Knowledge attitude and practices regarding mask usage during COVID-19 pandemic in general population of India: a qualitative study

INTRODUCTION

COVID-19 pandemic first appeared in Wuhan City, Hubei Province of China, in December 2019. With the constant rise in reported cases, the World Health Organization (WHO) declared this outbreak as a global pandemic on the 12 March 2020.¹ This disease which originated from bats and pangolins from Wuhan, China manifests as symptoms of fever, dry cough, and dyspnoea. Extra-pulmonary atypical symptoms like anosmia/hyposmia, dysgeusia, and diarrhoea can also be seen. Asymptomatic individuals can transmit the disease during incubation period.¹ The virus can survive on surfaces up to 5 days depending on the type of surfaces.^2,3

The Government of India confirmed India's first case of COVID-19 on 30 January 2020, in the state of Kerala. As of 25 October 2020, Ministry of Health and Family Welfare, Government of India has confirmed 7,864,811 COVID-19 cases and 118,534 deaths.⁴ Extreme prevention methods like closing schools and universities, complete lockdown, social distancing, hand sanitization, use of face masks, contact tracing, and quarantine facilities became the new normal. Bridging a gap of knowledge about the emerging pandemic disease can prevent chaos and fear among the public. Public awareness, attitude and practices have been studied during previous epidemics such as swine influenza and Middle East Respiratory Syndrome (MERS).^5,6

SARS-CoV-2 spreads primarily via respiratory droplets, ejected when speaking, coughing or sneezing. Face masks are recommended to control the COVID-19 pandemic transmission, and are made of different materials and designs which influence their filtering capability.^7,8

The knowledge, attitudes and practices toward COVID-19 impart an integral role to understand society’s readiness to accept and follow preventive guidelines from the health authorities. This baseline information helps to determine the type of intervention needed to change misconceptions about the virus. SARS outbreak taught us that knowledge and attitudes are coupled with levels of panic and emotions in society which could further complicate measures to contain the spread of the disease.^9,10

Hence, this study was conducted with a purpose to investigate the knowledge, attitude and practices among general population regarding the usage of face mask during COVID-19 pandemic to limit the spread of the coronavirus disease.

METHODS

Study area

Study design

A cross-sectional survey was conducted through Google forms. A survey is most appropriate method as it allows large population to be assessed with relative ease. Because it was not feasible to do a community – based national sampling survey during the COVID-19 pandemic period, hence the data was collected online after a call of participation and questionnaire was shared on social media.¹¹

Study period

The study period was from 17 November 2020 to 03 December 2020.

Study participants

We utilised several strategies to reach as many respondents as possible all over the country within the one-month data collection period. This included relying on professional and personal networks of the researchers, reaching out to community leaders and social media influencers to broadcast and share the survey. A standardised general description about the survey was given in the Whatsapp message/social media before the link of the questionnaire was provided. A total of 500 participants took part in the survey.

Study instrument

The survey instrument is an adaptation of the measures developed in a study on Chinese resident’s knowledge, attitudes and practices (KAP) towards COVID-19 in China.¹¹ The questionnaire consisted of four main themes: demographics, which surveyed participant’s sociodemographic information, including gender, age, state of residence, educational qualification and occupation; knowledge regarding mask usage during COVID-19 pandemic; attitudes towards mask usage during COVID-19 pandemic; and practices relevant to mask usage during COVID-19. The survey was offered in the English language.

To measure knowledge regarding the usage of mask during COVID–19, 7 questions were created. Participants were given response options to these questions. A correct response to a question was assigned 1 point, while an incorrect/blank response was assigned 0 point. The maximum total score ranged from 0–7, with a higher score indicating better knowledge about the usage of mask during COVID-19.

To measure attitudes towards mask usage during COVID-19, surveyed participants were asked whether they believe to wear mask necessarily in current situation of COVID-19 pandemic. They were also asked about their confidence to know the correct steps of wearing a face mask and what they think about cloth face mask effectiveness as compared to a regular surgical mask .To measure practices, participants were asked yes/no questions on whether they reuse the mask once wore; follow their local authorities advice on the use of masks; store the used surgical/cloth mask in a bag for later use if not sick. Participants were questioned for proper wearing, to which extent they need to cover their face with mask and how they remove their mask before eating?

Statistical analysis

The collected data were analysed using the statistical package for the social sciences (SPSS), version 20. Chi-square test, independent sample t-test and one-way analysis of variance (ANOVA) were utilised to determine the differences between groups for selected demographic variables. The statistical significance level was set at (p<0.05). Internal consistency of the knowledge measures was tested using a reliability test where the Cronbach alpha coefficient aided in determining the reliability of the variables. The results showed that the Cronbach alpha for knowledge (7 questions) was 0.761. The result added credence where according to Griethuijsen, the range of Cronbach alpha within 0.6 to 0.7 is considered adequate and reliable.¹² It is attested that the questions used to measure knowledge on COVID-19 are therefore acceptable.

RESULTS

Demographic characteristics

A total of 500 participants participated in the study. Out of the total participants, the average age was 32.1±8.2 years (range=20-60), 258 (51.6%) were women; 126 (25.2%) and 112 (22.4%) resided in Kerala and Himachal Pradesh respectively; 262 (52.4%) were graduates (Table 1).

Assessment of knowledge

A total of seven questions were used to measure knowledge on mask usage during COVID-19 pandemic.

Question’s each correct response was given a score of 1 and score of 0 if incorrect, thus making a maximum score of 7 for a subject. Accordingly, if the score was <3, individual had poor knowledge, 3-5: good knowledge and >5 had excellent knowledge. The average knowledge score for participants was 5. The overall correct answer rate of the knowledge questionnaire was 71.5% while the range of correct answers for all participants were between 21.4 to 100%. The mean knowledge score was higher among females (5.07%) as compared to males (4.93%) and the difference was statistically significant (Table 2). The mean knowledge was highest for lower age group as compared to highest age group (p<0.05) (Table 3).

The difference in mean score between males and females is statistically significant (p<0.05)

The differences in mean score between different educational levels and between different regions are statistically significant (p<0.05)

Most of the participants knew about the presence of valve in N95 masks and the purpose of metal strip in surgical mask is to fit on nose. They also knew that during home quarantine, while talking to someone and even at crowded places wearing mask is most important. Even so, there is noticeable confusion regarding which N95 mask (with or without valve) is more appropriate during COVID-19 pandemic (Table 4).

Assessment of attitude

Participants were asked three questions in assessment of attitudes. The first question asked whether or not they believe that it’s really necessary to wear mask in current situation of COVID-19 pandemic; second, whether cloth face mask is as effective as a regular surgical mask or not; and third, whether they are confident enough to know the correct steps of wearing a face mask.

For the first question, a majority of participants believed that it’s really necessary to wear mask in current situation of COVID-19 pandemic (97.6%). Even so, 2.4% were unsure of it (Figure 1).

For the second question, more than half of the participants thought that cloth face mask is not as effective as a regular surgical mask (58.1%) (Figure 2).

For third question, majority of participants were confident enough to know the correct steps of wearing a face mask (82.5%) and 16.3% participants were still confuse about it (Figure 3).

Assessment of practices

Practices towards mask usage during COVID-19 pandemic were measured using 5 questions enquiring on: reuse of the mask once wore; extent to cover your face with mask; follow local authorities’ advice on the use of masks; how they remove your mask before eating; storage of the used surgical /cloth mask in a bag for later use.

Majority of the participants cover their nose, mouth and chin with the face mask (75%), follow their local authority’s advice on the use of mask (74.7%) and completely remove the mask before eating (82.1%). Whereas more than half of the participants use the mask once wore (55.8%) and if not sick, didn’t store the used surgical/cloth mask in a bag for later use (52.9%).

DISCUSSION

COVID-19 is a relatively new virus that has had devastating effects within the short time since it was first detected.¹³ SARS-CoV-2 is the third coronavirus to have threatened global public health in the past 20 years, following severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012.¹⁴ To the best of our knowledge, this is the first study in India examining KAP regarding the usage of facemask during Covid-19 pandemic. Majority of participants (25.2%) were from Kerala State. Almost 97.6% reported that it was necessary to wear mask in current situation. The mean knowledge score was higher among females (5.07%) as compared to males (4.93%) and the difference was statistically significant. The mean knowledge was highest for lower age group as compared to highest age group (p<0.05). When they were asked if they know the correct steps for wearing a mask, almost 82.5% reported “yes” but while asking for coverage of mask on face only 75% were aware of wearing the mask correctly.

Given the similarity of SARS-CoV-2 (COVID-19) and SARS-CoV, initial political recommendations in China highlighted the use of masks and N95 respirators for protection against COVID-19. However, evidence-based guidelines remain scarce. By definition, N95 respirators are designed to reduce oral entry of small airborne particles with clear filtration requirements. The respirator must fit tightly to wearer’s face with limited seal leakage to be effective. Medical masks, also known as surgical masks, are used to protect the wearers from microorganism transmission, specifically during hand-to-face contact and large droplets and sprays. Both masks and N95 respirators are used to protect against airborne viral pathogens such as SARS-CoV and influenza virus.⁷

When someone is breathing, speaking, or coughing, only a small amount of what is coming out of their mouths is already in aerosol form.¹⁵ Nearly all of what is being emitted is droplets. Many of these droplets will then evaporate and turn into aerosolized particles that are 3 to 5- fold smaller.¹⁶ A previous review of published literature, including 67 randomized controlled trials and observational studies, indicated that surgical masks and N95 respirators were supportive measures offering the most consistent protection.¹⁷

CONCLUSION

The overall knowledge of our population was good. The knowledge was excellent for the age group of 20–30 and post-graduates. Due to limited access to internet and online health information resources, vulnerable populations of Indian society under the COVID-19 epidemic such as older adults and rural people at grass-root level are more likely to have poor knowledge, negative attitudes, and inappropriate preventive practices regarding mask usage during COVID-19 pandemic .Therefore, there is still need of educating the masses regarding the proper usage of mask.

India surely will win the battle against COVID-19 in the near future. Due to the limitation in representativeness of the sample, more studies are warranted to investigate the KAP regarding mask usage during COVID-19 among Indian residents of a low socioeconomic status.

ACKNOWLEDGEMENTS

The completion of this study could not have been possible without the expertise of Dr. Vinay Kumar Bhardwaj. A debt of gratitude is also owed to Dr. Shelja Vashisth for taking time and providing guidance for our framework.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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