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  Table of Contents 
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 49-56

Knowledge, attitude, and practice of the use of personal protective equipment and its psychological impact among Indian anesthesiologists during the COVID-19 pandemic: A questionnaire-based, multicenter, cross-sectional nationwide survey

1 Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Psychiatry, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
3 Department of Clinical Psychology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission09-Sep-2021
Date of Decision09-Nov-2021
Date of Acceptance11-Nov-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Karen Ruby Lionel
Department of Anaesthesia, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_125_21

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Background: Anesthesiologists, with their skills and expertise at performing various aerosol-generating procedures such as tracheal intubation and extubation, tracheostomies, and bronchoscopy-guided procedures, serve as frontline workers during the COVID-19 pandemic. They are exposed to the risk of infection as well as highly stressful environments in the operating theaters and intensive care units. Appropriate knowledge, attitudes, and practices (KAPs) with regard to the use of personal protective equipment (PPE) will help mitigate some of this stress.
Materials and Methods: Owing to the nation's lockdown situation, an online questionnaire-based survey was conducted through WhatsApp, Facebook, and E-mail among anesthetists working at different health-care sectors in India. The KAP with regard to the use of PPE during the COVID-19 and its psychological impact were assessed by using a prevalidated questionnaire. All analyses were performed using SPSS version 25.
Results: Among 301 study participants, 189 (62.8%) had good knowledge and 90% had favorable attitudes. Despite 66.4% of the study participants having received formal training regarding the use of PPE during the COVID-19 pandemic, good practices were seen only in 44.4%. Irrespective of the demographic variable assessed, 90% of the anesthesiologists felt that working was more stressful in the operating room during this pandemic, due to challenges with respect to effective communication, restrictions in movement and visibility attributed to PPE as well as an alteration in the usual routine.
Conclusions: Despite adequate knowledge and attitudes regarding the use of appropriate PPE, the translation into practice was deficient. Emphasis on the checklist, protocol-based approaches, and regular updates on practice recommendations will help to improve adherence to quality practices. Donning of appropriate PPE contributes to significant physical and emotional stress among anesthesiologists during the COVID-19 pandemic. A platform to provide psychological support is the need of the hour.

Keywords: Anesthesiologists, attitude, COVID-19, health-care survey, knowledge, personal protective equipment, practices, psychology

How to cite this article:
Avula J, Babu A, George DE, Rai S, Sahajanandan R, Lionel KR, Joselyn AS. Knowledge, attitude, and practice of the use of personal protective equipment and its psychological impact among Indian anesthesiologists during the COVID-19 pandemic: A questionnaire-based, multicenter, cross-sectional nationwide survey. Indian Anaesth Forum 2022;23:49-56

How to cite this URL:
Avula J, Babu A, George DE, Rai S, Sahajanandan R, Lionel KR, Joselyn AS. Knowledge, attitude, and practice of the use of personal protective equipment and its psychological impact among Indian anesthesiologists during the COVID-19 pandemic: A questionnaire-based, multicenter, cross-sectional nationwide survey. Indian Anaesth Forum [serial online] 2022 [cited 2022 Oct 3];23:49-56. Available from: http://www.theiaforum.org/text.asp?2022/23/1/49/340490

  Introduction Top

The 2019 novel coronavirus (COVID-19, also known as the 2019-nCoV) outbreak started in Wuhan, China.[1],[2] This was declared a pandemic by the World Health Organization on March 11, 2020. In July 2020, there have been over ten million cases worldwide, 6 lakh cases in India, with around 5.3 lakh deaths worldwide[3] which has drastically increased to more than 156 million cases worldwide with more than 3.25 million as of May 7, 2021.[4]

As community transmission is now rampant, to mitigate perioperative transmission, it is important that institutions develop protocols to be followed during interventions on patients who have suspected or confirmed COVID-19 infection. COVID-19 is caused by contact or droplet transmission attributed to respiratory particles from patients who are infected. Aerosol-generating procedures (AGPs) are procedures performed on patients that are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing.[5] These AGPs put health-care workers (HCWs) such as anesthesiologists at an increased risk for exposure to COVID-19.[6],[7] Nosocomial transmission represents a serious threat to health-care systems and is a burden on hospital systems and communities.[8]

Anesthesiologists are often at the frontline of the COVID-19 pandemic response with exposure to dangers such as pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout and stigma, and physical violence.[9] Personal protective equipment (PPE) should be designed not only to safeguard the health care worker but must also be user friendly and comfortable. It is mandatory to train HCWs with regard to the rational and effective use of PPE, their limitations, and their maintenance Occupational Safety and Health Administration (OSHA). The Centers for Disease Control and Prevention (CDC) requires strict adherence to standard, airborne, and contact precautions plus eye protection for the care of patients with or under investigation for COVID-19. Guidelines for HCWs with online refresher courses have been developed by the WHO, CDC, and various governmental organizations to boost knowledge and prevention strategies.[10] The provision of adequate theoretical and practical training to health-care providers before they treat COVID-19 patients will help ensure patient–health-care provider safety and prevent panic, which can cause distress among health-care providers.[11] It is imperative to ensure the safety of HCWs not only to safeguard continuous patient care but also to ensure they do not transmit the virus.[12],[13]

In the care of COVID-19 patients, anesthesiologists are vulnerable to both infection and mental health issues. They may experience depression by the situation, fear of contagion, and fear of spreading the virus to their contacts. The heavy workload and discomfort of wearing PPE for long durations can worsen this. Anesthesiologists are exposed to highly stressful environments in the operating theaters and intensive care units. This is compounded by numerous other stressors during this pandemic (e.g., family stress, social isolation, and physical and mental burnout). Ensuring good mental health is critical to sustaining COVID-19 preparedness, response, and recovery.[14] A research on past epidemics has highlighted the negative impact of outbreaks of infectious diseases on the psychological health of health-care workers.[15]

The objective of this study conducted among trainees and consultant anesthesiologists in India was to describe the current practices, availability, training, and confidence regarding the use of appropriate PPE and highlight the adverse and psychological effects due to the extended use of PPE.

  Materials and Methods Top

The initial pool of questions for the questionnaire was developed by the process of literature review, consultation with colleague anesthesiologists, as well as our understanding of the different aspects of the use of PPE. The questions were organized under various domains such as knowledge, attitudes, and practices (KAPs) and the psychological impact of the use of PPE. As a next step, the initial version of the questionnaire was given to four experts in the department of anesthesiology and two experts from the department of psychiatry. They were asked to grade each question based on the relevance, clarity, and essentiality on a score of 1–4. Based on the validation and comments from experts, ten questions were removed and four were modified from the original questionnaire. The content validity index was calculated to be 0.9. The questions with item content validity index <0.78 were not included in the final version of the questionnaire (n = 11).

The validated questionnaire had 5 sections with a total of 51 questions. The first section was related to consent and sociodemographic data (11 questions). The second section was designed to assess the anesthesiologist's knowledge regarding the appropriate use of PPE (10 questions). The next section was intended to gauge the attitude toward PPE use among Indian anesthesiologists (5 questions). Information regarding current practices was assessed in the fourth section (10 questions). The psychological impact of the use of PPE on the anesthesiologist was evaluated in the fifth section (15 questions). This was administered as a pilot to five anesthesiologists to access the ease of response as well as the estimated time taken to fill the form. The validated questionnaire used for the survey (Appendix 1) is attached in the Supplementary Material section of the manuscript.

This study was planned as a nationwide, cross-sectional survey conducted among trainees and practicing anesthesiologists in India inclusive of various health-care sectors based on the National Registry of Anesthesiologists, obtained from the Indian Society of Anesthesiologists website. Due to the country's lockdown during the study period, the questionnaire was administered as an online survey over a period of 10 days in the month of June 2020 (June 14–24). An online data collection tool was designed and executed using Google Forms (via docs.google.com/forms). The Google Forms link of the questionnaire was sent to anesthesiologists via E-mail, WhatsApp groups, and Facebook messenger. Data were collected only from anesthesiologists who gave their consent online. This study was approved by the Institutional Review Board of Christian Medical College, Vellore (India), IRB Number: 12871 dated June 13, 2020.

Based on the data from the study on the KAP of health-care professionals regarding infection prevention by Yazie and colleagues, 57% of the study population had adequate practices regarding infection prevention.[16] In order to estimate this with the precision of 5.6% and a 95% confidence interval, we required 300 survey responses Demographic details collected included gender, age, familial status, presence of people vulnerable to COVID-19 infection, academic qualification, place of work, work experience in the field of anesthesia, hours of work per day, formal training regarding appropriate PPE use, and prior experience of working during a pandemic. Government medical colleges, private medical colleges, and institutes of national importance were considered academic institutes, while corporate hospitals and secondary hospitals were considered nonacademic institutes. For subgroup analysis, the participants were classified as trainees, academicians, and free-lancing anesthesiologists. “More” experienced anesthesiologists were considered those who had more than 6 years of work experience in anesthesia.

Knowledge, attitude and practices of anesthesiologists regarding the use of personal protective equipment (PPE) and the psychological impact of the use of PPE during the COVID-19 pandemic.

The level of knowledge regarding the use of PPE was assessed by the response to ten questions which were based on the recent CDC and WHO guidelines.[17],[18] These knowledge questions were scored as 1 or 0 for correct or incorrect responses, respectively. The maximum score on the knowledge-based section was 10 and the minimum score was 0. Knowledge was graded as poor if the score was below the mean score value and good if the score was above the mean. Attitude was assessed using a 5-point Likert scale. The responses were “strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree.” Analysis was done by summing values of “strongly agree” and “agree” as “agree” response and “strongly disagree” and “disagree” as “disagree” response and neutral remaining the same. Data based on practices followed were described as good practices if there was compliance to the guidelines given by the CDC/WHO. The psychological effects of the use of PPE on the anesthesiologists were appraised and described.

Fully completed questionnaires were extracted from Google Forms and exported to a Microsoft Excel 2016 for cleaning and coding. The proportion KAP presented in terms of number and percentages. Chi-square was used for the comparison of categorical variables. Similarly, the psychological effect of using PPE that is measured on a 5-point Likert scale was also analyzed as above plus using Chi-square test as appropriate. Data were analyzed using SPSS version 25 (IBM SPSS Statistics for Windows. Armonk, NY: IBM Corp, Released 2017). P < 0.05 considered a significant level.

  Results Top

Of the 480 anesthesiologists who were sent invitations, 325 (67.7%) responded to the survey. Twenty-three respondents did not consent to participate and one responder was a nonanesthesiologist, and hence excluded from the analysis. Among 301 study participants, 153 (50.8%) were male and 146 (48.5%) were female and 2 participants did not want to reveal their gender. The sociodemographic details are depicted in [Table 1]. The distribution of respondents based on academic status and work setup is shown in [Figure 1].
Table 1: Demographic profile

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Figure 1: Distribution of respondents based on academic status and work setup

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The mean, maximum, and minimum knowledge scores were 6.9, 10, and 2, respectively. One hundred and twelve (37.2) participants had poor scores, while 189 (62.8) had a good score. Factors associated with knowledge were gender, place of work, years of experience, formal training regarding PPE use, and academic qualification, as shown in [Table 2]. Anesthesiologists with statistically significant good knowledge were female anesthesiologists, those who worked in academic institutes, those with years of experience of more than 6, and those with formal training regarding the use of PPE. Among 60 anesthesia trainees who had good knowledge, 46 (77%) had formal training.
Table 2: Demographics affecting knowledge

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On analysis of the responses by the study participants after summing the values as described in the methodology, there was an overall 90% favorable attitude. Almost all study participants (98.7%) responded that it is important to read out a PPE donning and doffing checklist as well as to adhere to the hospital policies on PPE use (92.4%). Similarly, 92.4% of the study participants believed that it is their professional duty to care for patients with COVID-19 infection [Table 3].
Table 3: Frequency of attitude of study participants among each Likert type of variable

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Two hundred and four anesthesiologists felt that the best ways to disseminate information regarding appropriate PPE use were by simulation and through displayed flashcards/posters in the operating rooms. In a subgroup analysis, we found that 130 (64%) of those in an academic setup preferred to use the abovementioned methods as compared to 74 (36%) in a nonacademic setup (P < 0.001). Only a small minority of anesthesiologists felt that didactic lectures (0.7%) and self-education from Internet sources (1.7%) were the best methods to disseminate information.

The practice of reading the checklist was significantly higher among anesthesiologists who worked in academic setups (P = 0.008) and those who had formal training (P < 0.001). 45.9% of the anesthesiologists never read the checklist.

The presence of only the essential staff in the operating room when AGPs were being performed was ensured by 62.7%. This correlated significantly with anesthesiologists who had prior formal training (P = 0.05) and with those who had more experience (P = 0.09). This was practiced significantly higher among male anesthesiologists (P = 0.04). [Table 4] shows an overview of the practices we surveyed.
Table 4: Summary of practices surveyed

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“Health of the health care workers being prioritized at my institution makes me feel confident and safe” was stressed by 64%. Of the 15% who felt that this was not a priority, the majority worked in government and corporate setups. Seventy-eight of the health-care workers, after donning full PPE, were more easily irritable during procedures in the operating room. [Figure 2] depicts the physical symptoms and emotional effects of prolonged use of PPE. Despite donning appropriate PPE, trainees (P < 0.001) and less experienced anesthesiologists (P = 0.01) felt less confident in anesthetizing COVID-19-positive patients. Irrespective of the demographic variable assessed, 90% of the anesthesiologists felt that working is more stressful in the operating room during this pandemic. Ninety-five percent felt that it was challenging to communicate effectively and clearly while using PPE. Due to restrictions in movement and visibility, procedures were more challenging attributing to work stress in 90% of the surveyed anesthesiologists, resulting in noncompliance to adequate PPE donning protocols in 50%.
Figure 2: Physical symptoms and emotional effects of prolonged use of personal protective equipment

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Ninety percent of the anesthesiologists felt that physical and psychological support reduces psychological stress and helps with adherence to PPE use.[Figure 3] depicts the practices used to reduce stress at the workplace and at home.
Figure 3: Practices to reduce stress at the workplace and at home

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  Discussion Top

During this COVID-19 pandemic, anesthesiologists play an important role as experts in emergent airway management, perioperative anesthetic care, and management of patients in intensive care units. They are involved to a great extent in performing AGPs which pose a risk of acquiring the infection, hence the anesthesiologist being at the frontline needs to be aware of the best available recommendations regarding the appropriate use of PPE.[19] This study presents the first nationwide survey conducted in India to obtain an insight into the KAPs regarding the use of PPE and its psychological effects on anesthesiologists across various health-care setups.

Our study showed that 62.8% (189) had good knowledge which was similar to the survey by Olum et al.[10] Of this, 67% had received formal training regarding the use of PPE, which emphasizes the importance for the need of ongoing methods of updating and training through simulations which were also highlighted in the PPE-SAFE survey.[20] Apart from training, we found that “more” experienced anesthesiologists and those who worked in academic institutes had better knowledge and practices.

Ninety-one percent of those with high scores in the knowledge domain had high scores in the attitude domain as well. In league with the survey conducted by Sahiledengle et al., we too found that the level of knowledge was good (62.8% and 55.4%) and the attitude was favorable in our study population (90% and 83.3%).[21] Good practices [Table 4] regarding the use of PPE were seen only in 44.4%, similar to the findings by Tabah et al.[20] In our study population, there were no constraints to the availability of PPE (72.4%) as compared to (52%) who had felt that there was a difficulty in obtaining PPE in the survey by Tabah et al.[20] Although 56.5% felt that importance was given for training and spreading of awareness regarding appropriate PPE use, overall good practices were implemented only by 45% of the anesthesiologists. Good practices are vital to prevent the transmission of infection from patients to patients and to the HCWs, thus requiring periodic audits within the department to improve adherence to policies as well as nationwide webinars to stress the importance of good practices.{Table 4}

In our study, we found that knowledge and practices were inferior among trainees as compared to the academicians (P < 0.01). Due to the shortage of workforce, trainees are often placed in the frontline of care, hence it is the responsibility of the health-care system to train and ensure that adequate knowledge is imparted and that good practices are strictly adhered to. Among the 9.9% of the responders who said that no importance was given for training, the majority were anesthesiologists who worked in government medical colleges and in corporate hospitals.

It was encouraging to note that the health of HCWs was prioritized among 64% of the participants, despite the place of work. With appropriate PPE, 81% felt confident about anesthetizing patients with COVID-19 infection as compared to the 45% seen in the PPE-SAFE survey.[20]

Challenges in communication, restriction in movement and decreased visibility during procedures attributed to work stress in 90% of the surveyed anesthesiologists. This also resulted in noncompliance to adherence to PPE protocols in 50% of those who responded to our survey. This information conveys the importance of simulation-based training and the urgent need for innovation of safe yet comfortable PPE. Communication may be improved by devising a universal sign language which could resolve this issue.


There are a few limitations to this study which must be noted. Being a voluntary survey, the data analyzed only reflect the opinions and perceptions and not the actual facts. Second, we did not use a systematic sampling strategy but rather made the survey broadly available and hence no denominator is available for calculating the response rate. Thus, our results may reflect only a small proportion and potentially biased reflection of the true opinions of all anesthesiologists. No standardized tool for assessing KAPs on COVID-19 has been previously validated, thus the questionnaire was formulated from the WHO and CDC guidelines and reports on COVID-19. However, this is one of the first few studies to assess the KAPs and psychological impact of PPE use on anesthesiologists, done as a countrywide survey.

  Conclusions Top

This survey provides an overview of reported PPE practices, its availability, knowledge, and attitude of anesthesiologists who work at the frontlines of the COVID-19 pandemic. We found that translation of good knowledge and good attitudes into good practices needs to be perfected with repeated training, emphasis on checklists, protocol-based approaches, and regular updates on practice recommendations. Regular audits and feedback will help to identify the changing needs and improvise the policies as we understand the COVID-19 pandemic better. To reduce workplace stress due to PPE, we advocate adopting newer methods of communication along with simulation-based education to provide confidence in performing various procedural skills. Overall stress can be decreased through webinars and departmental online meetings where health-care workers can express their problems and needs.


We acknowledge Mr Bijesh Yadav and Dr Jeyaseelan of the department of Biostatistics for their statistical inputs. A note of thanks to the experts from the departments of anaesthesia and psychiatry who helped with questionnaire validation.

Financial support and sponsorship

This study was supported by Department of Anaesthesia, Christian Medical College, Vellore, India.

Conflicts of interest

There are no conflicts of interest.

  Appendix 1 Top

The Supplementary Material for this article can be found online at: https://docs.google.com/forms/d/13l7ePvTzkLhMq9rTYCCCpai4 gdhrucvZB8Ed0onuw5U/prefill.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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