Compliance Analysis For The Use Of Covid-19 Personal Protective Equipment (PPE) Based On The Theory Of Planned Behavior On Health Workers

Background: One way to prevent the spread of the Covid-19 virus to health workers is to adhere to the use of personal protective equipment. Increased compliance by health workers will increase awareness of the dangers of Covid-19 infection. Methods: Use a cross-sectional approach to design and conduct a descriptive analysis of the research. The population of all health workers at the Usada Buana Inpatient Main Clinic Surabaya, with a sample of 102, was determined by a proportional random sampling technique . Structural Model Analysis (SEM-PLS) with significance T Value > 1.64, with steps: designing a measurement model (outer model), designing a structural model (inner model), constructing a path diagram, converting a path diagram to a system of equations, estimating path coefficient, loading, and weight, evaluating the goodness of fit, and hypothesis testing. Results: The results showed that 48% of the excessive or low intentions of health workers in the use of COVID-19 PPE can very well be explained by attitudes (X1), subjective norms (X2), and perceptions of behavioral control (X3). In the meantime, 65.1% of the excessive or low adherence to COVID-19 PPE in medical examiners can be defined with the aid of the version used in this study (the model idea of deliberate conduct), and other variables outside this study version explain the rest (34.1%). Conclusion: Attitudes, subjective norms, and perceived behavioral controls can affect compliance with PPE use through intention mediation. Further studies are also endorsed behavior research on the layout of instructional interventions based totally on the Theory of planned conduct in enhancing medical experts' compliance with adherence to PPE.


INTRODUCTION
WHO has officially declared the COVID-19 outbreak a global pandemic. Clinical signs of COVID-19 include acute breathing distress, fever, cough, and shortness of breath. The incubation duration averages five to six days, with the most extended incubation duration of 14 days (Cucinotta & Vanelli, 2020) (Wu et al., 2021). Severe cases of COVID-19 can cause pneumonia, acute respiratory syndrome, kidney failure, or even loss of life (Coelho et al., 2020). The scientific symptoms and signs and symptoms reported in most cases are fever, with a few instances having difficulty breathing, and X-ray outcomes display widespread pneumonia infiltrates in both lungs (Sohrabi et al., 2020).
Negligence in the use of PPE mainly causes the transmission of COVID-19. The majority of COVID-19 transmission occurs through direct contact between symptomatic and symptomatic humans and others who are not wearing the appropriate non-public protective equipment (PPE) (Wölfel et al., 2020). Therefore, in dealing with COVID-19, using PPE and utilizing medical experts who're immediately worried about handling sufferers, especially those who've been exposed to COVID-19, is essential. The PPE used is predicted to be PPE that has met the requirements so that it is robust in preventing the spread of the virus or contracting COVID-19 (Law, Leung, & Xu, 2020) (Thirkell, Griffiths, & Waller, 2022).
The nationwide health facility contamination control and quality control center stated that the high range of medical examiners was inflamed at some point during the pandemic. These reasons include the lack of good enough PPE due to the fact that the absence of compliance with using PPE is still missing. As of March 25, 2020, 414,179 cases have been suggested, with 18,440 deaths (CFR 4.4%) pronounced in 192 countries/regions.
In numerous cases, health workers have already been inflamed (Xiong et al., 2020). On March 2, 2020, Indonesia pronounced two confirmed cases of COVID-19 (Ministry of Health of the Republic of Indonesia, 2020). As of May 5, 2021, there were 1,686,373 confirmed cases, 1,541,149 recovered patients, and 46,137 deaths in Indonesia (Covid-19 Handling Task Force, 2021). Based on the latest data, as of December 2021, as many as 35 health workers at the Usada Buana Inpatient Essential Clinic in Surabaya have been showing high quality for COVID-19.
Based on a preliminary study performed on 15 medical experts at the Usada Buana Inpatient Principal Health Center in Surabaya, it was found that 10 out of 15 people no longer observe the use of PPE, and they say that it is inconvenient to use complete PPE at some stage in the professional timetable. Research conducted by Xiong et al., (2020) said that most medical examiners used PPE ultimately, but 62% used it correctly and in step with SOPs. Stewart et al., (2020) also found that medical experts' behavior in complying with the usage of COVID-19 PPE in line with standards remains low. Elements that affect compliance depend on many factors, including information, motivation, notion, selfassurance in disorder management and prevention efforts, environmental variables, high-quality health instructions, and the capacity to get the right of entry to current assets (Adiutama, Fauzi, & Ellina, 2021). Research conducted by Sari, (2020) shows that there is a relationship between information and compliance with using PPE as an attempt to save against COVID-19 (Sari, 2020).
According to Ajzen, (1991), in the Theory of Planned Behavior, behavior has a belief approach that shapes intentions and encourages individuals to perform a specific behavior. Attitude, subjective norms, and perceived behavioral control are the primary factors that shape intentions. Research by Miller, (2014) shows that attitudes, subjective norms, and perceived behavioral control significantly relate to intention. In other studies, Peleg et al., (2017a) mention that the structure of the theory of planned behavior gives rise to the intention of behaving obediently.
Studies conducted Addisu, Birhanu, Tilahun, & Assefa, (2014) show that the Theory of Planned Behavior can significantly predict a person's intentions and adherence to behavior. The novelty of this study is that the problem raised in the study has never been solved or studied before. This study uses the basis of the theoretical model to predict or explain health workers' compliance in using PPE in the era of the COVID-19 pandemic, namely using the basis or framework of the Theory of Planned Behavior.
Researchers chose to use the basic theory of planned behavior because the theory has proven to be accurate in predicting health compliance behaviors. However, until now, the accuracy of the Theory of Planned Behavior in explaining COVID-19 PPE compliance has not been known, so it still needs to be proven in this study. The purpose of this study is to determine the factors that affect the compliance of COVID-19 PPE in health workers using the Theory of Planned Behavior approach at the Main Inpatient Clinic of Usada Buana Surabaya.

MATERIALS AND METHODS
Design and conduct descriptive analysis research with a cross-sectional approach. The population of all health workers at the Usada Buana Inpatient Primary Health Center in Surabaya in 2021 (N = 112). A sample with a proportional random sampling approach was acquired with 102 respondents. The information collection has been completed with the use of a questionnaire sheet which was divided into five components together with a mindset towards behavioral questionnaire along with ten questions, subjective norms consisting of 10 maps; perception manages behavior along with ten questions, aim, which includes ten questions, and compliance with the use of PPE, including ten questions (list questions in attachment).
Grouping is done by creating a complete rating of every assessment aspect for each device. The solutions of every questionnaire with a scale (of 1-7) are then summed up with a total fee (10-70). The data was then analyzed using variance-based structural equation modeling (SEM), also known as partial least squares (PLS), with a significance of T = 1.64. Usada Buana Ethical Clearance with Number (No: 2954/KEPK/V/2022).

RESULTS
The following are the Characteristics of the Respondents Based on Table 1 above, the age of the respondents with the maximum quantity is within the age range of 41-60 years (51%). The majority of the respondents (61.8%) are girls. Most of the respondents (86.9%) had the benefit of everlasting personnel where they labored. In terms of carrier length, the majority of respondents (59,8%) have a carrier length of more than two years.  Table 2 indicates that the average price of the mindset variable is 47.03 from the scoring variety of 10-70, and the average price of the subjective norm variable is fortyeight. 79 from the score range of 10-70, the standard fee of the conduct management belief variable is 48.09 from the rating range of 10-70, and the average cost of the goal variable is 54.12 from the rating range of 10-70. The standard charge for the conduct PPE compliance variable is 62.59 from the rating range of 1-70.
The statistical processing approach to this takes a look at the use of the Partial Least Square (PLS) based SEM method. Which calls for 2 degrees to assess the match version of a study model, which includes assessing the extreme version or size version and testing the structural version (internal version) (Ghozali, 2014). The evaluation of this observation used structural equation modeling (SEM) primarily based on the variance commonly known as Partial Least Square (PLS).
The steps performed in PLS are: designing a size version (extreme version), creating a structural version (inner version), building a direction diagram, converting a direction diagram to a gadget of equations, estimating course coefficient, loading, and weight, evaluation goodness of match, and speculation testing. The motives for using PLS to conduct fact evaluation on this sample are: a) PLS is a robust evaluation technique as it isn't primarily based on many assumptions. Statistics are not required to be distributed and are typically multivariate (indicators with class scale, ordinal, or periods until ratios can be used on the same model). As a result, the pattern no longer needs to be significant; b) PLS can analyze constructs with both reflective and formative signs at the same time. Examine the structure formed by reflective signs in this case. The reflective model assumes that the latent assemble or variable impacts the indicator (the route of the causality dating from the build to the indicator or manifest); c) PLS is an analytical method regularly used to estimate version paths that use latent variables with multiple indicators. This study built the model using exogenous and endogenous latent variables.  Table 3, it appears that attitudes can achieve growth aims (T-records = 5.428 and p-fee = 0.017). Subjective norms can boost intention (T-records = 4.753 and p-value = 0.022). The belief of behavioral control can achieve a growth goal (T-records = 5,280 and p fee = 0.012). Intentions can improve compliance by using COVID-19 PPE (T-statistics = 14,813 and p fee = 0.001).
The table above also suggests that attitudes can affect PPE compliance through full or complete mediation of cause variables. Subjective norms can affect PPE compliance via full or partial mediation of motive variables. The belief is that behavioral management can affect PPE compliance through partial mediation of rationale variables.

DISCUSSION
The results showed that attitudes (mindset towards behavioral) could be a robust variable assembled to predict intentions (goal) in medical examiners using COVID-19 PPE completely. The consequences of hypothesis assessments that have been carried out additionally display that attitudes can affect the senses. The effects of the external model evaluation on this examination showed that strong notions, final results assessment, and belief content material are sturdy indicators in predicting the attitudes of medical examiners in the use of whole COVID-19 PPE.
Finally, the study's findings prove that the construct of the Theory of planned conduct and attitudes can explain the variables of appropriate intentions (Asare and Heights, 2015). This look's outcomes align with an observation of 680 respondents in Barcelona, which discovered that perception-based attitudes are mighty in constructing compliance behaviors (Guix-Comellas et al., 2017). In addition, a meta-analysis of disorder fitness education concluded that interventions based on changing attitudes and ideals have a pleasing effect on compliance conduct (Hidayat, Aini, Ilmi, Azzahroh, & Giantini, 2020).
The effects confirmed that attitudes (attitudes closer to behavioral) might be a robust variable assembled to predict intentions (purpose) in health workers using COVID-19 PPE. The consequences of hypothesis tests that have been carried out also display that attitudes can affect the senses. The outcomes of the external version evaluation on this look additionally confirmed that solid belief, final results assessment, and notion content are strong indicators in predicting the attitudes of medical experts in the use of complete COVID-19 PPE.
The examination findings prove that the theory of planned behavior and attitudes can explain the variables of proper intentions. Another look at counseling at some point of treatment in Rio de Janeiro illustrates that attitudes based on beliefs are longer lasting than attitudes fashioned from guidelines (Costa et al., 2017). The results showed that the subjective norm component could be a sturdy construct variable to ultimately predict medical experts' goal (aim) in using Covid-19 PPE.
The outcomes of the hypothesis checks that have been executed also show that subjective norms can affect intentions. The results of the outer version analysis in this paper also display that normative belief and motivation to conform are sturdy indicators in predicting subjective norms. Finally, the findings have proven that assembling the theory of planned conduct, particularly the subjective norm (subjective norm), can explain the variable aim (intention) nicely.
The consequences of every other examination conducted on 680 humans in Barcelona confirm that perception-based education effectively constructs normssubjective norms that favor obedience behavior (Guix-Comellas et al., 2017). Yan et al., (2018) conclude that interventions based on emotional, social, and mental norms must be optimized to improve a person's obedience. Proper obedience can be achieved by harnessing social effects by educating one's own family members on how to support obedience behavior (Kopelowicz et al., 2015).
A meta-analysis of treatment adherence interventions in persistent illnesses also revealed that interventions using a notion technique could have an extended effect (Rich, Brandes, Mullan, & Hagger, 2015). Every other look at affected person compliance performed in South Africa showed that good social aid changes are shown to improve compliance behavior (Akeju, Wright, & Maja, 2017). The results confirmed that perceived behavioral manipulation might be a sturdy construct variable to predict purpose in health workers using complete COVID-19 PPE.
The consequences of the hypothesis assessments that have been achieved also show that behavioral management's perception can impact meaning. The results of the external model evaluation in this study also showed that manipulated notion and electricity notion are sturdy signs in predicting the percept of behavioral control. Finally, the findings prove that the framework of the theory of deliberate behavior, namely perceived behavioral control, can explain the variable intention (purpose) well.
This study is supported by the aid of different studies that show that health schooling regarding perceived behavior manipulation can improve someone's compliance (Guix-Comellas et al., 2017). The notion of perceived behavior management in this case is keen personal perceptions of whether or not people are to comply with COVID-19 PPE and is a reflection of previous stories and obstacles that may be anticipated. The more helping and less inhibiting factors a character feels so that you can carry out the conduct, the more manipulation they experience over that conduct and vice versa. The belief is decided by someone's notion, also known as managing the idea to control the elements that hinder or encourage the emergence of conduct.
The outcomes showed that goal (goal) could be said to be a robust variable construct to be a predictor of the compliance of medical examiners in the use of COVID-19 PPE ultimately. The consequences of speculation assessments that have been conducted also show that intentions can affect compliance. Furthermore, this study discovered that mindset elements, subjective norms, and perceived behavioral things may be strong predictors of health workers' intentions to use COVID-19 PPE completely.
The findings of the study show that all assembled variables from the Theory of Planned Behavior model, namely mindset, subjective, and perceived behavioral management, can explain the variable purpose for carrying out the conduct, and the purpose variable itself can provide an explanation for the compliance variable for the usage of COVID-19 PPE in complete. Preceding research on goals in the principle of deliberate behavior explains that aim and conduct within the constructed concept of planned behavior can define a person's intentions and respectful behavior. Adherence in medicine also relies on the personal orientation of the man or woman.
Cognitive schooling fashions moderated by the assembled idea of planned conduct have been verified to be influential in information about someone's intentions and obedience behaviors (Peleg, Vilchinsky, Fisher, Khaskia, & Mosseri, 2017b). Conduct has a notion approach that shapes preferences and encourages people to behave positively. Attitude, subjective norms, and perceived conduct management are the primary factors influencing intentions (Ajzen, 2005).
The purpose of behaving obediently in COVID-19 PPE is the desire of health workers who deliberately prevent the transmission of COVID-19. Someone's goal is said to be splendid due to the energy of an individual's capacity to try a behavior, the amount of guidance from those closest to him, and the notion of the person to whom the behavior can be completed. Likewise, someone may have little aim because their character does not have the confidence to try a new behavior.
Moreover, there is no guide from the nearest person and that individual's belief that the conduct will now not be capable of being carried out. Therefore, the purpose indicates how robust a person's ideals will strive to conduct and what kind of attempt could be used to perform a behavior. The goal is a motivational element that has power over conduct so that humans can anticipate others to do something primarily based on their intentions. In terms of popularity, the plan has a high correlation with behavior. Consequently, it can be used to forecast conduct.
The outcomes confirmed that there had been an indirect impact on attitudes toward compliance with using Covid-19 PPE through the mediation of variable intentions. This further reinforces the opinion of Ajzen, (2005) within the idea of deliberate behavior that attitudes can be transformed into behavior through the formation of full intentions. With the belief approach, the appearance of a sturdy goal can be achieved.
The results of previous studies conducted by Modi et al., (2018) indicate that health advertising with behavioral counseling methods primarily based on the principle of deliberate behavior can improve the behavior that is preferred to be displayed and settled in destiny. Adiutama & Fauzi, (2020) also cited that the idea of planned conduct can explain someone's propriety behavior well. The most significant challenge for skilled medical professionals in preventing the transmission of the COVID-19 virus is to maintain compliance with the use of PPE while demonstrating that obedient behavior necessitates solid and consistent intentions (Farrag, Oraby, Ragab, Nasreldein, & Shehata, 2017).
In general, the more powerful the goal to interact in behavior, the more likely it is that its miles will be completed (Adiutama et al., 2018). Attitudes formed by signs of thought and converted into complete intentions provide long-term obedience behaviors. Perception is the principal idea that determines mindset. Perception represents the information that someone has towards an item, wherein belief connects an object with numerous attributes.
A fantastic feeling in the direction of an object (favorable) or a negative feeling (destructive) toward an item. Attitudes may be described as psychological dispositions that can be expressed by comparing an entity to a range of likes and dislikes. Attitudes are seen as affective or evaluative. The significant concept determining attitude is belief, in which the notion connects an item with several attributes.
The strength of this relationship is measured by a procedure that places someone in a subjective possibility dimension related to an object with related features. The results showed an indirect influence of subjective norms toward compliance with using Covid-19 PPE through the mediation of variable intentions. This similarly reinforces the opinion of Ajzen, (2005) in the Theory of Planned Behavior that subjective norms may be transformed into conduct through the formation of solid intentions. The construction of a vital aim can be finished using the belief method.
An almost identical look at compliance concludes that interventions based totally on subjective, social, and mental norms need to be optimized to enhance someone's obedience conduct (Yan et al., 2018). Proper obedience can be achieved by utilizing social impact via the education of family members on how to guide obedience conduct (Kopelowicz et al., 2015). A meta-analysis of compliance interventions additionally found that interventions using a notion technique would have an extended impact (Rich et al., 2015). Another look at patient compliance performed in South Africa showed that specific social support improves compliance behavior (Akeju et al., 2017).
A person who's believed to be someone who has an impact on them can be someone who's taken into consideration vital in searching for whether or not certain behaviors can be finished or not (Normative belief). While a person seems to be any other individual who's considered necessary and expects them to carry out the conduct, they have the inducement to do so. The person regarded as critical has electricity over the notion of the problem that makes it difficult to carry out the predicted conduct (motivation to comply).
Subjective norms transformed into intentions could have an extended effect on compliance conduct, which in this case is compliance with the use of complete PPE. The consequences confirmed that compliance with COVID-19 PPE might be well explained using all the construct variables of the model idea of deliberate conduct, including perceived behavioral factors through the mediation of intentions (goal). Furthermore, consequences of the external version evaluation show that the compliance variables for the use of COVID-19 PPE may be assessed by how obedient health workers are in equipping their non-public protection systems, namely medical/surgical masks, N95 respirators, eye safety (goggles), face shields, examination gloves, surgical gloves, disposable clothes, heavy-duty aprons, water-proof boots, and shoe covers.
Through the construction of perceptions that manipulate conduct, behavioral counseling can enhance compliance to behave obediently through the mediation of aim or aim. In line with the concept of deliberate behavior (SDGs), the objective was fashioned from three dimensions, namely; 1) mindset towards behavior: a person's preference to act because he knows the influential effect of the conduct; 2) subjective norms: someone's choice to carry out a behavior due to the assistance of those around him; and three) perceived behavioral manipulation: a person will maintain conduct due to the driving factors of mindset closer to behavior and subjective norms (Ajzen, 2005). Adiutama et al., (2018) said that the primary constructs of the principle of planned behavior (attitude, subjective norm, and perceived behavioral control) could explain more than 96% of a person's compliance conduct. We've got the idea that the theory of planned conduct may be used as a powerful version to expect or explain health workers' compliance using COVID-19 PPE in full.

CONCLUSION
The results showed that 48% of the high or low intentions of health workers in using COVID-19 PPE in total could be explained by attitudes (X1), subjective norms (X2), and perceptions of behavioral control (X3). Meanwhile, 65.1% of the high or low compliance with COVID-19 PPE in health workers can be explained by the model used in this study. This study's limitations are that the consequences confirmed that attitudes, subjective norms, and perceptions of behavioral manipulation have power over health workers' intention to use COVID-19 PPE completely.
In the meantime, purpose influences medical examiners' compliance in using COVID-19 PPE. So then, attitudes, subjective norms, and perceptions of behavioral control affect medical experts' compliance with COVID-19 PPE through goal mediation. Efforts to enhance the compliance of medical experts in using PPE are highly committed to all additives within the health center. That is so that medical examiners can show a high-quality mindset and be capable of controlling their perceptions so they stay on a beautiful path inside the PPE system.
Further studies are suggested to research compliance with PPE using a mixmethod (qualitative and quantitative) to dig deeper into aspects that can affect the compliance behavior of PPE use in health workers. Research using the mix-method is expected to be able to explore elements of respondents' subjectivity regarding compliance with the use of PPE. Further studies are also suggested to research the design of educational interventions based on the Theory of Planned Behavior in improving health workers' compliance with PPE use.