key: cord-0813971-fcnib1se
authors: Liebst, Lasse S.; Ejbye‐Ernst, Peter; de Bruin, Marijn; Thomas, Josephine; Lindegaard, Marie R.
title: Face‐touching behaviour as a possible correlate of mask‐wearing: A video observational study of public place incidents during the COVID‐19 pandemic
date: 2021-05-18
journal: Transbound Emerg Dis
DOI: 10.1111/tbed.14094
sha: 821b5ca18ad6521262a7b14e305a18976cb093a0
doc_id: 813971
cord_uid: fcnib1se

Most countries in the world have recommended or mandated face masks in some or all public places during the COVID‐19 pandemic. However, mask use has been thought to increase people's face‐touching frequency and thus risk of self‐inoculation. Across two studies, we video‐observed the face‐touching behaviour of members of the public in Amsterdam and Rotterdam (the Netherlands) during the first wave of the pandemic. Study 1 (n = 383) yielded evidence in favour of the absence of an association between mask‐wearing and face‐touching (defined as touches of face or mask), and Study 2 (n = 421) replicated this result. Secondary outcome analysis of the two studies—analysed separately and with pooled data sets—evidenced a negative association between mask‐wearing and hand contact with the face and its t‐zone (i.e. eyes, nose and mouth). In sum, the current findings alleviate the concern that mask‐wearing has an adverse face‐touching effect.

The coding began by splitting the eligible footage into 30 min segments and then randomly selecting 51 of these. We planned to sample seven masked and seven unmasked persons for each segment (in practice, we could not always satisfy this criterion because of too few mask wearers per segment). Mask-wearing included individuals wearing respirators (e.g. N95), surgical masks or fabric masks.

We excluded persons wearing face shields, eye protection, improvised masks (e.g. bandana, scarf), and persons wearing masks covering neither the nose nor the mouth. We also excluded persons who put the mask on or took it off, or changed the mask's placement in the face (e.g. from covering both nose and mouth to mouth only). As such, the current data offer insights into the face-touching rate related to one part of the behavioural sequence involved in face mask use (Von Cranach, 1982) -that is, the 'subconscious' face-touching (e.g. fidgeting, scratching) when mounted rather than 'deliberate' mask repositioning (Hall et al., 2007; Perl et al., 2020) . 1 We observed each person for the duration captured on camera walking through the study setting (although for a maximum of two minutes). The average observation time per individual was 25 s (SD = 7.42), with a total of 158 person-minutes of observation. In sum, we sampled 176 persons wearing a face mask and 207 not wearing one, comprising a total sample size of 383 persons. This sample size satisfies an a priori statistical power analysis suggesting that 339 observations would detect a small effect (f 2 = 0.05), with a power of 90% and a conservative alpha of 0.005 (Benjamin et al., 2018) .

Note that we coded beyond what the power analysis suggested to have a buffer for incomplete cases (the decision to terminate the sampling procedure was taken before any analyses were conducted).

For the inter-rater reliability test of the codebook, we selected 44 individuals and 25 contexts for independent double coding, with a Krippendorff's (2004) alpha (α) larger than 0.8 as a benchmark for acceptable agreement (each score is reported below).

The primary face-touching outcome was captured as a binary variable distinguishing between whether or not the person touched his or her face or a potential mask at least once with the hand (α = 0.89) (for illustrations of the face-touching measures see osf.io/7ek9d). This definition aligned with the recommendation that appropriate mask use involves that neither the face nor the front of the mask should be touched (WHO, 2020b) . Note that individuals who used hand sanitizer were disqualified from being recorded as a positive touching events.

Further, we included three secondary measures with a more narrow definition of face-touching, capturing direct hand-to-face contacts only (i.e. for these outcomes, touching the mask was defined as a non-event). These additional measures captured direct hand contact with the face, the mid-face, or the t-zone. The 'face' was defined as including eyes, nose, mouth, ears, cheeks, chin and forehead (α = 0.87). The 'mid-face' was restricted to the area from the top of the brows to the tip of the chin with the width of the jaw (α = 1.0), and the 't-zone' included the eyes, nostrils and mouth (α = 0.50). Note that a low incident rate of the t-zone measure entailed an unreasonably low α score despite a high percentage of between-coder agreement (98%). Gwent's (2008) AC1 is considered a more robust inter-rater statistic for such heavily skewed variables (i.e. t-zone touches were rare), and this test yielded an excellent score of 0.98.

The independent face mask variable captured whether the person wore a face mask covering the nose and mouth, or either the nose or the mouth (α = 1.00). We also included a number of controls: visual assessments of the persons' age (α = 0.86) and gender (α = 0.95), the number of seconds the person was observed (α = 0.94), and the level of people crowding of the 30 min segment from where the person was sampled (α = 1.00). 2

Data were estimated with linear probability models (using Stata 16's 'reg' module) (Breen et al., 2018) , specified with cluster-robust standard errors to account for the hierarchical data structure (i.e.

individuals nested in 30 min segments). Given the insight that the traditional alpha level of 0.05 offers a weak evidential threshold (Colquhoun, 2017) , we followed the recommendation to evaluate alpha levels of 0.05 and 0.005 as 'suggestive' and 'significant', respectively (Benjamin et al., 2018) . All reported p-values are twotailed. Besides p-values, we report Bayes factors (BFs) approximated from Bayesian information criteria (assuming a unit-information prior), which allow for quantification of evidence in favour of the absence of an association (Wagenmakers, 2007) . Table 1 presents the summary statistics of the study samples. The primary (face or mask touching) outcome was suggestively less common in Study 1 than in Study 2 (p = .006, Fisher's exact test). No between-study differences were found with respect to the secondary outcomes of direct hand touching of the face (p = .067, Fisher's exact test), the mid-face (p = .384, Fisher's exact test) or the t-zone (p = .877, Fisher's exact test). Further, there was no between-study difference in the gender composition (p = .105, Fisher's exact test). Compared with Study 1, Study 2 had a lower age average (t(804) = 3.8,p < .001), was more crowded (t(804) = −5.3,p < .001), included a larger proportion of persons in company with some else (p < .001, Fisher's exact test) and had a higher average temperature Bayes factor suggested that the H 0 was around 19 times more likely than H a , which may be considered substantial-to-strong evidence in favour of the absence of an association (Raftery, 1995) .

Next, regarding the secondary outcomes, 6% (11/176) of the touches. In terms of practical significance, these results indicate that mask-wearing was linked with around 6-8 percentage points lower probability for direct hand-to-face contacts. That is a small effect size-equivalent to a Cohen's (1988) d at around between −0.20 and −0.30-although the effect may cumulate across time (Funder & Ozer, 2019) . In sum, these results offer suggestive evidence for a negative association between masks and face-touching, although the robustness of the evidence hinges on how face-touching was operationalized.

Study 2 was designed as a replication of Study 1. There are a few noteworthy between-study differences, however. Specifically, data for Study 2 were collected as part of a larger research project evaluating the implementation of mandatory mask-wearing zones in Amsterdam and Rotterdam. Across these contexts, we collected footage from six comparable locations (rather than from a single camera, located in Amsterdam, as in Study 1), three of which had an operative mask mandate. The common denominator of the areas was that they were above-average busy pedestrianized streets-as also reflected in the circumstance that Study 2 was more crowded than Study 1. Across the included locations, data were selected during 

Across 

A prospect of the two current data sets is that they may be pooled into one large and high-powered dataset (Cooper & Patall, 2009 ).

Such combined ('mega') analysis is a more appropriate approach to synthesize results across the studies than to simply 'tally-vote' positive, negative, and null findings (Hedges & Olkin, 1980) . Further, given its added statistical power, it is also plausible that such pooled and highly powered analysis allows for a more accurate estimation of the associations reported in Study 1 and 2 (Gelman & Carlin, 2014; Maxwell et al., 2008) . 3

We combined this approach with an explorative assessment of how robust the link between mask-wearing and face-touching is across (the 'multiverse' of) other plausible data and model specifications (Steegen et al., 2016) . In total, we estimated 12,288 unique model specifications (using the 'mrobust' module by Young, 2018 

As we see in Figure 1 , the pooled analysis offered a less ambiguous and arguably more accurate picture of the patterns found in Study 1 and 2. The association between mask-wearing and the primary outcome remained non-significant, again with the Bayes factor offering evidence for a non-association, β = 0.02, CI 95% [−0.03, 0.08], p = .391, BF 01 = 19.38. Also, we found statistically significant and substantial-to-strong Bayes factor evidence for negative associations between mask-wearing and the secondary outcomes capturing direct touches of the face (β = −0.08, CI 95% [−0.12, −0.03], p = .001, BF 10 = 8.62), the mid-face (β = −0.08, CI 95% [−0.12, −0.04], p < .001, BF 10 = 65.34), and the t-zone (β = −0.06, CI 95%

[−0.09, −0.04], p < .001, BF 10 = 94.92).

Next, the robustness analysis across the 12,288 specifications added further credence to these findings: In more than nine out of ten models specified with one of the secondary outcomes, the association was negative and below an alpha level of 0.05. More specifically, for models specified with either face, mid-face, or t-zone touching as the outcome, we found a negative association in 100%, 98% and 92% of the models, respectively. This contrasts the subset of models specified with the primary (face and mask touching) outcome, in which only 4.7% yielded a suggestive, positive association.

Furthermore, when assessed with a conservative 0.005 alpha threshold, 0% of the models specified with the primary outcome remained significant. The models specified with the secondary outcomes were comparatively more (although not uniformly) robust, with 47%, 65%

and 63% significantly negative estimates with respect to models specified with the face, mid-zone and t-zone outcome, respectively. 5

The wide use of face masks as a measure against the coronavirus disease-2019 raises the question of whether mask-wearing by the general public is linked with adverse behavioural effects (ECDC, 2020; Mantzari et al., 2020) , including an increased face-touching frequency. The current paper showed that face-touching is a fairly common occurrence and tested the hypothesis that mask-wearing is linked with less face-touching. Initially, contrary to this hypothesis, our analysis of the primary face-touching outcome in Study 1 and 2 both found evidence in favour of a non-association. However, our secondary outcomes analysis found that the association with maskwearing hinges on how face-touching is operationalized-a common but underappreciated experience in statistical research (Silberzahn et al., 2018; Steegen et al., 2016) . Specifically, in line with our hypothesis, Study 1 and 2 and the Combined analysis found relatively robust negative correlations of mask-wearing with the secondary outcomes measuring direct hand-to-face contacts.

Our findings correspond with the prior studies, which either report no association (e.g. Tao et al., 2020) or a negative association (e.g. Lucas et al., 2020) , especially with respect to t-zone touches (Chen et al., 2020) . Taken as a whole, current and prior evidence alleviate the concern that mask-wearing has a positive and adverse face-touching effect (WHO, 2020a). The absence of such an effect may be ascribed to how face masks serve as a physical barrier for direct hand-to-face contact or offer a reminder that face-touching should be avoided (see Latour, 1999) .

One limitation of the current paper is how generalizable our results-based on cross-sectional data from video-monitored public spaces in two Dutch cities-are to other countries, settings or pandemic phases. In particular, we were restricted by the localization of the security cameras in outdoor public settings where people are mainly passing through. For example, it is plausible that mask-wearing

The data, scripts, and materials that support the findings of this study are openly available at osf.io/7ek9d. 

1 Note that this exclusion of (in total four) persons who repositioned or put the mask on/off was not part of the initial codebook of Study 1, and, as such, deviates from our pre-registration (see osf.io/bj7tg and an exclusion flow chart at osf.io/7ek9d). However, this was done to align Study 1 with Study 2 where this exclusion selection criterion was introduced, because this mask behaviour proved to be disproportionately common in this context. This reflects the area-based mask mandate operative in part of the Study 2 context, potentially skewing the sample towards this particular mask behaviour. We evaluate the statistical and conceptual implications of this exclusion in the study limitation section and in the Combined analysis (for this assessment, we relied on the four persons originally sampled in Study 1 and additional six persons from Study 2, who happened to be sampled despite their exclusion from sampling procedure). Note that the decision to exclude these persons was done before any analyses were run.

imal detectable effect of the pooled analysis was f 2 = 0.02, that is what is often considered the lower threshold of a small-sized effect (Cohen, 1988) . As such, a sample size larger than the pooled data set would only allow for a potential detection of an effect of limited practical significance (Kirk, 1996) . 4 The temperature measures were constructed using publicly available data from the Royal Netherlands Meteorological Institute (KNMI). The measurement of whether the person was alone or together with someone had an inter-rater score of 0.95. 5 Note that we explored (across 1,024 models) whether the control variables included in Study 1 and 2 and the Combined analysis were associated with the primary outcome and the secondary outcomes. None robust associations were found see (see osf.io/7ek9d), except (and obviously) the observation duration (i.e. the longer a person was observed, the more likely it was to record a face-touching event).

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