.
        • Al Nusair H.
        • Altamimi A.
        • Hatahet S.
        • Deyab F.
        • Fakhry R.
        • Saqan R.
        • Ahmad S.
        • Almazem F
        Self-Report Assessment of Nurses' Risk for Infection After Exposure to Patients With Coronavirus Disease (COVID-19) in the United Arab Emirates.
        J Nurs Scholarsh. 2021; 53: 171-179https://doi.org/10.1111/jnu.12625
        • Barratt R.
        • Gilbert G.L.
        • Shaban R.Z.
        • Wyer M.
        • Hor S.Y.
        Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians.
        Australas Emerg Care. 2020; 23: 105-113https://doi.org/10.1016/j.auec.2019.10.002
        • Canadian Institute for Health Information
        Nursing in Canada, 2020 — Data Tables.
        CIHI, 2021
        • Chokephaibulkit K.
        • Assanasen S.
        • Apisarnthanarak A.
        • Rongrungruang Y.
        • Kachintorn K.
        • Tuntiwattanapibul Y.
        • Judaeng T.
        • Puthavathana P.
        Seroprevalence of 2009 H1N1 virus infection and self-reported infection control practices among healthcare professionals following the first outbreak in Bangkok, Thailand.
        Influenza Other Respir Viruses. 2013; 7: 359-363https://doi.org/10.1111/irv.12016
        • Chor J.S.
        • Pada S.K.
        • Stephenson I.
        • Goggins W.B.
        • Tambyah P.A.
        • Medina M.
        • Lee N.
        • Leung T.F.
        • Ngai K.L.
        • Law S.K.
        • Rainer T.H.
        • Griffiths S.
        • Chan P.K.
        Differences in the compliance with hospital infection control practices during the 2009 influenza H1N1 pandemic in three countries.
        J Hosp Infect. 2012; 81: 98-103https://doi.org/10.1016/j.jhin.2012.04.003
        • Chughtai A.A.
        • Seale H.
        • Rawlinson W.D.
        • Kunasekaran M.
        • Macintyre C.R.
        Selection and Use of Respiratory Protection by Healthcare Workers to Protect from Infectious Diseases in Hospital Settings.
        Ann Work Expo Health. 2020; 64: 368-377https://doi.org/10.1093/annweh/wxaa020
        • College of Nurses of Ontario
        Membership Statistics Report 2021.
        College of Nurses of Ontario, 2021 (Retrieved Nov 14, 2021 from)
        • Darwish O.A.
        • Aggarwal A.
        • Karvar M.
        • Ma C.
        • Haug V.
        • Wu M.
        • Orgill D.P.
        • Panayi A.C.
        Adherence to Personal Protective Equipment Guidelines During the COVID-19 Pandemic Among Health Care Personnel in the United States.
        Disaster Med Public Health Prep. 2021; : 1-3https://doi.org/10.1017/dmp.2021.12
        • Home Care Sector Study Corporation
        Canadian home care human resources study.
        Ottawa: Canadian Health Human Resources Network (CHHRN). 2003
        • Houghton C.
        • Meskell P.
        • Delaney H.
        • Smalle M.
        • Glenton C.
        • Booth A.
        • Chan X.H.S.
        • Devane D.
        • Biesty L.M.
        Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis.
        Cochrane Database Syst Rev. 2020; 4CD013582https://doi.org/10.1002/14651858.CD013582
        • Hu X.
        • Zhang Z.
        • Li N.
        • Liu D.
        • Zhang L.
        • He W.
        • Zhang W.
        • Li Y.
        • Zhu C.
        • Zhu G.
        • Zhang L.
        • Xu F.
        • Wang S.
        • Cao X.
        • Zhao H.
        • Li Q.
        • Zhang X.
        • Lin J.
        • Zhao S.
        • Li C.
        • Du B.
        • China Critical Care Clinical Trial, G.
        Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
        PLoS One. 2012; 7: e44723https://doi.org/10.1371/journal.pone.0044723
        • Ippolito M.
        • Ramanan M.
        • Bellina D.
        • Catalisano G.
        • Iozzo P.
        • Di Guardo A.
        • Moscarelli A.
        • Grasselli G.
        • Giarratano A.
        • Bassetti M.
        • Tabah A.
        • Cortegiani A.
        Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
        Ther Adv Infect Dis. 8. 20212049936121998562https://doi.org/10.1177/2049936121998562
        • Lang A.
        • Edwards N.
        • Fleiszer A.
        Safety in home care: a broadened perspective of patient safety.
        Int J Qual Health Care. 2008; 20: 130-135https://doi.org/10.1093/intqhc/mzm068
        • McMichael T.M.
        • Duca L.M.
        • Lewis J.
        • Riedo F.X.
        • Wilde N.
        • McDonald M.
        • Spitters C.
        • Wechkin H.A.
        Use of standard, contact, and droplet precautions with eye protection for the prevention of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission among home healthcare personnel in hospice and home healthcare settings-King and Snohomish counties, Washington, February-October 2020.
        Infect Control Hosp Epidemiol. 2022; : 1-4https://doi.org/10.1017/ice.2021.499
        • Nichol K.
        • Bigelow P.
        • O'Brien-Pallas L.
        • McGeer A.
        • Manno M.
        • Holness D.L.
        The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals.
        Am J Infect Control. 2008; 36: 481-487https://doi.org/10.1016/j.ajic.2007.12.004
        • Nichol K.
        • McGeer A.
        • Bigelow P.
        • O'Brien-Pallas L.
        • Scott J.
        • Holness D.L.
        Behind the mask: Determinants of nurse's adherence to facial protective equipment.
        Am J Infect Control. 2013; 41: 8-13https://doi.org/10.1016/j.ajic.2011.12.018
        • Prakash G.
        • Shetty P.
        • Thiagarajan S.
        • Gulia A.
        • Pandrowala S.
        • Singh L.
        • Thorat V.
        • Patil V.
        • Divatia J.V.
        • Puri A.
        • Pramesh C.S.
        Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic.
        J Surg Oncol. 2020; 122: 1013-1019https://doi.org/10.1002/jso.26151
        • Sartori N.
        Evaluating Personal Protective Equipment Compliance in the Midst of a Pandemic.
        AORN J. 2021; 113: 397-399https://doi.org/10.1002/aorn.13343
        • Sayin F.K.
        • Denton M.
        • Brookman C.
        • Davies S.
        • Chowhan J.
        • Zeytinoglu I.U.
        The role of work intensification in intention to stay: A study of personal support workers in home and community care in Ontario, Canada.
        Economic and Industrial Democracy. 2019; 0143831X18818325
        • Shang J.
        • Chastain A.M.
        • Perera U.G.E.
        • Quigley D.D.
        • Fu C.J.
        • Dick A.W.
        • Pogorzelska-Maziarz M.
        • Stone P.W.
        COVID-19 Preparedness in US Home Health Care Agencies.
        J Am Med Dir Assoc. 2020; 21: 924-927https://doi.org/10.1016/j.jamda.2020.06.002
        • Shigayeva A.
        • Green K.
        • Raboud J.M.
        • Henry B.
        • Simor A.E.
        • Vearncombe M.
        • Zoutman D.
        • Loeb M.
        • McGeer A.
        • Team S.H.I.
        Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.
        Infect Control Hosp Epidemiol. 2007; 28: 1275-1283https://doi.org/10.1086/521661
        • Turnberg W.
        • Daniell W.
        • Seixas N.
        • Simpson T.
        • Van Buren J.
        • Lipkin E.
        • Duchin J.
        Appraisal of recommended respiratory infection control practices in primary care and emergency department settings.
        Am J Infect Control. 2008; 36: 268-275https://doi.org/10.1016/j.ajic.2007.08.004
        • van den Bulck A.O.E.
        • de Korte M.H.
        • Metzelthin S.F.
        • Elissen A.M.J.
        • Everink I.H.J.
        • Ruwaard D.
        • Mikkers M.C.
        In the Eye of the Storm: A Quantitative and Qualitative Account of the Impact of the COVID-19 Pandemic on Dutch Home Healthcare.
        Int J Environ Res Public Health. 2022; 19https://doi.org/10.3390/ijerph19042252
        • West E.A.
        • Kotoun O.J.
        • Schori L.J.
        • Kopp J.
        • Kaufmann M.
        • Rasi M.
        • Fehr J.
        • Puhan M.A.
        • Frei A.
        • Corona Immunitas Research, G.
        Seroprevalence of SARS-CoV-2 antibodies, associated factors, experiences and attitudes of nursing home and home healthcare employees in Switzerland.
        BMC Infect Dis. 2022; 22: 259https://doi.org/10.1186/s12879-022-07222-8
        • Wiboonchutikul S.
        • Manosuthi W.
        • Likanonsakul S.
        • Sangsajja C.
        • Kongsanan P.
        • Nitiyanontakij R.
        • Thientong V.
        • Lerdsamran H.
        • Puthavathana P.
        Lack of transmission among healthcare workers in contact with a case of Middle East respiratory syndrome coronavirus infection in Thailand.
        Antimicrob Resist Infect Control. 2016; 5: 21https://doi.org/10.1186/s13756-016-0120-9
        • Wong S.C.
        • Lam G.K.
        • AuYeung C.H.
        • Chan V.W.
        • Wong N.L.
        • So S.Y.
        • Chen J.H.
        • Hung I.F.
        • Chan J.F.
        • Yuen K.Y.
        • Cheng V.C.
        Absence of nosocomial influenza and respiratory syncytial virus infection in the coronavirus disease 2019 (COVID-19) era: Implication of universal masking in hospitals.
        Infect Control Hosp Epidemiol. 2021; 42: 218-221https://doi.org/10.1017/ice.2020.425
        • Zagrodney K.
        • Deber R.
        • Saks M.
        • Laporte A.
        Differences in PSW job characteristics and labour supply behaviours by care sector: The disadvantaged home and community PSW [conference presentation] Global Carework Summit, Toronto, ON. 2019