Risk perception, sociodemographic factors, and knowledge of COVID-19 associated with mask use outside the home in Indonesia during the mandatory policy

Background

The COVID-19 pandemic, which began in late 2019, was marked by an incidence of symptoms such as severe tightness in the chest, similar to those observed in Middle East Respiratory Syndrome (MERS). The initial laboratory examinations of the coronavirus occurred in Wuhan City, China, leading to its identification as SARS-CoV-2. The World Health Organization (WHO) reported the outbreak and officially labeled the disease as COVID-19. By March 2020, due to its rapid global spread (World Health Organization (WHO, 2020), the WHO declared COVID-19 a pandemic (WHO, 2020). By March 2020, due to its rapid global spread the WHO declared COVID-19 a pandemic (World Health Organization (WHO), 2020).

As of September 17, 2020, the pandemic had affected 213 countries, with approximately 30,340,825 reported cases worldwide. Out of these, 22,031,183 individuals recovered, while about 950,000 succumbed to the virus, resulting in a relative mortality rate of 0.3%. By July 21, 2023, global cases had surged to 768,237,788, with Europe, the Western Pacific, and the Americas reporting the highest numbers. Total deaths reached around 6.9 million, with a relative mortality rate of 1.1%. In Indonesia, there were 6,812,127 cases and 161,879 deaths, reflecting a higher mortality rate of 2.3% (COVID-19 Statistic Team, 2024).

COVID-19 is primarily transmitted through respiratory droplets, with an incubation period of approximately 14 days. The Indonesian Ministry of Health has implemented guidelines emphasizing preventive measures such as mask-wearing, regular hand hygiene with soap, maintaining physical distance, and avoiding crowded places (The Ministry of Health of The Republic of Indonesia, 2020; World Health Organization (WHO), 2021). Recommendations also included minimizing contact with the face, mouth, nose, or eyes in order to prevent sputum splashes and disinfecting surfaces potentially exposed to respiratory droplets (World Health Organization (WHO), 2021).

Risk perception significantly influences mask usage in combating COVID-19 (World Health Organization (WHO), 2019). The health belief model suggests that individual perceptions of risk, along with sociodemographic factors and knowledge, play crucial roles in determining mask adherence (Roth et al., 2024; Li et al., 2022; White et al., 2022).

Numerous studies have established the effectiveness of mask-wearing in preventing COVID-19 transmission (Wang et al., 2021). For instance, compliance was notably high in East Asian countries like Japan and Korea, with Hong Kong reporting a compliance rate of 96.6% (Fischer et al., 2021). This high adherence was linked to a marked reduction in COVID-19 cases compared to regions with lower compliance (Cheng et al., 2020). Moreover, a study in Singapore found the overall levels of compliance regarding mask use (84.5%), in which factors such as male gender and crowded settings influenced this compliance (Xiang Ong et al., 2023). In contrast, Europe countries displayed more varied compliance rates, often not correlating with health outcomes (Spira, 2022). For example, while in Germany’s mandatory mask policy improved compliance (Betsch et al., 2020), other countries, such as France and Spain, exhibit significant variation. In Eastern Europe, mask use is more evenly distributed with higher compliance not necessarily correlating with better health outcomes. Studies in Poland highlighted how cultural and social have shown that despite mandatory mask use, compliance levels remain influenced by cultural and social factors affect adherence, despite regulations (Matulewska et al., 2022). In the United States, compliance rates varied widely, with some regions experiencing low adherence alongside higher transmission rates.

During the COVID-19 pandemic, Indonesia enforced a mandatory mask policy (The Ministry of Health of The Republic of Indonesia, 2020), which led to increased usage (Kar et al., 2023). However, following the WHO declaration of COVID-19 as endemic in early May 2023, and also Indonesia, the strickness of this policy was relaxed, yet, transmission persisted. Given this context, this study aims to investigate the association between risk perception, sociodemographic factors, and knowledge of COVID-19 with mask-wearing behavior outside the home in Indonesia. By understanding this dynamic, it hopes to contribute valuable insight into public health strategies for future disease management.

Methods

The study was observational and employed a cross-sectional design. Data collection was performed online, using Google Forms. The questionnaire on Google Forms was distributed to the public via WhatsApp (WA) to the following groups: 1) government offices; 2) private offices; 3) companies; 4) self-employed; 5) professionals; 6) neighborhood association (RT); 7) university students; 8) other students; and 9) informal groups (Roosihermiatie, 2024). The questionnaire aimed to gather data associated with mask use during the COVID-19 pandemic.

The sample size was calculated based on the estimated population proportion with relative precision of confidence interval (α) = 0.05; proportion (P) = ranges 0.25 – 0.50, relative precision (ε) = 0.1 was

The sample size was 1153 people (Lwanga et al., 1991).

Data collection took place during the period from November 2020 to February 2021. Before proceeding to the questionnaire, respondents were firstly written informed consent asked to indicate whether they were willing to participate in the study as follow ‘this online study aims to determine factors related to preventive behavior against Covid-19 in the society in an effort to reduce Covid-19 in the society. I understand about the online study in the society. I agree to participate in the study voluntarily without any coercion. If I want, I can reject to participate without any sanctions. Those who consented and agreed, then selected the agree button, and proceeded to the questionnaires; while anyone who did not agree to participate in the study, then selected the reject button and thereby left the study website. A total of 1317 people responded to the questionnaire but 22 people declined to participate in the study and 142 people gave incomplete answers; therefore, 164 (12.4%) of initial respondents were not included in the study. Finally, 1153 participants were selected.

The study used a health belief model, which consists of risk perception, and the modifying factors of sociodemographic factors and knowledge of COVID-19 to influence mask use. The dependent variable was always mask-wearing outside the home. The responses of never, seldom, and sometimes relating to the use of a mask outside the home were all categorized as a negative response to consistent mask-wearing outside the home. The independent variables were risk perception, which consisted of perceptions about COVID-19, knowing someone who has COVID-19, ever having PCR-tested positive for COVID-19, or having had close contact with someone infected with COVID-19 during the past two weeks; the sociodemographic factors consisted of location, age, gender, education, occupation, family income, family members, and membership of a social health scheme; and knowledge of COVID-19 consisted of knowledge regarding its cause, transmission, prevention strategies such as regularly changing cloth masks, activities after going out, symptoms and severe symptoms, screening, confirmation diagnostics, management of mild and severe COVID-19, diseases causing severe COVID-19, and activities enhancing immunity.

Firstly, the questionnaires were pre-tested to varied occupation persons. Then, the questionnaires were critically improved based on the pre-test results.

Data were analyzed both bivariately and multivariately, using logistic regression analysis. The cOR of factors associated with consistent mask-wearing outside the home ≤ 0.2 proceeded to multivariate analysis. The multivariate analysis was performed using logistic regression analysis, backward likelihood ratio (LR), whereby interacting variables are deleted. The analyses were performed using SPSS software version 21 Code 4-1EA96. The level of significance was p < 0.05.

Results

Regarding the use of masks, 2 (0.2%) respondents reported that they never use them, 37 (3.2%) seldom use them, 257 (22.3%) sometimes use masks, and 857 (74.3%) always use them. Meanwhile, respondents reported the use of masks outside the home as follows: 3 (0.3%) never use, 24 (2.1%) seldom use, 88 (7.6%) sometimes use, and 1038 (90.0%) always use.

Tabel 1 shows that risk perceptions about COVID-19 disease were found to be positively correlated with consistent mask-wearing outside the home; in contrast of believing one’s neighbor to be infected with COVID-19. Meanwhile, the risk perceptions of having ever PCR-tested positive for COVID-19 and having had close contact with a person infected with COVID-19 during the past two weeks were found not to be significantly associated with consistent mask-wearing outside the home.

Table 2 presents the bivariate analysis, which illustrates the association of each of the sociodemographic factors – age, gender, education, occupation, family income, family member and insurance ownership – with consistent mask-wearing outside. The correlation between family member and consistent mask-wearing outside was found not to be significant (p = 0.611).

Table 3 shows the association of COVID-19 knowledge about causation, transmission, prevention and time to change cloth mask, activities after going out, symptoms, management, diseases causing severe COVID-19, activities enhancing immunity and consistent use of mask outside the home, respectively. Just the association of COVID-19 knowledge about prevention and consistent use of mask outside the home is not significant at p-value < 0.2, respectively.

Table 4 shows that age of 25 to 44 years aOR: 0.486 (95% CI: 0.254 – 0.932), and perception of COVID-19 as a viral disease that could cause death are protective factors for mask use outside the home aOR: 2.238 (95% CI: 1.215 – 4.746). Whereas, knowledge of confirmation of COVID-19 infection through PCR test aOR: 2.238 (95% CI: 1.215 – 4.120), severe symptom of COVID-19 aOR: 1.981 (95% CI: 1.175 – 3.342), COVID-19 transmission aOR: 1.974 (95% CI: 1.040 – 3.746), and changing cloth mask every 4-6 hours aOR: 1.686 (95% CI: 1.118 – 2.576) are significantly associated with the consistent use of masks outside. Activities after going out are not significantly associated with mask use outside.

Discussions

This online study investigated mask use during the COVID-19 pandemic in the Indonesia’s mask mandatory policy. In this study, consistent mask-wearing outside the home was higher (90.0%), with the types of masks were mostly surgical masks (60%), followed by cloth masks (36.4%), N-19 masks (3.0%), and others. Meanwhile, it was reportedly that during the COVID-19 pandemic mask-wearing in the West Pacific was 83%, followed by 82% in Southeast Asia, 73% in Eastern Mediterranean, 62% in Africa, 33% in Europe, and 32% in America (Li et al., 2022). Indonesia’s population initially showed less familiarity with mask-wearing compared to Japan, where mask use has been deeply ingrained in cultural practices (Ryall, 2020).

Our study revealed a relationship between risk perception of COVID-19 and consistent use of masks outside the home. In line with previous studies, the perceptions of COVID-19 as a viral disease that could cause death (aOR: 2.502) are correlated with the use of masks outside the home (Lo Moro et al., 2023; Shahnazi et al., 2020). However, contrary to other findings the multivariate analysis showed no association with feelings of depression, fear or anxiety when neighbors had contracted COVID-19 (Yang et al., 2024). Additionally, personal experiences, such as having previous contracted COVID-19 or being in close contact with infected COVID-19 individuals during the two weeks prior to the study were not associated with the consistent use of masks outside the home (White et al., 2022). The results suggest the perceived risk of death from COVID-19 can cause death play significant role in shaping mask-wearing behavior during public health crisis.

The health belief model posits that risk perception, sociodemographic factors and knowledge influence behaviors are key determinants of health behavior. In line with this model, the feelings of anxiety and fear, along with knowledge of disease significantly influence the risk perception (Sinicrope et al., 2021). Additionally, the anxiety and fear can shape social awareness (Xia et al., 2023), further impacting the adoption of preventive measures like mask-wearing. However, this study revealed that among the sociodemographic factors, only individuals of productive age (25 to 44 years) is negatively associated with consistent mask-wearing outside the home (UNICEF, 2020). Interestingly, family income was not associated with consistent mask-wearing outside the home, suggesting that other factors may play a more significant role in influencing this behavior.

Previous studies identified several sociodemographic factors such as older individuals, women, and public sector workers that were associated with adhere to mask use due to heightened awareness of COVID-19. Additionally, in urban areas, having more family members, and health insurance was linked to increased awareness of COVID-19 and subsequent mask use (Chu et al., 2020). In contrast, this study found that younger and older age groups, women, students or private employees, and those living in outer Surabaya as well as ownership of social health scheme failed to be associated with consistent mask-wearing outside the home in the multivariate analysis. Findings from the United States of America align with our results, indicating younger individuals and those from lower socioeconomics were not associated with mask use (Willis et al., 2021). However, older individuals in the United States demonstrated a higher likelihood of mask-wearing, likely due to their greater awareness of personal health in relation to comorbid conditions (Liu & Arledge, 2022). In this study, individuals of productive age were negatively associated with consistent mask-wearing outside the homes, possibly reflecting a shift for those who were not accustomed to wearing mask. The lack of association with other sociodemographic factors may be attributed to the the mandatory mask policy which required Indonesian citizen to wear mask, especially when in public. Moreover, the Indonesian government distributed free masks down to neighborhood levels, further supporting compliance.

This study identified specific knowledge areas related to COVID-19 that positively influenced consistent mask-wearing, including proper mask-changing intervals, severe symptoms, transmission, and confirmed diagnosis of COVID-19. This aligns with other findings indicating that general risk perception is positively associated with mask use (Duong et al., 2021; Lo Moro et al., 2023). Furthermore, the high prevalence of perceived effectiveness of mask use in public settings, as indicated by a global study (Li et al., 2022), support the potential influence of Indonesia’s mask mandate (Kar et al., 2023; The Ministry of Health of the Republic of Indonesia, 2020; Wismans et al., 2022). These insight underscore the importance of risk perception and knowledge in promoting effective public health behaviors.

While sociodemographic factors are challenging to modify, our study highlights the importance of risk perception and knowledge in promoting mask-wearing behavior. Our study revealed a relationship between risk perception of COVID-19 and consistent use of masks outside the home. In line with previous studies, the perceptions of COVID-19 as a viral disease that could cause death (aOR: 2.502) are correlated with the use of masks outside the home (Lo Moro et al., 2023; Shahnazi et al., 2020). However, contrary to other findings the multivariate analysis showed no association with feelings of depression, fear or anxiety when neighbors had contracted COVID-19 (Yang et al., 2024). Additionally, personal experiences, such as having previous contracted COVID-19 or being in close contact with infected COVID-19 individuals during the two weeks prior to the study were not associated with the consistent use of masks outside the home (White et al., 2022). The results suggest the perceived risk of death from COVID-19 can cause death play significant role in shaping mask-wearing behavior during public health crisis.

While sociodemographic factors are challenging to modify, our study highlights the importance of risk perception and knowledge in promoting mask-wearing behavior. Despite high initial vaccination rates in Indonesia (86.88% for the first dose and for 74.55% for the second dose), booster uptake has significantly declined (38.11% for the first booster and 1.92% for the second booster) as of July 31, 2023, highlighting a critical gap that must be addressed. Although COVID-19 vaccination provides immunity and reduces disease severity (Havard Medical School, 2024), risk perception and knowledge about the virus remains crucial for motivating mask use. Our findings underscore the need for targeted interventions that address risk perception and knowledge gaps, encouraging consistent mask-wearing, especially in light of declining vaccination rates (Wismans et al., 2022). Additionally, mask use can help prevent other respiratory infections (Liang et al., 2020; Wismans et al., 2022). Integrating these insights into ongoing public health strategies will be essential for improving health outcomes.

Conclusions

In conclusion, this study demonstrates that the risk perception of COVID-19 as a viral disease that can cause death was positively associated with consistent mask-wearing outside the home. While, specific sociodemographic factor, age of 25 to 44 years was found to be negatively influence mask-wearing behavior. Possessing knowledge about proper mask-changing intervals, severe symptoms, transmission, and the confirmed diagnosis of COVID-19 by PCR was positively associated with consistent mask-wearing. These findings underscore the importance of targeted public health interventions that address risk perception and enhance knowledge to promote mask use as effective COVID-19 prevention measures. Future research could explore additional factors influencing mask use and the long-term impact of these preventive measures on public health.

Ethics and consent

Ethical clearance approval for the study was granted by the Ethical Committee of the National Institute of Health Research and Development, The Ministry of Health of the Republic of Indonesia, No. LB.02.01/2/KE.415/2020 dated 5^th November 2020. It stated that the Ethics Committee, National Institute of Health Research and Development, The Ministry of Health of the Republic of Indonesia, in accordance with the Helsinki Declaration has conducted a thorough review of research protocol entitled Factors related to preventive behaviors of Covid-19 in society, Indonesia which involve human participant (s). As the principal investigator, Betty Roosihermiatie, has hereby declared the protocol is approved for implementation. This letter is valid 05 November 2020 to 04 November 2021. Should there be any modification (amandement) and/or extension of the study, the Principal Investigator is required to resubmit the latest version of protocol for approval.