Introduction

In 2020, the entire world was threatened by the SARS-CoV-2, a virus causing COVID-19. The most common symptoms include fever, dry cough, and shortness of breath,1 resulted to be dangerous, causing hospitalization and even death, especially in high-risk groups.2 For this reason, prevention and education about personal protective equipment (PPE) personal protective behaviors (PPBs) and against COVID-19 have become vital.

SARS-CoV-2 is characterized by significant high ability to spread and constantly mutate, which makes it challenging to incorporate coping strategies.3 Moreover, people have doubts about the safety of vaccinations. This is why a large part of the population remains unvaccinated.4 Research has showed that a number of factors—such as sex, age, and education level—influences the decision to get vaccinated against COVID-19. Occupational risk, perceptions of personal and public health risks, social responsibility, peer influence, and government actions also shape vaccination decisions.2,5

The COVID-19 pandemic, coupled with the fear of infection and the subsequent lockdown measures, has substantially contributed to the deterioration of the tourism industry.6 During the pandemic, the Polish government made numerous changes to the level of imposed restrictions, which included lockdowns and a requirement to wear protective masks both indoors and outdoors. Social distancing and limits on the number of people permitted to be in a given area at the same time were also enforced, along with bans on gatherings. Additional recommendations included washing and disinfecting hands, avoiding contact with infected people, refraining from traveling and staying in public places, and ventilating rooms. Despite legal consequences, many people did not follow these recommendations.7

Using face masks as a form of protection proved to be successful in reducing the transmission of the virus.8 Despite the decrease in the risk of infection, it is still possible to get infected while wearing a mask. The primary function of face masks is to limit the spread of the virus from an already infected individual.9 However, studies have shown that using this type of PPE offers protection also to the wearer, as it reduces the dose of viral droplets inhaled. As a result, if transmission occurs, the course of the disease is less severe.10 Previous findings suggest that different types of masks and their varying usage patterns distinctly influence the microbial composition of facial skin.11

A Cochrane review assessed how well physical interventions prevented the spread of respiratory viruses, focusing on new studies from the COVID-19 pandemic.12 It suggests that wearing surgical or medical masks probably has little-to-no effect on the spread of influenza-like illnesses or COVID-19. However, using N95 or P2 respirators may be effective in reducing respiratory infection dissemination. Hand hygiene is likely to have a modest beneficial effect on reducing the transmission of respiratory illnesses.

Cohen et al13 reported that the lack of sufficient PPE increased the spread of the virus. According to Hoffmann et al,14 among 1101 people in the general Polish population, only 38.87% adhered to the restrictions properly. Moderate compliance has been noted in 47.96%, and low in 13.17% of the sample. The use of masks and other hygiene items is controversial because research on their efficacy in reducing the risk of infection is inconclusive.12 It is also difficult to statistically separate individuals who adopted correct PPBs, as it is based on subjective opinions of the respondents. Other studies have shown that vaccinated individuals are generally more concerned about the posssibility of getting ill. They are also more likely to follow hygiene practices. In addition, they tend to use PPBs and PPE.

A previous study proved the effectiveness of the proper use of masks, gloves, and hand washing.15 We aimed to investigate the use of PPE and PPB against COVID-19 among unvaccinated people, and find predictors of willingness to use PPE and PPB in the target population, since current literature lacks comprehensive insights into these aspects. Our study provides essential information about the attitudes and practices of unvaccinated individuals during the pandemic.

Understanding the determinants that influence willingness to use PPE and PPB provides valuable insights not only for managing the COVID-19 pandemic but also guiding future public health interventions. By examining demographic, behavioral, and psychosocial factors associated with protective practices, our study highlights the mechanisms of compliance and noncompliance with restrictions and recommendations. Such knowledge is essential for developing effective risk communication strategies, tailoring interventions to specific populations, and improving preparedness for potential future epidemics.

Methods

Study design and instrument

This study was conducted among the general Polish population when the number of COVID-19 infections was on the increase. It had a form of a survey, and the questionnaires were filled from January 13 to February 14, 2022. During the study period, only 56.62% (n = 21 400 739) of the population in Poland had completed their vaccination regimen against COVID-19.16 Of the 7025 adults who completed the survey, 1276 (18.16%) were qualified to participate in the study.

The inclusion criteria were as follows: 1) age over 18 years, 2) completion of the online survey, 3) being unvaccinated against COVID-19, 4) living in Poland, and 5) provision of informed consent to participate in the project. The respondents who failed to answer all the questions were excluded. The data selection process is shown in Figure 1.

Figure 1. Data selection process

The study was conducted remotely via an online survey. It was distributed through social media platforms, such as Facebook, Instagram, and LinkedIn, as well as via email through the Polish Society of Lifestyle Medicine newsletter, university groups, and health-focused forums. Due to the ongoing pandemic and limitations on in-person contact, an online survey was chosen as the most feasible method. This approach allowed for the collection of a relatively large and diverse sample. Although the sample was not randomly selected, efforts were made to include participants from a wide range of age groups, both sexes, and various geographic regions to approximate the characteristics of the general population.

Ethics

The study was conducted in adherence to the Declaration of Helsinki and approved by the Bioethical Committee at the Medical University of Warsaw (AKBE/259/2023). The survey was completed by volunteers. The participants did not receive financial or material remuneration.

Survey descrption

The survey consisted of 2 main parts: 1) general and demographic questions: age, sex, marital status, education level, occupation, and residence area; and 2) health status assessment: chronic diseases, methods used to protect against COVID-19 (face masks, disinfecting hands, wearing gloves, keeping distance, and carrying an amulet). The participants were asked to declare whether they had history of COVID-19, as confirmed by a laboratory test, and whether they were vaccinated against COVID-19 or not. The questionnaire form is available in Supplementary material. The survey was designed by a team of general practitioners, a public health specialist, members of the Polish Society of Lifestyle Medicine, an environmental epidemiologist, and medical students. To ensure reliability, most of the questions were based on the validated questionnaire provided by Polla et al.17

Questions about personal protective equipment and personal protective behavior

This part of the form consisted of 5 questions, to which the participants had to answer “yes” or “no”: 1) I wear a face mask in confined areas; 2) I wash and disinfect my hands frequently; 3) I wear gloves in public areas; 4) I try to keep my distance from other people and avoid large gatherings; and 5) I carry an amulet or a ribbon against infection. Answering each question was mandatory.

Statistical analysis

Descriptive data were categorized and stratified depending on the usage of PPE or PPB. Basic variables were shown as numbers (percentages). The differences between the subgroups were calculated using the χ2 test.

The prevalence of using PPE and PPB against COVID-19 was analyzed by maximum likelihood techniques based on a log-linear analysis of contingency Tables. This method allows for the estimation of associations between categorical variables and their interactions while accounting for the multidimensional structure of the data. The dependent variable (declared usage of PPE or PPB) was coded as a binary factor: yes and no. The following variables were implemented in the regression: sex (man, woman, or not specified); age (18–29, 30–39, 40–49, and ≥50 y); education level (higher, upper secondary, lower secondary, primary, and basic vocational); having undergone COVID-19 (yes or no); and having declared willingness to use PPE and PPB (yes or no). Model selection was performed using stepwise procedures, and the goodness-of-fit of each log-linear model was assessed to ensure an adequate representation of the data. Potential confounding factors and interactions were evaluated, and sensitivity analyses were conducted to minimize bias.

A 2-sided P value equal to or below 0.05 was considered significant. All analyses were conducted using Statistica software 13.3 (TIBCO Software Inc., Palo Alto, California, United States).

Results

Sociodemographic characteristics

Description of the study sample stratified for age, sex, marital status, education level, occupation, residence area, and occurrence of chronic comorbidities is presented in Table 1. In total, 1276 unvaccinated individuals took part in the study (930 women, 339 men, and 7 individuals of unspecified sex). A total of 81.11% (n = 1035) declared using at least 1 type of PPE or PPB. As many as 18.34% (n = 234) denied the use of PPE and PPB against COVID-19. The PPE and PPB users and nonusers differed in terms of age (P = 0.003), sex (P <⁠0.001), occupation (P = 0.002), and the occurrence of chronic comorbidities (P <⁠0.001). Most of the participants (n = 618; 48.43%) were in the youngest age group (18–29 y), followed by the individuals aged 30–39 years (n = 151; 11.83%). The participants primarily resided in large cities of over 500 000 inhabitants (n = 425; 33.31%; P = 0.2), had higher levels of education (Bachelor’s or and Master’s degree or its equivalent; n = 829; 65.0%; P= 0.41), worked in the service sector (n = 946; 74.1%; P = 0.002), and were married (n = 499; 39.1%; P = 0.495). A total of 717 respondents (56.19%) declared to be in good general health and only 559 (43.81%) suffered from any chronic comorbidity (P <⁠0.001).

Table 1. Characteristics of the study population

Variable

Total (n = 1276)

Use of PPE or PPB

χ2 value

P value

Yes (n = 1035)

No (n = 234)

Age, y

18–29

618 (48.43)

516 (40.44)

98 (7.68)

13.83

0.003

30–39

151 (11.83)

107 (8.39)

43 (3.37)

40–49

465 (36.44)

380 (29.78)

83 (6.5)

≥50

42 (3.29)

32 (2.51)

10 (0.78)

Sex

Men

339 (26.57)

242 (18.97)

97 (7.6)

31.95

<⁠0.001

Women

930 (72.88)

793 (62.15)

137 (10.74)

Not specified

7 (0.55)

6 (0.47)

1 (0.08)

Marital status

Married

499 (39.11)

404 (31.66)

92 (7.21)

3.39

0.495

Single

425 (33.31)

350 (27.43)

75 (5.88)

Divorced

41 (3.21)

29 (2.27)

12 (0.94)

Widow(-er)

4 (0.31)

4 (0.31)

0

Cohabitation

307 (24.06)

248 (19.44)

55 (4.31)

Education level

Primary

3 (0.24)

3 (0.24)

0

3.95

0.41

Lower secondary

24 (1.88)

21 (1.65)

3 (0.24)

Upper secondary

395 (30.96)

318 (24.92)

75 (5.89)

Basic vocational

25 (1.96)

17 (1.33)

8 (0.63)

Higher

829 (64.97)

676 (52.98)

148 (11.6)

Occupation

Services

946 (74.14)

765 (59.95)

176 (13.79)

14.43

0.002

Industry

137 (10.74)

99 (7.76)

36 (2.82)

Agriculture

11 (0.86)

8 (0.63)

3 (0.24)

Unemployed

182 (14.26)

163 (12.77)

19 (1.49)

Population in the residence area

<⁠50 000

203 (15.91)

166 (13.01)

37 (2.9)

5.95

0.2

50 000–150 000

224 (17.55)

182 (14.26)

41 (3.21)

150 000–500 000

217 (17.01)

166 (13.01)

49 (3.84)

>500 000

425 (33.31)

343 (26.88)

79 (6.19)

Village

207 (16.22)

178 (13.95)

28 (2.19)

Chronic comorbidities

Yes

559 (43.81)

476 (37.3)

79 (6.19)

11.6

<⁠0.001

No

717 (56.19)

559 (43.81)

155 (12.15)

Data are presented as number (percentage).

Abbreviations: PPB, personal protective behavior; PPE, personal protective equipment

Frequency of use of personal protective equipment and personal protective behavior among unvaccinated individuals

The use of PPE and PPB was declared as follows: wearing a mask in enclosed spaces (n = 762; 59.72%), frequent washing and disinfecting hands (n = 862; 67.54%), wearing gloves in public places (n = 31; 2.43%), keeping distance from other people and avoiding large gatherings (n = 533; 41.77%), and wearing an amulet / ribbon (n = 11; 0.86%). There were no differences among the unvaccinated men and women in terms of wearing a mask in public places (χ2 = 0.88; P = 0.35) and using an amulet or a ribbon (χ2 = 0.2; P = 0.65). In the case of the remaining 3 methods (wearing gloves, frequent hand washing, and keeping distance), there were differences between the sexes (all P <⁠0.001).

Predictors of willingness to use personal protective equipment and personal protective behavior against COVID-19

The variables used in the analysis were: sex, age, education level, having undergone COVID-19, and having declared willingness to use PPE and PPB. The results of all fitting k-factor interactions are presented in Table 2. The least complex model that fits the frequency Table is the one without any 3-way interactions. A test of marginal and partial models was performed and its results are outlined in Table 3. The frequency of PPB and PPE use stratified by sex is illustrated in Table 4.

Table 2. Results of all fitting k-factor interactionsa

k-factors

Degree of freedom

Pearson χ2

P value

1

10

8306.98

<⁠0.001

2

36

365.02

<⁠0.001

3

58

35.11

0.99

4

43

11.05

>0.99

a k-factors indicate tolerance intervals for normal distribution.

Table 3. Test of marginal and partial 2-factor associationsa

Effect

Degree of freedom

Marginal association χ2

P value

Partial association χ2

P value

1 and 2

3

1.7

0.64

0.8

0.86

1 and 3

4

24.6

<⁠0.001

29.8

<⁠0.001

1 and 4

1

1.7

0.2

0.4

0.51

1 and 5

1

30.6

<⁠0.001

34.3

<⁠0.001

2 and 3

12

148.6

<⁠0.001

163.8

<⁠0.001

2 and 4

3

22.1

<⁠0.001

33.7

<⁠0.001

2 and 5

3

20.7

<⁠0.001

19.8

<⁠0.001

3 and 4

4

10.9

0.03

23.5

<⁠0.001

3 and 5

4

7.9

0.1

14.9

0.005

4 and 5

1

3.2

0.07

1.5

0.22

a Numbers 1–5 indicate the factors taken into account in the model, and the individual rows present the relationship between the factors: 1 (sex), 2 (age), 3 (education level), 4 (having undergone COVID-19), and 5 (previous usage of PPE or PPH against COVID-19). Goodness-of-fit for the model was satisfactory; the maximum likelihood χ2 =61.32 and degree of freedom = 122; P >0.99.

Table 4. Frequency of use of personal protective equipment and personal protective behavior stratified by sexa

PPE and PPB

Total (n = 1276)

Sex

χ2 value

P value

Men (n = 339)

Women (n = 930)

Wearing a mask in closed spaces

Yes

762 (59.72)

142 (41.89)

616 (66.24)

61.24

<⁠0.001

No

514 (40.28)

197 (58.11)

314 (33.76)

Frequent washing and disinfecting hands

Yes

862 (67.54)

197 (58.11)

662 (71.18)

19.41

<⁠0.001

No

414 (32.46)

142 (41.89)

268 (28.82)

Wearing gloves in public places

Yes

31 (2.43)

6 (1.77)

25 (2.69)

0.88

0.35

No

1245 (97.57)

333 (98.23)

905 (97.31)

Keeping distance from other people and avoiding large gatherings

Yes

533 (41.77)

86 (25.37)

443 (47.63)

50.67

<⁠0.001

No

743 (58.23)

253 (74.63)

487 (52.39)

Wearing an amulet or ribbon

Yes

11 (0.86)

3 (0.88)

6 (0.65)

0.2

0.65

No

1265 (91.14)

336 (99.12)

924 (99.35)

Data are presented as number (percentage).

a Participants could choose more than 1 PPE and PPB.

Abbreviations: see Table 1

Discussion

This is the third study in a series regarding COVID-19. It showed that the groups least willing to adopt protective measures against the disease, despite not being vaccinated, were men, middle-aged individuals, and those without chronic diseases. On the other hand, women, younger people, individuals with concomitant chronic diseases, and the unemployed showed a greater tendency to use PPE.

Previous studies on the use of PPE in the Polish population did not distinguish between vaccinated and unvaccinated individuals.16 In addition, most of them focused only on the use of masks, or limited the analysis to a narrow age group.18-20 Our study analyzed factors not previously included in Polish studies: occupation and chronic comorbidities. Among the unvaccinated people with chronic diseases, 85.87% used at least 1 PPE item, while among the healthy respondents, this rate was 78.24%. Other criteria we used did not reach significance, and were not addressed in other studies in Poland either.

A study from the United States (US) suggests that men are less likely to seek health care services than women, which is driven by entrenched cultural norms and delays in seeking help when ill.21 Additionally, during the pandemic, men were particularly vulnerable to a decline in both physical and mental quality of life.22 The findings suggest that women are more driven and effective in taking care of their health. Age and education also affect health-related behaviors. Younger individuals tend to be more proactive in maintaining their health. Women show greater concern for both their own and their family’s health. In contrast, older individuals are more accepting of the occurrence of diseases and are less inclined to take preventive measures.22

Our study was conducted between January and February 2022. During this period, regulations pertaining to wearing masks in public transport and public buildings were in effect. Research conducted in Russia, where similar restrictions were in place, examined the impact of legal measures on failure to use PPE. The study showed that such measures effectively increased the number of people using PPE in public transport.23 Top-down restrictions imposed by governments led to a rise in PPE usage. This increase is visible in a comparison of Internet trends in Poland and Portugal, as measured by Google Trends.24 At the same time, those regulations were the subject of a public debate regarding their impact on civil liberties and rights, a sense of which is strongly rooted in democratic Western countries.25 In April 2020, during the early stage of the COVID-19 outbreak, Khubchandani et al26 conducted a study on the US population. It showed that 76% of the respondents reported wearing face masks more frequently during the pandemic. In China, which introduced very harsh COVID-19 restrictions, a survey conducted in April–May 2020 demonstrated that 99% of the population used face masks.27 Moreover, the polls carried out in US in May 2020 showed a decrease in the number of people using face masks, with 69% wearing them always or most of the time.28 This downward trend continued in June 2020, when the number of people using masks always or most of the time dropped to 65%.29 The attitude among the Polish society toward the use of PPE and PPB has also been influenced by the government restrictions. The varied results in different countries may stem from the level of trust in the government and the restrictions implemented by it, as well as the educational efforts carried out during the pandemic.30,31

The possibility of negative consequences of not following guidelines might encourage people to use PPE. Willingness of the population does not always lead to taking active measures. A study conducted in the Midwestern US found that 91% of the respondents were willing or very willing to wear face masks. However, only 79% actually wore them more frequently during the pandemic.26,32 On the other hand, the survey conducted on US citizens in April 2020 showed that most people would be likely or extremely likely to wear face masks if they were required to do so by local authorities.33

In our study, face masks proved to be the most popular form of PPE, with 59.72% declaring using them in enclosed spaces. These results match the findings of studies conducted on Chinese and US populations, respectively.26,27 A study of US-based Twitter users showed that the majority of the population supported wearing masks in the public, with some encouraging others to do so.34 Among the users who opposed wearing masks, the main concern was physical discomfort. This included unpleasant sensations, rashes, acne, shortness of breath, and fear of damaging the immune system. Another concern was the belief that masks were ineffective, not always effective, or that better alternatives were available. Personal comfort was also a key factor behind the adherence to using a given mask type.35 These subjective feelings are reflected in the measurements of the effect of masks on the respiratory, cardiovascular, and nervous systems, as well as psychological aspects of long-term compliance.36

Keeping distance from other people and avoiding larger groups was the second most popular form of protection declared in our study. Zhang et al11 concluded that social distancing was generally perceived very positively or supported by the majority of the public. However, the people’s opinion shifted and was impacted by major public events, during which the approval for social distancing tended to fall, returning to its previous state some time after the event. Regarding the effectiveness of this method, studies have found that areas with the highest compliance with social distancing experienced a greater decrease in virus transmission.37 Despite these results, confidence in the effectiveness of this method, after the initial increase, decreased over time.38

Hand washing and disinfecting were the third most commonly adopted PPBs indicated in our study. Maintaining hand hygiene is influenced by several main factors, such as feasibility, aesthetic acceptability, and a lack of skin irritation.39 Hand hygiene was generally considered to be an effective method in reducing the spread of the virus by the majority of the public, as common soaps and alcohol disinfectants are effective in combating SARS-CoV-2 infection.38 Despite the effectiveness of hand washing, frequently doing so can have adverse consequences.40 One of them is hand dermatitis, which itself also requires prevention through the use of skin moisturizers.40 The adverse effects of washing hands were more discouraging for women than men among the Polish adolescents.20 Fortunately, predictions regarding the frequency of hand washing necessary for reducing the risk of transmission show that highly intensive use of this PPB shows no advantage over a more moderate approach.41

Practical implications

Our results should make the readers reflect on the effectiveness of education on the use of PPE and PPB against COVID-19. People in contact with infected individuals (eg, relatives) and medical professionals (eg, doctors, nurses, and pharmacists) should be encouraged to implement protective measures. Our findings are a valuable guideline for policymakers and governments to modify strategies of dealing with the COVID-19 pandemic and possible future pandemics.

Our study emphasizes the importance of tailoring COVID-19 management strategies to account for age and sex differences. Policymakers should customize informational campaigns and protective measures to address specific needs and preferences of diverse social groups. Additionally, investments in scientific research and technological advancements could contribute to the development of more tailored and effective protective measures for various demographic groups.

Limitations

The results should be interpreted with caution. The respondents answered according to their subjective opinion. Conducting an online survey carries a risk of inaccurate or false responses, which may affect the reliability of the findings.42 Additionally, although efforts were made to include a diverse range of participants, the sample was not randomly selected and may not be fully representative. In future studies, we recommend adjusting the analysis for perceptions, knowledge, or income level. It is possible that the respondents did not fully understand the study protocol and marked biased answers. A cross-sectional study in comparable populations should be conducted to ensure that the results are reproducible. Our study did not include a control group of vaccinated individuals. Direct comparison between vaccinated and unvaccinated individuals would ensure objectivity of the presented results. We highlight the need for future studies to include both control (vaccinated) and experimental (unvaccinated) subgroups. Direct comparison between both subgroups would add a clearer view on willingness to use PPE and PPB. We also did not ask the respondents about their motivations to use PPE and PPB. Future research should include questions about the reasons behind using PPE and PPB to enrich the quality of the presented findings.43 Some questions were not validated due to the preponderance of questions on demographic data.44 We recommend further research with a proposed questionnaire for its validation. More rigorous approaches to data collection are needed in further research. Methods involving personal contact would help reduce potential bias and inaccuracies.

Conclusions

The majority of unvaccinated individuals adhered to at least 1 form of PPE or PPB that helped limit the transmission of COVID-19. Age and sex were the strongest predictors of willingness to use preventive measures, with women and individuals aged 18–29 years demonstrating higher compliance. The most commonly used protective measure was wearing masks in enclosed spaces. Medical professionals and public health practitioners should take these predictors into account to effectively tailor vaccination and prevention strategies to specific cohorts. Although the data were collected in 2021, the findings remain highly relevant, as they provide insights into enduring behavioral patterns and factors influencing adherence to preventive measures. Understanding these patterns can help public health authorities anticipate challenges, design more effective risk communication strategies, and develop interventions adapted to specific populations. Ultimately, these insights enhance preparedness for future infectious disease outbreaks and strengthen overall resilience in public health practice.