TABLE 3.
Synthesis results (themes and supporting quotes): Perceptions of personal protective equipment use and physical distancing in healthcare settings.
| S/N | Analytical theme | Descriptive themes (review findings) | Studies contributing to the review finding | Supporting data (example quote) |
|---|---|---|---|---|
| 1 | Health and care workers value the use of masks and PPE in patient care | PPE gave peace of mind | Sivaraman, 202227 (India) | ‘When I began working with COVID patients, I was frightened of coming into contact with them. However, knowing that my PPE covered my entire body provided me peace of mind that I was not in direct contact.’ (Nursing Officer) (Sivaraman, 2022, India) [italics added by author] |
| Masks and PPE create a safety climate to deliver optimal care | Sivaraman, 202227 (India); Ribeiro, 202132 (Portugal) | ‘… [T]he face mask contributes to creating a safety climate and protecting clients’ and therapists’ physical health, making it possible to do face-to-face therapy.’ (Ribeiro, 2021, Portugal) [italics added by author] | ||
| 2 | Health and care workers were anxious about being put at risk | Anxiety and insecurity about the level of protection provided | Broom, 202225 (Australia); Hoernke, 202137 (UK) | ‘I was looking at videos of my friends who were in other countries, because I have a lot of classmates from uni and we’re spread all over the world, and we were comparing PPEs and I was shocked with what we have. We were just having goggles, N95 mask, and also gown. Whereas with them, they are all covered with all those hazmat suits and with different layers as well and they’ve got all their hats and everything. Whereas I don’t even have any hat at all. So, for me, I feel really, really insecure about the PPE that we had.’ (ICU nurse Queensland) (Broom 2022, Australia) [italics added by author] |
| Perception of susceptibility and risk | Hoernke, 202137 (UK); Sivaraman, 202227 (India) | ‘The first thing to do is I … don’t make them feel like a pawn in a bigger game, because sometimes we feel like we are obliged to do stuff to save the rest, but we are part of the rest too.’ (Doctor, consultant) (Hoernke, 2021, UK) [italics added by author] | ||
| 3 | Masks and other PPE cause physical discomfort to health and care workers | Health workers experience physical discomfort wearing masks and PPE | Setiawan, 202129 (Indonesia); Broom, 202225 (Australia); Sivaraman, 202227 (India); Hoernke, 202137 (UK); Fan, 202026 (China); Koken, 202235 (Turkey); Venesoja, 202131 (Finland); Markkanen, 202138 (US); Ribeiro, 202132 (Portugal) | ‘During a long day at work, wearing a mask can cause all sorts of trouble, such as headaches, a burning sensation in the lungs, the rubber bands abrading behind the ears, and eyeglasses becoming foggy.’ (Venesoja, 2021, Finland) [italics added by author] ‘… And I think as well, wearing the N95 mask that there’s an element of re-breathing, so it was quite tiring as well. So, a 12-hour shift of caring for a patient with those precautions was quite tiring as well.’ (Broom, 2022, Australia) [italics added by author] ‘Of course, I must hold it if I want to take a pee, but if I want to defecate when I am still wearing PPE, … I am permitted by another member to leave …. (Setiawan, 2021, Indonesia) |
| 4 | Masks and other PPE challenge effective communication | PPE compromises communication with colleagues | Hoernke, 202137 (UK); Hayirli, 202136 (US) | ‘I feel like it’s been a lot more challenging with the PAPRs to hear each other very well. […] It’s hard to tell if people got you. I’ll say something […] but I don’t know that they heard me. I think that’s the hardest thing. […] So then, you’re saying three or four times instead of moving on. Everything takes longer.’ (Hayirli, 2021, US) [italics added by author] ‘I think it does make you feel very… dehumanised because you can’t recognise any of your colleagues.’ (Hoernke, 2021, UK) [italics added by author] |
| Masks and PPE affect communication and relationship with patients | Koken, 202235 (Turkey); Ferrari, 202133 (Italy); Setiawan, 202129 (Indonesia); Sivaraman, 202227 (India); Clay, 202239 (UK); Markkanen, 202138 (US); Ribeiro, 202132 (Portugal) | ‘When I talk, with mask and at a distance, they [patients] would not fully understand what I am speaking, and this led to misunderstandings and arguments.’ (Sivaraman, 2022, India) [italics added by author] ‘The reduction in facial cues may result in other non-verbal cues being heightened, or nuance normally conveyed by facial expression being lost. The intended message can therefore be misinterpreted … It’s a bit like a text message … it can be perceived in lots of different ways … patients are not keeping up with who’s being spoken to … non-verbal cues that are really important to aid their understanding are either removed or dampened down because of the masks.’ (Clay, 2022, UK) [italics added by author] |
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| Learning to communicate effectively with patients while wearing a mask | Ribeiro, 202132 (Portugal); Ferrari, 202133 (Italy) | ‘… [T]herapists talked about reinforcing the use of active listening and interviewing skills, encouraging the verbal expression of emotions, trusting in the therapeutic process, and asking for supervision … Find some alternatives to help the client signal what he is feeling, be aware that you will need more time to understand the client.’ (Ribeiro, 2021, Portugal) [italics added by author] | ||
| 5 | Familiarly with masks and other PPE helped health workers adapt for COVID-19 | Already familiar with PPE pre-pandemic | Sivaraman, 202227 (India) | ‘… [S]ince we were already using surgical masks, we became comfortable with its daily usage very easily.’ (Sivaraman, 2022, India) [italics added by author] |
| Progressive adaptation over time occurs with masks | Ribeiro, 202132 (Portugal) | ‘Therapists’ indications that early discomfort, feelings of strangeness, or difficulties were progressively solved and as well as mentions of a progressive adaptation to the use of the face mask in the therapy context. In this regard, one therapist said: “It is uncomfortable in the beginning since we are unable to see the entire face and identify the facial expressions so well, but over time this discomfort disappears”.’ (Ribeiro, 2021, Portugal) [italics added by author] | ||
| 6 | Health and care workers in care homes experienced unequal access to PPE | Inequality in access to PPE | Romeu-Labaven, 202234 (Spain); Markkanen, 202138 (US) | ‘You see that they come from the health service to do some tests in the nursing home or whatever and […] obviously, it’s nice to see how they dress, undress, all new, they take it off, they don’t touch anything. It’s a little sad, in that sense, that some have so much and others so little.’ (Nurse) (Romeu-Labaven, 2022, Spain) [italics added by author] |
| 7 | Individual health worker factors affecting PPE use | Donning PPE takes time and affects the ability to carry out clinical procedures | Goodarzi, 202230 (Iran); Hoernke, 202137 (UK); Sivaraman, 202227 (India); | ‘At times doctors are faced with the dilemma regarding ‘patient care first or personal safety first?’ Donning of the PPE takes time. So, if a patient requires emergency care, there would be no time to put the PPE on.’ (Sivaraman, 2022, India) [italics added by author] ‘It’s strangling, and it’s lowering the quality of work, particularly for us. We feel exhausted during resuscitation. It’s not at all comparable to the resuscitation in non-COVID patients and comfort of the clothes there … Using this equipment in resuscitation is tough. You may not believe that 5 minutes of resuscitation with this cover equals one hour of normal resuscitation.’ (Nurse) (Goodarzi, 2022, Iran) [italics added by author] |
| PPE design and fit influences risk of contamination | Fan, 202026 (China); Sharma, 202228 (India) | ‘When unzipping, the front of the coverall often curled inward, making contact with the health workers’ scrubs and neck. Taking off the coverall requires a certain amount of force, which creates a risk of splash pollution. After removing the outer gloves, the wrist skin was occasionally exposed, increasing the risk of infection’ … ‘PPE design does not enable easy distinction between the contaminated and clean sides of the items. In addition, some areas were not well covered by PPE, for instance, gowns were often too large and left parts of the neck exposed, even when sized appropriately. Participants’ backs occasionally became exposed during work.’ (Fan 2020, China) [italics added by author] ‘… There are some PPEs, which come with a zip closure, and their quality is so bad that it rips apart when I wear them. Also, we get different size of head caps and it is very loose which exposes us and hinders our vision while working.’ (Sharma 2022, India) [italics added by author] |
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| Questions about the effectiveness of PPE | Fan, 202026 (China); Sivaraman, 202127 (India); Broom, 202225 (Australia) | ‘The impermeability and tightness of the covering, including connections between various parts of PPE, is a common concern. Some HCP described that they found it difficult to assess the impermeability ratings and described the body covering as a similar impervious material but without a logo or any hints. Three participants … also wanted to obtain valid evidence of the duration of effectiveness of the PPE and the optimal frequency of replacement.’ (Fan, 2020, China) [italics added by author] | ||
| 8 | Health system factors that affected PPE use | Availability and supply of PPE | Romeu-Labaven, 202234 (Spain); Hoernke, 202137 (UK); Setiawan, 202129 (Indonesia) | ‘I think the one thing that’s probably been the biggest challenge has been sourcing PPE … That was probably the single biggest anxiety-inducing thing for staff on the ground. … but there was always this sense that we don’t know where next week’s is coming from …’ (Hoernke, 2021, UK) [italics added by author] |
| Gap between guidelines and protocols and implementation of PPE | Romeu-Labaven, 202234 (Spain); Hoernke, 202137 (UK); Fan, 202026 (China); Broom, 202225 (Australia) | ‘Because they can’t say 50 protocols […] perfectly describing what to do with PPE, and then not have PPE. […] I try to make people respect the protocol as much as possible, I’ll make use of what I have, right? And I’ll adapt according to the general conditions or common sense in many things. But if you’re telling me to put on, to throw away the FFP2 every time or the FFP3. […] Because protocol tells you that you have to throw it away every time you go in, but if you don’t have [enough], you can’t throw it away every time.’ (Nursing supervisor) (Romeu-Labaven, 2022, Spain) [italics added by author] | ||
| 9 | Facility-level factors that affected PPE use | Institutional support and role modelling helped PPE use | Sivaraman, 202227 (India) | ‘The timely, regular release of updated guidelines by the institute that were aligned with the global scenario encouraged the HCP to abide by the PPE usage … In addition, regular “supervision” by senior doctors promoted PPE use. A junior resident told, “the faculty were doing it and I did see them.” “Role modelling” [my seniors do; hence I should do] worked here.’ (Sivaraman, 2022, India) [italics added by author] |
| Layout of health facility affected PPE use | Fan, 202026 (China); Sharma, 202228 (India) | ‘Participants also discussed how the space layout influenced their ability to follow PPE protocols. It seems that the areas considered clean and contaminated varied across different HCP. In fact, the rules pointed that red zone was within the wards and outside corridors were considered clean, but some individuals did not follow the rules strictly.’ (Fan, 2020, China) [italics added by author] ‘… Yes we have, but it is not enclosed. It is in an open area and I think there is no privacy due to which I do have a problem changing there.’ (Sharma, 2022, India) |
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| 10 | Health and care workers responded creatively to the lack of masks and other PPE | Reusing, rationing and improvising with PPE or mask | Romeu-Labayen, 202234 (Spain); Sivaraman, 202227 (India) | ‘We’ve suffered a lot over equipment. […] Looking for tutorials on how to make gowns out of garbage bags. The cleaning woman giving us large garbage bags. A midwife who knows a lot about sewing, making tutorials on how to do it. One [nurse] who has a neighbour whose husband works in China giving her masks … My mother making cloth hats for all my co-workers’ … I would sometimes go out sweaty, with my whole mask wet, dripping, and wanting to change my mask and they [the supervisor] would say, “No! It has to last for a week!”.’ (Romeu-Labayen, 2022, Spain) [italics added by author] ‘… I will put my N95 mask in a paper cover. And I put it aside without touching, to do anything else. And once the 1 week is over, I’ll use it …’ (Sivaraman, 2022, India) [italics added by author] |
| Procurement and quality control of masks | Venesoja, 202131 (Finland); Martinelli, 2020 (20 Euro countries, China, S Korea); Broom, 202225 (Australia); Sharma, 202228 (India) | ‘Very much varying ‘guts’ about quality, some of them feel very high quality and safe in the face while some are like any kind of rag piece in the face.’ (Venesoja, 2021, Finland) [italics added by author] ‘… I have experienced that PPE does not sustain and gets torn if I wear it for more than 3 hours.’ (Sharma 2022, India) | ||
| 11 | Solidarity in not physically distancing | Peer and social pressure to comply (or not) with physical distancing | Berry, 2022 (UK); Farrell, 2021 (Ireland); Eraso, 2021 (UK); Fauk, 202242 (Indonesia) | ‘I have often seen there are people who do not want to wear masks or keep social distancing in social events they attend, and even influence their friends or family members not to comply with COVID-19 guidelines. Some said to their neighbours ‘it is not necessary to wear masks. We know each other, so why we should wear masks all the time and keep distance or sit far from each other …’ (Fauk, 2022, Indonesia) [italics added by author] |
| Difficulty complying with physical distancing among friends and family | Berry, 2022 (UK); Fauk, 202242 (Indonesia); Keller, 202243 (US) | ‘We’re all friends in the hospital so it’s hard to [physically distance]. I think it’s a sense of camaraderie also to not social[ly] distance. People say things like “Let’s do a contraband hug or illicit hug,” and that’s a sign of endearment’… we tend to be more lax [with physical distancing] than strict just because … this is the only contact we have with the outside world a lot of times.’ (Keller, 2022, US) [italics added by author] | ||
| 12 | Physical distancing is a barrier to relational care | Physical distancing affects relationships with patients | Kane, 202241 (Belgium, France, Italy, Luxembourg); Stulz, 202240 (Australia); Ferrari, 202133 (Italy) | ‘I don’t try to stay a hard one point five metres away from the women I’m caring for all the time. Because I can’t help them breastfeed that way, and I can’t effectively reassure somebody from one point five metres away if it looks like you’re keeping your distance. That’s not actually part of how relational care works.’ (Stulz, 2022, Australia) [italics added by author] |
| 13 | Difficult to challenge those higher up the hierarchy | Workplace hierarchy influences social distancing | Keller, 202243 (US) | ‘It was difficult for HCWs to ask those higher in the hierarchy, or in a different hierarchy [e.g., resident physicians versus nurses] to physically distance. Hierarchy even determined where HCWs sat … However, leaders promoted physical distancing … higher up physicians, those guys are pretty good at being responsible and … calling out when we need to remain physically distanced.’ (Keller, 2022, US) [italics added by author] |
| 14 | Physical infrastructure prevents physical distancing | Health facility infrastructure prevents physical distancing | Keller, 202243 (US); Berry, 2022 (UK) | ‘So, we were told we should socially distance but there weren’t enough chairs in the offices. We were told to socially distance, but the computers were not spaced such that we can do that. And so suddenly, if there were 7 computers in the room, to socially distance we could only use three.’ (Keller, 2022, US) [italics added by author] |
| 15 | Service delivery presents barriers to physical distancing | Clinical workflows require health workers to gather in proximity | (Keller, 202243 US) | ‘When you have beginning-of-the-shift huddles that makes it a little harder to physically distance yourself when you have now 12 or 13 people between the day shift and night shift together.’ (Keller, 2022, US) [italics added by author] |
Note: Please see the full reference list of the article Arikpo DI, Oku AO, Onyema OA, et al. Health and care workers’ perceptions of PPE and physical distancing for COVID-19: A qualitative evidence synthesis. J Public Health Africa. 2025;16(2), a621. https://doi.org/10.4102/jphia.v16i2.621, for more information.
PPE, personal protective equipment; COVID, coronavirus; ICU, intensive care unit; UK, United Kingdom; US, United States; PAPRs, powered air-purifying respirators; HCP, healthcare personnel.