key: cord-0949043-odqchykg authors: Gerundo, Gerardo; Ruvolo, Claudia Collà; Puzone, Brunella; Califano, Gianluigi; La Rocca, Roberto; Parisi, Valentina; Capece, Marco; Celentano, Giuseppe; Creta, Massimiliano; Rengo, Giuseppe; Leosco, Dario; Abete, Pasquale; Longo, Nicola; Mirone, Vincenzo; Ferrara, Nicola title: Personal protective equipment in Covid-19: evidence-based quality and analysis of YouTube™ videos after one year of pandemic date: 2021-11-26 journal: Am J Infect Control DOI: 10.1016/j.ajic.2021.11.013 sha: 0c54ce447682e4e755f1222dc34c0ad8f7cc4f2a doc_id: 949043 cord_uid: odqchykg BACKGROUND: The correct use of personal protective equipment (PPE) during the Covid-19 pandemic is mandatory to minimize the contagion risk. The current study aimed to evaluate quality information of YouTube™ videos on PPE use during the pandemic. MATERIALS AND METHODS: Using Google™ Trend tool, the frequency of worldwide YouTube™ and Google™ searches for “donning and doffing” was examined. We queried YouTube™ with terms related to donning and doffing of PPE. Validated quality information assessment tools were used. RESULTS: From the 1(st) December 2019 to the 31(st) January 2021, according to YouTube™ and Google™ searches, both peaks occurred in April 2020 (69.5 and 72.0%,respectively). Of all videos, 144 were eligible for the analyses. According to misinformation tool, 90 (62.5%) videos contained inaccuracies. The median DISCERN Section 1 ranged from 3 to 5. The median DISCERN Section 3 was 4. According to Global Quality Score, 8.3% (n=12), 14.6% (n=21), 22.9% (n=33), 30.6% (n=44) and 23.6% (n=34) were classified as poor, partially poor, moderate, partially good and excellent quality videos, respectively. CONCLUSIONS: Nowadays, YouTube™ may be recommended as a reliable source of information. Nevertheless, a not negligible number of videos contained inaccuracies. Future authors should improve videos contents to provide more complete information. More than 17,000 healthcare providers worldwide have lost their lives due to Covid-19 infection and its complications, since the beginning of the pandemic (1, 2) . Currently, one year after the outbreak declaration, it is estimated that approximately 120 million people got infected and more than 2.5 million died in 223 different countries (3, 4) . The transmission mechanisms of Covid-19 have been largely studied by the scientific community (5) (6) (7) (8) . In this regard, international official recommendations primarily focused on the correct use of personal protective equipment (PPE), with the aim to break down the viral spreading (9) (10) (11) . However, the use of PPE in healthcare settings may be highly dangerous if the staff executing the donning and doffing procedures is not adequately skilled and trained to the purpose (12) . Over the years, online medical resources and instruments have increased. YouTube™ is the main free video platform, containing over 100 million videos and more than 1.9 billion users in over 100 different countries (13, 14) . YouTube™, as well as other social medias (15) (16) (17) (18) (19) , is commonly used as a source of medical information and it is successfully used as a learning and self-training tool, among healthcare workers as well (20, 21) . Previous studies have already evaluated the quality of the videos concerning several medical fields (22) (23) (24) (25) . To the best of our knowledge, no previous investigators examined the quality information of YouTube™ videos on the use of PPE for Covid-19 patients care. The aim of the current study was to evaluate the evidence-based quality of YouTube™ videos on the correct donning and doffing procedures and usage of PPE at one year from the beginning of Covid-19 pandemic. We evaluated the interest of the worldwide web users on the donning and doffing procedures. We queried Google™ Trends (26) with the terms "donning and doffing", using the following search settings: "worldwide", "period from 01/12/2019 to 31/01/2021", "all the categories". The trends of Google™ search and YouTube™ search were independently recorded. To examine changes in search frequency over time, we compared the relative frequency of searches between all 14 months (December 2019-January 2021). We queried YouTube™ (27) with 40 combinations of keywords (Supplementary Table 1 ). Internet cache cleared, the log-out from any personal account and a proxy located in United Kingdom through a free VPN software were set to minimise the search history and the geographic related biases. The first 50 videos were examined for each of the 40 keywords combinations. A total of 2000 videos was achieved. The following exclusion criteria were applied: non-English language, live-actions, interviews, news reports, webinars or lectures non-topic related, non-medical content, non-donning/doffing procedures and duplicate videos. Only Videos contents were assessed independently by two medical doctors, both staff members in the "Intermediate Care Covid-19 Unit" of the University of Naples "Federico II". A third investigator, a medical doctor staff member from the same Unit, adjudicated any differences and consensus was achieved among all reviewers. Videos contents were evaluated according to the CDC recommendations (28) , in which the donning and the doffing procedures were reported as step-by-step checklists Table 2 ). For each of the donning and doffing steps, five possible scores from 1 (strongly disagree) to 5 (strongly agree) were assigned. After evaluating the content of the videos according to CDC recommendations, the investigators judged if inaccuracies were present in reporting information. The inaccuracies reasons were categorized according to the following non-exclusive groups, as previously done (29) Table 3 ). The DISCERN instrument is a validated tool used to evaluate the good quality evidence-based and the reliability of the information given (29, 30) . The original version of the DISCERN tool, made by The British Library, was used for the study (31) . The instrument is based on a scale of five possible answers per question (1=no; 2=partially no; 3=partially; 4=partially yes; 5=yes). DISCERN Section 1 (questions 1 to 8 aimed to evaluate if a publication is reliable) and Section 3 (question 16 aimed to evaluate the overall rating of the publication) were used. DISCERN Section 2 was not applicable to the current study, since it aimed to evaluate information on treatment choices. However, to date, the only possible preventive treatment available for people dealing with Covid-19 patients is the correct usage of PPE. The GQS is a validated tool assessing the quality, the feasibility and the clinical utility of each video (32) (33) (34) . It was firstly used to assess the internet quality content on Crohn's Disease and Ulcerative Colitis (35) . The original English version of the GQS was used for the porpoise of the study. Five possible scores from 1 (poor quality, poor flow, most of information missing, not at all useful) to 5 (excellent quality, excellent flow, completely accurate information, very useful) were assigned. Descriptive statistics were presented as medians and interquartile ranges (IQR) for continuously coded variables or counts and percentages for categorically coded variables. Chi-square test and Kruskal-Wallis test examined the statistical significance in proportions and medians differences. In all statistical analyses, R software (www.rproject.org) environment for statistical computing and graphics (R version 4.0.0) and Microsoft Excel 2019 were used. All tests were two-sided with a level of significance set at p<0.05. From the 1 st December 2019 to the 31 st January 2021, an increased users interest on both Google™ and YouTube™ was recorded (Figure 2) . Specifically, according to YouTube™ search, the relative search frequency ranged from 2.4 to 21.6%, with the peak recorded in April 2020 (69.5%). Similarly, according to Google™ search, the relative search frequency ranged from 3.2 to 22.6%, with the peak recorded in April 2020 (72.0%). Of 144 videos (Table 1) According to the donning CDC recommendations step-by-step checklist, the median scores recorded ranged from 3 (for step 1) to 5 (for step 2). According to the doffing CDC recommendations step-by-step checklist, the median scores recorded ranged from 4 (for steps 2-5) to 5 (for steps 1 and 6) (Supplementary Figure 1) . According to misinformation tool, 90 videos were defined as inaccurate. Specifically, 90.0% (n=81), 50.0% (n=45), 46.7% (n=42), 35.6% (n=32) and 24.4% (n=22) were inaccurate for incomplete presentation of data, for inconsistent with CDC recommendations, for weak or inconsistent supporting data, for misrepresentation of data and for false or without any supporting data, respectively (Table 2) . The median DISCERN for the Section 1 ranged from 3 to 5. Specifically, the highest median score was recorded for the question 5. Conversely, the lowest median score was recorded for the question 4, 7 and 8. The median DISCERN for the Section 3 was 4. Moreover, statistically significant differences were recorded when DISCERN Section 1 and Section 3 were compared according to the videos authoring entity. Specifically, videos produced by public health institutions obtained a median score ≥4 in 8 out of 9 questions. Conversely, videos produced by individuals obtained a median score ≤3 in 8 out of 9 questions (Table 3A) . Of all videos, 8 Table 3 . DISCERN instrument Section 1 and Section 3 (A) and Global Quality Score (B) of 144 videos recorded on the 25 th of February 2021. The current study aimed to evaluate the evidence-based quality and accuracy of YouTube™ videos on the correct usage of PPE for the care of Covid-19 patients. To the best of our knowledge, no previous investigators examined this topic. We addressed this void and identified several noteworthy observations. For this reason, the contents shown in the videos should be correctly reported. Second, of all videos examined, approximately 40% were produced by public and government health institutions and approximately 90% were targeted to the healthcare workers, who are the most exposed professionals to the virus. In consequence, it is important that YouTube™ videos explaining donning and doffing steps report accurate and high-quality information in order to avoid mistakes. In this regard, we recorded higher medians for all the doffing steps (ranged from 4 to 5), relative to the donning steps (ranged from 3 to 5). It is important to underline how the doffing, more than donning, is the most dangerous procedure, due to the prolonged contact with infected patients during the care (39) . In the future, it will be important for the video authors to maintain good standards on the high-quality represented steps and give more attention to the low-quality represented ones, providing a more complete and exhaustive information. Third, we recorded inaccurate contents in 90 videos (62.5%), according to the misinformation tool based on the CDC recommendations (28) . Specifically, the main inaccuracy reason was the incomplete presentation of data. For example, we observed that several YouTube™ videos have given partial information on the step of washing hands, even though it is widely known that this procedure decreases the risk of infection (40, 41) . Thus, future videos should focus more their attention on the worst represented aspects. Fourth, according to DISCERN instrument, the median of the question 16, which is a surrogate of the overall quality, was 4. Moreover, videos produced by public health institutions showed higher quality, relative to videos produced by other entities. Table 4 ). The current study is not devoid of limitations. First, YouTube™ search results rely on Google™ proprietary search algorithms, based on user's previous search activities and location. However, the log-out from any personal accounts and the change of location via VPN proxy were performed. Second, only English-language videos were included in the final sample. Other languages videos could provide different information. Third, some reliable or non-reliable videos might be missed, due to our search terms. However, we used 40 keywords combinations in order to minimize selection errors. Fourth, quality assessment videos were subjectively evaluated. However, three investigators were independently involved to analyse video contents. Fifth, YouTube™ is a constantly expanding multimedia platform and the contents may rapidly change significantly with new updates over time. During the Covid-19 outbreak, YouTube™ was used as an easy and quick access source of information on donning and doffing of PPE, especially during the first pandemic wave. According to DISCERN instrument and GQS, YouTube™ may be recommended as a reliable source on correct usage of PPE for the Covid-19 patients care. In the future, it will be important for the video authors to maintain good standards on the high-quality represented steps and give more attention to the low-quality represented ones, providing a more complete and exhaustive information. 001) and by alternative medicine channels (28.1%, p<0.001). The highest rate of poor quality videos was recorded in videos produced by individuals COVID-19: Health worker death toll rises to at least 17000 as organizations call for rapid vaccine rollout | Amnesty International WHO Director-General's opening remarks at the media briefing on COVID-19 -11 Coronavirus disease (COVID-19) -World Health Organization Live): 120,822,563 Cases and 2,673,622 Deaths from COVID-19 Virus Pandemic -Worldometer COVID-19 transmission-up in the air Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental Factors Centers for Disease Control and Prevention SARS-CoV-2 infection affects the lower urinary tract and male genital system: A systematic review Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19 European Centre for Disease Prevention and Control Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China Competitive Analysis, Marketing Mix and Traffic -Alexa Exploring the use of entertainment-education YouTube videos focused on infection prevention and control Trend of influenza vaccine Facebook posts in last 4 years: a content analysis Twitter message types, health beliefs, and vaccine attitudes during the 2015 measles outbreak in California What can we learn about the Ebola outbreak from tweets? Social media and outbreaks of emerging infectious diseases: A systematic review of literature English-language videos on YouTube as a source of information on selfadminister subcutaneous anti-tumour necrosis factor agent injections Use of YouTube TM as a self-directed learning resource in oral surgery among undergraduate dental students: a cross-sectional descriptive study YouTube as a source of information on dialysis: A content analysis: Online information on dialysis Are video sharing Web sites a useful source of information on hypertension? YouTube as a source of information on penile prosthesis YouTubeTM as a source of information on bladder pain syndrome: A contemporary analysis Google Trends Evidence-based quality and accuracy of YouTube videos about nephrolithiasis Is YouTube a quality source of information on sarcopenia? DISCERN -The DISCERN Instrument Evaluating the Accuracy and Quality of the Information in Kyphosis Videos Shared on YouTube. Spine Does YouTube provide high quality information? Assessment of secukinumab videos YouTube as a source of information on COVID-19 and rheumatic disease link A systematic review of patient inflammatory bowel disease information resources on the World Wide Web Personal Protective Equipment and Covid-19 Problems and solutions of personal protective equipment doffing in COVID-19 Using effective hand hygiene practice to prevent and control infection Hand hygiene and the novel coronavirus pandemic: the role of healthcare workers Our research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.conflict of interest None