How the public used face masks in China during the coronavirus disease pandemic: A survey study

Since January 2020 Elsevier has created a COVID-19 resource center with free information in English and Mandarin on the fresh coronavirus COVID-19. The COVID-19 resource center is hosted on Elsevier Connect, the ship’s company ‘s populace news program and information web site. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource center – including this research message – immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted inquiry re-use and analyses in any class or by any means with acknowledgment of the original reservoir. These permissions are granted for release by Elsevier for ampere farseeing as the COVID-19 resource center remains active. closely all people wore face mask and most of them used it by rights during the COVID-19 pandemic. Hand hygiene before and during mask-wearing, choosing an allow type of face mask, reusing disposal side mask, and dispose of use font masks should be peculiarly emphasized in future tell dispersion or behaviour-change interventions. information on social media platforms for attest dissemination and behavior change may benefit the public the most, but this inaugural requires far research to investigate its effectiveness. about all ( 99 % ) people wore a mask during the covid-19 pandemic, with most ( 73.3 % ) demonstrating full conformity with face mask function. however, 41.8 % of the participants rarely cleaned their hands before putting on a face dissemble, and more than one-half ( 55.3 %, 62.1 % ) of those who touched ( n=8108, 79.8 % ) or adjusted ( n=9356, 92.0 % ) their disguise while using it failed to consistently wash their hands subsequently. When removing a exploited masquerade, 7.6 % of the participants discarded it into a garbage bin without a hat and 22.5 % discarded it into a garbage bin in their pass regardless of bearing of a eyelid. Participants reported wearing disposable aesculapian masks ( 93.8 % ), followed by N95 respirators ( 26.2 % ), and fabric face masks ( 8.5 % ). Some participants wore multiple masks simultaneously ( occasionally 26.5 %, much 2.1 %, constantly 1.5 % ). A sum of 5,981 ( 58.8 % ) participants reported reusing disposable masks, with closely two thirds ( n=3923, 65.6 % ) argue they would hang the practice masks in well-ventilated places. More than one-third ( 37.6 % ) of the respondents did not replace dissemble when it had been used for more than 8 hours. exposure to instructions on front mask use was the strongest forecaster of good complaisance ( odds ratio=4.13, 95 % confidential interval= 3.60-4.75, p=0.000 ). early factors included particular situations, placement, and gender. The influence of age needs further investigation. Most participants ( 76.4 % ) accessed data chiefly via social media platforms. When recommending that the general population wear masks, however, health authorities and experts warned that improper face mask use could increase the risk of infection ( Mahase, 2020 ; WHO, 2020b ; Feng et al., 2020 ). Although the virus may survive on the open of the face masks ( Osterholm et al., 2015 ), the public may not change masks much, wash hand frequently, and properly remove and dispose of use masks ( Mahase, 2020 ). furthermore, fabric masks, disposable medical masks, and N95 respirators are recommended based on different situations ( National Health Commission of the People ‘s Republic of China, 2020 ), but the populace may not have entree to the relevant data, which may lead to irrational number survival of face masks and put up to waste of resources. frankincense, this cogitation used social media to conduct an on-line sketch on the public ‘s mask-wearing behavior in the context of the COVID-19 pandemic and provide the guidelines for participants with strategies to preserve the achievements in extenuate and controlling the covid-19 epidemic.

In China, the recommendation to wear face masks at the start of the begin of the COVID-19 epidemic ( National Health Commission of the People ‘s Republic of China, Jan. 31, 2020 ). From mid-to-late March, increasingly more provinces of China declared no more confirmed cases of COVID-19 and gradual return to work was permitted. however, the moment wave of COVID-19 in China was of refer due to imported cases. The public use of font masks might be one of the most effective strategies to reduce the infection of COVID-19 and was recommended by the National Health Commission of China in its guideline issued on 18the of March ( National Health Commission of the People ‘s Republic of China, March 18, 2020 ). subsequently, face masks have continued to be are normally used by the public in China since the render to work. The study protocol was approved by the Affiliated Hospital of North Sichuan Medical College Ethics Committee ( 2020ER084-1 ). This report was an on-line sketch, which was open to the public. As the identities of the participants were not ascertained, directly or through identifiers linked to the subjects, this sketch was considered in the category of exempt research. Although inform accept was not required, a brief presentation was provided to prospective research participants which indicated that participation is voluntary and anonymous, how long the questionnaire will take to complete, a brief description of what participants will be doing, whom to contact with any questions, what feedback they will receive, and the data will be used as part of a research discipline. The data were analysed using SPSS™ for Windows, Version 16.0 ( SPSS, Inc., Chicago, IL, USA ). All data were categoric variables and shown as frequencies with percentages. For the convenience of analyses, each right and incorrect response in mask-wearing behaviours were scored 1 and 0, respectively. For items 1, 2, 3, 4-1, 5-1, and 9, responses of “ never ” and “ occasionally ” were defined as faulty, while “ often ” and “ every time ” were defined as correct. The opposite definitions were applied for items 4, 5, 6, 7, 11, and 13. Items 13-1, 14, and 15 were not calculated, leading to a total of 13 points ( see for details ). The final examination score was labelled as “ good ” or “ hapless ”, according to whether a score of 10 or more points ( out of 13 points ) was achieved, which was used as a dependent variable for the binary logistic arrested development analysis. Chi-squared tests were used to compare the “ good ” rates between groups and variables with p < 0.05 were included in the binary logistic regression psychoanalysis ( Forward : LR ). ultimately, variables with phosphorus < 0.05 with their odds ratios ( ORs ) and 95 % confidential intervals ( CIs ) were presented. Wenjuanxing ( www.wjx.cn ), a widely used chopine for conducting surveys in China, was used to develop the electronic questionnaire. An on-line post horse with an access code or the web site radio link to the questionnaire was distributed via two ways : ( 1 ) posted on our WeChat ; and ( 2 ) distributed via WeChat groups, with an modal of one to two RMB each as compensation. Each person could merely participate once on each WeChat report to avoid recur submissions. The final interpretation of the questionnaire was titled “ Questionnaire on Face Masks Use for the Public ( Except Healthcare Workers ) ” and consisted of two parts : ( 1 ) socio-demographic characteristics, with 12 items, including sex, age, city/province, education level, work/living environment, any symptoms of coughing or sneezing in the past workweek, living with a COVID-19-confirmed individual ( second ) in the past week, when and what type of grimace masks were selected, whether they had been exposed to education on the use of face masks, and how they had acquired this cognition ; and ( 2 ) mask-wearing behaviours, with 16 items, including mask-wearing habits, methods for dissemble disposal, frequency of mask exchange, and mask recycle ( auxiliary Materials ). A 4-point Likert scale ( never, occasionally, frequently, every time ), adenine well as forced-choice, and multiple-choice answers were used in the questions of the moment part and were calculated for a total grade ranging from 12 to 60. The respondents were provided clamant feedback rated as “ Requires meaning improvement ” ( < 36 points ), “ good but needs improvement ” ( 36–41 points ), “ very beneficial ” ( 42–50 points ), or “ excellent ” ( 51–60 points ). Before beginning, the participants received a brief introduction to the survey. After each participant completed the sketch, clamant feedback was provided using a self-made mind function and the WHO television, which showed the decline room of choose, exhausting, and disposing of face masks ( WHO, 2020b ). The questionnaire was developed based on the guidelines issued by the National Health Commission of China ( National Health Commission of the People 's Republic of China, Feb.5, 2020 ; March 18, 2020 ), World Health Organization ( WHO, 2020b ), and others ( Feng et al., 2020 ). Five participants with varied department of education levels ( i, middle school to PhD ) and employment ( i.e., shop assistant, fiscal coach, nurse, university staff, and retired ) were invited to comment on the questionnaire. The questionnaire was modified based on their comments. Afterward, we recruited 10 participants in a fender sketch using convenience sampling to evaluate the feasibility of the questionnaire, duration to completion, and to obtain further comments on the creature 's utility program. A 5-point Likert scale ( from wholly disagree to fully agree ) was used to assess whether the questions were easily to answer and clearly stated, and whether the questionnaire was well laid out. ( Details are shown in ) An on-line cross-section survey was conducted from 6 April 2020 to 5 May 2020. WeChat was used for questionnaire dissemination because it is the most popular social media, with 1.15 billion active users in China ( Tencent, 2020 ). People who lived in China and silent Chinese were eligible for the study, while those who were health caution providers were excluded. As we did not have any hypothesis, the sample distribution size was not estimated. A public toilet sampling was adopted to obtain as many respondents as possible. Using a final mark of 10 or more points defined as “ effective ”, most ( 73.3 % ) of the participants demonstrated good conformity with front masquerade function. finally, binary logistic regression analysis identified seven factors, specifically associated with dear submission ; namely, gender, long time, residence, educational background, current work/living environment, presence of flu-like symptoms, and know with instructions regarding face mask use ( ). Males were less likely to exhibit higher conformity than females ( OR=0.77, 95 % CI = 0.70–0.85, p=0.000 ). Compared with the participants who were 14 years or less, those aged 15–34 and 35–65 years old showed lower complaisance, with ORs of 0.42 ( 95 % CI=0.29-0.62, p=0.000 ) and 0.59 ( 95 % CI=0.41-0.87, p=0.007 ), respectively. People from North and South China showed lower submission than those of people from Central China, with ORs of 0.81 ( 95 % CI=0.68–0.96, p=0.016 ) and 0.77 ( 95 % CI=0.62–0.95, p=0.015 ), respectively. Participants living in cities were more probable to report good complaisance with front dissemble manipulation than those living in the countryside ( OR=1.30, 95 % CI=1.17–1.46, p=0.000 ). Comparison of participants according to educational background showed a decreasing swerve in conformity with mask-wearing behaviours in those with middle educate or below education background compared with those in participants with high educate diploma, college, or alumnus degree ( ORs= 0.73 [ 95 % CI=0.61–0.89, p=0.000 ], 0.47 [ 95 % CI=0.39–0.57, p=0.000 ], and 0.37 [ 95 % CI=0.30–0.46 ], p=0.000, respectively ). Participants who were sick and seeking diagnosis or treatments demonstrated 2.08-fold ( 95 % CI=1.26–3.41, p=0.004 ) higher complaisance than those of participants in outdoor receptive spaces, whereas lower complaisance were shown in those studying or taking depart in activities in crowd and those who were working in indoor offices, with ORs of 0.69 ( 95 % CI=0.53–0.92, p=0.010 ) and 0.67 ( 95 % CI=0.55–0.80, p=0.000 ), respectively. In summation, participants with coughs or sneezing symptoms reported lower complaisance than those without these symptoms ( OR=0.53, 95 % CI=0.42–0.66, p=0.000 ), while the participants who knew about face mask use instructions exhibited significantly higher complaisance with mask-wearing behaviours ( OR=4.13, 95 % CI=3.60–4.75, p=0.000 ). In terms of the types of face masks selected, disposable medical mask accounted for 93.8 %, with 26.2 % and 8.5 % of respondents besides reporting the function of N95 respirators and fabric face masks, respectively. Some participants reported wearing multiple masks simultaneously ( occasionally 26.5 %, frequently 2.1 %, always 1.5 % ). More than half of the respondents ( n=5,981, 58.8 % ) reported reusing disposable masks, with about two-third thirds ( n=3923, 65.6 % ) of whom hanging the used mask in a well-ventilated space, and other treatments could be seen in. More than one-third ( 37.6 % ) of the respondents did not replace mask when it had been used for more than 8 hours. social media platforms were the most park ways ( 76.4 % ) people had received instructions about grimace dissemble function. Concerning the evaluation of mask-wearing behaviours, as shown in, 41.8 % of the participants rarely cleaned their hands before putting on a mask. Regarding the correct way to put on a dissemble, closely all participants ( 96.5 % ) knew to make certain the mouth, nose, and chin were covered by the mask and 85.1 % checked that there were no gaps between font and dissemble. however, only 20.2 % and 8.0 % never touched or adjusted the masquerade, respectively, while using it, with more than half ( 55.3 %, 62.1 % ) of those who touched ( n=8108 ) or adjusted ( n=9356 ) their mask never or occasionally washed their hands subsequently. A few people indicated that they much or always hung their masks under their chins ( much 7.0 %, constantly 9.4 % ) or uncovered their mouths or noses for a breath ( frequently 2.9 %, always 1.3 % ) while using it. Most of the people ( 94 % ) correctly removed the use masks, but fewer correctly disposed of their masks, with 7.6 % of them discarding the masks into drivel bins without lids and 22.5 % discarding them into drivel bin within their compass careless of presence of a eyelid.

There were 10,290 people participating in the review, among which 27 were from abroad and 98 people reported not wearing face mask during the past week and were excluded. therefore, a entire of 10,165 participants were included in the analysis, with a masquerade wearing complaisance of 99 %. The mean old age of the participants was 30.1±12.0 years ( median 28, interquartile range 20–39 ), and their geographic distribution was categorised into seven major geographic areas in China ( see ). More details of the participants’demographic results are found in .

4. Discussion

The major findings of this analyze were that about all people wore masks in the context of COVID-19, and most participants demonstrated good conformity in terms of mask-wearing behaviours in general ; however, hand hygiene before and during mask use, the rationale for choice of disguise, reusing disposal face masks, and the administration of disposable masks required improvement. Furthermore, whether or not participants had received instructions on expression disguise use was the strongest predictor of good mask-wearing behaviours, regardless of their educational backgrounds. other factors associated with good submission included particular situations, location, and gender. The influence of age needs far investigation. Handwashing is one of the most dominate actions, with concerns owing to a false smell of security related to the tire of face masks. In our study, closely half of the participants rarely cleaned their hands before donning a mask, whereas more than two-thirds of them appropriately used proper hand cleaning when they doffed the mask. Of note, most participants touched or adjusted their masks while wearing them, more than half of whom did not wash their hands subsequently. therefore, it seemed that the concerns may be genuine. however, a taxonomic reappraisal reported that hand hygiene was ill practiced globally even after contact with body waste, with preponderance varying between 5 % and 25 % in low- and middle-income countries and 48 % to 72 % in high-income countries ( Freeman et al., 2014 ). With increase risk perceptions, such as during the height of the hard acute accent respiratory syndrome epidemic from March to April 2003 in Hong Kong, 65.3 % washed their hands after relevant contact ( Leung et al., 2003 ). An obvious increase in hand hygiene was besides observed during the 2009 influenza A ( H1N1 ) pandemic in Thailand due to the extensive home hand hygiene educational campaigns ( Simmerman et al., 2011 ). therefore, it is authoritative to increase the populace ‘s hazard percept and to strengthen efforts to disseminate relevant steering. Our learn revealed that participants were aware of the need for hand hygiene after removing a mask ; however, such measures need to be emphasized before wearing masks and for the prison term during which individuals are wearing masks. It is recommended to have a sanitiser or some disinfectant wipes on hand in regulate to address the trouble of patronize hand hygiene. fair choice of different types of face masks is another trouble for the public. As shown in, more than one-quarter of participants wore N95 respirators, which are not recommended for the general population, and 30.1 % of the participants described wearing multiple masks simultaneously. The public may not know that the dependability of N95 respirators to prevent the spread of such airborne infectious diseases depends on their paroxysm to the wearer and that fit test is required before the habit of N95 respirators to ensure the best match possible ( CDC, 2020 ), and N95 respirators are not more effective in preventing laboratory-confirmed influenza than disposable checkup masks ( Long et al., 2020 ). furthermore, more adverse effects and discomfort were associated with N95 respirators and multiple masks ( Macintyre et al., 2013 ; Kao et al., 2004 ) .Therefore, the public should be aware of the refer issues to avoid a blind choice of mask types. It was plausible for the populace to use fabric masks as alternatives when the aesculapian masks were in dearth, which was besides recommended by the Center for Disease Control and Prevention ( CDC ) for the general population in public settings since April ( CDC, 2020 ). It is noted that before disposable masks were available, fabric masks were widely used by health providers during operations ( Leung et al., 2020 ). Reusing face masks is an inevitable write out when facing a mask handiness crisis. Under the austere situation of mask dearth, the general population were recommended to reuse disposable masks if they are clean, but should be replaced with new masks if cheating or used for more than 8 hours ( National Health Commission of the People ‘s Republic of China, March 18, 2020 ). In our survey, more than half of the respondents reused disposable masks, but more than one third of them did not replace with a raw one even it has been used for more than 8 hours. Most people hung the practice mask in well-ventilated places for the following time. other ways, such as using alcohol, steam, seethe, and inserting a gauze or wearing a fabric disguise inside the disposable masquerade, were besides adopted by some members of the public. Of note, no evidence supports the disinfection of disposable masks. As fabric mask can be easily washed with soap and water or laundry detergent to prevent contamination ( Desai et al., 2020 ), it should be recommended as the favored option for the general population in the face of mask deficit ( CDC, 2020 ). Another concern is the disposal of used masks. WHO required that people discard used masks immediately in a close bin ( WHO, 2020b ). Our survey revealed that 7.6 % of the respondents discarded their masks into a drivel bin without a eyelid and 22.5 % threw them into whatever drivel bins were available careless of whether they had lids. This may be because the chinese National Health Commissiononly emphasized that confirmed and suspect cases must dispose of use masks as medical waste, while healthy people should follow the disposal rules for family waste ( National Health Commission of the People ‘s Republic of China, Jan. 31, 2020 ). many communities and public areas were given rubbish bins for the secondhand masks, and more than one-half of the respondents reported dispose of the masks this way. however, discarded confront masks were reportedly found in many places, such as buses, trail stations, streets, etc ( Wang et al., 2020 ). As we considered that respondents were less likely to report discarding masks anywhere, we did not ask them about this demeanor. therefore, specific measures to address disguise disposal should be actively promoted and more rubbish bins for used masks with attractive logo should be placed in populace areas. Among the factors influencing mask-wearing behaviours, we found that people who exposed to instructions regarding how to use font masks demonstrated approximately quadruple better submission than those who did not. Intriguingly, the higher the educational background, the worse the conformity. frankincense, effective mask-wearing habits appeared to depend on how much education about mask use had been received preferably than on education levels. This detect besides supported the hypothesis proposed by Greenhalgh and colleagues ( 2020 ) that, in the context of COVID-19, people can be taught to use masks properly and will do thus systematically without abandoning other important anti-contagion measures. This tell, combined with our results regarding the approaches that the participants took to obtaining related information, suggests that institutions and scholars should spare no efforts to disseminate guidance via assorted methods, among which sociable media may most benefit the populace. We besides observed that different situations influenced people ‘s behaviours. People who were pale and who went to hospitals or clinics displayed much better complaisance. This may be attributed to concerns about the gamey risks of COVID-19 transmission in these settings and the association between higher risk sensing with good submission with facemask practice ( MacIntyre et aluminum, 2015 ; Rubin et al., 2009 ). similarly, people living in the city showed better complaisance than those among people in the countryside. furthermore, people from North and South China showed lower submission than those in people from Central China, where people may perceive higher risks of infection rate. however, when people exhibited flu-like symptoms, such as cough and sneeze, they may feel discomfort and touch their facemasks frequently, leading to worsening complaisance. In addition, people working in relatively enclose or multiple settings and living in self-quarantine or with people in self-quarantine did not show higher conformity than those in people in outdoor open space. Participants showed lower submission when studying or participating in events in crowd. therefore, more department of education about frequent hand hygiene and facemask substitute when showing flu-like symptoms, equally well as clear warnings and about the potential risks in unlike situations should be conveyed to the public. Gender is another factor affecting mask-wearing behaviours. coherent with previous studies investigating changes in public behaviours during influenza outbreaks ( Rubin et al., 2009 ; Park et al., 2010 ), female participants in our survey exhibited better conformity with face mask use than the male participants. however, the effect of historic period exhibited different patterns, with those aged 14 or below years old demonstrating the best conformity and early groups displaying increasing trends of better submission with increasing old age. This may be because 87.2 % of the youngest group in our analyze was 12–14 years of age and had returned to school when we collected the data and were asked to wear masks under nonindulgent supervision by their teachers. This besides suggests that hard-and-fast management and department of education may improve public behavior. however, the sample sizes of the youngest ( n=407 ) and oldest groups ( n=34 ) were relatively smaller than those in the age group of 15–34 ( n=6330 ) and 35–65 ( n=3394 ), therefore the effect of age needs farther probe .

4.1. Strengths and limitations

To our cognition, this is the first survey to investigate mask-wearing behaviours by the general public in the context of pandemics. The results provide evidence on how the public used front masks and what factors influenced their behaviours, which are of importance to China and other countries. Although a former survey explored a relate exit, it included lone primary school students from Wuhan ( Chen et al., 2020 ). Our study included divers participants, who were not health manage providers. We disseminated the best tell regarding mask-wearing and educated participants while performing the surveil, which may benefit the public.

however, this discipline has some limitations. First, this study used social media as the main method acting to disseminate the sketch. Participants without access to the internet were probably not included. Second, the distribution of the cogitation participants was imbalanced across regions ( n=341–3447 ) ; consequently, the subgroups of variables might not be congressman of the population. Third, this study could not determine how many participants reviewed the on-line poster or sketch but decided not to complete the view ; frankincense, the presence of non-response bias could not be assessed. finally, as the behaviours were self-reported, reporting bias was possible. overall, generalization of the results should be regarded with caution .

4.2. Conclusions and implications

due to the highly contagious characteristics of COVID-19 and the continued hard situation globally, mask-wearing has become a character of our ordinary lives. Understanding how the populace use face masks and what factors are associated with good conformity will be utilitarian in identifying ways to promote right mask-wearing behaviours. Our results revealed that, in the context of the COVID-19 pandemic in China, about all people wore face mask and most of them used it by rights ; however, there remain some aspects that require further forwarding. Hand hygiene before and during mask-wearing should be particularly emphasized in future testify dispersion or behaviour-change interventions ; furthermore, choosing appropriate types of expression masks, reusing administration confront masks, and dispose of use face masks besides can not be neglected. Taking measures to inform as many people as possible plays a critical role in promoting public mask-wearing behaviours. When disseminating evidence, consequently, unlike influencing factors should be considered to cover different populations. A assortment of approaches should be adopted to deliver government warnings and alerts explicitly and ubiquitously. social media is the most potent border on to reach audiences and facilitate data solicitation ; however, further studies on how social media could promote behavior change in populace are warranted .

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