Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : JC17 - JC21 Full Version

Impact of Training on Knowledge, Attitude and Perceived Barriers for Compliance Regarding use of Personal Protective Equipment Kit among Frontline Healthcare Workers during COVID-19 Pandemic

Published: January 1, 2022 | DOI:
Jyoti Sangwan, Sumit Lathwal, Kirti Lohan, Kumkum Yadav, Neha Adlakha, Pratibha Mane, Sheetal Gole

1. Professor, Department of Microbiology, SHKM GMC, Nalhar, Nuh, Haryana, India. 2. Assistant Director, Health, Department of Community Medicine, Indian Armed Forces, New Delhi, Delhi, India. 3. Postgraduate Student, Department of Microbiology, SHKM GMC, Nalhar, Nuh, Haryana, India. 4. Postgraduate Student, Department of Microbiology, SHKM GMC, Nalhar, Nuh, Haryana, India. 5. Assistant Professor, Department of Opthalmology, SHKM GMC, Nalhar, Nuh, Haryana, India. 6. Professor and Head, Department of Microbiology, SHKM GMC, Nalhar, Nuh, Haryana, India. 7. Professor, Department of Pathology, SHKM GMC, Nalhar, Nuh, Haryana, India.

Correspondence Address :
Jyoti Sangwan,
Professor, Department of Microbiology, SHKM GMC, Nalhar, Nuh, Haryana, India.


Introduction: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the novel Coronavirus, the causative agent of Coronavirus Disease-2019 (COVID-19) pandemic has grasped the whole world. Healthcare Workers (HCWs) are at an increased risk. The usage and awareness of entire Personal Protective Equipment (PPE) kit in hospitals on such wide scale has not been seen for some time in healthcare setting. Improper use of these equipment may result in the spread of infection.

Aim: To assess the knowledge and attitude of HCWs regarding the correct use of PPE at the beginning of COVID-19 pandemic in order to find the gap in knowledge and to address the perceived barriers in compliance and further to assess the same after training and reinforcement to ensure the HCWs safety.

Materials and Methods: A cross-sectional hospital based study was carried out in a designated COVID-19 hospital of Shaheed Hasan Khan Mewati Government Medical College from April 2020 to October 2020 on frontline HCWs posted in various areas of hospital. Sample size was calculated as a minimum of 500 HCWs using appropriate statistical formula. A predesigned, pretested structured questionnaire both online and offline mode was used. The data that was obtained was analysed using Statistical Package for the Social Science (SPSS) version 20.0.

Results: Seven hundred frontline HCWs were included in the study. Mean age of study population was 30.5 years. Among 700 HCWs, 200 (28.57%) were doctors, 360 (51.42%) were nursing staff and 140 (20%) were housekeeping staff. Knowledge level of PPE kit and its use varied across doctors, nursing staff and housekeeping staff. Knowledge about donning and doffing was largely lacking with only 9% doctors and none of other staff were aware which improved to more than 80% post-training. Attitude regarding PPE kit usage was largely positive.

Conclusion: The study concludes that there is a constant need of training and re-training of HCWs in order to keep them safe from not only COVID-19 but also from future infections. An active infection prevention training program is crucial to ensure HCWs safety.


Coronavirus disease-2019, Doffing, Donning, Infection control

The novel Coronavirus Disease-2019 (COVID-19), which first emerged in the Chinese city of Wuhan in December 2019, has infected more than 169,597,415 people globally, leading to 3,530,582 deaths as on May 2021 as per World Health Organisation (WHO) (1). Indian subcontinent is no exception, with being world’s second most populous country and spending a meagre 4.69% GDP expenditure on health, we only have 20 HCW for every 10,000 people (2). With such statistics we were bound to face a larger impact of COVID-19 pandemic than anywhere else.

The COVID-19 is known to have a higher mortality than the seasonal influenza, even as wide variation is reported. Though continuing research on COVID-19 provides hope but taking precautions remain the mainstay. Global healthcare workforce bears the intense pressure in two forms. First being the overwhelming patient load stressing healthcare system capacity and second the heightened risk of acquiring the infection while caring for COVID-19 patients (3).

Centers for Disease Control and Prevention’s (CDC) has recommended guidelines to ensures safety of HCWs. The SARS-CoV-2 is spread by droplet and contact with possibility of air borne transmission. Hence, observing droplet barrier precautions, environmental hygiene and following Infection Control Practices (IPC) is must. For the HCWs, while treating or caring for patients with COVID-19, the CDC recommends the utilisation of Personal Protective Equipment (PPE) (4). The term PPE as per definition given by the Occupational Safety and Health Administration (OSHA), is the “equipment that protects employees from serious injury or illness resulting from contact with chemical, radiological, physical, electrical, mechanical, or other hazards. PPE includes gown, gloves, boots and either an N95 respirator plus a face shield/goggles or a Powered, Air-Purifying Respirator (PAPR) (5).

The HCWs providing care to COVID-19 patients are at increased risk of getting infected themselves and subsequently their families. It is therefore mandatory for them to have correct knowledge, awareness about PPE, its correct use and disposal. This can be addressed by specific training and encouragement of adherence to correct PPE usage, contact precautions and hygiene recommendations (4). In the present pandemic, because of lack of adequate knowledge about coronavirus and the panic that the world is facing, the varied perceptions exist among HCWs. Telling caregivers to focus on their safety and being clear and specific about how to do so can promote calm during an epidemic. However, many times due to urgency in caring for the patients, overlook, lack of knowledge about its importance, breech happens in healthcare settings as was observed in studies conducted in Ohio and Pittsburgh which reported self-contamination rates >40% while doffing PPE, especially during the removal of gloves (6),(7).

With this background, present study was conducted to assess the knowledge and attitude of HCWs regarding the correct use of PPE at the beginning of COVID pandemic in order to find the gap in knowledge and to address the perceived barriers in compliance and further to assess the same after training and reinforcement to ensure HCWs safety.

Material and Methods

This hospital based cross-sectional study was carried out at a designated COVID-19 hospital of Shaheed Hasan Khan Mewati Government Medical College, Nalhar, Nuh, Haryana, India from April 2020 to October 2020. Institutional Ethics Committee approval was obtained wide letter no SHKM/IEC/2020/35 dated 24-04-2020.

Sample size calculation: Sample size was calculated as 424 using paired t-test formula using statistical software with α=1%, β=20%, Effect size=0.5 and Standard Deviation (SD)=3.0. Therefore, minimum sample size was decided as 500. Study population was frontline HCWs employed at our institute such as Senior Residents (SRs), Junior Residents (JRs), Interns, Nursing staff and Housekeeping staff who gave consent to be part of study. These frontline HCWs were involved in various areas catering for COVID-19 patients such as, Flu corner, Triage, COVID-19 ICU and COVID-19 ward.

Inclusion criteria: HCWs working as front line HCWs having maximum risk of getting in contact with COVID-19 patients only, were included.

Exclusion criteria: All those HCWs who did not give consent to fill the questionnaire and those who did not fill both pre and post test questionnaire were excluded.

Questionnaire Design

A pre-tested and pre-validated questionnaire containing 21 closed ended questions along with demographic information (Cronbach alpha score was 0.69) and two open ended questions based on OSHA and CDC guidelines was used to collect data from HCWs regarding PPE knowledge, attitude and perceived barriers for compliance (4),(5). An online Google form as well as offline print version (for those who did not have access to online form) survey was conducted in English and in Hindi for those who were not comfortable with English language. The questionnaire consisted of three components including: demographic information, knowledge/awareness and attitude/perceptions. Knowledge or awareness items were 12 multiple choice/multi option questions marked as 1 if correct and 0 if incorrect/partially correct. Attitude or perceptions items were 9 and were scored using a Likert-scale, which ranged from 1 (disagree) to 3 (agree). In the end there were two open ended questions about perceived barriers hampering the adequate use of PPE kit and suggestions to improve the same.

Study Procedure

A total of 15 training sessions were organised under aegis of Hospital Infection Control Committee (HICC) under infection prevention and control program from beginning of COVID pandemic during study period. The session was taken by Infection Control Officer assisted by Infection Control Nurses. All norms of social distancing were followed while conducting these sessions. Every session had less than 50 participants maintaining social distancing. A pre-test was taken before starting the session for knowledge assessment. The session comprised of brief introduction followed by live demonstration of donning and doffing and hand hygiene steps by trained staff under supervision of the Infection Control Officer. Correct usage of all the components of PPE and all seven steps of hand hygiene as per WHO guidelines were explained followed by clarification of all doubts (1),(4),(5). A post-test was taken for knowledge improvement if any after the training session. Also, the questionnaire was filled by participants after the session for assessing the attitude, perceived barriers in compliance and suggestion for improvement. All the data was compiled and analysed.

Statistical Analysis

Qualitative data were expressed in percentages and mean was calculated. Pre and postscore for knowledge were compared by t-test. A p-value of <0.05 was considered statistically significant. All statistical calculations were done using computer program Microsoft Excel version 7 (Microsoft Corporation, NY, USA) and SPSS version 20.0 (Statistical Package for the Social Science SPSS Inc. Chicago, USA).


A total of 700 participants took part in the study. Among these 200 (28.57%) were doctors (SRs, JRs and Interns), 360 (51.43%) were nursing staff and 140 (20%) were housekeeping staff. Mean age of study population was 30.5 years being 27 years for doctors, 32 years for nursing staff and 31 years for the housekeeping staff.

While assessing the knowledge among doctors before training, it was observed that 166 (83%) and 159 (79.5%) doctors knew the correct meaning and intended use of ‘PPE’ respectively but only 46 (23%) were aware of all the types of PPE kits available and further 137 (68.5%) could name all the components of PPE kit correctly. Only 99 (49.5%) knew about the term donning and doffing and only 18 (9%) frontline doctors had correct knowledge of all the steps of donning. Similarly, though 171 (85.5%) knew about importance of hand hygiene in preventing COVID, only 73 (36.5%) knew all the steps of hand hygiene correctly. Knowledge about all the above aspects of PPE usage improved to more than 96% post-training (Table/Fig 1). Mean score for knowledge before and after training were 5.7 and 11, respectively, the difference being significant (p<0.05) (Table/Fig 2).

About the knowledge among nursing staff before training, it was observed that only 59 (16.3%) and 68 (18.8%) nurses knew the correct meaning and intended use of ‘PPE’ but no one had complete knowledge of all the types of PPE kits available however 168 (46.6%) could name all the components of PPE kit correctly. None of the nursing staff knew about the term donning and doffing and the steps involved. Similarly, 208 (57.7%) nurses knew about importance of Hand hygiene in preventing COVID and only 68 (18.8%) knew all the steps of hand hygiene correctly. Knowledge about all the above aspects of PPE usage improved to more than 90% post-training (Table/Fig 1). Mean knowledge score before and after training were 4.2 and 10.7, respectively, the difference being significant (p<0.05) (Table/Fig 2).

Similarly, no housekeeping staff was aware of PPE kit or its correct use. However, 36 (25.7%) staff were able to tell the disposal of PPE components correctly. A total of 48 (34.2%) housekeeping staff knew about importance of hand hygiene in preventing COVID-19 but none could identify all the steps of hand hygiene correctly. Knowledge about all the above aspects of PPE usage improved to more than 64% post-training (Table/Fig 1). Mean knowledge score before and after training were 1.3 and 8.4, respectively, the difference being significant (p<0.05) (Table/Fig 2).

The attitude of HCWs is presented in (Table/Fig 3). Total of 94.5% doctors, 85.8% nurses and nurses and 100% housekeeping staff agreed that COVID-19 made them more aware about PPE usage than ever before. Almost all HCWs agreed that correct use of PPE can prevent chances of infection. A 89% doctors, 90.8% nurses and 100% housekeeping staff agreed that wearing of PPE kit is cumbersome and time consuming but almost all (≥96%) agreed that they are still willing to wear it in order to stay safe. A 94% doctors, 97.5% nurses and 100% housekeeping staff agreed that remembering the order of donning and doffing is important. A 100% HCWs agreed that hand hygiene plays an important role in preventing not only COVID-19 but any infection. A 98.5% doctors, 98.8% nurses and 100% housekeeping staff agreed that there is need of regular training on donning and doffing of PPE. Also, 99.5% doctors, 98.6% nurses and 94.2% housekeeping staff found the training on donning and doffing of PPE useful. The barriers responsible for inadequate compliance towards PPE use as perceived by HCWs are listed in (Table/Fig 4). Similarly, the suggestions for improved compliance as given by study participants are depicted in (Table/Fig 5).


Before the 2014 Ebola outbreak, the majority of studies on PPE kit usage were in industrial setup to safeguard their employees (8),(9). In HCWs the most studies have been carried out post Ebola (10),(11). Indian subcontinent has largely remain deficient in such studies in HCWs. The usage and awareness of entire PPE kit in hospitals on such wide scale has not been seen for some time in our healthcare setting. In present pandemic, because of lack of adequate knowledge about coronavirus and the panic world is facing, the varied perceptions exist among HCWs. All these can be addressed only by specific training and encouragement/reinforcement of adherence to barrier precautions and hygiene recommendations. Therefore, the present study was conceived.

The present study demonstrated that the level of knowledge regarding the term ‘PPE’, its use and all the components of PPE kit was higher in doctors (83%, 79.5 and 68.5%, respectively) compared to nurses (16.3%,18.8, 46.6%, respectively) and housekeeping staff (no knowledge). This can be simply because the education level and training of former is better and more rigorous than later. However, the knowledge about donning and doffing and its correct order was largely poor across all three groups, only 9% of doctors being aware and none of nursing and housekeeping staff being aware. All three groups had similar knowledge about correct disposal of PPE components also was largely lacking. It was observed that knowledge about importance of hand hygiene in spread of COVID-19 was maximum in doctors compared to nurses and housekeeping staff but when it comes to practical aspect of knowing all steps of hand hygiene, even doctors had inadequate knowledge.

This was an alarming situation as nursing staff and housekeeping staff is in direct vicinity of patients and their environment and can play an important role in spreading the disease. Recently, Mishra A et al., from West Bengal have also documented 0% knowledge of donning and doffing among doctors in their study (12). All these issues were addressed in training and the post test scores were significantly better across all groups difference being statistically significant (p≤0.05).

The present study concludes that all the HCWs had positive attitude towards PPE kit usage for prevention of infection (more than 84% agreeing). All HCWs (100%) agreed that inspite of difficulty faced they would want to use PPE kit to keep themselves safe. Similarly, all staff agreed that memorising all steps of donning and doffing are important to stay safe. More than 90% participants did not receive any training in infection prevention and control in last six months which was way below than other studies (12),(13). Almost everyone agreed that there is constant need of training and re-training for correct and adequate use of PPE kits. Similarly, more than 90% participants agreed that training was useful to them. Other recent study also demonstrated positive attitude of HCWs towards PPE usage (12).

While studying the perceived barriers for non compliance, it was found that non availability of PPE, forgetting steps, cumbersome to wear and remove, difficulty in breathing and increased sweating inside PPE kit and lack of training were main reasons. Others studies have found non availability and lack of proper training as main cause (14),(15). This could be because during COVID-19 pandemic, all HCWs have to stay donned for extended hours. To improve the compliance, some of the suggestion given by participants is depicted in (Table/Fig 5).

Corrective measures: Post training, many steps based on the study findings were taken to ensure HCWs safety. All new joined HCWs are being trained in IPC at the beginning only. Weekly re-enforcement sessions are being conducted. Also charts depicting all steps of donning, doffing and steps of hand hygiene are pasted at donning, doffing areas and across the hospital. Due to these, the HCWs infection rate in the institute was considerably lower during first wave of COVID-19.


It was a hospital-based study with cross sectional design. The study was conducted over a shorter period of time however authors tried to include a large number of participants. Real time observation of the practice of donning and doffing of PPE among the participants could not be done due to infectious nature of disease and time constraints. To continue achieving compliance for correct and adequate use of PPE, the training for the same needs to be included as an integral part of ongoing IPC training in the healthcare settings whereby along with education, regular surprise visits and evaluations should be conducted to observe the IPC practices of HCWs and taking remedial actions based on observations.


COVID-19, inspite of being more than a year old with vaccines being available, largely remains an enigmatic disease with more and more complications being reported. Therefore, prevention is the mainstay. HCWs due to their work are largely exposed to the disease. The adequate and correct use of PPE can be a key to prevent infection spread. Present study concludes that though doctors are aware about the importance of PPE, still lack training as to correctly use it. The housekeeping staff remains largely untrained and hence end up spreading infection. Therefore, periodic training and re-training of HCWs holds a key to prevention of not only COVID-19 but future infections.


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DOI and Others

DOI: 10.7860/JCDR/2022/50845.15913

Date of Submission: Jun 13, 2021
Date of Peer Review: Sep 16, 2021
Date of Acceptance: Nov 25, 2021
Date of Publishing: Jan 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jun 14, 2021
• Manual Googling: Nov 24, 2021
• iThenticate Software: Dec 30, 2021 (7%)

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