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Abstract
Objectives During the COVID-19 pandemic, healthcare workers (HCWs) are at a serious risk of contracting this virus. Therefore, they should use personal protective equipment (PPE) to protect themselves. Long-term use of these devices has led to many side effects, including headaches. This study investigated the prevalence of headaches related to using PPE in HCWs during the COVID-19 pandemic.
Design Systematic review and meta-analysis.
Data sources Embase, PubMed, Scopus and Web of Science databases were searched from December 2019 to February 2023.
Eligibility criteria for selecting studies All cross-sectional studies that investigated the prevalence of headache complications caused by PPE were included.
Data extraction and synthesis Two researchers reviewed the articles separately and independently. The Appraisal Tool for Cross-Sectional Studies was used to address study design quality and the risk of bias in cross-sectional studies. The heterogeneity of the studies was checked with the I2 statistic, and due to the high heterogeneity, the random effects model was used for synthesis. Data were analysed using Comprehensive Meta-Analysis software V.3.3.70.
Results Out of 3218 articles retrieved for all side effects, 40 were eligible for this meta-analysis. The prevalence of headaches related to the use of PPE in these 40 studies, with a sample size of 19 229 people, was 43.8% (95% CI 43.1% to 44.6%, I2=98.6%, p<0.001). Based on the meta-regression results, no significant relationship was observed between the prevalence of headaches and variables such as year of publication, study location, sample size and quality of studies.
Conclusion Headache is one of the common side effects of PPE, which can interfere with HCWs’ performance. It is suggested that manufacturers improve the quality of their equipment while healthcare managers should equip and train staff adequately to minimise side effects, ensuring health and enhanced service delivery.
PROSPERO registration number CRD42021264874.
- health & safety
- public health
- neurology
Data availability statement
Data are available on reasonable request. Extracted data are available on request to the corresponding author. Details of excluded papers are also available from the corresponding author on request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This meta-analysis included more studies than the previous one, allowing a more accurate estimate of headache prevalence.
There is a possibility that the credibility of the results may be affected by the heterogeneity of the studies included.
The study also failed to estimate headache prevalence by gender.
Introduction
The disease caused by the COVID-19 was first identified in December 2019 in Wuhan, China. This virus, with its high transmission rate, infection and mortality, quickly spread across the world and led to unprecedented changes in the global hospital system.1 2 Worldwide, healthcare workers (HCWs) on the front lines of this disease face a lot of work pressure, which continues to damage their physical and mental health.3 A study in Australia between 25 January 2020 and 8 July 2020 showed that HCWs are almost three times more likely to contract COVID-19 than others in the community.4 The statistics, published by the International Council of Nurses from 31 December 2020 to 13 January 2021, show that more than 1.6 million HCWs in 34 countries have been infected with this virus and about 10% of all confirmed COVID-19 infections among HCWs.5 These statistics indicate that HCWs are directly exposed to this disease, and here, the use of personal protective equipment (PPE) is the main protective measure for primary prevention.6 Since this virus is highly contagious and is mainly transmitted through the respiratory tract and airborne droplets containing live virus with sneezing, coughing and secretions of infected people, equipment such as special breathing masks, face shields, glasses, gloves and overalls are somewhat they protect HCWs so that they can provide safe and effective care to patients.7 8 With the emergence of the global crisis caused by COVID-19, the whole world suffered from a shortage of protective equipment, and HCWs have sometimes had to use these types of equipment for long hours without changing them. Even if these types of equipment were available in the required number, it was not possible to replace or remove this equipment in a short time due to not having enough time and being too busy; as a result, the equipment themselves and their long-term use lead to complications such as reactions. Adverse skin reactions, pain, allergic reactions, fatigue, feeling thirsty and hot, and headaches have been reported among HCWs.6 9 10
The systematic review and meta-analysis conducted by Galanis et al, which examined the effect of the use of PPE on the physical health of HCWs during the COVID-19 pandemic, identified headaches as the most common complication (55.9%) reported among 11746 HCWs.11
A study in Turkey on 315 HCWs showed that headaches are the most common symptom associated with using PPE (36.5%), which recently started in these people, and every hour of PPE use increases 1.38 times the number of new symptoms. Approximately 70% of participants with new PPE-related headaches in this study required medication.12
A study of 2132 people in the Baltic states showed that more than half of the medical workers experienced headaches caused by PPE, and this risk was higher among those with a history of headaches. This complication was also associated with symptoms such as nausea, photophobia, phonophobia, osmophobia, visual disturbances and increased use of painkillers.13 One of the causes of these headaches is the mechanical pressure that these pieces of equipment put on the head and face. Compression of the soft tissue around the skull by masks, glasses and hats causes headaches that have previously been reported in other people, such as swimmers and police officers.13 14 Other reasons include hypoxaemia (lack of blood oxygen), hypercapnia (increased carbon dioxide (CO2) in the bloodstream), dehydration, heat or stress caused by the use of these devices.10 15 16 If the equipment causes discomfort and complications such as headaches, they may be worn incorrectly and reduce their effectiveness in preventing disease. Also, the possibility of exacerbating the problem in employees who exist due to heavy workload, frequent stressful situations and night shift work, therefore, as an important problem, needs attention so as not to lead to self-medication and insufficient pain control.13
In Ong et al’s study in Singapore, where 81% of employees experienced headaches, headaches-related symptoms were seen in almost one-fourth of the respondents.14 In Srinath et al’s study, the headaches were accompanied by nausea and vomiting symptoms in about one-third of HCWs.17 Jafari et al also mentioned nausea (37%) and vomiting (14.4%) as the most common symptoms of headaches.10 In the studies, it has been mentioned that the decrease in efficiency and concentration is one of the essential side effects caused by headaches so considering that this issue impacts not only the physical health of employees but also their efficiency.10 12 14 18 A meta-analysis was conducted by Sahebi et al from January 2020 to January 2022 to investigate the prevalence of headaches caused by the use of PPE in employees during the COVID-19 era. During this study, which is the only review study in this field, the results of 26 studies were synthesised, and the prevalence rate was reported as 48.27%.19 According to the Cochrane guidelines, systematic review studies can be updated regularly based on the importance of the topic and when new studies are conducted. Increasing the number of studies can improve the accuracy of effect estimation.20 Therefore, the current research was conducted in a broader, more up-to-date time frame to estimate this issue. The results can be used to design interventions, guidelines and policies and even modify the construction and production of this equipment to reduce the complications of these devices.
This study aims to estimate the prevalence of headaches in HCWs when using PPE during the COVID-19 pandemic.
Method
Study design
The current meta-analysis study of the prevalence of headache complications caused by PPE use in HCWs, including doctors/dentists, nurses/midwives and other medical staff who were required to use PPE during the COVID-19 pandemic. It has been reported according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guideline.21 The study protocol, of which the present paper is part of its findings, has been registered with CRD42021264874 in the Systematic Review Studies Registration System (PROSPERO).
Data sources and search strategy
From December 2019 to February 2023, all the articles in Scopus, Embase, Web of Science and PubMed databases that investigated the prevalence of complications of using PPE in HCWs were retrieved. The searches were conducted on different platforms, including ELSEVIER for EMBASE and SCOPUS, Clarivate for Web of Science and the National Library of Medicine for PubMed.
In addition, Google Scholar was used as a resource for the retrieval of grey literature and additional articles. The keywords were consistent across all primary databases and Google Scholar. These keywords included “complication, side effects, adverse effects, adverse reactions, complaints, headaches, personal protective equipment, PPE, mask, healthcare worker*, healthcare personnel, staff, nursing staff, doctor, physician, nurse*, midwife*, healthcare professional and COVID-19”. The search was conducted using AND and OR operators in the articles’ titles, abstracts and keywords. To enhance the sensitivity of the search, restrictions were kept to a minimum. The complete strategy for searching in the main databases is given in online supplemental appendix 1.
Supplemental material
For example, the search strategy in Embase was as follows:
’side effect':ti,ab,kw OR 'physical health':ti,ab,kw OR physiologic:ti,ab,kw OR complication:ti,ab,kw OR ‘dermatological complaints':ti,ab,kw OR 'adverse effect':ti,ab,kw OR 'adverse reaction':ti,ab,kw OR 'adverse event':ti,ab,kw OR 'thermal stress':ti,ab,kw OR 'thermal discomfort':ti,ab,kw OR 'adverse skin reaction':ti,ab,kw OR ’skin reaction':ti,ab,kw OR ’skin injury':ti,ab,kw OR ’skin damage':ti,ab,kw OR ’skin problem':ti,ab,kw OR ’skin dryness':ti,ab,kw OR ’skin lesions':ti,ab,kw OR 'dry hands':ti,ab,kw OR acne:ti,ab,kw OR rosacea:ti,ab,kw OR irrita*:ti,ab,kw OR rash:ti,ab,kw OR headache:ti,ab,kw OR 'heat stress':ti,ab,kw OR 'heat-related illness':ti,ab,kw OR 'contact allerg*':ti,ab,kw OR dermat*:ti,ab,kw OR scratch:ti,ab,kw OR pruritus:ti,ab,kw OR itch*:ti,ab,kw OR 'mechanical pressure':ti,ab,kw OR 'cutaneous lesion*':ti,ab,kw OR 'cutaneous manifestation':ti,ab,kw OR 'cutaneous allergy':ti,ab,kw OR indentations:ti,ab,kw OR ’skin tears':ti,ab,kw OR ’skin breakdown':ti,ab,kw OR 'post inflammatory':ti,ab,kw OR hyperpigmentation:ti,ab,kw OR crusting:ti,ab,kw OR erythema:ti,ab,kw OR 'device-related pressure ulcers':ti,ab,kw OR ulceration:ti,ab,kw OR edema:ti,ab,kw OR deformations:ti,ab,kw OR redness:ti,ab,kw OR 'pressure damage':ti,ab,kw OR 'pressure injur*':ti,ab,kw OR 'pressure related*':ti,ab,kw OR 'liner pressure ulcers':ti,ab,kw OR sweat:ti,ab,kw OR perspiration:ti,ab,kw OR 'intense heat':ti,ab,kw OR 'high humidity':ti,ab,kw OR friction:ti,ab,kw OR occlusion:ti,ab,kw OR 'hyperhidrosis overheating':ti,ab,kw OR 'vision problem*':ti,ab,kw OR occupational:ti,ab,kw OR hyperemia:ti,ab,kw OR allerg*:ti,ab,kw OR dermatologic*:ti,ab,kw OR atopy:ti,ab,kw OR eczema:ti,ab,kw OR breath*:ti,ab,kw OR burning:ti,ab,kw OR maceration:ti,ab,kw OR wrinkl*:ti,ab,kw OR 'reduce visibility':ti,ab,kw OR urticaria*:ti,ab,kw OR ’secondary infections':ti,ab,kw OR impetigo:ti,ab,kw AND 'ppe':ti,ab,kw OR 'protective equipment':ti,ab,kw OR 'protective gear':ti,ab,kw OR 'protective suits':ti,ab,kw OR 'eye protection':ti,ab,kw OR 'eye wear':ti,ab,kw OR 'protective visors':ti,ab,kw OR 'mask':ti,ab,kw OR 'face shield':ti,ab,kw OR 'goggles':ti,ab,kw OR 'glove*':ti,ab,kw OR 'overalls':ti,ab,kw OR ’shoe cover':ti,ab,kw OR 'head cover':ti,ab,kw OR 'gown':ti,ab,kw OR 'aprons':ti,ab,kw OR 'n95':ti,ab,kw OR 'filtering facepiece particles':ti,ab,kw OR 'ffp2':ti,ab,kw OR 'ffp3':ti,ab,kw OR 'filtering facepiece respirators':ti,ab,kw OR 'ffrs':ti,ab,kw OR 'half face mask respirators':ti,ab,kw OR 'air purifying respirator':ti,ab,kw OR 'half-face elastomeric respirator':ti,ab,kw OR 'balaclava':ti,ab,kw OR ’surgical hood':ti,ab,kw OR ’surgical cap':ti,ab,kw AND 'hcw':ti,ab,kw OR 'health care worker*':ti,ab,kw OR 'health-care worker*':ti,ab,kw OR 'healthcare worker*':ti,ab,kw OR 'health care professional*':ti,ab,kw OR 'health-care professional*':ti,ab,kw OR 'healthcare professional*':ti,ab,kw OR 'professional*':ti,ab,kw OR 'health care personnel':ti,ab,kw OR 'health-care personnel':ti,ab,kw OR 'healthcare personnel*':ti,ab,kw OR 'health personnel':ti,ab,kw OR 'health care staff':ti,ab,kw OR 'health-care staff':ti,ab,kw OR 'healthcare staff':ti,ab,kw OR 'health care provider*':ti,ab,kw OR 'health-care provider*':ti,ab,kw OR 'healthcare provider*':ti,ab,kw OR 'health care employee*':ti,ab,kw OR 'health-care employee*':ti,ab,kw OR 'healthcare employee*':ti,ab,kw OR 'hospital staff':ti,ab,kw OR 'nurs*':ti,ab,kw OR ’staff':ti,ab,kw OR 'worker*':ti,ab,kw OR 'doctor*':ti,ab,kw OR 'clinician*':ti,ab,kw OR 'physician*':ti,ab,kw OR 'paramedical staff':ti,ab,kw OR 'paramedic*':ti,ab,kw OR 'practitioner*':ti,ab,kw OR ’sanitation workers':ti,ab,kw OR 'technicians':ti,ab,kw AND 'COVID*':ti,ab,kw OR 'coronavirus*':ti,ab,kw OR ’sars-cov-2':ti,ab,kw OR ’severe acute respiratory syndrome coronavirus 2':ti,ab,kw OR 'ncov':ti,ab,kw OR ’sarscov2':ti,ab,kw AND (2019:py OR 2020:py OR 2021:py OR 2022:py) AND 'article'/it AND ([english]/lim OR [persian]/lim)
Inclusion and exclusion criteria
The inclusion criteria included (1) the language of the articles was Persian and English, (2) the date of publication was from December 2019 to February 2023 and was selected during the COVID-19 pandemic, (3) studies that examined the complications related to the use of PPE reported, (4) the target population was HCWs who are in contact with patients and (5) cross-sectional studies that reported prevalence. Two researchers screened the studies based on the title and abstract of all Persian and English articles related to the subject and following the entry criteria. We used EndNote software to eliminate duplicate results effectively. Furthermore, studies not related to the topic as well as case reports, interventional studies, posters, lectures, reviews and letters to the editor were excluded from the study. Then the articles’ full text was reviewed. Our systematic review was comprehensive, encompassing all complications related to the use of PPE. However, for the purpose of this paper, we specifically selected studies that reported on the complications of headaches. This approach allowed us to focus our meta-analysis on this particular complication, providing a more detailed understanding of this specific issue within the broader context of PPE use.
Study selection and data extraction
The review of the abstracts and titles of the articles was done separately and independently by two researchers (NZ and ME). After the first screening, the full text of the selected articles was also reviewed. There were disagreements on several articles, which were refereed by a third person (RN). EndNote software (V.X8, Bld 10063) was used to manage reports. Two researchers (NZ and ME) separately extracted the data using a checklist designed by the researchers in Microsoft Excel.
Assessment of articles quality and risk of bias
The Appraisal Tool for Cross-Sectional Studies (AXIS) was used by two researchers independently to address study design quality and risk of bias. This tool was developed by Downes et al to evaluate the quality of observational cross-sectional studies. AXIS includes five parts (Introduction, Method, Results, Discussion and Others) and 20 questions that are answered as ‘yes’, ‘no’ or ‘do not know/no idea’. The number of yes responses determines study quality.22
Statistical analysis
The heterogeneity of the selected studies was evaluated by the I2 index, which expresses the heterogeneity as low (less than 25%), medium (25%–75%) and high (more than 75%).23 Due to the high heterogeneity of the studies, the random effects model was used for meta-analysis.24 Meta-regression was used to investigate the role of possible covariates in the heterogeneity. Data were analysed using Comprehensive Meta-Analysis V.3.3.70 software. Furthermore, narrative synthesis was used to identify the factors reported as being related to headaches.
Patient and public involvement
Patients and the public were not involved in this study.
Results
In this review study, a search was done for all complications related to the use of PPE. During this review, by searching the selected databases, 3218 articles were obtained, and by removing 936 duplicate articles, 2282 articles were examined in the stage of title and abstract screening in terms of criteria. No Persian article was found on this subject.
Figure 1 shows the process of identifying and selecting eligible studies for the systematic review according to the PRISMA checklist. Of these, 152 articles reached the stage of full-text screening. For this meta-analysis, 87 articles that did not investigate the prevalence of headaches were excluded. Then, 21 articles were excluded because the full text was other than English or Persian languages, did not report the prevalence of headaches or the type of article (letter, commentary).
PRISMA flow diagram of study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Furthermore, the full text of four articles was not available for full-text review; therefore, communication was made with the authors, but no reply was received. Finally, 40 articles that reported the prevalence of headaches passed to the data extraction and meta-analysis stage. The specifications of these studies are shown in table 1.
Characteristics of the studies included in the systematic review
A total of 40 selected studies involved 19 229 HCWs, including doctors, dentists, nurses, midwives and paramedics. Of the 37 studies that mentioned the number of men and women, 6877 were men and 11 622 were women. The smallest sample size (59 people) was related to Hunt et al’s study in Australia,25 and the largest sample size (3658 people) was related to Zhu et al’s study in China.26 62.5% of studies were conducted in Asian countries (25 studies), and other studies were conducted in European countries (8 studies), African countries (4 studies), American countries (2 studies) and Australia (1 study), respectively. The lowest (10%) and the highest incidence of headaches (91%) were reported in Indian studies among 2451 and 75 participants, respectively.27 28
Out of these 40 studies, the target population was 30 studies of HCWs, and data collection was done from a group of doctors, nurses and other hospital workers during the COVID-19 pandemic; 4 studies studied only nurses, and the target group of 6 studies were doctors and dentists. According to the report of 35 studies that mentioned people separately, 6832 doctors/dentists, 6648 nurses/midwives and 1687 other HCWs were studied. According to the report of 20 studies that mentioned the age as an average, the average age range of people was 25.6–43.7. In the context of assessing the risk of bias, the quality of the articles was evaluated on a scale of 11–19 points. Most of the studies (52.5%) scored 16 points in terms of quality, indicating a relatively low risk of bias in the majority of the studies. Most of the studies did not receive a score in the parts related to non-responders because they did not address the description and non-response bias.
Due to the heterogeneity of the selected studies, I2=98.6% (p<0.001), the random effects model was used to combine studies and joint estimation. Based on the combination of the results of the studies, the estimated prevalence of headaches due to the use of PPE in HCWs was 43.8% (95% CI 43.1% to 44.6%, I2=98.6%, p<0.001) (figure 2). Figure 2 shows the prevalence of headaches and its 95% CI (the horizontal lines around the mean) for each study, and the middle line represents the overall prevalence estimate.
Forest plot of the prevalence of headache due to PPE use and 95% CI based on the studied population in the conducted researches. PPE, personal protective equipment.
Studies have identified a variety of factors contributing to the incidence of headaches, including prolonged usage, mechanical elements such as sustained external pressure, hypoxia, the specific type of mask used and the demographic characteristics of HCWs, namely their gender and age. Despite the infrequent mention of these factors across studies, they have been collectively considered significant. Consequently, a narrative synthesis has undertaken for these findings. The results of meta-regression did not show a significant relationship between the prevalence of headaches and associated variables such as publication year, study location, study quality and sample size.
Discussion
This study aimed to investigate the prevalence of headaches in HCWs due to PPE use during the COVID-19 pandemic. The findings of this meta-analysis showed that, according to the studies conducted, 43.8% of HCWs suffered from headaches caused by using PPE. In the only review study that dealt with the meta-analysis of the prevalence of headaches caused by using PPE during the COVID-19 pandemic, the percentage of headache prevalence was reported as 48.27%,19 which is close to the results of this study.
This study also synthesised all factors associated with headaches caused by the use of PPE. This analysis has allowed us to identify and understand the various factors contributing to this issue, providing a more detailed and nuanced perspective than previous studies. We believe that this unique aspect of our research significantly enhances its value and relevance in the current context.
According to studies, headaches associated with PPE have a multifactorial origin. Many studies consider headaches and other health issues related to PPE as a result of long-term use of this equipment.6 9 14 29–31 Long-term use of equipment can lead to headaches by creating continuous external pressure (mechanical factors), hypoxemia, breathing CO2 and hypercapnia.30 The findings of the studies by Collado-Ortiz et al and Chowdhury et al provide valuable insights into the health implications of prolonged PPE usage among HCWs. The correlation between the frequency of PPE usage and the onset of headaches, as well as the association between average weekly mask usage and neurological disorders, highlights the physical toll that protective measures can take on those in the healthcare profession. These studies underscore the need for further research into the long-term effects of PPE usage on HCWs.30 32 It would be beneficial to explore the specific factors contributing to these health issues, such as the type of PPE used, the duration of usage and the working conditions. This could lead to developing guidelines for optimal PPE usage to minimise health risks. Nonetheless, it was impossible to examine these issues in this systematic review due to the lack of such information in the primary studies.
According to some studies, the N95 mask is the most commonly reported cause of headaches.10 14 18 In a study in Spain, headaches were independently associated with using a filter mask (KN95 or FFP2).18 In another study, no significant difference was observed between the headaches caused by using N95 and surgical masks.33 The headaches caused by masks can be due to external pressure with tight straps and the accumulation and rebreathing of CO2 in the mask chamber.17 30 34
Collado-Ortiz et al suggest that external pressure is the primary mechanism of headaches,32 and in the study by Jafari et al, about one-fourth of the people perceived the headaches as external pressure.10 Nonetheless, after the removal of PPE, headaches attributed to face masks and goggles resolved spontaneously within half an hour in most cases.14
In a study of 723 HCWs in Tunisia, headaches due to hypercapnia were 24.6%.3 Hypercapnia can even lead to symptoms of confusion and cognitive impairment. To prevent these problems, a study in India recommended taking frequent short breaks, massaging the neck, increasing hydration, especially before starting the work shift, and alternating between surgical masks and N95 (if possible).30 These studies show that we need to improve PPE and use more advanced techniques to provide safe protection for a long time and make people feel comfortable wearing them.
In several studies, neurological problems, including headaches, were more common in females, and this relationship was reported to be significant.10 15 18 34 35 Regarding people’s age, studies also mentioned it related to the incidence of headaches.18 In the study of Bongers et al, age less than 40 years old,36 and in the study of Dominguez-Moreno et al, age older than 30 years was associated with a higher prevalence of headaches.15 However, in our systematic review and meta-analysis, estimating the prevalence of headaches for different ages and genders was not feasible. This limitation could be attributed to various factors, such as the lack of age-specific and gender-specific data in the primary studies included in our review.
Headaches can significantly impact the efficiency and focus of HCWs and disrupt patients’ treatment and care process. Given the critical nature of their work, this issue is of considerable concern, as highlighted in various studies.10 12 14 18 In the study by Ramirez-Moreno et al, more than half of the HCWs (66.5%) reported a lack of concentration on tasks due to headaches caused by the use of PPE,18 and in Çağlar et al’s study of 315 people, most employees (92.8%) experienced at least a slight decrease in work performance.12 Such issues are fundamental for HCWs directly or indirectly dealing with patients’ lives. The decrease in operational efficiency and the potential for diminished task focus due to headaches underscores the need for effective management strategies to mitigate these adverse effects. Furthermore, a 6-month follow-up in a study in Mexico where 78% of people (210/268) experienced PPE-related headaches showed that 13.1% of these people’s headaches turned into chronic headaches.15 Therefore, it is crucial to pay more attention to the health of employees and screen and treat them as soon as possible.
In light of the significant impact of headaches caused by using PPE, it is crucial to consider potential strategies to mitigate these effects. The following recommendations aim to address this issue and enhance the well-being and productivity of HCWs:
Regular breaks for HCWs are crucial, as they provide an opportunity for rest and respiration. However, the provision of safe spaces for these breaks is equally important. These spaces should be designed to allow HCWs to remove their PPE in a controlled environment, reducing the risk of contamination.37
Furthermore, healthcare managers and policy-makers should consider these findings when developing worker health and safety strategies. This could include investing in higher quality PPE, implementing training programmes on proper PPE usage and advocating for policies limiting continuous PPE usage duration.
It is recommended that manufacturers of PPE reduce the additional pressures of these types of equipment on the head and face by changing the nature of the constituent materials increasing the flexibility of these equipment, and trying to ventilate the breathed air and reduce the creation of hypercapnia with new designs.
Strengths and limitations
This meta-analysis includes more studies than the previous meta-analysis on this topic, thus allowing a more accurate estimate of the prevalence of headaches. Furthermore, factors associated with headaches, as delineated in the primary research, have been synthesised to facilitate a more comprehensive understanding of this subject matter. While this systematic review provides valuable insights, it is important to acknowledge potential limitations. The heterogeneity among primary studies, however, may affect the credibility of this meta-analysis. It was also impossible to estimate headache prevalence according to age and gender in this study. Future research could further explore the role of age and gender in this context. Another limitation is the possibility of language bias. The articles included in this review were restricted to those published in English and Persian. Consequently, relevant studies published in other languages may have been overlooked, which could potentially influence the findings and conclusions drawn from this review. Future research should consider a more inclusive approach by incorporating studies published in multiple languages to minimise language bias and provide a more comprehensive understanding of the topic.
Conclusion
The use of PPE has led to complications such as headaches in HCWs, and the prevalence of this complication is significant, according to the results of this study. Since HCWs have to use this equipment at various times to maintain their physical health and the patients at work, the design of new equipment can eliminate or reduce the risk factor of headaches, increase the tolerance of using this equipment, and improve compliance and efficiency of PPE among HCWs. It is suggested that the manufacturers look for materials and structures that improve the quality of their products. Providing enough human resources to help reduce the personnel workload is also recommended. Reducing side effects by providing suitable and sufficient equipment and training for its use results in maintaining health and providing better services.
Data availability statement
Data are available on reasonable request. Extracted data are available on request to the corresponding author. Details of excluded papers are also available from the corresponding author on request.
Ethics statements
Patient consent for publication
Ethics approval
This study has been evaluated and approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1400.305).
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors made a substantial contribution to this work. NZ, RN and ME all contributed to the conception and design of the review. RN and NZ involved in conceptualisation, methodology, investigation, writing the original draft and Supervision. NZ and ME involved in literature search, data extraction, read and screened abstracts and titles of potentially relevant studies, and read the retained papers and were responsible for extracting data and rating their quality independently. RN analysed the data and supervised the review and meta‐analysis. RN is responsible for the overall content as the guarantor. All authors approved the final version for submission.
Funding This study was carried out with the approval and support of Tehran University of Medical Sciences and Health Services (grant number 52775).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.