key: cord-0734016-9hj831yz authors: Mirmolaei, Seyedeh Tahereh; Geranmayeh, Mehrnaz; Salehiniya, Hamid; Mohammadi, Azam; Ebrahimi, Marzieh title: Knowledge and performance of the Iranian general population in the use of masks during the 2019 coronavirus date: 2022-01-31 journal: J Educ Health Promot DOI: 10.4103/jehp.jehp_1471_20 sha: d23b78bcce69532356e6ebb5382e3d04c1a932c0 doc_id: 734016 cord_uid: 9hj831yz BACKGROUND: The use of personal protective equipment (especially face masks) has increased in different communities amid the COVID-19 pandemic. Therefore, the present study aimed to assess knowledge and performance of Iranian general population in wearing face masks. MATERIALS AND METHODS: The present study is a cross-sectional study conducted using a valid and reliable questionnaire on 1843 eligible individuals. The questionnaires were shared by Link (www.porsall.com) in groups and social networks. Data were analyzed using SPSS (Version 24.0, SPSS Inc., Chicago, IL). RESULTS: The mean age of the participants was 42.84 years (standard deviation: 16.84). The majority had inadequate and low knowledge of masks (69.2%), nearly 30% had moderate (30.1%), and few had adequate and high knowledge of masks. The individuals' knowledge on when to wear a mask was also assessed and the results showed poor and low in 42.2%, 46.9% moderate and high performance in 10.7%. The participants' performance on how to properly wear a mask was also assessed and 12% showed poor, 69.3% showed moderate, and 18.7% showed high performance. Safe removal of masks was also assessed, and the results showed 52% low and poor, 27.6% moderate, and 20.3% high performance. A significant and direct correlation was found between the overall score knowledge and performance regarding use of masks (P < 0.001). CONCLUSION: The results showed poor to moderate knowledge and performance of majority of Iranian general population regarding the masks. Therefore, further effective training courses and action plans are needed in Iran given the importance of masks for the prevention of COVID-19, especially in public places. Educational package about how to use the mask and its benefits, through the media and health centers is recommended. C OVID-19 is caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and poses a threat to public health. [1] Coronaviruses are widespread in humans and several other vertebrates and cause respiratory, enteric, hepatic, and neurologic diseases. The novel coronavirus is spread from person to person (human-to-human transmission) through respiratory droplets (aerosols) or close contact. The virus infects people of all ages. However, current evidence suggests that two groups of people are at a higher risk of getting severe disease, namely, older people and those with underlying medical conditions. Therefore, the WHO emphasizes that all people should protect themselves from. [2] Transmission of the disease in health facilities is a very serious threat. Of 138 patients infected with COVID-19 in a hospital, 40 (29%) were reported to be medical personnel. Although further studies are needed, asymptomatic people are also careers of CoV-2019. [3] WHO recommends that people should wear masks in public areas because face masks have restricted transmission of respiratory droplets from patients with respiratory infections (e.g., flu) to healthy people in earlier times. Face mask usage as a public health intervention by asymptomatic infected people could interrupt the transmission chain given the high viral load in early phase of the disease. [4] Wearing a medical mask is one of the prevention measures that can limit the transmission of certain respiratory viral diseases including COVID-19. However, masks alone do not prevent and protect people from the disease and other measures including hand hygiene should also be taken. The use of medical masks can create a false sense of security if proper usage was not taught to people who could easily neglect other preventive measures including hand hygiene. There is not adequate evidence supporting this recommendation that wearing a surgical mask would significantly reduce the risk of disease transmission to a healthy person. [5] The WHO called for a 40% increase in the production of personal protective equipment (PPE) including face masks. Meanwhile, health authorities should optimize face mask distribution to prioritize the needs of frontline health-care workers and the most vulnerable groups of society including older adults (particularly those older than 65 years) and people with underlying health conditions. [5] Outbreak of a respiratory infection is associated with huge human and economic costs including illness of healthcare workers. Therefore, planning and strategizing in response to such crises should put on the agenda health-care services and preventive measures. Infection prevention and control are the most important measures taken during epidemics given the available evidence. Therefore, the optimal use of PPE including masks by health-care workers and the general population is the first solution to protect against respiratory pathogens and prevent transmission of the diseases while caring for infected patients or attending public places. However, little is known about general population awareness, attitudes, decisions, and practice of wearing protective masks. [6] Use of PPE and masks by general population has dramatically increased in Iran since the COVID-19 pandemic. The proper use of masks is a crucial point in this crisis. Various guidelines on how to wear face mask and assessment of health behaviors help to make practical health policies that would allow development of effective prevention and protection training programs as well as rational use of masks and financial resources. Therefore, the study aimed to assess Iranian general population knowledge and performance regarding the use of masks during the COVID-19 epidemics in Iranian general population. The research method is descriptive correlation study. The necessary license was obtained from the Ethics Committee of the deputy of Research and Technology of Tehran University of Medical Sciences (Code: IR.TUMS. VCR.REC.1399.143). This study was performed on 1915 members of the general population living in Iran from April 10, 2020 to May 6, 2020. Inclusion criteria were willingness to participate in the study, possession of a smartphone, and 15-80 age group. Exclusion criteria were the questionnaires completed with the same ID twice and incomplete questionnaires. To estimate the sample size, sample size formula for estimating the population ratio ( used. The p = 0.34, confidence interval (z) = 95% and d = 0.03 were considered into account, considering the design effect = 2. Therefore, the sample size was obtained equal to 1915 people. Nonrandom sampling was used in this study. The questionnaire as an online link was posted on different social media groups and channels. Objectives of the research, data confidentiality, and inclusion criteria were carefully explained on the first page of the questionnaire to respect ethical considerations. Eligible individuals were asked to participate in the study if they were willing. An Iranian website specialized in design of online questionnaires was used to prepare the questionnaire. This website also had the ability to provide time to complete the questionnaire. ID of the person filling out the questionnaire could also be found. A self-report questionnaire based on the WHO, Center for Disease Control and Prevention (CDC) website, and related article was developed by the research team to meet the research objectives. [7] [8] [9] [10] To assess face validity of the questionnaire, a small group of people (20 men and 20 women) were asked to complete the questionnaire and write down their views on attractiveness, suitable format and sequence, and comprehension of items. Necessary changes were made to the questionnaire based on their views. To assess content validity of the questionnaire, ten experts in health education, reproductive health, and midwifery of Tehran University of medical sciences were asked to write down their views on grammar, wording, sequence of items, and scoring. The questionnaire was modified based on their views. Cronbach's alpha was calculated to assess the reliability of the questionnaire. The Cronbach's alpha was obtained more than 0.7 for each item and domains of the questionnaire. The reliability of questionnaire for all questions was confirmed (Cronbach's alpha = 0.84). The final questionnaire was prepared following necessary modifications. It was divided into three main parts. The first part collected data on demographic information including age, gender, marital status, education, occupation, place of employment, place of residence, source of information on mask and how to access it, and information on infected persons among friends, family members, and acquaintances. The second part consisted of 17 items assessing general knowledge on mask specification and usage. Each item had three options of true, false, and I don't know (true = 1, false and I don't know = 0). The third part consisted of 16 items assessing general population performance regarding the use of masks. Three domains of when and where to wear masks (5 items), how to properly put masks on (8 items), and how to properly take masks off (3 items) were included in this third part. The items were scored based on a five-point Likert scale (always, often, sometimes, rarely, and never). The highest score was assigned to "always" (4) and the lowest score belonged to "never" (0) in positive phrases. The lowest score was dedicated to "always" (0) and the highest score was allocated to "never" (4) in negative phrases. The web-based survey was posted on various social media groups and channels. The participants could easily click on the link and answer questions. The first page of the questionnaire showed a brief introduction on the research team, the objectives, methods, voluntary participation, data confidentiality, and anonymity of participants. Data were analyzed using SPSS (Version 24.0, SPSS Inc., Chicago, IL). Descriptive statistics including frequency, percentage, mean, and standard deviation (SD) were used to describe the sociodemographic characteristics of the participants. Normal distribution of data was examined using skewness and kurtosis. Pearson correlation test was used at a significance level of <0.05. The number of people completed the questionnaire was 1843 from April 10, 2020 to May 6, 2020 (response rate: 0.96%). The main social media were WhatsApp (96%) and Telegram (4%). The average time to complete the questionnaire was 9:19 min. The mean age (SD) of the participants was 42.84 (16.84 The participants also showed no statistically significant differences between general population performances regarding mask usage in terms of gender, marital status, place of residence, and access to masks (P > 0.05). However, statistically significant differences were found between general population performances regarding masks usage in terms of occupation (medical group and nonmedical group), education, type of employment, infection of family and acquaintances, and knowledge on masks (P < 0.05). Mean scores of performance of mask usage in people with clinical jobs, master degree, nursing or midwifery position, history of infection in family members and acquaintances, and knowledge on masks were higher than others [ Table 3 ]. Pearson correlation test results showed a significant and direct correlation between the overall score of knowledge of mask usage and the overall score of performance regarding mask usage (P < 0.001, r = 0.368). The present study aimed to assess knowledge and performance of the general Iranian people regarding mask usage during the COVID-19 pandemic. The results showed that the majority had low-to-moderate knowledge and performance regarding mask usage for prevention of COVID-19. A significant correlation was found between individuals' knowledge and performance regarding mask usage. As knowledge on masks increases, performance of mask usage will improve. Although the CDC recommended that people should wear cloth face coverings in public settings at April 3, 2020, guidelines and instruction for the use of masks are different and constantly changing in different populations. [11] Knowledge and awareness has a crucial role in human life. Knowledge is the unique privilege of humans over their peers. It is used as a unique tool to distinguish advanced societies from backward societies. Awareness affects health behaviors of people. It encourages people to acquire knowledge, affects their interests, beliefs, and actions, creates incentives to make more productive decisions, and helps people to control their behaviors. Awareness is also an important factor in health promotion and help people to recognize their health problems, resolve these problems, and preserve their health. [12] Effective control and prevention of viral diseases are the most important measures in COVID-19 pandemics. [13] However, fake news and misleading information on COVID-19 on different social media and websites obliged WHO to design a discussion forum in its official website to interact with people on social media and answer their questions about COVID-19. [14] Awareness is an important step in disease control and prevention. The Chinese government put on the agenda effective measures to develop training courses for general population to control and prevent the COVID-1. [15, 16] The results showed unfavorable knowledge and performance of Iranian people regarding mask usage despite abundant information on the use of masks in public setting for prevention and control of COVID-19. Probably, other factors should be considered in future studies to raise general population awareness on masks for control and prevention of COVID-19. Preventive measures are highly regarded at global scale. These strict measures included severe punishments for those who violate the rules, subsidies for all citizens to compensate for closure of private companies, and free distribution of masks and sanitary products for the poor in Hong Kong. [17] Use of masks is one of the preventive measures during the COVID-19 pandemic. Transmission of large respiratory droplets would be minimized in case that infected people wore masks. [18] Transmission of the disease would be reduced by 80% if health-care personnel wore masks. [17] Unfortunately, a review of literature showed no survey on knowledge and performance of Iranian general population regarding COVID-19 control and prevention. Therefore, a similar study is discussed. The results of the present study showed that most of the participants unfortunately had poor knowledge and performance regarding mask usage, which might be due to underestimating the disease, neglecting the disease transmission, and having misconceptions about COVID-19. Another study in the United States in 2020 showed that people in the United States and the United Kingdom believed in misconceptions about COVID-19 rather than facts. They overestimated fatal rates of the disease and believed that surgical masks could protect them from COVID-19. [19] These results were consistent with the results of the present study. More than 90% had poor to moderate knowledge about COVID-19. Although the proper use of mask and correct knowledge on the proper use of masks promote the optimal use of masks, training courses for proper use of PPE is still vague and not comprehendible by general population. One study found out that 43% of physicians were informed of proper use of masks in the college and even 8% of nurses had received training in the use of masks. [20] Many people might never use what learned before, even medical and health-care personnel. [21] Therefore, style and time of giving information on emerging disease seem to promote theoretical and practical knowledge, which should be investigated in future studies. The results of the present study were also consistent with the results of the study by Souli et al. [22] who assessed knowledge, attitude, and performance of 2380 high school students regarding COVID-19. They found out that Italian high school students had suitable knowledge and attitude toward mask usage to prevent clinical symptoms, and promoted general population health principles to prevent disease, reduce transmission, and protect against viral disease. These results were not consistent with the results of the present study. The possible reason for this inconsistency may be due to the age difference between the participants in the two studies. Participants in the study by Souli et al. were high school students who could access internet to acquire information on COVID-19, whereas participants of the present study were the general population. Geldsetzer in the United States (2020) found out that more than 90% of people respected preventive measures against COVID-19 including wearing masks and washing hands. They had suitable performance. These results were not consistent with the results of the present study that showed poor-to-moderate Iranian general population performance regarding masks. Although crisis managers might have warned against the COVID-19 at early phase of the disease, the warning messages probably were not understood by the general population and ambiguous messages might have misled people. [23] Iranian society does not believe in the warnings of the authorities, which is evident in their current attitudes. They do not take serious preventive measures and do not reduce their social activities. [24] Probably, these factors have reduced the use of preventive orders among the general population. Al-Hanawi et al. [25] The strengths of the present study were specificity of the questions about the mask, relatively high sample size, and selection of a sample from the general population that increased the generalizability of the data to the entire population. The study was also carried out in the period that the United States and the Europe were not still affected by COVID-19. This can affect general population knowledge and performance regarding the mask. One of the limitations of the present study was an electronic questionnaire that restricted accessibility of the questionnaire to those possessing smartphones. Since this was a descriptive study, general population knowledge and performance might be under the influence of culture and education. This was resolved by widespread distribution of the questionnaire in different populations with diverse cultures in Iran. Less than 500,000 people were infected with COVID-19 worldwide at time scope of the study when the disease was more prevalent in Asian countries. However, more than 10 million people were infected with the disease worldwide as soon as the results of the study were released. Complexity, difficulty, and extent of the COVID-19 are constantly increasing. The widespread use of masks is emphasized, especially in public places. Some countries imposed severe punishments for those who do not wear masks. In this study, an online questionnaire was used to collect data; therefore, generalizing the results to the whole community can be done with caution. Educational package about how to use the mask and its benefits, through the media and health centers is recommended. The results showed poor-to-moderate knowledge and performance of majority of Iranian general population regarding the masks. Therefore, further effective training courses and action plans are needed in Iran given the importance of masks for prevention of COVID-19, especially in public places. The project was approved by the ethics board of Ethics Committee of the deputy of Research and Technology of Tehran University of Medical Sciences (Code: IR.TUMS. VCR.REC.1399.143). Defining the epidemiology of COVID-19 -Studies needed COVID-19): Situation Report, 72. World Health Organization Mass masking in the COVID-19 epidemic: People need guidance Rational use of face masks in the COVID-19 pandemic Clinician perceptions of respiratory infection risk; a rationale for research into mask use in routine practice Surgical Masks, Respirators, Face Shields: Which Masks Actually Protect Against Coronavirus? 2020 N95 Respirators, Surgical Masks, and Face Masks Recommended Guidance for Extended use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. US Government; 2020. www.jems.com/ operations/equipment-gear/recommended-guidance-forextended-use-and-limited-reuse-of-n95-filtering-facepiecerespirators-in-healthcare-settings To mask or not to mask: Modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic The Knowledge and Attitude of Male Students at East Asia's strategies for effective response to COVID-19: Lessons learned for Iran How to fight an infodemic Staff safety during emergency airway management for COVID-19 in Hong Kong Facing the COVID-19 outbreak: What should we know and what could we do COVID-19: Infection prevention and control guidance for all ultrasound practitioners Respiratory virus shedding in exhaled breath and efficacy of face masks Using rapid online surveys to assess perceptions during infectious disease outbreaks: A cross-sectional survey on COVID-19 among the general public in the United States and United Kingdom Are health care personnel trained in correct use of personal protective equipment? Healthcare workers' decision-making about transmission-based infection control precautions is improved by a guidance summary card Knowledge, attitude and practice of secondary school students toward COVID-19 epidemic in Italy: A cross selectional study Risk perceptions and behaviour: Towards pandemic control of emerging infectious diseases: International research on risk perception in the control of emerging infectious diseases Factors influencing Iranians' risk perception of COVID-19 Knowledge, attitude and practice toward COVID-19 among the public in the Kingdom of Saudi Arabia: A cross-sectional study Researchers need to thank the Research Vice Chancellor for Research at Tehran University of Medical Sciences for funding, and thank all those who have helped complete the research questionnaire to achieve its goals. This study was financially supported by Tehran University of Medical Sciences. There are no conflicts of interest.