Utilization of Personal Protective Equipment and Associated Factors among Large-Scale Factory Workers in Debre-Berhan Town, Amhara Region, Ethiopia, 2021

Background Personal protective equipment was designed to protect workers from serious workplace injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards. Use of personal protective equipment has been identified as an important hazard control strategy in work environments where it may not be practical to adopt other strategies. Objective To determine personal protective equipment utilization and its associated factors based on health belief model among large scale factory workers in Debre-Birhan, Ethiopia. Methods An institution-based cross-sectional study was employed in Debre-Birhan Town, North Shoa Ethiopia, from April 1 to May 1, 2021. The data were collected by using an interviewer-administered structured questionnaire. A total of 412 samples were selected by systematic random sampling method. The data were entered to EpiData version 3.1 and analyzed by SPSS. All independent variables were fitted into the binary logistic regression model to evaluate the degree of association and variables with a p value of <0.2 that was fitted for multiple logistic regressions. Finally, variables with a p value of <0.05 was found to be statistically significant. Result A total of 412 workers were study participants with 100% response rate. The mean age was 29 (±7.3) years. Most workers, 367 (89%) knew that PPE can prevent work-related injury and illness. Overall, 172 (41.7%) of the workers were considered to have good personal protective equipment utilization. Perceived susceptibility (AOR = 1.2, 95%, CI (1.076–1.38)), perceived severity (AOR = 1.1, 95%, CI (1.088–1.163)), perceived self-efficacy (AOR = 1.2, 95%, CI (1.082–1.349)), and perceived barrier (AOR = 0.87, 95%, CI (0.800–0.956)) were found to be significant predictors of good personal protective equipment utilization. Conclusion The study revealed that good personal protective equipment utilization in large-scale factory workers. Perceived susceptibility, perceived severity, perceived barrier, and perceived self-efficacy were found to be predictors of PPE utilization. It is recommended that, during delivery of health education special emphasis should be given to severity, susceptibility, barrier, and self-efficacy of occupational disease.


Background
Personal protective equipment was designed to protect workers from serious workplace injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards. It may include items such as gloves, safety glasses and shoes, earplugs or muffs, hard hats, respirators, or coveralls, vests, and full body suits [1]. It is a significant determining factor between an accident and safety in the working environment.
Evidence suggests that wearing the correct personal protection at all times is extremely important in reducing accidents and should be given high priority [2]. Globally, 34% of occupational accidents were resulting from the lack of use of PPE available at workplace at the time of the accident [3]. In addition, 13% of work-related accidents result from the inappropriate use of PPE [3]. e use of personal protective equipment has been identified as an important hazard control strategy in work environments where it may not be practical to adopt other strategies, and there is a great concern however that PPE usage remains low [4]. Evidence indicated that workers use of PPE is influenced by various factors. It has been reported that the influencing factors include sociodemographic factors, perception about occupational disease, and expectations of the benefits and barriers of PPE use [5,6].
In Ethiopia, reports indicated that only 5 to 10% of workers have access to occupational health services in their respective workplaces [7]. But nearly half (44.66%) of the workers in Ethiopia have experienced occupational injury. Upon reviewing several literature studies about occupational health and safety among factory workers for this study, the PPE utilization rate typically ranges between 20.6% and 82.4% [7][8][9][10].

Methods
An institution-based cross-sectional quantitative study was employed from April 1 to May 1, 2021, in Debre Birhan North Shoa, Amhara region, Ethiopia. Based on CSA estimation, the town has a total population of 114,652. Among these, 51,843 are men and 62,809 are women. It is located at 130 km northeast of the capital Addis Ababa and has a total of 22 large scale factories. ese factories are mainly involved in the production of processed food, textile, beverage, glass, and other products. e town is one of the most preferred investment destinations in the country. us, the study was conducted at selected large-scale factories in Debre Birhan town.

Source Population.
All large-scale factory workers in Debre Birhan town were considered as a source population.

Study Population.
Factory workers working in the selected factories in Debre Birhan town who could meet the inclusion criteria.

Study Unit.
Selected factory workers working in the selected factories in Debre Birhan town who could meet the inclusion criteria.

Inclusion Criteria.
All factory workers that were present at work during the study period were considered for the study.

Exclusion
Criteria. Factory workers working in quality control and finishing section in beer and blanket factories were, respectively, excluded.

Sample Size Determination.
e sample size for the dependent variable was calculated using single population proportion formula based on the following assumptions. Utilization of PPE was taken from a study done at Kombolcha textile factory which was 58.2% [11], level of confidence of 95%, margin of error of 5%, and nonresponse rate of 10% and gives a sample size of 412. Similarly, for associated factors by taking significantly associated variables with multivariate analysis in different studies, the sample size was calculated by using Epi Info 7 STATCAL software, cohort or cross-sectional study.
2.7. Sampling Technique and Procedure. A total of 22 largescale factories in Debre-Birhan town were considered for sampling. Based on the assumption of 30% representatives, 7 factories were selected by simple random selection method. Before the data collection was started, all the necessary PPE for the workers working in different sections of the factory were identified based on literatures [12,13]. Workers utilizing the similar type of PPE were considered for this study. e required sample size was taken proportional to the size of the selected factories. To get the individual sample at the selected factory, systematic random sampling was conducted by using the total number of factory workers who have worked during the study period and number of sample required in each selected factory. After getting the sampling fraction in the selected factory the first participant was obtained by lottery method among the first "k" units.

Data Collection Method.
Interviewer-administered structured questionnaire was used to collect the required quantitative information on utilization and determinates of PPE use. Questionnaire was developed after review of similar literatures [11,14,15]. It includes socio-demographic characteristics of the workers, knowledge about PPE and occupational exposures, and seven HBM construct measures, namely, perceived susceptibility of occupational-related health problems, perceived severity of occupationalrelated health problems, perceived benefits of using PPE, perceived barriers to using PPE, perceived self-efficacy of using PPE, and cues to action of using PPE. e constructs of HBM were answered on a 5-point Likert's scale (1 � strongly disagree; 5 � strongly agree). e score of each participant was summed to get a score for each construct. e questionnaire is prepared in English and translated to Amharic. e required data were collected by Four Environmental health professionals who are worked in woreda health office and health center. Training was provided for data collectors on different issues regarding the research.

Data Processing and Analysis.
e collected data were checked for its completeness manually; data entry was done using EpiData version 3.1. e entered data was exported to SPSS version 21 for further cleaning and analysis. Data editing, coding, checking, and organization were done to transform the data into suitable format for further analysis. e model fitness was checked by Hosmer Lomeshow goodness of fit test. Assumptions of model including Multicollinearity and outlier were checked by variance inflation factor (VIF) and normal P-P plot, respectively. All independent variables were fitted separately into binary logistic regression model to evaluate the degree of association with utilization of PPE. e variables with a p value<0.20 was fitted to multiple logistic regression model. en, AOR value with 95% CI was calculated to identify independent variables which were significantly associated with PPE utilization, a p value <0.05 was used as level of significance for the final qualifiers as factors associated with PPE utilization.

Sociodemographic Characteristics of Factory Workers.
A total 412 factory workers were involved in this study with 100% response rate. As shown in Table 1, the participants were predominantly male (66.3%). e age of the participants ranged from 18 to 57 with the mean age of 29.4 (±7.3) years. A majority of (97.3%) the participants were employed on a permanent basis with a small percentage of temporary workers 11 (2.7%). Concerning marital status of the workers, 47.3% were married (Table 1).

PPE Utilization Status.
Overall, 41.7% (95% CI, 37.1-46.1) of the factory workers had good PPE utilization. e utilization was highly varied among the type of PPE. Respirator was found to be the most utilized PPE with a mean utilization score of 3.94 ± 1.42 followed by coverall. On the other hand, ear protector (1.14 ± 0.62) was found to be the least utilized PPE. Helmet, eye protector, coverall, safety shoe, and glove had a mean utilization score of 2.11 ± 1.26, 2.53 ± 1.63, 3.42 ± 1.71; 2.95 ± 1.82, and 2.41 ± 1.64, respectively (Table 2).

Knowledge towards PPE Utilization.
In this study, 367 (89%) of workers knew that PPE can prevent work related injury and illness, of them, 164 (39.8%) were good PPE utilizers. Generally, in this research, 342 (83%) of factory workers had good knowledge about PPE, while the remaining 70 (17%) workers had poor knowledge regarding PPE utilization.

Perception towards Occupational Disease and PPE
Utilization. Concerning perception of workers towards PPE utilization and occupational disease, it was measured using HBM constructs and treated as a continuous variable as shown in Tables 3 and 4. e mean score of perceived susceptibility was found to be 17.1(±8.7). For perceived severity, possible values range from 7 to 35 and the mean score was 20.2(±11.4). In addition, the mean scores of perceived benefit, perceived barrier, cues to action, and perceived self-efficacy were found to be 10.5 (±5.8), 22.0 (±9.3), 29.2 (±8.9), and 15.7 (±7.6), respectively.

Multivariate Analysis of Associated Factors.
Of the total eight potential candidate predictors of PPE utilization of factory workers that were included in the multiple logistic regression model, only four (i.e., perceived susceptibility, perceived severity, self-efficacy, and perceived barriers) were found as predictors of PPE utilization (Table 5).
Generally, after controlling possible confounding factors, the result of the research indicated that per a unit increases in the total score of perceived susceptibility towards PPE utilization, the odds of using PPE increased by 20% (AOR � 1.2, 95%, CI (1.07-1.38)). Similarly, per a unit increases in the total score of perceived severity towards PPE utilization the odds of using PPE increased by 10% (AOR � 1.1, 95%, CI (1.01-1.16)). e other variable which independently associated with PPE utilization was perceived self-efficacy in which, per a unit increases in the total score of perceived self-efficacy towards PPE utilization the odds of using PPE was increased by 20% (AOR � 1.2, 95%, CI (1.08-1.34)). Perceived barrier was also found to be a negative predictors of PPE utilization in which per a unit increases in the total score of perceived barrier towards PPE utilization the odds of using PPE was decreased by 13% (AOR � 0.87, 95%, CI (0.80-0.95)).

Discussion
e finding of this research indicated that, only 172 (41.7%) of the workers were considered to have good PPE utilization.
is finding was much lower than the study done in ailand and Addis Ababa which indicated that 70.1% and 64.80% of the workers had good PPE utilization, respectively [16,17]. On the contrary, the finding of this research was higher than the study done in Gujarat, India, that showed only 25% of the workers were considered to have good PPE utilization [18]. is difference might be due to methodological differences, like study population and methods of data collection, and workplace conditions, employees' level of awareness on hazard control and disease prevention. e use of PPE varied considerably depending on the item examined with the respirator and overall being the most commonly used protective items. e finding was inconsistent with the study done in Hawasa town among Wood and Metal Worker that showed eye protector and safety shoe were the most utilized protective items [19]. On the other hand, in this research ear protector was found to be the least utilized type of PPE. e finding was different with the study done in Missouri, USA, that indicates helmet was found to be the least utilized PPE type [20]. is difference might be due to the difference in the nature of factories considered in the study.
In this research, none of the sociodemographic factors were significant at a p value of <0.05.
is finding was inconsistence with the study done in different countries. For example, a research done in Uganda showed that, among the sociodemographic factors sex was found to be a significant predictors of PPE utilization in which female respondents were used PPE more than male respondent (AOR) � 6.64; 95% CI: 1.55-28.46 [21]). Similarly in Nepal female respondents were used PPE 3.65 times than male (AOR) � 6.64; p � 0.031) [22]. is difference might be due to the difference in educational level and culture of the participants.
Another sociodemographic factor which was found to be insignificant predictors of PPE utilization was age of the workers. e finding was consistent with the study done in Uganda and Mombasa County, Kenya [21,23]. But finding of this research regarding age was against with different     [24]. Similarly, employment form, income, working experience, and marital status was among the sociodemographic factors that were not predictors of PPE utilization. Similar finding was obtained from a study conducted in Kenya and Addis Ababa, in which employment form, income, working experience, and marital status were not determinant factors of PPE utilization [23,25].
Regarding the HBM constructs, perceived susceptibility, perceived severity, perceived self-efficacy, and perceived barriers were significantly associated with PPE utilization. On the other hand, perceived benefit and cues to action towards PPE utilization were not found to be independent predictors.
Perceived susceptibility of occupational illness and injury has shown statistically significant association with PPE utilization. e study showed that, as a unit increase in total score of perceived susceptibility, the odds of utilizing PPE also increased by 20%. is finding is in line with different studies conducted in USA and ailand [15,17]. is might be explained as the study participants those having high susceptibility may belief that using PPE has the potential to protect work-related disease and injuries. Similarly, as a unit increases in total score of perceived severity, the odds of using PPE was increased by 10%. is finding is consistent with the studies conducted in Indonesia and USA. is might be due to the workers beliefs about the seriousness of the occupational illness, injury, and possible outcome of the disease. e other explanation may be high perceived susceptibility and severity towards occupational illness and injury may also increase the perceived threat of respondents; thus the participants could use PPE. In general, workers who perceived as they are highly susceptible to work related illness and injury and that they perceived work related disease is a serious disease, they would be more likely to utilize PPE. e other predictor variable towards PPE utilization was perceived barrier, it was significantly associated with PPE utilization, and it indicated that, as a unit increases in sum score of perceived barriers, the odds of using PPE was decreased by 13%. Similar finding was reported from crosssectional study conducted in Hawassa and Nigeria that showed barriers like inconvenience, unavailability, and increased cost were found to be predictors of PPE utilization [8,26].
Self-confidence in using PPE (perceived self-efficacy) was found to be a significant predictor of PPE utilization, in which, per a unit increases in the total score of perceived selfefficacy towards PPE utilization the odds of using PPE was increased by 20% (AOR � 1.2, 95%, CI (1.082-1.349)). e possible justification might be People with high self-efficacy show elevated confidence in their skills and have no doubt about themselves. In these cases, factory workers consider the problems as a challenge, not a threat, and they actively search for new situations. In addition, high self-efficacy reduces fear of failure, increases the level of motivation, and improves problem-solving and analytical thinking abilities. In the same way, high self-efficacy in working a hazardous environment may promote the use of PPE.
On the other hand, perceived benefit (AOR � 1.05, 95%, CI (0.95-1.17, p � 0.302)) were not found to be  is inconsistency may be due to the difference of educational level, media exposure, and culture of the participants.

Conclusion
e finding revealed that there was good PPE utilization among large-scale workers. Perceived susceptibility, perceived severity, perceived self-efficacy, and perceived barrier were found to be strong predictors of PPE utilization.

Recommendations
(i) For health professionals delivering health education or health information should create an awareness to increase personal protective equipment utilization (ii) ey should also provide special emphasis to susceptibility and severity of occupational disease and injuries (iii) For regulatory bodies, workers association and other stake holders have to work hard towards increasing personal protective equipment utilization focusing on modification of barriers and increasing self-confidence of workers in using PPE (iv) For factory managers in order to increase personal protective equipment utilization, focus should be on reducing barriers of PPE utilization

Limitation of the Study.
Since the study is cross-sectional, it does not show cause and effect relationship between dependent and independent variables.

PPE:
Personal protective equipment HBM: Health belief model OSHA: Occupational Health and Safety Act.

Data Availability
e data collected for this study can be obtained from the first or last author upon a reasonable request.

Ethical Approval
Ethical clearance was obtained from the Institution Review Board of Debre Berhan University with a protocol number of 28/21/CHS/SPH. Permission was obtained from the factory before collecting data.

Consent
Brief explanation has been given to all respondents about the purpose of the study, and the privacy of their responses during data collection was maintained. Informed Verbal consent was received from each respondent before the data collection. It was clearly stated that their response was only for research purpose, and the data collected were kept confidential.

Disclosure
Muluken Tessema and Wondimu Sema are first authors.

Conflicts of Interest
e authors declare that they have no conflicts of interest.