General public’s knowledge and practices on face mask use during the COVID-19 pandemic: a cross-sectional exploratory survey from Dharan, Nepal

Introduction

The World Health Organization (WHO) received information about a pneumonia of unknown cause from Chinese authorities in Wuhan, China on December 31, 2019. This was soon shown to be caused by a coronavirus temporarily named 2019-nCoV and later called Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2).¹ Coronaviruses (CoV) are a large family of viruses causing illness ranging from the common cold to more severe diseases. A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans.² Due to the severity and spread, Coronavirus disease (COVID-19) was declared a global pandemic by the WHO on 11 March 2020. As per the WHO press release on 27 June 2020 at 8:18 am, globally there have been 9653048 confirmed cases of COVID-19 and 491128 deaths.³ The first case in Nepal was diagnosed and reported on 25^th January 2020.⁴ As of 6^th July, 2020, the total infected, active cases, and death toll due to COVID 19 in Nepal was 15784, 6547 and 34 respectively.⁵ The government of Nepal has increased the provision of isolation beds in the country, locked down the whole country, and sealed international borders including the open border with India.^5,6

Measures to prevent and control coronavirus disease-19 (COVID-19) include regular handwashing, physical distancing, and covering the mouth and nose with a face mask, thereby reducing spread of droplets. It is advised to wear masks in public during this pandemic in order to reduce the risk of infection transmission.⁷ The disease is highly contagious and can be transmitted by respiratory droplets¹ which can be released during activities like speaking, coughing, and sneezing.⁸

Covering the face is one of the major measures recommended for prevention. It prevents the spread of droplets and helps in maintaining respiratory hygiene. Several guidelines suggest that the use of face masks reduces infection transmission. A study from Bangladesh suggested that about 72% of people strongly believed that covering the nose and mouth when coughing and sneezing prevents COVID-19 transmission.⁹

Masks are considered as one of the important protective measures for all individuals. Masks can be made of different materials and are of various designs. These different types of masks have different filtering capacities.¹⁰ There are several types of masks, including surgical masks, cotton face masks, N-95 face masks, cloth masks and plastic lined masks. Among these, the most effective mask has been the N-95 face mask and it is recommended for use while conducting clinical procedures and for delivering clinical care for COVID-19 patients.¹¹ There are no studies published from Nepal, hence, the study was planned to assess the knowledge and practice of the Nepalese public on face mask use during the lockdown period of the COVID-19 pandemic.

Methods:

Study design: A cross sectional survey assessing the general public’s knowledge and practice regarding face mask use.

Study duration: Data collection was carried out during 15^th May to 20^th June 2020, when the country was under lockdown due to COVID-19.

Study site: The study was conducted in Dharan, a city located in the eastern part of Nepal with a population of approximately 150,000, located close to the border with India. This city was selected since it has a mixed population in terms of age, gender, ethnicity, and educational qualifications etc., who would be available at the time of lockdown as the city hosts many healthcare and educational centers.

Sample selection: Any individual willing to participate in the study as per the inclusion and exclusion criteria were enrolled. A mixed population with multiple knowledge levels, and from multiple professions covering both genders were enrolled.

Sample size calculation: The sample size was calculated using Raosoft sample size calculator using the formula below:¹⁵

Sample size = Z²*(p)* (1-p)/c²

where, c = margin of error, P = Prevalence of the characteristic

Thus, the sample size (n) at 95% confidence interval and 5% margin of error

Calculated sample size was n = 1.96² x 0.564 x 0.463/ (0.05)2 = 377.86 ∼ 378

The prevalence (p) value was taken from study conducted by Kumar J et al. in Pakistan.¹²

The calculated sample size was 378 and a total of 380 responses were collected.

Sampling Technique: Since Dharan has a mixed population it was difficult to identify a definite population at a definite locality. Ten areas spread uniformly through the city were identified and pharmacists having pharmacies in those localities were contacted to serve as data collection centers. The community pharmacists were trained by the principal investigator (KA) on aspects such as contents of the questionnaire, obtaining participants’ consent and responses from the public while maintaining social distancing, stratification of the sample, and entering the responses.

Inclusion and exclusion criteria: Individuals of both gender who were over 15 years of age were considered eligible for the study. Any individual visiting the pharmacies with respiratory symptoms or who were unwilling to respond to the survey were excluded.

Stratification of study sample: The stratification of the total sample of 378 was based on the National demographic data of Nepal- 2019.¹³ The gender distribution was stratified as 0.96 males per one female, age group 15-40 yrs. 50% and above 40 yrs. 50%; literate (56%) versus illiterate (44%): urban 20.2% rural: 79.8% However, due to ongoing lockdown, strict stratification could not be maintained during the study.

Study questionnaire: The study questionnaire was designed by the researchers based on their understanding and reference to the WHO guidelines on face mask use published during the COVID-19 pandemic.¹⁴ The questionnaire had two parts Part I: Demography, Part II: General public knowledge and practice on face mask use and related aspects.

Results

381 individuals participated in the study. Table 1 shows their demographic characteristics. The majority of respondents were below 50 years of age. There were more males [211 (55.4%)] than females and the highest percentage overall were housewives and students [127 (33.3%)]. Most respondents [200 (52.5%)] had studied till high school (standards VIII to XII). Majority of respondents were from the hill tribes [129 (33.9%)]. The hill tribes included Rai, Limbu, Kirati, Gurung, Magar, Tamang, among others. The Hindu castes (other than Brahmin and Chettri) and Christian were included in ‘Others’.

The questionnaire used is shown in Additional file 1. The total score was obtained by adding the scores of statements/questions 1, 2, 3, 4 (with five subsections), 5 and 7 (with nine sub questions). Question 6 dealt with measures other than lockdown which can reduce the spread of the pandemic. Seventy-two respondents (18.9%) mentioned lockdown, 305 (80.1%) mentioned handwashing, 135 (35.5%) mentioned sanitization of objects and surroundings, 25 (6.6%) mentioned avoiding handshake as a form of greeting, 28 (7.3%) mentioned covering of face before sneezing, while avoiding crowds, and following social distancing measures were mentioned by 80 (21.0%) and 218 (57.2%) respondents.

The distribution of the individual and the total scores were checked for normality using one-sample Kolmogorov-Smirnov test (p < 0.05). The distribution was not normal and hence median and interquartile range were used as measures of central tendency and variation. The median total score was 16 and the interquartile range was 3. The maximum possible score was 18.

Figure 1 shows the general public’s ability to mention the WHO recommended steps for using a face mask correctly. All the individual steps had over 75% correct response with Step V having 85.04% responses.

Figure 1. General public’s knowledge on WHO recommended face mask use steps.

Step I: Before putting on a mask, clean hands with alcohol-based hand rub or soap and water; Step II: Cover mouth and nose with mask and make sure there are no gaps between your face and the mask; Step III: Avoid touching the mask while using it; if you do, clean your hands with alcohol-based hand rub or soap and water; Step IV: Replace the mask with a new one as soon as it is damp and do not re-use single-use masks; Step V: To remove the mask: remove it from behind (do not touch the front of mask); discard immediately in a closed bin; clean hands with alcohol-based hand rub or soap and water, adopted from Reference 14.

Table 2 shows the distribution of median scores according to demographic characteristics of the respondents. The scores were significantly higher among younger respondents, and more educated respondents. On doing pair-wise comparisons the scores were significantly higher among respondents between 10 to 20 years of age compared to those between 50 to 60 years (p = 0.042) and those between 60-70 years (p = 0.012). Regarding education the scores were significantly lower among illiterate respondents compared to those who had completed secondary school (p = 0.022), and among illiterate compared to respondents with professional education (p = 0.012). The median score of all individual statements was 1.

Table 3 mentions the number and percentage of respondents who answered each question yes or correctly. The percentage was over 90% for most questions. The number of respondents who could mention all five steps of using a face mask properly was 201 (52.8%). The proportion of respondents who mentioned all five steps correctly was higher among younger respondents (less than 50 years of age) (p = 0.001). The proportion was also higher among those with higher education levels (p = 0.005).

Discussion

COVID-19 pandemic is a major public health emergency. Lack of effective drug treatments and preventive vaccines has required adoption of different non-pharmacological measures to mitigate the problem to the maximum possible extent. Various strategies such as social distancing, lock downs, and use of facemasks are considered effective interventions by many health experts and policy makers. The wearing facemasks by the public was tried even during previous pandemics, including influenza, and SARS as a viable strategy to prevent virus transmission through the respiratory route.¹⁶ During the COVID-19 pandemic several countries have emphasized wearing face masks by the public and implemented multiple measures to compel people to wear masks,¹⁷ to such an extent that some countries are imposing fines for not wearing masks in public.¹⁸ In Nepal, the government recommends use of face masks by the public in line with the WHO guidelines on face mask use.¹⁹ Face masks reduce the spread of infection through nasal and oral routes and controls the spread of COVID-19 by reducing the amount of infected saliva and respiratory droplets released into the air from individuals with subclinical or mild COVID-19 symptoms.²⁰ SARS-CoV-2 is a large sized virus (approximately 120 nm in diameter)²¹ and can be filtered by face masks. Currently there are no studies in Nepal assessing the general public’s knowledge and use of face masks during the ongoing COVID-19 pandemic.

In the current research only one-fifth of the respondents have ever used facemask at the time when COVID-19 was already present in the country for about four months and the country was under lockdown during the time of conducting the research. In a similar study from Malaysia, nearly half of the public studied wore face masks²² and in Pakistan 91% of general public felt wearing facemask should be used as a preventive measure for COVID-19.²³ In contrast to their practice of wearing face mask, the respondents in the current study showed a very high knowledge as demonstrated by correct response to most questions by over 90% of study respondents. Thus, as shown in the Malaysian study,²² the present research also documents that knowledge scores are not associated with face mask use behaviors. Such a situation of high knowledge linked to poor facemask use was even observed in a study from Pakistan conducted among health professionals which showed a positive attitude among health professionals, but moderate-to-poor level of knowledge and practice regarding the use of face mask.²⁴

In the present research the respondents’ knowledge scores were significantly lower among the illiterate cohort compared to those who had completed secondary school and those with professional education. This can be attributed to the availability of digital technology,^{24, 25} electronic and print resources in spreading awareness to the educated people who are more likely to benefit from these resources. The telecommunication service providers in Nepal have also created awareness messages which are played while dialing any phone numbers in the country, which is a welcome effort, as most of the country now has access to mobile phones.²⁶ Thus, it is mandatory to explore initiatives such as radio programs,²⁷ street plays,²⁸ art²⁹ etc., as alternative options which could reach even illiterate and aged people.

In the present research, the knowledge scores were significantly higher among respondents between 10 to 20 years of age compared to those between 50 to 60 years and those between 60-70 years. Similar to the current study findings, the Malaysian study²² found that the wearing of face masks was associated with gender, age group, region, occupation, and income group. In general, younger people are more likely to be aware about the pandemic and its prevention strategy of using face masks. However, poor knowledge among elderly people is worrisome as the elderly are more likely to suffer from COVID-19 complications and associated mortality.³⁰ Thus, it is mandatory to create age specific awareness programs using media which the elderly are aware of and have access to.

In the current research, only just over half of the respondents (52.8%) could correctly mention all the five steps of using a face mask properly. Face masks do not provide protection if they fit improperly and there are gaps between the surface of the mask and face.³¹ Of the respondents answering all steps correctly, a higher proportion was among younger respondents aged less than 50 years and those with higher education levels. Interventions are needed to demonstrate correct use of face masks which can be conducted by distributing pamphlets and information on the correct steps to be followed. The WHO has videos demonstrating correct use of face mask which could be used to educate the public.¹⁹

While answering one of the questions on whether face mask can be made from a piece of cloth, more than half of the respondents disagreed, suggesting that public were not aware of home-made masks. Homemade face masks could be potentially beneficial, economic, and easily available at all times and can be even reused with adequate care and not be shared among others.³²

This study had a few limitations. Though the study found a high knowledge among respondents and identified the factors influencing the knowledge scores, the source of knowledge among respondents was not assessed. Assessing the knowledge source would have given the researchers an opportunity to recommend more specific interventions. This study also did not evaluate any specific reasons (including myths) for not using facemask by the public, and finally the study was conducted only in one city in Nepal and hence cannot be generalized to the entire nation. This study also lacks triangulation as the information was collected only by using a questionnaire. In Nepal, currently there are two layered and three-layered face masks and this research focused on face mask as a generic and not on any of the specific types.

Conclusions

The public in Dharan, Nepal possessed a high knowledge on facemask use during COVID-19. However, the practice of face mask use was low and influenced by education, literacy, and age. Specific interventions targeting elderly and illiterate people using methods other than electronic and printed sources may be beneficial.

List of Abbreviations

CoV: Coronaviruses; nCoV: Nobel Coronavirus; WHO: World Health Organization.

Declarations

Ethical Approval and consent to participate: The research proposal was approved by the Nepal health Research Council, the National health research authority that oversees conduct of human research in the country. (Approval number 2385 dated 12^th May 2020). The participants were informed about the purpose of the research and written consent from participant was obtained prior to enrolling them. In the case of participants under the age of 15, consent was taken from their parent or legal guardian. Anonymity was maintained throughout the research and no information related to individual respondents are available in the public domain.

Consent for publication: Written informed consent was obtained from all participants/the participants’ parent or legal guardian.

Data availability:

Authors’ information:

¹Department of Clinical Pharmacology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal. ²Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE. ³IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia. ⁴Department of Clinical Pharmacology and Therapeutics, KIST Medical College, Lalitpur.