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Appropriate attitude promotes mask wearing in spite of a significant experience of varying discomfort

Published:February 18, 2021DOI:https://doi.org/10.1016/j.idh.2021.01.002

      Highlights

      • Out of 402 survey respondents, 78.4% complained of mask-related discomfort.
      • Difficulty breathing, difficulty communicating and sweating were the top 3 causes of discomfort.
      • There was no demographic correlation to the level of discomfort reported.
      • Younger mask-wearers were more likely to report dermatological issues and sweating.
      • There was a higher incidence of dermatological issues and sweating in those who wore masks for longer hours per day.

      Abstract

      Background

      Despite increasing evidence to support mask effectiveness in mitigating the spread of COVID-19, there is still raging controversy regarding the use of masks. Evaluation of public perceptions, attitudes and the individuals’ experience towards mask-wearing is integral to ensuring reasonable compliance and allows authorities to address concerns held by the population.

      Methods

      A cross-sectional survey of lay-people was conducted within a high volume tertiary level institution in Singapore, from 16 October to 16 November 2020. Surveys administered evaluated five questions: 1) duration of mask wear per day, 2) mask-type used, 3) perceived necessity, 4) discomfort level experienced and 5) causes for discomfort.

      Results

      Out of 402 respondents, 67.2% primarily wore disposable surgical masks. 72% felt mask-wearing was necessary to control COVID-19 transmission. 78.4% reported discomfort while wearing masks, with mean discomfort levels of 4.21 out of 10. Impairment to breathing and communication difficulties were the most common discomforts faced. Younger respondents complained of higher incidence of dermatological issues and sweating (p < 0.05). Respondents who wore masks for longer duration reported higher incidence of dermatological issues (p = 0.001) and sweating (p = 0.032).

      Conclusion and Relevance

      Even with an available vaccine, adjunctive public health measures such as mask-wearing will likely continue in order to curb COVID-19 transmission. Experience from past pandemics is likely to propagate self-protective behavior within a community. Our study identified several common mask-wearing discomforts, allowing respective organizations valuable market feedback for research and development. With appropriate public attitudes, effective mask-wearing compliance can be attained in a concerted effort against the coronavirus.

      Keywords

      Introduction

      Mask-wearing is traditionally practiced for various reasons including providing protection against respiratory pathogens in pandemics such as the Spanish Flu and more recently, SARS and H1N1 [
      • Strasser Bruno
      • Schlich Thomas
      A history of the medical mask and the rise of throwaway culture.
      ]. Amidst the COVID-19 pandemic, community masking has been put into practice in many countries and has been shown to substantially reduce the transmission of COVID-19 amongst healthcare workers and patients [

      Brooks JT, Butler JC, Redfield RR. Universal masking to prevent SARS-CoV-2 transmission—the time is now. JAMA. Published online July 14, 2020

      ].
      SARS-CoV-2, or COVID-19, is a highly virulent organism with a high infection fatality ratio (IFR) for the elderly and those with comorbidities [
      • Li Q.
      • Guan X.
      • Wu P.
      • Wang X.
      • Zhou L.
      • Tong Y.
      • et al.
      Early transmission dynamics in wuhan, China, of novel coronavirus-infected pneumonia.
      ]. Public infection prevention and control (IPC) measures like community masking, hand hygiene and social distancing, as detailed by WHO guidelines [
      • World Health Organization
      Mask use in the context of COVID-19.
      ], remain our main armamentarium in curbing the spread of COVID-19 [
      • Cowling B.J.
      • Ali S.T.
      • Ng T.W.Y.
      • Tsang T.
      • Li J.
      • Fong M.
      • et al.
      Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study.
      ]. Hong Kong, one of the first countries to adopt significant community masking practices, has seen a significantly lower rate of COVID-19 infections as compared to other Western nations [
      • Cheng V.C.
      • Wong S.C.
      • Chuang V.W.
      • So S.
      • Chen J.
      • Sridhar S.
      • et al.
      The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2.
      ].
      The evidence to support mask effectiveness in curbing the spread of COVID-19 has been borne by both scientific experiments [
      • Prather K.A.
      • Wang C.C.
      • Schooley R.T.
      Reducing transmission of SARSCoV-2. Masks and testing are necessary to combat asymptomatic spread in aerosols and droplets.
      ], systematic reviews [
      • Chu D.K.
      • Akl E.A.
      • Duda S.
      • Solo K.
      • Yaacoub S.
      • Schünemann H.J.
      COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.
      ] and epidemiological studies, documenting lower community spread and sharp decline in cases in countries adopting early mask-wear practices [
      • Esposito S.
      • Principi N.
      • Leung C.C.
      • Migliori G.B.
      Universal use of face masks for success against COVID-19: evidence and implications for prevention policies.
      ]. Early modelling of the use of moderately effective (50%) face masks by 80% of the population showed the theoretical possibility of reducing 17–45% of projected deaths and decreasing the daily peak death rate by 34–58% [
      • Eikenberry S.E.
      • Mancuso M.
      • Iboi E.
      • Phan T.
      • Eikenberry K.
      • Kuang Y.
      • et al.
      To mask or not to mask: modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic.
      ]. This assumes a reasonable degree of compliance by 80% of the general population. However, potential barriers include societal attitudes to mask wearing, lack of availability especially in the early pandemic, counter-propaganda [
      • Feng S.
      • Shen C.
      • Xia N.
      • Song W.
      • Fan M.
      • Cowling B.J.
      Rational use of face masks in the COVID-19 pandemic.
      ], and discomforts or medical issues encountered by individuals wearing masks. Indeed, various governments have advocated widespread mask-wearing of varying degrees and at various points in the course of the pandemic. For example, the American Centre for Disease Control and Prevention (CDC) recently began advocating two-way masking [
      Scientific brief: community use of cloth masks to control the spread of SARS-CoV-2, centers for disease control and prevention. 2020. Coronavirus disease 2019 (COVID-19).
      ], the concept that masking not only prevents virus spread from an infected individual, but also protects an uninfected person from contracting the virus; An idea that had been adopted by some other countries earlier in the pandemic [
      • Khalik S.
      Coronavirus: chief medical officer responds to view that everyone should wear A mask to avoid infection.
      ].
      Singapore's population was not a habitual mask-wearing society during the pre-COVID period but was hard hit economically and socially by Sars in 2003 in similarity to HK and Taiwan, thus there was greater adoption of precautions and public health measures at the onset of the pandemic. Yet the controversy regarding large scale community masking and the need to ensure reasonable compliance for masking to be effective as a measure makes it important to understand the lay individual's viewpoint and potential issues encountered while wearing masks on a daily basis.
      Working on the null hypothesis that usage of face masks causes no discomfort to the individual, this study aims to explore the attitudes, mask wearing trends and potential discomfort among the lay population in a developed country. Understanding such barriers could potentially help to inform public health authorities on how best to encourage and implement mask usage within an urgent context of stemming out the upscale explosion of COVID-19.

      Methods

      Design & setting

      This is a cross-sectional survey of lay individuals, conducted within a busy orthopaedic surgery outpatient setting of a tertiary level institution, which receives the highest patient volume amongst orthopaedic surgery departments in Singapore. This is essential for an amply sized study population to be accrued within a relatively short time frame, as attitudes and trends in mask wearing can swiftly evolve from time period to time period during this tumultuous pandemic. This study was conducted in the context of ongoing IPC measures in the institution and community, with active screening on all hospital visitors and strict hand hygiene practices and social distancing reinforced in the outpatient clinic.

      Participants & recruitment

      The study population included patients and their accompanying persons seen in our outpatient specialist clinics. The period of study was from 16 October 2020 to 16 Nov 2020. The period corresponds to Singapore's COVID-19 Phase II re-opening; from an institutional viewpoint, patient numbers were normalizing to a pre-COVID workload while still maintaining strict temperature and contact screening precautions. The patients were seen by the various services across orthopaedic surgery within our department, ensuring that it involved a sample group representative of the population, across various socioeconomic, ethnoreligious and educational stratas. The study was administered via simple random sampling on an anonymous basis, with participation being voluntary. Printed questionnaires were distributed at random by clinic staff to patients and accompanying relatives in waiting areas, researchers were on site to clarify if queries were made.

      Outcomes & data collection

      Basic demographics such as age, gender, ethnicity and occupation were recorded, but no participant identifiers were captured. The survey comprised of four questions; the brevity to minimize survey fatigue and simplicity in printed form to accommodate for varying social backgrounds. These included the duration of mask wear per day, the type used, the perceived necessity and the discomfort experienced. Pictorial examples representative of the common mask categories were provided for the participants.
      Attitudes toward necessity explored the degree of personal conviction towards the need for mask wearing for the purposes of safeguarding public health during the COVID-19 pandemic, weighed against that of personal liberty. Perceived discomfort level was quantified utilising a visual analog scale in similarity to that commonly used in pain scoring, with 0 being the absence of discomfort and 10 representing extreme discomfort.
      Respondents were encouraged to indicate all types of discomfort experienced and express any additional inconveniences not otherwise listed.

      Comparisons & data analysis

      Statistical analysis was performed with SPSS v23 (Chicago, IL) with the univariant chi-square test being applied to discrete variables and the Student's t–test used to analyse continuous variables. Associations between demographic data and mask-wearing practices, attitudes and reported discomforts were explored. Correlations were made between the level and category of discomfort, versus duration of mask usage and types of masks donned. A p-value of 0.05 was set to define any significant correlation.

      Results

      Our cross-sectional survey found n = 402 respondents almost quota-representative of Singaporean population demographics in terms of race distribution and age [Table 1.]. The mean duration of mask-wearing was 5.98 h per day, with the majority using disposable surgical masks. Majority felt that mask-wearing was absolutely necessary to curb transmission of COVID-19 [Table 2.]
      Table 1Demographic data.
      n = 402
      Age (years)No. of Respondents (% of Total)
      <2525 (6.2%)
      25–65281 (69.9%)
      >6596 (23.9%)
      Mean Age52.7 (median 54, s.d.16.0)

      Range 15-98
      Gender
      Male165 (43.4%)
      Female215 (56.6%)
      Racer
      Chinese255 (73.9%)
      Indian32 (9.3%)
      Malay42 (12.2%)
      Others16 (4.6%)
      Table 2Mask-Wearing practices and attitudes.
      n = 402
      Duration of Wear (hours)No. of Respondents (% of Total)
      0–8288 (71.6%)
      9–16103 (25.6%)
      17–242 (0.5%)
      Mean Duration (hours)5.98 (median 5, s.d. 3.89)
      Type of Mask Primarily Worn
      Disposable Surgical Mask270 (67.2%)
      N95 Respirator4 (1%)
      Filter-fitted Mask20 (5%)
      Re-useable Cloth Mask106 (26.4%)
      Cloth Muffler0 (0%)
      Reason for Mask-Wearing
      Feels it is absolutely necessary for prevention of COVID-19 transmission288 (71.6%)
      Feels it offers some protection from COVID-19 transmission63 (15.7%)
      Mandated by government30 (7.5%)
      Questions the efficacy of public mask-wearing2 (0.5%)
      Absolutely will not wear a mask in public0 (0%)
      78.4% of respondents reported discomfort while wearing masks, with a mean discomfort level of 4.21 (median 4, s.d. 2.66, on a scale of 0–10). A detailed breakdown of the types of discomforts reported and their incidence is detailed in Table 3 [Table 3.].
      Table 3Breakdown of discomfort types with reported incidence.
      Discomfort Types (n = 402)
      Difficulty BreathingDifficulty CommunicatingDifficulty Recognizing FacesDermatological Issues (e.g. rash, acne)Issues with Self-AppearanceSweatingPoor fittingFogging of Spectacles
      Yes215 (53.5%)187 (46.5%)74 (18.4%)80 (19.9%)10 (2.5%)134 (33.3%)44 (10.9%)116 (28.9%)
      No180 (44.8%)208 (51.7%)321 (79.9%)315 (78.4%)385 (95.8%)261 (64.9%)351 (87.3%)279 (69.4%)
      In our analysis, we compared discomfort levels and nature of discomforts with demographic data and mask-types. We found that there was no significant difference in the mean discomfort levels reported when comparing across age groups (p = 0.533), gender (p = 0.95), race (p = 0.11), duration of wear (p = 0.169) and mask-type (p = 0.585). When comparing different types of discomforts reported with demographic data and mask-types, we found that more females reported discomfort of sweating compared to males (38% vs 28%, p = 0.036). Younger respondents complained of dermatological issues (p < 0.001) and sweating (p < 0.05). Respondents who wore masks for longer hours reported higher incidence of dermatological issues (p = 0.001) and sweating (p = 0.032) [Table 4.]
      Table 4Positive correlations found between specific discomfort types when compared against demographic groups, duration of wear and mask-type.
      Had Dermatological IssuesHad SweatingHad Fogging of Spectacles
      No. of Respondents (% of Total)SignificanceNo. of Respondents (% of Total)SignificanceNo. of Respondents (% of Total)Significance
      Gender
      Male30 (18.6%)45 (28%)53 (32.9%)
      Female47 (22%)82 (38.3%)58 (27.1%)
      (p = 0.43)(p = 0.036)(p = 0.222)
      Age (Years)
      <2512 (48%)13 (52%)12 (48%)
      26–6560 (21.7%)101 (36.6%)86 (31.2%)
      >658 (8.5%)20 (21.3%)18 (19.1%)
      (p < 0.001)(p = 0.004)(p = 0.009)
      Duration of Wear (hours)
      0–843 (15.2%)87 (30.9%)75 (26.6%)
      9–1632 (31.4%)41 (40.2%)38 (37.3%)
      17–24n < 5n < 5n < 5
      (p = 0.001)(p = 0.032)(p = 0.106)
      Mask Type
      Surgical Mask62 (23.5%)101 (38.3%)77 (29.2%)
      N95 Maskn < 5n < 5n < 5
      Filter-fitted Maskn < 5n < 57 (35%)
      Re-useable Cloth Mask15 (14.3%)30 (28.6%)30 (28.6%)
      (p = 0.029)(p = 0011)(p = 0.763)
      Statistically significant results in bold.
      Statistical comparison between discomfort types and mask types was confounded by low usage of certain mask types, in particular N95 and filter fitted masks. Hence Pearson Chi–Square Test was conducted excluding cells with values less than 5. This showed that respondents who regularly wore surgical masks were more likely to complain of dermatological issues (p = 0.029) and sweating (p = 0.011) compared to those wearing re-useable cloth masks. Respondents wearing re-useable cloth masks were more likely to report poor fitting masks compared to those who wore surgical masks (12.4% vs 11%, p = 0.033).
      Analysis of mask-wearing attitudes showed no significant differences in attitudes among respondents of various age groups or race. However more females than males believed that mask-wearing was absolutely necessary to control COVID-19 transmission (82.7% vs 65%, p = 0.003).

      Discussion

      Our study set out to explore public opinion, mask-wearing trends and its associated discomforts, and found that under mandatory mask-wearing conditions [
      Channel News Asia Singapore
      COVID-19: what the law says about having to wear a mask when outside your home.
      ] majority of respondents acknowledged that mask-wearing was essential to curb COVID-19 spread. As global race for a COVID-19 vaccine continues, non-pharmacological interventions remain critical to the world's fight against COVID-19 [
      • Cowling B.J.
      • Ali S.T.
      • Ng T.W.Y.
      • Tsang T.
      • Li J.
      • Fong M.
      • et al.
      Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study.
      ,
      • Chu D.K.
      • Akl E.A.
      • Duda S.
      • Solo K.
      • Yaacoub S.
      • Schünemann H.J.
      COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.
      ]. It is postulated that even with the introduction of the vaccine, adjunctive public health measures will still be required in the midterm [
      • Lerner A.M.
      • Folkers G.K.
      • Fauci A.S.
      Preventing the spread of SARS-CoV-2 with masks and other “low-tech” interventions.
      ]. Our study found that nearly 70% of respondents thought mask wear was absolutely necessary to control spread of the virus. Respondents most commonly wore disposable surgical masks and for an average of 6 h. The most common associated discomforts identified were difficulty breathing, communication and fogging of spectacles. Significant correlations were found between dermatological issues, sweat and fogging of spectacles, with certain demographic groups. These correlations further our understanding of this new mandatory practice which is likely to persist for the time-being.
      Our study found that the commonest mask type used is the disposable surgical mask, which have been shown to be an appropriate choice of deterrence against COVID-19 [
      • Infectious Diseases Society of America
      Infectious Diseases Society of America guidelines on infection prevention in patients with suspected or known COVID-19.
      ]. Efficacies in filtration efficiency between different types of masks have been looked into, with surgical masks being superior to cloth masks [
      • MacIntyre C.R.
      • Seale H.
      • Dung T.C.
      • Hien N.
      • Nga P.
      • Chughtai A.
      • et al.
      A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.
      ]. Comparing N95 and surgical masks, there was no significant difference in respiratory illness events and the safety profile of surgical masks in the setting of COVID-19 [
      • Dugdale C.M.
      • Walensky R.P.
      Filtration efficiency, effectiveness, and availability of N95 face masks for COVID-19 prevention.
      ]. Singapore increased public access of masks through organised distribution of cloth masks, explaining the sizeable proportion of our respondents (26.4%) using cloth masks regularly.
      Approximately 72% of our population believe that mask-wearing is absolutely necessary to control COVID-19 transmission. No significant differences in attitudes was observed between age or race groups. This suggests that with public education and appropriate attitudes, effective levels of compliance can be achieved. Perceptions and behaviours of individuals evolve rapidly during pandemics and attitudes towards mask-wearing have been evaluated in countries like Hong Kong after the SARS epidemic [
      • Ho H.S.
      Use of face masks in a primary care outpatient setting in Hong Kong: knowledge, attitudes and practices.
      ]. Lau et al. anticipated a psychological public response to any new pathogen and it was concluded that in the event of future novel respiratory illness outbreak, the Hong Kong public had a high likelihood of upholding preventive measures for self-protection and protection of the community [
      • Lau J.T.
      • Kim J.H.
      • Tsui H.Y.
      • Griffiths S.
      • et al.
      Anticipated and current preventive behaviors in response to an anticipated human-to-human H5N1 epidemic in the Hong Kong Chinese general population.
      ]. The gravity of these behavioural response forms an integral part of effective implementation, and dissemination of accurate information through public health education campaigns may reduce anxiety levels and deter inappropriate behaviours [
      • Ho H.S.
      Use of face masks in a primary care outpatient setting in Hong Kong: knowledge, attitudes and practices.
      ]. Having been through past pandemics such as SARS, such experience is likely to similarly propagate self-protective behaviours within our Singapore community. A higher percentage of females perceived the necessity for mask wearing to curb disease transmission compared to males. This could be related to a higher tendency for females to engage in protective behaviours as it was previously shown that masking correlated positively with other protective behaviours [

      Betsch C, Korn L, Sprengholz P, Felgendreff L, Eitze S, Schmid P, et al. Social and behavioural consequences of mask policies during the Covid-19 pandemic. Proc Natl Acad Sci Unit States Am. 117(36): 21851-21853

      ].
      Nearly 80% of our survey participants reported discomfort in mask-wearing, with a median discomfort level of 4 out of 10. Respondents who wore masks for longer hours each day logically reported higher levels of discomfort.
      More than half of our respondents complained of difficulty breathing, though there was no significant correlation with the number of hours wearing a mask. Both N95 and surgical face masks have been shown to reduce cardiopulmonary exercise capacity [
      • Fikenzer S.
      • Uhe T.
      • Lavall D.
      • Rudolph U.
      • Falz R.
      • Busse M.
      • et al.
      Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity.
      ]. Studies have shown changes to the nasal airway resistance and minimum cross-sectional area in the time after wearing N95 or surgical masks [
      • Lee H.
      Effects of long-duration wearing of N95 respirator and surgical facemask: a pilot study.
      ]. Panic prone individuals have a potential risk of respiratory discomfort when wearing respiratory protective devices. However, a recent study showed no significant decline in oxygen saturation in an elderly group of patients wearing a 3-layered nonmedical face mask [

      Chan NC, Li K, Hirsh J. Peripheral oxygen saturation in older persons wearing nonmedical face masks in community settings. J Am Med Assoc. Published online October 30, 2020. doi:10.1001/jama.2020.21905

      ].
      An under-recognised issue of mask wearing is that of verbal and non-verbal communications. Up to 46% of respondents had difficulty with communicating due to having a mask on while 18.4% reported problems with recognizing faces. Face masks were previously found to increase vocal effort, symptoms and discomfort, especially in individuals donning them for professional and essential activities [
      • Ribeiro V.V.
      • Dassie-Leite A.P.
      • Pereira E.C.
      • Santos A.D.N.
      • Martins P.
      • Irineu R.A.
      Effect of wearing a face mask on vocal self-perception during a pandemic.
      ]. As communications and facial recognition are increasingly employed by security access technologies, mitigating measures should be actively researched. Interruptions to communications also pose challenges for special needs groups including those who lip-read. Innovations like transparent face masks allowing people to lip read and see facial expressions might be useful, especially for those in the teaching field.
      The use of face masks by healthcare workers has been reported to cause peri-oral dermatitis [
      • Phelamei S.
      The times now; 2020. Wearing face masks is the “new normal”: know these tips and tricks to avoid common side effects.
      ]. Longer hours of mask-wearing has been associated with higher rates of facial itch [
      • Szepietowski J.
      • Matusiak, Szepietowska M.
      • Krajewski P.
      • Białynicki-Birula R.
      Face mask-induced itch: a self-questionnaire study of 2,315 responders during the COVID-19 pandemic.
      ]. Szepietowski et al. reported a 19.6% incidence rate of facial itch and found that individuals with facial dermatoses were more likely to complain of facial itch after mask-wearing. This coincides with our findings where 19.9% of respondents complained of dermatological issues associated with mask-wearing, with higher reported dermatological issues in those wearing masks for longer hours. Scarano et al. reported a 0.7–1.9 °C increase in facial skin temperature while wearing N95 respirators [
      • Scarano A.
      • Inchingolo F.
      • Lorusso F.
      Facial skin temperature and discomfort when wearing protective face masks: thermal infrared imaging evaluation and hands moving the mask.
      ]. This was less evident in individuals wearing surgical masks but both mask-types elicited sensations of facial thermal discomfort in their test subjects. While 33% of our respondents complained of uncomfortable sweating while mask-wearing, we could not determine whether those wearing N95 respirators were more likely to report such discomfort due to low absolute numbers of N95 wearers. Cloth masks tended to be of poorer fit, leading to more air leakage from the sides which in turn could explain the lower incidence of sweating and dermatological complaints.
      28.9% of respondents complained of spectacle fogging when breathing through a mask. Fogging of spectacles generates an uncomfortable feeling with an impulse to touch the face [
      • Lazzarino A.I.
      • Steptoe A.
      • Hamer M.
      • Michie S.
      Covid-19: important potential side effects of wearing face masks that we should bear in mind.
      ].
      Despite the high incidence of various discomforts in mask wearing, 88% of our respondents recognise its importance for public health control. We emphasize that mandatory mask-wearing was put in place in addition to travel restrictions and social distancing measures such as restricted gathering sizes, restrictions on dining-in at food outlets and enhanced screening at malls and offices. Dissemination of public health messages in Singapore were done daily through various media platforms by a Multi-Ministry Task Force. Since the implementation of these measures on April 14th 2020 [
      • Lerner A.M.
      • Folkers G.K.
      • Fauci A.S.
      Preventing the spread of SARS-CoV-2 with masks and other “low-tech” interventions.
      ], Singapore has seen higher mask-wearing rates compared to Western countries [
      • The Strait Times Singapore
      Reach poll shows most Singaporeans complied with circuit breaker measures to stem spread of Covid-19.
      ], and as of 14th November 2020 there were no locally transmitted cases amongst the Singapore population.

      Strengths

      Whilst several existing studies illustrate the discomforts levels experienced by mask-wearing frontline healthcare workers [
      • Lee H.
      Effects of long-duration wearing of N95 respirator and surgical facemask: a pilot study.
      ], to our knowledge no other articles report the public perception to mask-wearing. Our study is one of the first to distinguished various types of discomforts experienced by individual mask-wearers across various age groups and ethnicity, providing mask-producing organizations valuable market research allowing mitigation of these discomforts for specific demographic groups, with the aim to make masks more comfortable for mass usage.

      Limitations

      Due to the need to maintain anonymity and encourage participation, we were unable to correlate the co-morbidities of respondents to specific discomforts. Our questionnaire attempted to collect data on participant's occupations, but 28% of respondents declined to reveal their occupation, which may be due to conservative cultural attitudes, and this prevented us from performing any reliable analysis in this regard. This study is limited to a sample of the Singaporean population and other cohorts in different cultural and socioeconomic settings may yield different findings.

      Conclusion

      COVID-19 measures are expected to be in place for the long term. Our study illustrates public perceptions and behaviours with regard to mask-wearing and suggests that despite the significant discomforts faced by the Singapore population, with good public attitudes, acceptable mask-wearing compliance may be achieved. This article also identifies the specific challenges associated with mask-wearing, highlighting associations between certain demographic groups with particular mask-wearing practices and discomforts. We hope that our study can bring the global collective one step closer to a unified response to the COVID-19 pandemic.

      Ethics

      The survey was approved on review by our institutional review board (CIRB number 2020/2850).

      Authors statement

      GJWC: Methodology, Validation, Formal Analysis, Investigation, Data Curation, Writing of Original Draft, Writing Review and Editing, Manuscript Submission. CG: Methodology, Investigation, Data Curation, Writing of Original Draft, Writing Review and Editing. CHSS: Investigation, Data Curation, Writing of Original Draft, Writing Review and Editing. YHN: Conceptualization, Methodology, Validation, Writing Review and Editing. KXKT: Conceptualization, Validation, Formal Analysis, Writing of Original Draft, Writing Review and Editing. TSH: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Writing Review and Editing, Project Administration. JSBK: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Writing of Original Draft, Writing Review and Editing, Project Administration. All authors contributed to the final analysis and interpretation of the results. All authors contributed to the drafting of this manuscript and approved it for submission.

      Conflict of interest

      None.

      Funding

      No funding was received as part of this study.
      None of the authors, their immediate families, nor any research foundation with which they are affiliated have received any financial payments or other benefits from any commercial entity related to the subject of this article.

      Provenance and peer review

      Not commissioned; externally peer reviewed.

      Acknowledgements

      Our study acknowledges the invaluable assistance rendered by the staff of ‘H’ clinic, Singapore General Hospital, in the distribution of our questionnaire. We would particularly like to thank Ms Nur Aqilah Muzini for her kind efforts in collating our questionnaire forms.

      References

        • Strasser Bruno
        • Schlich Thomas
        A history of the medical mask and the rise of throwaway culture.
        Lancet. 2020; 396https://doi.org/10.1016/S0140-6736(20)31207-1
      1. Brooks JT, Butler JC, Redfield RR. Universal masking to prevent SARS-CoV-2 transmission—the time is now. JAMA. Published online July 14, 2020

        • Li Q.
        • Guan X.
        • Wu P.
        • Wang X.
        • Zhou L.
        • Tong Y.
        • et al.
        Early transmission dynamics in wuhan, China, of novel coronavirus-infected pneumonia.
        N Engl J Med. 2020 Mar 26; 382 (Epub 2020 Jan 29. PMID: 31995857; PMCID: PMC7121484): 1199-1207https://doi.org/10.1056/NEJMoa2001316
        • World Health Organization
        Mask use in the context of COVID-19.
        2020 (WHO reference number: WHO/2019-nCoV/IPC_Masks/2020.5)
        • Cowling B.J.
        • Ali S.T.
        • Ng T.W.Y.
        • Tsang T.
        • Li J.
        • Fong M.
        • et al.
        Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study.
        Lancet Public Health. 2020 May; 5 (Epub 2020 Apr 17. PMID: 32311320; PMCID: PMC7164922): e279-e288https://doi.org/10.1016/S2468-2667(20)30090-6
        • Cheng V.C.
        • Wong S.C.
        • Chuang V.W.
        • So S.
        • Chen J.
        • Sridhar S.
        • et al.
        The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2.
        J Infect. 2020 Jul; 81 (Epub 2020 Apr 23. PMID: 32335167; PMCID: PMC7177146): 107-114https://doi.org/10.1016/j.jinf.2020.04.024
        • Prather K.A.
        • Wang C.C.
        • Schooley R.T.
        Reducing transmission of SARSCoV-2. Masks and testing are necessary to combat asymptomatic spread in aerosols and droplets.
        Science. 2020; 368 (published online ahead of print on May 27th 2020): 1422-1424
        • Chu D.K.
        • Akl E.A.
        • Duda S.
        • Solo K.
        • Yaacoub S.
        • Schünemann H.J.
        COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.
        Lancet. 2020 Jun 27; 395 (Epub 2020 Jun 1. PMID: 32497510; PMCID: PMC7263814): 1973-1987https://doi.org/10.1016/S0140-6736(20)31142-9
        • Esposito S.
        • Principi N.
        • Leung C.C.
        • Migliori G.B.
        Universal use of face masks for success against COVID-19: evidence and implications for prevention policies.
        Eur Respir J. 2020; (published online June 18th 2020)https://doi.org/10.1183/13993003.01260-2020
        • Eikenberry S.E.
        • Mancuso M.
        • Iboi E.
        • Phan T.
        • Eikenberry K.
        • Kuang Y.
        • et al.
        To mask or not to mask: modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic.
        Infect Dis Model. 2020 Apr 21; 5 (PMID: 32355904; PMCID: PMC7186508): 293-308https://doi.org/10.1016/j.idm.2020.04.001
        • Feng S.
        • Shen C.
        • Xia N.
        • Song W.
        • Fan M.
        • Cowling B.J.
        Rational use of face masks in the COVID-19 pandemic.
        Lancet Respir Med. 2020 May; 8 (Epub 2020 Mar 20): 434-436https://doi.org/10.1016/S2213-2600(20)30134-X
      2. Scientific brief: community use of cloth masks to control the spread of SARS-CoV-2, centers for disease control and prevention. 2020. Coronavirus disease 2019 (COVID-19).
        ([online] Available at:)
        • Khalik S.
        Coronavirus: chief medical officer responds to view that everyone should wear A mask to avoid infection.
        ([online] The Straits Times. Available at:https://www.straitstimes.com/singapore/health/coronavirus-chief-medical-officer-responds-to-view-that-everyone-should-wear-a-mask)
        Date: 2020
        Date accessed: November 16, 2020
        • Channel News Asia Singapore
        COVID-19: what the law says about having to wear a mask when outside your home.
        15th April 2020
        • Lerner A.M.
        • Folkers G.K.
        • Fauci A.S.
        Preventing the spread of SARS-CoV-2 with masks and other “low-tech” interventions.
        JAMA. Published online. October 26, 2020; https://doi.org/10.1001/jama.2020.21946
        • Infectious Diseases Society of America
        Infectious Diseases Society of America guidelines on infection prevention in patients with suspected or known COVID-19.
        April 27, 2020
        Date accessed: June 21, 2020
        • MacIntyre C.R.
        • Seale H.
        • Dung T.C.
        • Hien N.
        • Nga P.
        • Chughtai A.
        • et al.
        A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.
        BMJ Open. 2015; 5e006577https://doi.org/10.1136/bmjopen-2014-006577
        • Dugdale C.M.
        • Walensky R.P.
        Filtration efficiency, effectiveness, and availability of N95 face masks for COVID-19 prevention.
        JAMA Intern Med. 2020; (Published online August 11)https://doi.org/10.1001/jamainternmed.2020.4218
        • Ho H.S.
        Use of face masks in a primary care outpatient setting in Hong Kong: knowledge, attitudes and practices.
        Publ Health. 2012 Dec; 126 (Epub 2012 Nov 13. PMID: 23153561; PMCID: PMC7111693): 1001-1006https://doi.org/10.1016/j.puhe.2012.09.010
        • Lau J.T.
        • Kim J.H.
        • Tsui H.Y.
        • Griffiths S.
        • et al.
        Anticipated and current preventive behaviors in response to an anticipated human-to-human H5N1 epidemic in the Hong Kong Chinese general population.
        BMC Infect Dis. 2007; 7: 18https://doi.org/10.1186/1471-2334-7-18
      3. Betsch C, Korn L, Sprengholz P, Felgendreff L, Eitze S, Schmid P, et al. Social and behavioural consequences of mask policies during the Covid-19 pandemic. Proc Natl Acad Sci Unit States Am. 117(36): 21851-21853

        • Fikenzer S.
        • Uhe T.
        • Lavall D.
        • Rudolph U.
        • Falz R.
        • Busse M.
        • et al.
        Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity.
        Clin Res Cardiol. 2020; (published online July 6th 2020)https://doi.org/10.1007/s00392-020-01704-y
        • Lee H.
        Effects of long-duration wearing of N95 respirator and surgical facemask: a pilot study.
        Journal of Lung, Pulmonary & Respiratory Research. 2014; 1https://doi.org/10.15406/jlprr.2014.01.00021
      4. Chan NC, Li K, Hirsh J. Peripheral oxygen saturation in older persons wearing nonmedical face masks in community settings. J Am Med Assoc. Published online October 30, 2020. doi:10.1001/jama.2020.21905

        • Ribeiro V.V.
        • Dassie-Leite A.P.
        • Pereira E.C.
        • Santos A.D.N.
        • Martins P.
        • Irineu R.A.
        Effect of wearing a face mask on vocal self-perception during a pandemic.
        J Voice. 2020 Sep 30; (S0892-1997(20)30356-8) (Epub ahead of print. PMID: 33011037; PMCID: PMC7527314)https://doi.org/10.1016/j.jvoice.2020.09.006
        • Phelamei S.
        The times now; 2020. Wearing face masks is the “new normal”: know these tips and tricks to avoid common side effects.
        June 10th, 2020
        • Szepietowski J.
        • Matusiak, Szepietowska M.
        • Krajewski P.
        • Białynicki-Birula R.
        Face mask-induced itch: a self-questionnaire study of 2,315 responders during the COVID-19 pandemic.
        Acta Derm Venereol. 2020; 100 (adv00152)
        • Scarano A.
        • Inchingolo F.
        • Lorusso F.
        Facial skin temperature and discomfort when wearing protective face masks: thermal infrared imaging evaluation and hands moving the mask.
        Int J Environ Res Publ Health. 2020 Jun 27; 17 (PMID: 32605056; PMCID: PMC7369838): 4624https://doi.org/10.3390/ijerph17134624
        • Lazzarino A.I.
        • Steptoe A.
        • Hamer M.
        • Michie S.
        Covid-19: important potential side effects of wearing face masks that we should bear in mind.
        BMJ. 2020; 369 (published May 21st 2020): m2003https://doi.org/10.1136/bmj.m2003
        • The Strait Times Singapore
        Reach poll shows most Singaporeans complied with circuit breaker measures to stem spread of Covid-19.
        20th April 2020