































 Epidemiology and Society Health Review| ESHR 
Vol. 6, No. 1, 2024, pp. 13-23 ISSN 2656-6052 (online) | 2656-1107 (print) 
 
 

      10.26555/eshr.v6i1.8972  

13  
 

  

Review Article 
 
Factors Influencing Compliance to the Utilization of 
Personal Protective Equipment among Healthcare Workers: 
A Systematic Review 
 
Atni Setiyo Ningsih1,2* and Dyah Suryani1 
1Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia 
2 PKU Muhammadiyah Bantul Hospital, Bantul, Indonesia 
 
* Correspondence: 2108053045@webmail.uad.ac.id  Phone: +6281226323510 
 
Received 03 September 2023; Accepted 29 January 2024; Published 31 January 2024 
 

ABSTRACT 

Background: Hospitals, as providers of health services for the community, must be able to 
maintain the quality of services provided, one of which is by providing safety and comfort 
guarantees to officers from infectious diseases and other hazardous substances with 
policies regarding the use of personal protective equipment (PPE) and conducting 
evaluations from the behavior of officers when using PPE. Many factors affect the 
compliance of officers in the use of PPE. This research analyzed the factors influencing 
officers' compliance with PPE. 
Method: This study used a literature review method. Articles were collected from the online 
database of Pubmed, Sage, and SpingerOpen from 2012 to 2023. Using the keywords 
“compliance,” “health workers," and "personal protection equipment." Two hundred thirty-
eight articles were obtained and filtered based on inclusion and exclusion criteria. Finally, 
16 articles were included in the analysis. 
Results: Internal factors that affect the compliance of officers in the use of PPE include 
age, years of service, knowledge, attitudes, and motivation, while external factors that 
influence compliance are facilities, training, and supervision carried out by management 
Conclusion: To increase officer compliance, it is necessary to have supervision and 
support from management, such as facilities, ease of access, and conducting training. 

Keywords: Compliance; Health worker; Personal Protective Equipment 

 

INTRODUCTION 

Hospitals, as suppliers of health care services, must be able to improve the quality of their 
services because they differ from other services and are influenced by scientific, technological, 
and socioeconomic improvements. To increase service quality, hospitals must protect health 
professionals against all dangers of nosocomial infections.1  Nurses are health workers who 
have an essential role in comprehensive patient care, such as providing nursing care, direct 

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assistance, or nursing services to patients and families, both inpatient and outpatient.2 
Therefore, hospitals must protect nurses from contagious diseases and other hazardous 
substances. Hospitals may mandate personal protective equipment (PPE) while providing 
services.3 

Personal Protection Equipment (PPE) is a tool that is correctly used by every worker who 
strives to protect from all dangers generated by employment, especially nurses who use it to 
protect themselves and patients from hazardous materials such as chemical, physical, 
biological, and viral threats.4 The usage of PPE does not remove hazards or risks at work. 
Nonetheless, it remains a barrier to reducing direct contact with hazardous chemicals or 
dangers, particularly during direct contact with patient fluids, giving health workers to patients 
with infectious diseases.5 Health workers frequently utilize PPE such as masks, gloves, 
protective gowns or gowns, protective shoes, aprons, eye or facial protection, and head 
protection.1 

PPE compliance is essential to avoid direct contact with dangerous materials or risks while 
working. Adherence to PPE will alter disease transmission; if PPE is ignored, the likelihood of 
transmission of infectious illnesses increases.6 The use of PPE must be based on the amount 
of danger and usage practices to ensure that PPE provides maximum protection.7 Factors 
influencing nurse compliance with PPE require cooperation from various sources, particularly 
management.8 PPE compliance is influenced by knowledge, employment, education, training, 
attitudes, motivation, communication, availability of PPE, supervision, punishment and reward, 
workload, infection prevention and control guidelines, and hospital rules.9 This article provides 
an overview of health professionals' compliance with PPE and the factors influencing 
compliance. This article can also help health workers and health facilities increase compliance 
with using personal protective equipment (PPE) and understand the elements that can 
influence health workers' compliance with PPE.  

METHOD 

This research was a systematic review following Prisma Guideline, a guide or step for 
analyzing a systematic review,10 aimed to collect evidence related to using PPE among health 
workers to prevent nosocomial infections. We used keywords to search articles in the following 
databases: Pubmed, SpingerOpen, and Sage. The keyword for the searched article was 
“Compliance, health workers, personal protective equipment.” The inclusion criteria in this 
study were articles from 2012 - 2023, published in English, full articles available for free 
access, using cross-sectional research design, and assessing health worker compliance using 
PPE. The exclusion criteria were a qualitative research article and a review article.  

RESULT 

Screening Process with Prisma Guideline 

Figure 1 shows that the articles that have been obtained are checked to avoid duplication, as 
well as to check the completeness of the article's content and then reselecting based on 
inclusion and exclusion criteria. From the first screening results, 47 articles were obtained 
based on the suitability of the title and abstract. In the next step, we performed another 
screening based on the abstract, research method, sample, inclusion criteria (year of 
publication, language in English, full text free available), and exclusion criteria. Accordingly, 

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we got 21 articles. Finally, we included 15 articles in our study, while 6 other articles were 
eliminated since the full-text reading did not use a cross-sectional design.   

Data extraction  

From data extraction summarized in Table 1, 10 articles stated that the prepositioning factors 
(age, length of working, attitude, knowledge, motivation), enabling factors (facilities and 
infrastructure), and reinforcing factors (training and supervision) had a significant relationship 
with PPE compliance, five articles stated that PPE compliance among health workers was 
influenced by knowledge, workload, motivation, and PPE facilities, two articles stated the PPE 
compliance among training and supervision.  

 

 

 
 
 
 

 
 

 
 

 
 

Figure 1. PRISMA diagram result of this study 

Table 1. Article synthesis of this study 

No Author and Year Article Title  Method (design, 
sample, variable, 

instrument, analyses) 
 

Result 

1 Mary Eyram 
Ashinyo, Stephen 
Dajaan Dubik, 
Vida Duti, Kingsley 
Ebenezer 
Amegah, Anthony 
Ashinyo, Brian Adu 
Asare, Angela  

Infection prevention and 
control compliance 
among exposed 
healthcare workers in 
COVID-19 treatment 
centers in Ghana 

D: Descriptive cross-
sectional 

The research results 
stated that gender, age, 
work experience, place of 
residence, and training 
had no relationship with 
compliance with PPE. 
However, there are risk 
factors for PPE 

S: Convenience  
sampling 
V: clinical and nonclinical 
healthcare workers 
working in COVID-19 
treatment centers 

47 records 
38 are from PUBMED, 7 are from 

SAGE, and 2 are from SpingerOpen. 

There were 15 articles analyzed. 

 

26 articles were excluded 
because they did not meet our 
criteria, i.e.,  

1. articles from 2012 – 
2023 

2. having a health worker 
as a respondent 

3. published in English,  
4. free available in full 

text 
 

 

 
Articles obtained per database: 
Pubmed 238 articles, Sage 86 

articles, SpingerOpen 21 articles  
(n = 345).  

 

21 full-text publication articles are 
eligible 

Articles were eliminated because 
they did not fit the title and 

abstract (n = 298): 200 Pubmed 
articles, 79 SAGE articles, and 

SpingerOpen 19. 

6 articles were removed 
because, after full-text reading, 
the article did not apply a cross-

sectional design. 

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No Author and Year Article Title  Method (design, 
sample, variable, 

instrument, analyses) 
 

Result 

Ama Ackon, 
Samuel Kaba 
Akoriyea, Patrick 
Kuma-Aboagye 
(2021) 
 
 

I: Those who ( health 
workers) consented to 
participate were given the 
questionnaire 

compliance, namely 
divorce status, education, 
profession, and 
availability of PPE .11 

 A: Logistic regression 
analyses 

2 Muna Abed Allah, 
Sami Abdeen, 
Nagah Selim, 
Dhouha Hamdani, 
Eman Radwan, 
Nahla Sharaf, 
Huda Al-Katheeri, 
Iheb Bougmiza   
(2021) 
 

Compliance and barriers 
to the use of infection 
prevention and control 
measures among health 
care workers during 
COVID-19 Pandemic in 
Qatar: A national survey 

D: A national web-based 
cross-sectional study 

During the Pandemic, 
officer compliance in 
using PPE (49.7%). 
Factors influencing officer 
compliance are the need 
for more facilities and 
increased workload. 12 

S: doctors, nurses, 
pharmacists, and other 
health workers who do not 
work in the administration 
department at 6 
government and 40 
private health facilities. 
V: Complaince PPE to 
health workers during 
Covid 19 pandemic in 
Qatar. 
I: Questionnaire and 
checklist from WHO 
assessment tool 
A: Chi-square test, 
multivariable logistic 
regression 

3 Noha Elshae, 
Hesham Agage 
(2022) 
 

Nurses perception and 
compliance with personal 
protective equipment and 
hand hygiene during the 
third wave of COVID-19 
pandemic 

D: Cross-sectional survey The research results 
stated that there was a 
relationship between 
compliance with the use 
of PPE and sound 
knowledge, perception of 
the importance of PPE, 
age, and length of 
service. 13 
 

S: All nurses with a 
minimum of 1-year 
service consisted of 
internal medicine nurses 
(n=133) and emergency 
care, neurosurgical care, 
intensive care (n=221) 
V: Perception and 
compliance with PPE 
during wave 3 of the 
COVID-19 pandemic in 
Egypt. 
I: A questionnaire 
A: correlation with chi-
square test 
 

4 
 

Roslyn M Seitz, 
Anna Q Yaffe, 
Elizabeth Peacock, 
Timothy P Moran,  
Andrew Pendle, 
Jonathan D Rupp   
(2021) 
 

Self-reported use of 
Personal Protective 
Equipment among 
Emergency Department 
Nurses, Physicians, and 
Advanced Practice 
Providers during the 2020 
COVID-19 Pandemic 
 

D: survey analytic, cross-
sectional 

The research results on 
health workers stated that 
Knowledge about PPE 
influences compliance in 
using PPE, and training 
can increase knowledge. 
Apart From that, factors 
that support PPE 
compliance are the 
positive attitude of 
officers, completeness of 
facilities, and supervision 
from management. 14 

 

S: total populations 
emergency departemen 
V: Compliance using PPE 
to health workers during 
the COVID-19 
I: A questionnaire 
A: correlation, che square 
tes  
S: Total sampling 
V: effectiveness of health 
workers' PPE when 
contacting Covid 19 
patients 

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No Author and Year Article Title  Method (design, 
sample, variable, 

instrument, analyses) 
 

Result 

I: health worker and 
questionnaire 
A: correlations  

5 André Rose, 
William Ian 
Duncombe Rae  
(2019) 
 

Personal Protective 
Equipment Availability 
and Utilization Among 
Interventionalists 

D: a cross-sectional study 
using mixed methods 

Compliance with the use 
of PPE among health 
workers to prevent 
exposure to racism is 
related to the availability 
of PPE based on gender, 
work unit, and age. 9 

S: total sampling and 
purposive sampling 
(interviews) 
V: staff working in the 
catheterization laboratory 
I: A questionnaire and 
interview 
A: logistic regression and 
analyzed thematically.  

  6 Davie Madziatera, 
Kondwani Stanslas 
Msofi , Thokozani 
V Phir, Samuel 
Devaughn 
Mkandawire, Amy 
Comber (2020) 
 

Availability, Accessibility, 
and Proper Use of 
Personal Protective 
Equipment in Wards at 
Queen Elizabeth Central 
Hospital (QECH) 
Blantyre, Malawi: An 
Observational Study 
 

D: survey analytics with a 
cross-section design 

Compliance with PPE for 
health workers is 80%; 
this is influenced by the 
availability of PPE in each 
care unit, PPE training, 
supervision by 
management, and 
policies regulating PPE 
use. 15 

S: accidental sampling 

V: enabling factors and 
adherence to PPE 

I: checklist observation to 
adopt the CDC 

A: Chi-square and 
Logistic regression 
analysis 

7 Xiaoyun H, Zhidan 
Zhang, Na Li, 
Dexin Liu, Li 
Zhang, Wei He, 
Wei Zhang, Yuexia 
Li, Cheng Zhu, 
Guijun Zhu, Lipeng 
Zhang, Fang Xu, 
Shouhong Wang, 
Xiangyuan Cao, 
Huiying Zhao, 
Qian Li, Xijing 
Zhang, Jiandong 
Lin, Shuangping 
Zhao, Chen Li, Bin 
Du; China Critical 
Care Clinical Trial 
Group (2012) 
 

Self-reported use of 
personal protective 
equipment among 
Chinese critical care 
clinicians during the 2009 
H1N1 influenza pandemic 

D: survey analytic with 
cross-sectional  

From the research 
results, the level of 
compliance with the use 
of PPE by officers is 
>80%. At the same time, 
the influencing factors are 
compliance with PPE for 
administering vaccines, 
positive attitudes, 
availability of PPE, 
infection prevention and 
control measures, and 
surveillance activities. 16 

S: Total sampling 

V:  ICU staff in 17 Chinese 
provinces when treating 
H1N1 patients 
I: a questionnaire 

A: chi-square test  
 

8 Muna Talal 
Theyab Abed 
Alam, Sami 
Abdeen, Nagah 
Selim, Elias Tayar, 
Iheb Bougmiza 
(2022) 
 

Occupational Prevention 
of COVID-19 Among 
Healthcare Workers in 
Primary Healthcare 
Settings: Compliance and 
Perceived Effectiveness 
of Personal Protective 
Equipment 
 

D: cross-sectional Overall compliance with 
PPE use was 53%, and 
compliance with PPE use 
during AGP procedures 
was 76.3%. Level of 
compliance based on 
care unit, training 
implementation, 
completeness of facilities, 
work experience, 
perception, work shift, 
profession, and length of 
contract. 17 

S: total sampling 
V: compliance of health 
workers in using PPE 
when treating Covid -19 
patients 
I: Questionnaire 

9 Junaid  Ahma, 
Saeed Anwa, 
Abdul Latif, Najib 

Association of PPE 
Availability, Training, and 
Practices with COVID-19 

D: A cross-sectional 
survey 

The research results 
stated a relationship 
between compliance with S: total sampling 

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No Author and Year Article Title  Method (design, 
sample, variable, 

instrument, analyses) 
 

Result 

U Haq, 
Muhammad Sharif, 
Ahmed A Nauman  
(2022) 
 

Sero-Prevalence in 
Nurses and Paramedics 
in Tertiary Care Hospitals 
of Peshawar, Pakistan 

V: PPE compliance 
factors with the incidence 
of Covid 19 among health 
workers 

the use of PPE and the 
number of COVID-19 
incidents among health 
workers, including the 
availability of PPE, 
timeliness of obtaining 
PPE, and training. 18 

I: Questionnaire 
A: chi-squared test 

10 Usman Abubakar, 
Mohammed Ndagi 
Usman, 
Mohammed Baba, 
Aliyu Sulaiman, 
Mohammad Kolo, 
Fatima Adamu, 
Ammar Ali Saleh 
Jaber (2022) 
 
 

Practices and perception 
of healthcare workers 
towards infection control 
measures during the 
COVID-19 pandemic: a 
cross-sectional online 
survey from Nigeria 

D: cross-sectional study Factors influencing PPE 
compliance among health 
workers are the type of 
health facility, knowledge, 
and PPE training. In 
contrast, age, gender, 
education, and kind of 
profession have no 
relationship to PPE 
compliance among health 
workers. 19 

S: snowball  sampling 
V: pharmacists, 
nurses/midwives, and 
medical in Nigeria 
I: online questionnaire 
A:  Chi-Square Test 

11 S U Arinze-Onyia, 
A C Ndu, E N 
Aguwa, I Modebe, 
U N Nwamoh   
(2018) 
 

Knowledge and Practice 
of Standard Precautions 
by Healthcare Workers in 
a Tertiary Health 
Institution in Enugu, 
Nigeria 

D: descriptive study, 
cross-sectional 

One application of 
standard precautions is 
the use of PPE. Level of 
PPE compliance among 
health workers (68.9%). 
Factors that hinder PPE 
compliance are lack of 
facilities and training that 
should be carried out 
more routinely. 20 

S: Purposive Sampling 

V:  health workers who 
carry out standard 
precautions  in a Tertiary 
Health Institution in 
Enugu,    Nigeria 
I: questionnaire 

A: Chi-Square Test 

12 Okwudili C Ezike , 
Linda C Odikpo, 
Evert N Onyia, 
Michel C 
Egbuniwe, Ifeoma 
Ndubuisi, Ada C 
Nwaneri, Chikodili 
N Ihudiebube-
Splendor, Chijike 
C Irodi, Sambo B 
Danlami, Amina W 
Abdussalam 
(2021) 
 

Risk Perception, risk 
Involvement/Exposure 
and compliance to 
preventive measures for 
COVID-19 among nurses 
in a tertiary hospital in 
Asaba, Nigeria 

D:  descriptive survey, a 
cross-sectional 

The research results 
showed that health 
workers' PPE compliance 
was 77%. This is 
demonstrated by the 
small and inadequate 
amount of PPE and the 
need for updates on PPE 
usage. 21 

S: purposive sampling 
V: knowledge and 
implementation of 
standard precautions in 
the use of PPE for health 
workers 
I: questionnaire 

A: descriptive statistics, 

13 Naveen K Suda, P 
B Smithamol, Ann 
S Toms, G K 
Meera, Grace J 
Rebekah, S 
Trinaya, 
Mohammed A 
Haroon, Raj 
Sahajanandan, 
Ekta Rai   
(2018) 

Aerosol-generating 
procedures: how best did 
anesthesiologists use 
available personal 
protective equipment 
during the early COVID-
19 pandemic in a tertiary 
care center in southern 
India? A prospective 
cross-sectional study 

D: prospective cross-
sectional 

The highest compliance 
with PPE is using N95 
masks (99.5%) and face 
shields (84.4%). Officer 
compliance is influenced 
by supervision, 
availability, and ease of 
obtaining PPE. 22 

S: Descriptive statistics 

V: compliance with the 
use of PPE by 
anesthesiologists when 
carrying out AGP 
procedures 
I: observation 

A: descriptive statistics 

14 Khalifa 
Abdulrahman 
Yusuf (2023) 
 
 

Assessment of 
knowledge, accessibility, 
and adherence to the use 
of personal protective 
equipment and standard 

D: A prospective cross-
sectional study 

The research results 
showed the % PPE 
compliance rate for health 
workers was 82.1%. PPE 
compliance is related to 

S:  non-probability 
sampling (voluntary 
sampling) 

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No Author and Year Article Title  Method (design, 
sample, variable, 

instrument, analyses) 
 

Result 

 preventive practices 
among healthcare 
workers during the 
COVID-19 pandemic 

V: the medical doctors 
(physicians, surgeons, 
pathologists, radiologists, 
gynecologists, and 
anesthetists) and nurses 
at BDF-RMS Military 
Hospital 

age factors, availability of 
PPE, knowledge, 
implementation according 
to protocol, and training 
PPE.23 

I: questionnaire 

A: Chi-square and 
Fisher’s  

15 Dina K. Abou El 
Fadl, Yasmin A. F. 
Aly, Ebtissam 
Abdel Ghaffar 
Darweesh, Nagwa 
A. Sabri & Marwa 
Adel Ahmed 
(2023) 

Assessment of neonatal 
intensive care unit nurses’ 
compliance with standard 
precautions of infection 
control and identification 
of enabling factors 

D: A descriptive cross-
sectional study:  

The level of adherence to 
surgical masks or 
concurrent use of goggles 
or face shields was 48.3% 
due to the availability of 
PPE in the NICU room. 24 

S: total population  
V: Factors of compliance 
with implementing 
standard precautions 
(PPE) among NICU 
nurses. 
I: questionnaire 
A: Kolmogorov–Smirnov 
test and ANOVA 

Note : D = research design, S= research sample, V= research variables, I= instruments, A= 
analysis 

DISCUSSION 

Based on the previous article, this study overviews the factors influencing officers' compliance 
with PPE. In this study, there are 16 research articles located in hospitals with health worker 
participants: doctors,17,19,22,29 nurses,9,11,12,13,14,15,17,18,19,22,25,26, pharmacy,11,14,19,25 
laboratories,11,25 midwives11,12 and non-medical11 and one research article conducted in 
hospitals with nursing student participants.20 At the time of the study, were 11 articles 
conducted during the COVID-19 pandemic (69%). Some professionals have been explored in 
the 15 publications involved in this research, including nursing as providers of direct services 
to patients, 7 papers involving professions other than nurses, and one article on practical 
students.   

Table 2 represents factors that inhibit or affect officer compliance in the use of PPE, among 
others: age, length of service, attitude, knowledge, motivation, facilities in the form of 
availability of PPE and easy access for officers to obtain it, training to improve knowledge and 
practice in the use of PPE and monitoring and support from management. 

Table 2. Factor affecting compliance 

Factor Reference 
Predisposing factor (age, length of working, 
attitude, knowledge, motivation) 

1,2,3,4,5,6,7,8,12,13,15 

Enabling factor (facilities) 1,2,3,4,5,6,7,8,10,11,12,13,14,15 
Reinforcing factor (supervision and training) 1,3,4,5,6,7,8,9,13 

 

 

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Predisposing Factor 

Health workers ' compliance with Personal Protective Equipment (PPE) is based on internal 
factors, including age, length of service, attitude, knowledge, and motivation. Based on age 
characteristics, a person's length of service can be related to one's experience; the longer the 
work, the higher the experience, knowledge, and skills of an officer in using PPE.27 Experience 
will affect a person's work performance, based on the work experience officers have that can 
be adjusted to their work.28 But based on some studies, the longer they work, the more bored 
they will be.29 Thus, hospitals must protect nurses from all infectious diseases and other 
hazardous materials and provide them security. One of the efforts that hospitals can make is 
to make it mandatory to use PPE when providing services. 

According to Notoatmojo, behavioral factors built based on experience and knowledge are 
much better than behavior not based on knowledge.28 While motivation has a role in officer 
compliance in using PPE, the use of PPE is the officer's perception of PPE based on 
knowledge, work experience, and high motivation to protect themselves from the risk of 
infectious diseases or hazardous materials; this is due to good behavior from health workers. 
Motivation also has a very supportive role in increasing compliance; officers who tend to have 
high motivation will have high morale. Factors influencing officer motivation include 
physiological needs and a sense of security from infectious diseases or hazardous materials. 
In contrast, officer non-compliance is often related to discomfort, especially in using PPE.30 In 
the article that has been reviewed, the obstacle that often causes non-compliance in the use 
of PPE is the discomfort when using PPE. Using PPE for a long duration often causes impacts 
that officers avoid, including excessive sweating that irritates the skin, dehydration, and pain.31  

Enabling Factor 

Hospitals must prevent and protect health workers from exposure to risks, especially infectious 
diseases, and other hazardous materials, so hospitals must ensure the availability of PPE 
equipment for health workers based on risk levels and quality PPE following official standards 
to create a sense of comfort and security when using and ensure the PPE supply chain runs 
well.32 From the previous article, it was found that factors that hinder compliance in using PPE 
are the unavailability of PPE according to standards, the difficulty of obtaining access, and the 
lack of funds to buy PPE.2 The availability of PPE is partly due to the inability of hospitals to 
provide all PPE because the availability of PPE is very dependent on the existing budget and 
funds.  

Reinforcing Factor 

The training provided can increase officers' knowledge of the use of PPE.28 The training 
provided must be relevant and appropriate to the needs and have a direct impact on services; 
the training provided must also be able to improve expertise and competence, especially 
infection prevention and control.33 With the training or workshop, it will increase the knowledge 
and skills of officers in the use of PPE.34 Another factor supporting officer compliance is 
supervision or monitoring from management. This step is influential on compliance with PPE 
by health workers. Supervision is an activity that begins with planning, directing and guiding, 
observing, encouraging, improving, and evaluating continuously the abilities and limitations of 
the officer. Supervision can be carried out through behavioral assessments, how health 
workers comply with PPE by existing policies and procedures and identifying training needs 
for health workers.35 Policies and guidelines for the use of PPE for officers will improve 
compliance.36 Supervision can increase a person's awareness to behave in a positive direction 
and can motivate officers.28 

 

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CONCLUSION 

Based on a literature review, age, length of service, knowledge, attitudes and motivations, 
facilities, training, and staffing are vital in improving officer compliance with PPE. To improve 
officer compliance, there needs to be support from management to improve compliance, 
among others, by providing PPE, conducting training, and conducting regular supervision to 
maintain established behavior. To maintain officer compliance in PPE, hospitals or health 
facilities always strive to improve the quality of human resources and adequate facilities by 
regularly monitoring and evaluation. 

Declaration  

Authors’ contribution  

ASN collected data, designed the study, wrote the article draft, and conducted the analysis; 
DS reviewed the results. All authors assisted in reviewing and evaluating this work for 
publication. 

Funding Statement  

This research has not received external funding.  

Conflict of interest 

There is no conflict of interest in this research.  

 

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