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During Infectious Disease Epidemics, What Factors Determine the Conformity of Healthcare Workers? Rapid Evidence Review

Executive summary

Following the emergence of a new coronavirus in 2019, concerns have been made about the potential of nosocomial transmission, which is defined as an illness that occurs in a hospital setting. A healthcare worker’s inability to follow the recommended personal protective precautions is one of the most major drivers of nosocomial transmission, as evidenced by previous epidemics of new infectious diseases. Using the most recent research on infectious disease outbreaks, we scoured the literature for indicators of healthcare workers’ adherence to social and behavioral infection prevention techniques. As a fast evidence assessment, the goal was to identify the social and behavioral infection control techniques that are most likely to be adhered to by healthcare professionals. A number of useful links were uncovered after reviewing the thirty papers, including the following: Those who worked in an emergency or intensive care unit were more likely to adhere to rules, and there was some evidence that communicating with confirmed cases boosted compliance. Anxiety and heightened concern about the possibility for infection were noted by employees, and it was shown that supervisors’ monitoring could aid enhance compliance with the guidelines. Additionally, we uncovered a number of unfavorable associations during our analysis. Non-compliant coworkers can make it more difficult for others to follow the company’s rules and regulations. It is difficult to comply with personal protective equipment (PPE) because of several variables, including a lack of availability, perceived difficulty and efficacy as well as the inconveniences and discomforts associated with PPE use. A range of communication and comprehension issues with infection control recommendations have been discovered, according to the study. The following are our recommendations for improving infection control at the hospital: For a wide range of professional positions in the medical system, infection control training and teaching is needed; administrative personnel who “set the tone,” enough resources for infection control, and timely dissemination of practical, evidence-based suggestions for infection control.

Review Protocol


An in-depth literature review was used to undertake a quick overview of the available information. A search of grey literature and a quality assessment of peer-reviewed publications retrieved via the internet were employed to conduct the research.

Search strategy

Four search terms were utilized in the study to find information about the research issue. “conformity,” “protective behavior,” “infectious disease epidemics,” and “healthcare worker” are some of the words used. Four search phrases were used in the technique, as follows:

The initial search was for phrases connected to conformity, such as comply, adhere, or conform. Do a second search for terms relating to protective behavior such as handwashing, illness infection prevention, or the usage of mask or PPE, as well as social distance or protective gear. Health care workers include healthcare staff, healthcare personnel, medical personnel, hospital staff, health care worker, medical employee, frontline worker, doctor, dentist, midwife, hospital worker, surgeon, nurse, general practitioner, and physician. SARS, H1N1, swine flu, H5N1, pandemic, coronavirus, severe acute respiratory syndrome, Middle East respiratory syndrome, COVID-19, avian influenza, bird flu, and n-COV or SARS-COV-2 were all included in the fourth search. The term “and” was frequently used in the study’s searches for 1, 2, 3, and 4.

MEDLINE®, Web of Science, PsycINFO®, Global Health, and Embase® are the databases used.

Inclusion criteria

It is important to include data from study participants who worked in the healthcare industry, as well as information on the use of social or behavioral infection control measures during pandemic outbreaks, as well as information from a peer-reviewed English-language journal. For the third criterion, quantitative data required to include stats on factors that are connected with adherence. Instead of relying just on quantitative data, qualitative data must also include a wide range of research on participants’ perceptions about the factors that encourage and hinder their compliance with preventive behavior guidelines.


The student searched all databases on December 21, 2021, for information. There were citations created, and they were stored in Mendeley. According to the inclusion criteria, abstracts and complete texts were screened for relevance, and those that did not meet the criteria were omitted from consideration.

The initial search approach yielded 192 papers, of which 132 were duplicates, and 25 were rejected based on the title or abstract of the paper being read. Thirty papers remained for inclusion once the full-text screening was completed.. Additional studies were found by manually searching the reference lists of all remaining papers.

Data extraction and synthesis

The student conducted an investigation on the demographics, professions, protective habits, and measurements used by participants in an outbreak of disease, as well as the outcomes of articles. Thematic analysis was used to synthesis the data and organize the results into themes (Braun and Clarke, 2006).


Demographic characteristics

Overall, there seems to be no association between age or gender and protective behavior. Even though female employees were more likely to participate in protective behaviors than male employees, one study by Kim and Choi (2016) found that older age was a major predictor. Saudi employees were shown to be significantly more likely than non-Saudi employees in the same city to engage in protective behavior, according to a study (Al-Amri et al., 2019). A mixed bag of findings emerged from studies comparing behavior in various countries. Compared to the United Kingdom, workers in Hong Kong and Singapore were more likely to comply with some recommendations, but not others, while workers in Singapore vs. Indonesia or Hong Kong vs. Canada were more likely to comply with some recommendations but not others, respectively (Chor et al., 2012). (Chor et al., 2012; Koh et al., 2009). Countries do not differ significantly when it comes to their ability to defend oneself in an international study (Kamate et al., 2020).

Compliance was not correlated with religious or marital status (Kim and Choi, 2016; Pratt et al., 2009). Employees with greater socioeconomic status were shown to be more likely to comply in a study than those with lower socioeconomic status (Jeong et al., 2012). Higher-educated employees were more likely to comply in another study than lower-educated colleagues, researchers found (Kim and Choi, 2016; Pratt et al., 2009; Taghrir et al., 2020). H1N1 flu immunizations were strongly linked to high vaccination compliance (Hu et al., 2012). None of these factors had an effect on the level of compliance with protective behaviors among women who had a chronic disease or were pregnant (Evirgen et al., 2014).

Occupational role

It was hard to discover a consistent trend due to the large range of responsibilities assessed in the research. Role and compliance have been linked in numerous research (Al-Amri et al., 2019; Evirgen et al., 2014; Chor et al., 2012; Alsahafi and Cheng, 2016). In five experiments, role and compliance were found to be unrelated. Two studies (Koh et al., 2005; Mitchell et al., 2012) indicated that healthcare workers with more than ten years of experience were more likely to be compliant than those with fewer than ten years of experience (Koh et al., 2005; Mitchell et al., 2012). (Vinck et al., 2011).

Training and knowledge

One study (Taghrir et al., 2020) found a non-significant rise in protective practices following outbreak-specific training and instruction, while another found that recent infection control training was a strong predictor of compliance with suggested behaviors (Cheu et al., 2008). Visit Jeong et al. (2012) for more information on the epidemic and infection control. According to qualitative findings, staff considered their earlier training and instruction was ineffective in dealing with rapidly evolving infectious disease epidemics. According to the participants, lack of training and the need for annual infection control training would improve compliance (Alsahafi and Cheng, 2016; Corley et al., 2010).

Only one study linked textbook knowledge to CME attendance, whereas two found no link between epidemic knowledge and protective behavior (Kim and Choi, 2016; Taghrir et al., 2020). On the other hand, Kim and Choi (2016) found that awareness about outbreaks was associated with compliance but not outbreak-specific training. Another study (Alsahafi and Cheng, 2016) found that a lack of comprehension of the epidemic itself was connected to a lower level of compliance. Knowing the most up-to-date guidelines was linked to greater compliance in three studies (Yap et al., 2010, Nour et al. in 2015, and Hu et al. 2012) however it was not in three other studies (Nour et al. in 2015, and Hu et al. 2012). (De-Perio et al., 2012; Al-Amri et al., 2019). According to Hsu and colleagues (2011), more than a third of individuals polled stated that they were unable to comply because they were illiterate.

Hospitals with emergency rooms, intensive care units, and inpatient beds had greater compliance rates (De-Perio et al., 2012; Shigayeva et al., 2007; Chia et al., 2005; Ki et al., 2019). High-infection zones had workers more inclined to wash their hands and disinfect but less likely to observe quarantine rules, Wong et al. found (2004). Setting and compliance were not linked in the two studies (Evirgen et al., 2014; Taghrir et al., 2020).

Improved infection control staff policing was found to be the most effective way to increase compliance. In two trials, aspects of patient engagement were linked to increased patient compliance. According to De Perio and colleagues, if they were just in the patient’s room for a brief time, did not contact the patient, or did not come within six feet of the patient, they did not apply the recommended PPE, as specified (2012). Shigayeva et al. (2007) found that patients with more serious diseases were less likely to adhere to guidelines (perhaps due to the time necessary to don barrier equipment, leading personnel to prioritize patient safety before self-protection).

Factors that influence a person’s protective behavior

Lack of suitable PPE, challenging protective behaviors, logistical hurdles, and the effectiveness, perceived significance, convenience and comfort, and impact on patient care were documented in several studies without statistical analysis. The lack of personal protective equipment (PPE) was a major concern (De-Perio et al., 2012; Corley et al., 2010; Hsu et al., 2012). Due to the lack of PPE, workers were forced to wear the improper size (Tan et al., 2006; Corley et al., 2010). Eyewear and gloves were found to increase the likelihood of using personal protective equipment (PPE), but not surgical masks or gowns, according to a separate study (Mitchell et al., 2012). PPE couldn’t be used properly in the hospital because to a lack of space.

The use of Personal Protective Equipment (PPE) was reported to be a stressful experience by Khalid et al. (2016) individuals. Wearing protective equipment that is too tight might have a negative impact on participation in many qualitative investigations. PPE-related symptoms included dehydration, skin peeling, trouble breathing, confusion, sweating, migraines, and rashes.

It was more common for people to wear eye protection and N95 respirators if they felt comfortable using them, whereas those who reported feeling short of breath, claustrophobic, or dizzy while wearing them were less likely to do so.

Because of muted voice, an inability to develop nonverbal cues with patients, and a lack of visibility to patients, wearing Personal Protective Equipment (PPE) can negatively impact healthcare workers’ ability to interact with the patients they serve. Some psychiatric patients were scared of masks, while others were afraid of PPE because they had been exposed to the virus by health care workers (Tan et al., 2006). Patients are less likely to wear Personal Protective Equipment (PPE) if they fear that it may interfere with their capacity to give care (Hu et al., 2012).


There were no clear rules for treating infected individuals and protecting oneself mentioned by various participants (Alsahafi and Cheng, 2016). Guidelines that were not up to the task were frequently mentioned. In the wake of the aforementioned “information overload,” employees received conflicting information from various sources to keep up with the ever-changing protocols. An inability to prioritize (Corley et al., 2010) and a lack of relevance to the community the instructions were transmitted produced a host of challenges. (Corley et al., 2010; Locatelli et al., 2012). While the information was passed down from other sources rather than directly handed to them, the employees were sent an email with new guidelines that they did not read before going to work.

Distress and risk perception

Concerned workers were more likely to follow recommended safety precautions, according to studies by Chia et al. (2005) and Wong et al. (2004). Certain staff members reported high levels of stress due to quarantine, but it is not clear how many of them did.

Risk perception was a factor in determining compliance. In four studies (Kim and Choi, 2016; Joeng et al., 2011; Parker and Goldman, 2006), compliance was associated with the perceived severity of the outbreak, but not in Singapore or the United Kingdom (Chor et al., 2012). Moreover, participants in three qualitative research said that they believed that personnel followed recommended behavior when the danger was great. In a study, researchers established a link between protective behavior and fear of infection (Taghrir et al., 2020).

Attitudes and behaviors of others

Participant perceptions of non-compliance among coworkers or supervisors were common (Hu et al., 2012), which may have contributed to their lack of adherence to company policies and procedures. According to Kang et al. (2018), Restrictions on quarantine were eased to accommodate staff shortages. Merati et al. (2021) reported participant attitudes of various healthcare occupational groups, while Hsu et al. (2011) found that senior staff ‘leading by example and adhering to specified behaviors was the single most essential means of promoting staff compliance.

A wide range of results was found in the evaluation of the investigations. It’s possible to identify at-risk groups or direct actions using some risk indicators. Concerns about the efficacy or relevance of PPE; concerns about the annoyance and pain associated with PPE; concerns about the detrimental influence on patient care; absence of infection control guidelines. Organizations who are concerned about the spread of nosocomial infections can look into these areas to help their employees practice good hygiene.


Many papers (particularly those on SARS and MERS) have been published in other languages (primarily Asian), and we are aware of this; however, due to the time constraints of this review and the scope of the review, we have restricted inclusion to English-language publications only, in accordance with that scope.

Translation and analysis of the various relevant foreign-language publications that have been published in the past should be taken into consideration during future evaluations of the candidate. Aside from that, due to the urgency with which the evaluation was carried out, no quality assessment of individual articles was carried out, as this is not typically deemed suitable when urgent evidence synthesis is required, as previously indicated.

Protection behavior compliance did not appear to be associated with any of the sociodemographic or personal characteristics investigated. The reasons for variation could be attributed to changes in guidance communication, variable risk perceptions as a result of media coverage of the outbreak, varying levels of training received, or even cultural differences among participants.

Some of the research was conducted using a qualitative technique, and as a result, the conclusions cannot be applied to a broader population at this time. It was more difficult to follow up on the original research with larger samples and different approaches, as well as to collect the necessary information in the least amount of time, after the initial research was completed.

The studies were bulk and messy, hence getting information from them was tiresome. The search gave numerous feedback therefore some crucial information may have been missed in the process of perusal of the documents.


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