Personal protective equipment (PPE) is a device designed to create physical barriers between the worker and workplace hazards to protect the worker against work-related injuries and illnesses [
Hospital laundries are in charge of distributing disinfected linen throughout several units of a hospital. This is a very crucial activity in a health care institution, as either lack of or delayed distribution of hospital linens affects the activities of the hospital and influences the quality of health care [
Despite the importance of this service, there is little concern for the workers’ safety and health in many hospitals [
A large number of factors have been identified as barriers to PPE use in prior studies in this area. Equipment unavailability, lack of safety training, workers’ perceived lack of time to wear PPE, and pressure from colleagues have been reported to be significant barriers to PPE use among hospital laundry staff. Similarly, fear of compromising productivity was also reported as an important PPE use hindering factor among hospital laundry workers [
Ethiopia envisions reaching universal health coverage by 2035. Evidence of realizing this can be found in the efforts currently being made to raise the number of hospitals in the country to 800 [
The study was conducted in two government hospitals in Hawassa City from March 25 to April 22, 2019. The two government hospitals were purposively selected for this study because of their large patient flow and the high productivity demand prevalent in their laundry departments.
The study team consisted of three main researchers, four health and safety professional data collectors, and one experienced supervisor. A day-long intensive training was given to the supervisor and the four data collectors. During the training, lessons on data-gathering tools in the study and how the study participants could best be approached were discussed in detail.
The study had two groups of participants. One group consisted of workers from the laundry departments, while participants in the other group were Infection Prevention and Patient Safety Officers within the hospitals. Infection Prevention and Patient Safety Officers were environmental and occupational health professionals who were in charge of dispensing personal protective equipment to hospital staff. They were also responsible for supervising the work of laundry and cleaning departments. To select the study participants, an on-site census was conducted in both hospitals. During the on-site census, a total of 80 workers were recognized as operating in the laundry departments. The Infection Prevention and Patient Safety Offices had nine staff members.
The design of this study is qualitative. The data-gathering instruments used in this study were semistructured key informant interviews (KII) and focus group discussion (FGD) guides. The guides were developed by the research team following a thorough review of related literature. The data collection guides revolved around the participants’ perceptions and experiences of PPE use in the workplace and their perceived impediments to PPE use. In addition, the guide had sections related to the workers’ daily life in the laundry and the workers’ vertical and horizontal relationships. The discussion guides used with both groups of the study participants were made similar to ensure the comparability of the responses obtained from them.
Inclusion in the FGDs was determined based on the study participants’ homogeneity, convenience, and willingness. Key informant interviews were conducted in both hospitals alongside the focus group discussions. Personnel from Infection Prevention and Patient Safety Offices were the interview participants. Both the focus group discussions and the interview processes were held until the data reached saturation—a point at which recurrent patterns became evident in the participants’ narratives. Apart from the study participants, the interview and FGD sessions consisted of a nonparticipant moderator/interviewer, a note-taker, and an observer. All the FGDs and the interviews were audio-recorded.
Open code software 4.03 was used for data analysis, which followed a thematic framework. First, the information gathered in the local language (i.e., Amharic) was transcribed verbatim. Later, the transcribed data was translated into English. The translation was made by an independent English language instructor. The data was analyzed after comparing the original transcript (i.e., the Amharic version) with its translated version (i.e., the English language version). This ensured the absence of discrepancies in words, meanings, and contents of the translated items.
Following this, the authors independently reviewed the transcripts before the process of sorting, coding, and theme identification. Next, data were validated and themes were developed based on an inductive and deductive process of issues that emerged from the discussions and the interviews. First, the authors developed themes independently. Later, the themes that could address the research questions evolved from the researchers’ in-depth study of the individually developed themes. In presenting the data, relevant verbatim quotes are reported to aid the interpretation of the data.
Ethical clearance was obtained from the Institutional Review Board (IRB) of Hawassa University College of Medicine and Health Sciences. Before data collection, a permission letter was obtained from Hawassa City Health Bureau. Moreover, the participation of respondents was based on their full acceptance and volunteerism.
Workers in the laundry departments were generally grouped into smaller units specializing in different tasks. Different activities are designated to the units in the department. For example, collecting dirty linens, washing dirty linens, drying, folding, storing, and distributing clean linens are among the tasks in the laundries of both hospitals. Altogether, 61 hospital workers participated in this study. Of these, 55 were laundry workers and six were personnel from Infection Prevention and Patient Safety Offices in the two hospitals. Participants in the FGDs were laundry workers while personnel from Infection Prevention and Patient Safety Offices were participants in the key informant interviews. Thirty-five (i.e., 53.0%) of the study participants were female. The mean age of the participants was 42.2 with SD ± 8.8 and range between18 and 56.
Two main themes emerged from the narrations of the participants regarding the barriers to PPE use: Organizational-level barriers and individual-level barriers. Within the theme of organizational-level barriers, two subthemes were identified: PPE unavailability and a disharmonious work environment. Within the theme of individual-level barriers, two subthemes were identified: low perception of susceptibility and belief about PPE interference with work performance (Table
Barriers to PPE use among laundry staff of Government Hospitals in Hawassa, Ethiopia, April 2019.
Main themes | Subthemes (category) | Subcategories |
---|---|---|
Organizational-level barriers | PPE unavailability | Lack of ready access to full complement PPE in the workplace |
Poor quality of PPE: | ||
Lack of comfort | ||
Lack of durability | ||
Lack of fit | ||
A disharmonious work environment | Insufficient training | |
Poor communication between workers and managers | ||
Productivity demands | ||
Lax control and monitor for PPE compliance | ||
Workplace policies | ||
Individual-level barriers | The belief of PPE interference with work | Concerns of PPE interfering with work |
Low perception of susceptibility | Perceptions of beneficial age-related changes such as safe work practices | |
Long service years without any recorded workplace injury |
Implementing a PPE program is one of the most important strategies in hazard and risk management programs of hospitals [
The same respondent also described further the different tasks they often performed in the absence of PPE, exposing themselves and their families (at home) to health hazards.
In cases where PPE was available, not having them replaced regularly was also identified as a constraint to working with the full complement of PPE they needed.
Key informants considered in this study also had their share of discontent about the gaps in the continuous supply of PPE in the laundry departments. …
Many participants stated that besides insufficiency in the supply of items of PPE, the pieces of equipment that are currently in use are defective and poorly designed. The researchers endeavored much to understand the
Another key mention made was the issue of comfort or lack thereof felt by laundry workers when using PPE. Comfort is a nonstarter in the implementation of an effective PPE program [
A similar dissatisfaction, this time with respirators, was raised by another participant.
Other than the problems with comfort and durability for some, these problems were compounded by working with ill-fitting equipment. Participants at various times reported that personal protective equipment such as overalls, boots, masks, gloves, and goggles was either too big or too small for them to work comfortably. Thus, it appears that the laundry workers had nothing much to use. Many largely appear to do their jobs with no protective equipment in the face of high-risk situations. One participant had the following to report in connection with the ugly choice she had due to ill-fitting gloves.
Data from key informants tends to agree with FGD participants’ data.
The data obtained in this study reveals the prevalence of unfriendly working situations in hospitals. For example, many participants in the study characterized the workload in the department as exhausting due to productivity demands. Others had the impression that they were working under constant pressure from managers. A significant number also expressed their dissatisfaction with what they called a “rigor control” from their immediate managers. In some cases, middle management representatives were also reported to have an unfriendly and authoritarian attitude toward workers. They said some personnel from the middle management appear to believe, perhaps wrongly, that the route to increasing and improving productivity and achieving goals in the workplace is through exhibiting an authoritarian attitude toward workers. This feeling of the reported “rigorous control” over workers’ work pace and work break may have repercussions on the workers’ health. In this regard, for example, many workers reported compromising between work pace and work safety.
This frustration was shared by another worker who stated the following.
The absence of best practices in policy management was also discernable from the participants’ testimonies. This had an impact on PPE use. For example, the condition of employment of a worker, i.e., whether one is employed on a permanent or a temporary basis, matters in terms of their getting PPE although both types of employees may have a similar exposure opportunity.
The apparent mismatch between the participants’ expectation to benefit from incentive programs and the reluctance of hospital administrators to set up relevant programs seems to affect the workers’ enthusiasm for PPE use.
Alongside workplace policies, the unavailability of inventory tracking systems within the hospitals was identified as a factor that markedly impedes the workers’ pursuit of PPE use.
The issue of training was also raised by the respondents as another important factor for the workers’ failure to use any or some of the required protective pieces of equipment. The participants discussed the training they were given and expressed their dissatisfaction with the frequency (and the adequacy by implication) of the training. One participant, a linen collector was quoted stating the following:
The same participant explained why a training given only once in a year was not adequate.
Key informants had their administrative views of the hospitals’ training systems. They explained that running training frequently is expensive, given the expenses that go into organizing them more than once or twice in a year. The next excerpt illustrates this. The excerpt also reveals the informants’ observation of incorrect worker behavior. We are granted training budgets for only three days a year. We come prepared with slides and pictures to teach laundry workers how to wear gloves, masks, etc. Admittedly, we come across workers who find it difficult to remember lessons from the training and who do not respect hospital protocols. (Adare hospital key informant)
In the group discussions, low susceptibility was mentioned as a reason for not using some or all of the recommended PPE during work. One reason in this regard was the service year in the workplace. Several workers, for example, who had long years of service in the department reported not using any PPE. They said they had enough experience performing tasks without getting sick or injured. For some, relying on experience and self-confidence when performing the work was most important in preventing infections; this is reflected in their positive perceptions of themselves and their conceptualizations of beneficial age-related changes such as the ability to carry out tasks with minimal risk to one’s self. We found that overall older workers were more likely to view their late career more in terms of development than decline.
Likewise, other young participants generally agreed that more experienced workers are less likely to use PPE than their inexperienced counterparts. One participant linked this to the levels of a job promotion that come with experience as illustrated in the excerpt below.
In the focus group discussions, the workers expressed concerns about the negative impact that using items of PPE might have on work performance. They were convinced that safety measures were a burden and an impediment to their ability to achieve productivity goals. Most understood the risks but assumed that they are capable of dealing with it to get the job done.
The level of personal protective equipment use among workers in two government laundry hospitals in Hawassa City, Ethiopia, was observed to be noticeably low. The impetus for this study arose from the recognition of the health risks associated with such a low level of PPE use in a hazardous work environment. This study was, therefore, designed to explore barriers to personal protective equipment use among laundry workers in the hospitals in Hawassa City. The data gathered and analyzed in response to the research concern shed light on some organizational- and individual-level barriers to laundry workers’ use of PPE.
The scarcity of personal protective equipment in the hospitals was noted as a significant organizational-level barrier to the laundry workers’ use of PPE at their workplace. This finding is similar to findings of other earlier studies conducted in India and the USA [
Likewise, for effective PPE use, employees should be provided with equipment of an acceptable level of quality. This refers to equipment that can reduce physiologic burdens, improve communication, and be more comfortable and less of an encumbrance to wear. Otherwise, workers’ commitment to PPE will be challenged [
Hospital policy may affect the use of and adherence to PPE [
The paramount need for a safe climate to prevail at the workplace was an issue of an in-depth discussion during the FGDs. For example, providing incentives for appropriate PPE use emerged during the FGDs as an example of the desirable safety climate of the workplace. However, incentive programs focusing on providing awards to employees solely for PPE use may only improve the employees’ safety performance in the short term as they are unsustainable. On the other hand, incentive programs that promote safety awareness and employee participation in safety-related activities have been proven to be most effective [
In any health-related workplace, safety practices need to be sustained by a good level of knowledge and scientific evidence. The absence of this may lead to the spread of infections in the health care setting [
Similarly, some participants, in the present study, exhibited misconceptions about PPE interference with performance. It is known that these types of beliefs result in increased risk-taking and ill-preparedness for the next unknown [
This study has some limitations. This is a two-site study, and the findings are not likely to be representative of other hospitals in their totality. Other hospitals will inevitably have their characteristics that mediate barriers to optimal PPE use, though it is probable that those identified in this study may have resonance there. Moreover, participant responses may be biased as a result of social desirability to provide sociably preferred answers. This means that opportunities for reluctance to reflect their real experiences among some participants cannot be ruled out. The outcomes reported in the present study are almost totally based on the perception of the study partakers, rather than hard evidence, e.g., tests of effectiveness, durability, and fit of protective clothing. The reported results have not been verified independently. Though perceptions are valuable, they can sometimes be colored by the enthusiasm and vested interests and, thus, may fail to accurately mirror actual circumstances as they exist. Also, the use of observations to monitor social dynamics and body language of participants during discussions could have been better approached through techniques that reduce observer biases such as video-observation. Aside from these limitations, the study possesses important strengths. The study provides a full and meaningful assessment of barriers to PPE use by including perspectives of laundry workers and infection prevention officers. The results add to a sparse body of the literature on barriers to PPE use among hospital laundry staff and can help future studies and interventions.
Circumstances surrounding the ongoing Coronavirus (COVID-19) pandemic, together with very challenging working conditions, scarce resources, and stretched health care systems, make it difficult to collect data regarding the number of laundry workers dropping out because of infectious diseases possibly resulting from PPE nonuse. However, efforts to collect this data should be undertaken wherever possible. Similarly, an assessment of costs associated with PPE nonuse related injuries and worker and process downtime as a result of the injuries should be undertaken to better inform managers and policymakers. Future research would also benefit from a more structured sampling plan enabling the synthesis of larger sample sizes. In the future, studies related to PPE use among hospital laundry workers should incorporate designs that provide for carefully controlled intrahospital and interhospital comparisons over longer periods. The current study demonstrated that training is an important determinant of PPE use; nevertheless, it was examined in a general manner. Future studies may need to disaggregate it further and study the type and frequency of training, the content delivered, and the effect of the workers’ prior knowledge on this training. Finally, one fairly narrow but an essential issue that struck the researchers’ mind after their completion of the collection of the data used in the present study was related to the ethical implications of employing less educated and “underprivileged” members of a community in high-risk and infection-prone settings, particularly, settings like hospital laundries.
PPE nonuse was related to organizational- and individual-level factors such as PPE unavailability, workplace disharmony, low perception of susceptibility, and belief of PPE interference with work performance. Improving institutional supplies in quantity and quality may, therefore, have a positive implication for the improvement of infection prevention practices. Also, designing sustainable strategies and raising laundry workers’ awareness of a safe work environment may lead to the improvement of PPE use. Workers, on their part, are expected to demonstrate personal responsibility for observing PPE protocol as needed at the workplace.
Personal protective equipment
Health care acquired infections
Focus group discussions
Key informant interview.
The data sets used to support the findings of this study are available from the corresponding author upon request.
The study was done as part of the employment of the author at Wachemo, University.
The authors declare no conflicts of interest.
AT was the primary investigator. AT, AA, and LM developed the tool used for the study and analyzed and interpreted the data. All authors read and approved the manuscript.
The authors are grateful to the hospitals. They would like to thank the participants.