The Association between Using Personal Protective Equipment and Headache among Healthcare Workers in Saudi Arabia Hospitals during the COVID-19 Pandemic

It is mandatory that healthcare workers wear personal protective equipment (PPE) while caring for COVID-19 patients. Studies have shown that wearing PPE for a prolonged time may lead to symptoms of physical discomfort including headache. The aim of this study is to assess the prevalence and association between prolonged use of PPE and headaches. This was a cross-sectional study. A convenience sample of healthcare workers who worked with COVID-19 patients in clinical settings was recruited. The data were collected through an electronic survey shared as a link through social media. This study included 1060 participants, 753 (71%) female and 307 (29%) male. Participants were divided into two groups. Group A had 628 (60%) participants who did not have chronic headache before the COVID-19 pandemic, while Group B contained 432 (40%) participants who had a previous chronic headache. Headaches differed significantly between Groups A and B in frequency, type, location, and quality during the COVID-19 period. The analysis found a significant relationship between duration of PPE use and headache occurrence. The significant relationship between the duration of PPE usage and headache occurrence among healthcare workers should be considered when refining policies and procedures regarding prolonged PPE use.


Introduction
The World Health Organization (WHO) identified the outbreak of the coronavirus (COVID-19) as a global pandemic in March 2020 [1]. Worldwide, health authorities of each country mandated that healthcare workers wear personal protective equipment (PPE) while dealing with suspected or confirmed COVID-19 cases. The Saudi Ministry of Health (MOH) reinforced the importance of standard precautions using the required PPE during this time [2].
The PPE included close-fitting N95 face masks, protective eyewear (goggles, face shields, or face masks), gowns, gloves, or/and the use of powered air-purifying respirators (PAPR) [3]. However, many frontline healthcare workers found the PPE uncomfortable and cumbersome, especially when it was worn for a prolonged period of time [4].
Headache was one type of physical discomfort experienced by many frontline healthcare workers due to wearing PPE. Headache may be produced by the sustained compression of the peri-cranial soft tissues by wearing tight bands or straps around the head. The PPE face shield, for instance, is attached tightly around the head [5].
Studies have shown that wearing PPE for prolonged time periods may lead to symptoms of physical discomfort including headache [6][7][8]. However, there is a lack of literature related to PPE-associated headaches that examines the combined usage of N95 face masks and protective eyewear, specifically goggles. The aim of this study is to assess the prevalence and association between prolonged use of PPE and headaches.
The study's objectives are as follows: • To determine the prevalence of headaches from PPE use among healthcare workers; • To assess the association between prolonged PPE use and headaches; • To identify risk factors for the occurrence of headaches among healthcare workers during the COVID-19 outbreak; • To identify symptoms associated with headache episodes.
Due to the escalation of infectious diseases and the COVID-19 outbreak, frontline healthcare workers in Saudi Arabia were mandated to wear personal protective equipment (PPE), such as close-fitting N95 face masks, disposable gloves, and protective gowns, while attending to patients, regardless of their COVID-19 status [9]. Healthcare workers have adequate knowledge of the appropriate use of PPEs and their role in safeguarding patients' health [10]. In Saudi Arabia, nurses understand the responsibility they share with other healthcare workers to reduce infection risks by adhering to PPE requirements [10]. However, many nurses experience physiological issues, such as headache, due to long shifts and prolonged PPE use. Headaches in general are widely experienced, and nearly 90% of the world population has experienced a headache at least once in their lifetime [11,12]. Nurses who wear N95 masks are likely to experience some breathing resistance [7,13]. In turn, breathing resistance may lead to hypoventilation, a reduction in the depth and frequency of breathing. If the mask is worn continuously for over one hour, labored breathing causes the accumulation of carbon dioxide in the bloodstream [14,15]. Ultimately, a headache develops due to the increased concentration of carbon dioxide. Studies exploring this association indicate that breathing through the N95 mask impedes gaseous exchange and increases the metabolic system's work, especially when the healthcare worker is pregnant [16]. In the Middle Eastern region, some healthcare workers view wearing the N95 mask as counterproductive as they find it difficult to tolerate.
Full body PPEs may cause heat stress and breathing difficulties that result in headaches. In addition, prolonged use of PPE worsens headaches among healthcare workers with a history of tension headaches or migraines [17,18]. Furthermore, the location of headacheassociated discomfort and pain corresponds anatomically to the regions compressed by mask straps or protective goggles. The association between PPE and headache is two-fold; it results from both prolonged and incorrect PPE use. According to a recent study, headache is one of the main outcomes of the incorrect use of N95 masks [19]. This outcome, as well as the discomfort of wearing face masks and head straps, reduces nurses' tolerability for using PPEs. Other scholars argue that prolonged use of N95 masks among nurse practitioners stems from its association with impaired mental performance and increased headache [20]. Headaches associated with PPE usage have significant and adverse impacts on healthcare workers' health and performance outcomes. A study contended that most healthcare workers develop exacerbation of their pre-existing headache disorders [21], which affects their level of work performance. Approximately 91% of respondents in a study exploring the association between headache and PPE stated that increased protective wear usage impacted their control of existing headache issues [8]. These studies suggest that despite the protective potential of PPEs, they are associated with significant discomfort and physiological outcomes that hinder nurses' optimal performance and productivity.
Studies exploring the effect of PPE on people's health have focused on its association with headaches. For instance, a study of healthcare providers wearing N95 face masks during the 2003 severe acute respiratory distress syndrome (SARS) epidemic in Singapore reported a prevalence rate of 37.3% for face-mask-associated headaches [6]. Another study found that nurses who wore N95 face masks while working in a medical intensive care unit reported headache as one of their main sources of physical discomfort [22].
However, these studies are largely based on Western societies, leaving a significant literature gap. Research on the association between PPE and headache has rarely investigated the experiences of healthcare workers in other regions, such as Saudi Arabia, hence the need for this analysis.

Research Design
This study was a quantitative, cross-sectional survey.

Settings
The study was conducted in Ministry of Health hospitals, Saudi Arabia, which required the use of PPE during the COVID-19 outbreak.

Participants
A convenience sample of healthcare workers who worked with COVID-19 patients in clinical settings was recruited. Inclusion criteria included healthcare workers aged 21 years or more who worked in Saudi Arabia, in a hospital during the COVID-19 outbreak, wore PPE, and understood the English language.

Sample Size
G*Power was utilized to estimate the sample size [23]. The input parameters were an alpha of 0.05, power of 0.85, and a medium effect size of 0.3. The minimum sample size was calculated to be 75.

Research Instrument
An electronic self-administered questionnaire was used. The questionnaire contained six sections: (1) demographic questions, such as age, gender, and occupation; (2) medical history; (3) PPE usage pattern since the start of the COVID-19 outbreak in Saudi Arabia; (4) headache types; (5) characteristics of pre-existing headaches; (6) perceived changes in pre-existing headache characteristics since the start of the COVID-19 outbreak. The questionnaire was evaluated by experts in the healthcare field for content validity.

Data Collection Procedures
The data were collected through an electronic survey shared as a link through social media from September 2020 to November 2020.

Ethical Considerations
Ethical approval was obtained from the Ministry of Health (Log No. 2020-28). The confidentiality of participants was maintained throughout the study process.

Data Analysis
Data were analyzed using SPSS version 27 (2020; IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated to describe the study variables. The associations between the demographic variables and headache types were examined using one-way analysis of variance (ANOVA), Pearson's chi-square test, and Fisher's exact test. The statistical significance level was set at p < 0.05. The dataset for this study is missing 10% of its data. The data were missing at random, according to analysis by SPSS. It appeared that the data missing were due to the participants' responses. The missing data came from headache characteristics and were included in the person chi-square analysis; therefore, the result should be interpreted cautiously.

Results
This study included 1060 participants, 753 (71%) female and 307 (29%) male, as shown in Table 1. Most participants were married (63%), and the majority were between 31 and 40 years old (42%). The majority were nurses (68%). Respondents practiced in critical care units (21.5%), patient wards (18%), outpatient clinics (17%), emergency departments (13.5%), and isolation wards (10%). This study focused on participants' experience of headache, taking into consideration whether they had chronic headache before the COVID-19 period (Table 2). Participants were divided into two groups. Group A had 628 (60%) participants who did not have chronic headache before the COVID-19 pandemic, while Group B contained 432 (40%) participants who had previous chronic headache. A chi-squared analysis showed that the medical histories of Group A and Group B participants differed significantly, as shown in Table 2. More individuals in Group B had asthma (p < 0.001), ischemic heart disease (p < 0.001), eczema (p < 0.001), depression (p < 0.001), and anxiety (p < 0.001).  Groups also differed on lifestyle factors (Table 2). Significant differences were found in smoking history (p = 0.041), insufficient hydration (p < 0.001), emotional stress (p < 0.001), physical stress (p < 0.001), lack of exercise (p < 0.001), and irregular mealtimes (p < 0.001). More individuals in Group A experienced headache during the COVID-19 period than those in Group B, and Group A tended to have more individuals who smoked, experienced emotional and physical stress, and did not maintain hydration and regular meals. The exception was that more individuals who lacked exercise experienced headache during the COVID-19 period in Group B than in Group A.
In addition, participants' responses to headache stimulating factors (sound, light, movement sensitivity, and neck discomfort) significantly differed (p < 0.001), with Group B demonstrating a greater response to stimulating factors than Group A.

Headache Character among Healthcare Providers
A significant difference between Groups A and B in the frequency of headaches, expressed as days with headache per month, was found during the COVID-19 period (p < 0.001; Table 3). A total of 33% of participants reported experiencing headache 1-4 days per month. A further 26% reported experiencing headache 5-9 days per month. Group B showed more individuals experiencing headache 1-4 days per month (34%) and experiencing headache 5-9 days per month (46%), while Group A showed 33% and 12%, respectively.   Headache duration and intensity also differed significantly (p < 0.001) between Groups A and B as shown in Table 3. Almost one-third (27%) of participants experienced headache for 1-2 h. Among those participants, 39% of Group B reported experiencing headache for 1-2 h. Of the participants who experienced headache for less than an hour (23%), the majority were in Group B (24%). Regarding intensity, the majority of participants rated their headache intensity as ranging from mild (32%) to moderate (47%). Those who rated the intensity as mild were mostly in Group A (41%), while those who rated the intensity as moderate were mostly in Group B (64%).
The two groups significantly differed from each other in the number of headache episodes and the duration change during the COVID 19 period (p < 0.001; Table 3). The change in headache days per month was measured on a five-point Likert scale (significant decrease in frequency, slight decrease in frequency, no change, slight increase in frequency, significant increase in frequency). Participants' responses were distributed as follows: 32% reported no change in frequency, 27.5% reported a slight increase, and 25% reported a significant increase; the other responses were less than 10% each. The majority of respondents who reported no change were in Group A with 41%. The majority of respondents who reported a slight increase in frequency or a significant increase in headache episodes were in Group B with 30% and 44%, respectively. The change in headache duration during COVID-19 was also measured on a Likert scale. The participants' responses were as follows: 32% reported no change in duration, 28% reported a slight increase, and 25% reported a significant increase, with the other responses at 10% or less. The plurality of participants who reported no change in headache duration during COVID-19 were in Group A at 41%. The majority of respondents who reported a slight increase or a significant increase in duration were in Group B (31% and 46%, respectively).
The two groups differed significantly in terms of PPE used, namely face masks (p < 0.001), eye protection (p < 0.001), and a combination of both (p < 0.001; Table 4). The use of a face mask, eyewear, and a combination was measured on a four-point Likert scale (from unlikely to very likely). The majority of participants were distributed between two categories for face mask use: likely (29%) and very likely (43%). Of participants likely to use a face mask, 67% were in Group A; groups were equally represented among those very likely to use a face mask. Similarly, Groups A and B showed varied responses to the use of eye protection and a combination of face mask and eye protection. Group A participants comprised the majority of respondents on all Likert scale levels (likely, maybe, and unlikely), except one (very likely).  How often participants used PPE before and during the COVID-19 period was measured on a 5-point Likert scale (from no change in frequency to a significant change in frequency). The results are reported in Table 4. A significant difference was found in PPE use between groups since the start of the COVID-19 pandemic. More than half (56%) of participants reported a significant increase in the frequency of use, and more than half of those respondents were from Group A (52%).
Moreover, a significant difference was found between Groups A and B in their use of different types of eyewear (p = 0.020) and face masks (p = 0.047). The majority of healthcare providers used face shields (78%) and surgical face masks (65%) during their shifts. Group A (58%) participants reported a greater use of face shields than Group B (42%) and a greater use of surgical masks (60% and 40%, respectively). Furthermore, Groups A and B showed significant differences in the duration of PPE use (p < 0.001; Table 4). Duration was divided into four different lengths of time, and 43% of participants stated that they used PPE for 5-9 h per shift; 40% reported that they used PPE for 5-9 h (hours/day over a month).

Association between Prolonged PPE Use and Headache
A logistic regression analysis was used to examine the association between the duration of PPE use and headache ( Table 5). The analysis found a significant relationship between the duration of PPE use and headache occurrence for the periods of 5-9 h (p < 0.001) and 10-12 h (p = 0.013). These results indicate that when healthcare workers use PPE for 5-9 h a day, they are four times more likely to experience headache than those who use PPE for shorter amounts of time.

Symptoms among Healthcare Providers
Participants' symptoms during their headache episodes significantly differed between Groups A and B (Table 6), specifically nausea/vomiting (p < 0.001), light sensitivity (p = 0.006), sound sensitivity (p = 0.040), neck discomfort (p < 0.001), and movement sensitivity (p < 0.001). More individuals in Group B reported nausea/vomiting (53%), neck discomfort (54%), and movement sensitivity (55%) than Group A. Finally, this study tested the association between headache occurrence and symptom occurrence. Univariate logistic regression analysis was used to test each headache and symptom occurrence and found a significant association between headache occurrence and all symptoms (Table 7). Note. The Bonferroni test was used with an adjusted α level; p < 0.05 is considered significant.

Discussion
One objective of this study was to identify headache risk factors. Participants were categorized into Group A, those who did not have chronic headaches before the COVID-19 period, and Group B, those who had prior chronic headaches. Healthcare workers who had chronic headache before COVID-19 were found to have more pre-existing conditions, including asthma, ischemic heart disease, depression, and anxiety. Since a majority of those who experienced headaches before the pandemic had pre-existing conditions, medical history was essential in the establishment of the relationship between PPE and headaches. In addition to medical history, age and marital status have been found to influence the prevalence of headaches [5]. Social issues are vital to the health of practitioners. For instance, a recent psychological study found that marriage contributed to healthcare workers' stability [17]. Therefore, knowledge of these parameters was necessary to determine the specific influence of PPE on healthcare workers' health.
This study found an association between prolonged use of PPE and headaches in healthcare workers. A previous review supports these findings during the COVID-19 period. Ong and colleagues have done a review and found a total of six published studies, all of which revealed an association between headache and the use of PPEs among HCWs during the COVID-19 pandemic [24]. One possible reason for the association might be that the prolonged use of N95 causes an increased concentration of Carbon monoxide in the blood, which leads to headache [13]. It is expected that during the pandemic, the frequency of healthcare workers donning full PPE would increase [6], a possible cause to study participants' frequency and intensity of headaches increasing with longer hours of PPE use.
Additionally, participants' type and frequency of headaches were vital in the investigation of risk factors. The frequency of headaches reported by healthcare workers during the COVID-19 period varied. The majority of participants experienced tension-type headaches, which are likely to stem from wearing PPE, rather than migraines [24]. While the majority of participants reported a difference in the occurrence of headache episodes before and during the pandemic, the frequency differed between the two groups. Participants with prior headaches in Group B reported an increase in the occurrence of headache episodes. The majority of participants in Group B reported 5-9 headaches per month, while more Group A participants experienced headaches 1-4 days per month. Thus, those with a history of headaches experienced more headaches during the COVID-19 period. Both the intensity and the magnitude of headache discomfort varied with participants' medical history and lifestyle, supporting previous findings from Saudi Arabia [2].
The presence of a significant relationship between duration of PPE usage and headache occurrence suggests that those with pre-existing conditions will likely continue to endure increased frequency and intensity of headache. This result is supported by a previous finding [19] that disclosed that practitioners with pre-existing headache disorders were likely to suffer more as a result of prolonged use of PPE. Therefore, wearing them for longer periods increases the chances that practitioners will experience headaches. In addition, a study reported the sense of duty felt by nurses in Saudi Arabia, some of whom had pre-existing conditions that escalated their headaches [10].
These previously reported findings suggest that healthcare workers in Group B, who had a greater number of pre-existing conditions, are at a higher risk of adverse effects of PPEs relative to their Group A counterparts. Overall, the results demonstrated that those who experienced headaches before the pandemic were likely to experience headaches of greater intensity on a greater number of days per month. This knowledge can be used to devise appropriate measures to address the different levels of headache challenges that the two groups experience. The association of PPE and headaches is likely to continue or exacerbate in the wake of the virus due to the health protocols prescribed by WHO.
In addition to headaches, healthcare workers reported other discomforts due to wearing PPE such as nausea/vomiting, light sensitivity, sound sensitivity, neck discomfort, and movement sensitivity. In the current study, participants in both groups reported an increase in discomfort, with those who combined face masks and eye protection reporting the most discomfort. Similar results were reported by Williams et al. (2020), noting a range of physiological discomforts, when wearing PPEs including facemask and eye protection for a prolonged period [13]. Furthermore, according to the literature, PPE use was associated with discomfort that could affect performance [7,8,21]. Thus, there is a need to discuss the consequences of wearing PPE.
Practitioners wore PPE in specific units, before the pandemic, especially the intensive care unit (ICU). Current guidelines necessitate that those attending to patients, regardless of their status, should wear PPE, resulting in an increase in the amount of time that healthcare workers must wear protection [10]. Despite the resulting discomfort, healthcare practitioners adhere to WHO protocols in work settings, supporting the Hippocratic Oath, which prioritizes the needs of the patient. Additionally, the current findings regarding the differences in the level of use of protection between the two groups refute Tong et al.'s (2015) claim of the counterproductivity of N95 masks [13].
The symptoms manifested by participants illustrate the relationship between wearing PPE and resultant discomfort. The main symptoms of Group B participants were nausea/vomiting, neck discomfort, and movement sensitivity, while Group A participants' main symptoms were light and sound sensitivity. Two studies reported that PPEs caused heat stress and breathing difficulties despite having powered air-purifying respirators [17,18]. Therefore, wearing them for longer periods increases the chances that practitioners will experience headaches. Moreover, the location and intensity of headache and discomfort are associated with regions compressed by the straps of masks and eyewear. Consequently, these items may be responsible for the manifestation of unilateral headaches that affected both healthcare worker groups in the current study.
The results of the current study support previous findings [19] that found that practitioners with pre-existing headache disorders were likely to suffer more as a result of prolonged use of PPE. Therefore, as nurses and other health workers fulfill their responsibilities to safeguard patients following WHO protocols, their role comes at a cost to their comfort, which may in turn affect their performance and thus public health. The situation may only worsen due to the increasing rate of the spread of infection, especially if a cure is not found and the virus continues to mutate. Our findings suggest that the consequences of the PPE protocol for healthcare workers in Saudi Arabia are similar to those in Western regions. Therefore, it is vital to determine alternative means of protection to safeguard the health of practitioners [7]. Moreover, engineers could use these findings to facilitate improvement in PPE ergonomics to reduce the occurrence of headaches. Training for HCWs with "PPEs fit-test" was also suggested.
This study has several implications for research, clinical practice, and policy. Future research can replicate this study using randomized controlled trials to assess the causal relationship between headache and PPE use. Further, future research could develop an intervention to alleviate headache occurrence with PPE use. Finally, policymakers in clinical settings can use these findings to inform PPE policy and use.
This study has some limitations. Since this was a cross-sectional design, no causal inference can be made between headache occurrence and PPE use. In addition, other factors that may contribute to headache occurrence, such as sleep disturbance, were not controlled for. The study used a self-report questionnaire, where recall bias is common. Furthermore, a PPEs usage log was not used; however, the period of COVID-19 requires using the PPE throughout the working hours. Another potential limitation is the lack of differentiation between the types of headache in the questionnaire. Although study participants were from different regions of Saudi Arabia, the results may not be generalizable as PPE policies and procedures, availability, and exposure to COVID-19 may vary between healthcare workers.

Conclusions
This study presented important findings on the prevalence and association of headache among healthcare workers using PPE during the COVID-19 pandemic, symptoms associated with headache, and risk factors for headache occurrence. The study provides several implications for future nursing research, practice, and policy. The findings suggested a significant relationship between the duration of PPE usage and headache occurrence among healthcare workers, which should be considered when refining policies and procedures regarding prolonged PPE use.