Prevalence and acceptance of face mask practice among individuals visiting hospital during COVID-19 pandemic: Observational study

Background: The COVID-19 transmission has been established to occur through respiratory droplets from coughing and sneezing. Health agencies have strongly recommended the use of facemask as a precaution from cross-transmission. Objective: This study investigated the prevalence of facemask use among visitors to the hospital. This study also investigated the demographic factors contributing to unacceptable facemask practice. Setting: This prospective observational study was done among hospital visitors to a district specialist hospital during COVID-19 pandemic outbreak. Methods: Individuals entering through dedicated entry point were observed for the type, category and practice of wearing personal protective equipment. Inclusion criteria for this study were any individual's ≥2 years old entering the treatment facility from selected entry points. Patients were categorized into two groups of acceptable and unacceptable facemask practice. The Pearson chi-square was used to test for differences in investigated variables in the univariate setting and Binary Logistic regression model was used in the multivariate setting. Main Outcome Measure: Prevalence, acceptance practice and odds ratio of unacceptance of facemask use. Results: Among 1652 individuals included in the final analysis, 1574 (96.9%) was observed wearing facemask with 1269 (72.0%) of individuals worn medical-grade facemask. However, among them, only 1397 (88.8%) individuals' facemask practice was acceptable while the reaming 177 (11.2) individuals were perceived with unacceptable facemask practice. Male individuals, Malay ethnic and high risk age group are 1.47 times (Odds Ratio: OR=1.47;95% CI, 1.06-2.06;p=.023), 2.18 times (OR=2.18;95% CI, 1.55-3.08;p<.001) and 1.99 times (OR=2.18;95% CI, 1.42 - 2.77;p<.001) more likely to exhibit unacceptable facemask practice respectively. Conclusion: Extensive use of facemasks coupled with environmental hygiene measures is a public health strategy which can help to mitigate the COVID-19 epidemic impact. However, a targeted comprehensive strategy to improve compliance to proper facemask practice among the high-risk population is needed to achieve maximal protective benefit.


Methods
Individuals entering through dedicated entry point were observed for the type, category and practice of wearing personal protective equipment. Inclusion criteria for this study were any individual's ≥ 2 years old entering the treatment facility from selected entry points. Patients were categorized into two groups of acceptable and unacceptable facemask practice. The Pearson chi-square was used to test for differences in investigated variables in the univariate setting and Binary Logistic regression model was used in the multivariate setting.

Main outcome measure
Prevalence, acceptance practice and odds ratio of unacceptance of facemask use.

Conclusion
Extensive use of facemasks coupled with environmental hygiene measures is a public health strategy which can help to mitigate the COVID-19 epidemic impact. However, a targeted

Introduction
In late December 2019, an initial clusters of pneumonia cases of unknown novel coronavirus disease (COVID-19; previously known as 2019-nCoV or SARS-CoV-2) was reported in Wuhan, China [1,2]. By March 2020, the outbreak subsequently spread to more 26 countries worldwide which promoted the World Health Organization to declared the infection a pandemic, indicating significant public health emergency of international concern [3]. In general, COVID-19 is an acute systemic and respiratory disorders which appear after an incubation period of approximately 5.2 days with common symptoms such as fever, cough, fatigue, , sneezing , sore throat and sometimes accompanied by rhinorrhoea, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia [ [4][5][6][7]. Although the infection is selflimiting in 81 % of the cases , 19 % of the infection will require medical support with a 1.5-3.6% fatality rate according to Clinical and epidemiological data from the China Centres for Disease Control and Prevention [8,9].
As with other respiratory pathogens, including flu and rhinovirus, the transmission is believed to occur through respiratory droplets from coughing and sneezing [10,11]. It is now concluded that sustained human-to-human transmission aided in the establishment of the COVID-19 epidemic [12,13] .Although the consensus of asymptomatic individuals transmitting the virus before symptoms develop seems to be inconclusive, a risk on transmission cannot be fully excluded [8,14,15]. This data suggests that the use of respiratory protection and isolation is the best way to contain this epidemic.
During the early stage of the outbreak ; graphic pictures of civilian, authorities and health care personnel wearing extensive personal protective equipment (PPE) were widely covered by media highlighting the importance hygiene barriers in preventing infection [16]. Once local epidemics begin, a substantial increase in the use of PPE both in community and healthcare settings were reported [17][18][19]. While there was consistency in the recommendation that symptomatic individuals and health care workers should use facemasks, discrepancies in practice were observed in the general population. A research group led by Feng S et al have complied the conflicting recommendation by difference agencies ; For example, the western countries such as the United States, United Kingdom and Germany health authorities have advised against buying masks for use by healthy people while Asian countries such as China , South Korea and Japan have adopted a risk-based approach by distributing facemask to the general public [20] . This sudden uptake in the use of PPE especially facemasks by the general public exacerbates the global supply shortage of facemasks, risking supply constraints to both health-care workers and vulnerable population particularly those older than 65 years and immunocompromised individuals [21,22] .
Ideally, basic PPE to such as facemasks should be available en masse, especially worn by vulnerable populations and people with underlying health conditions. However, the usage of facemask depends on the recommendation of local health authorities as well as the availability of the commercial product in the market. The facemask practice among real world general population is relatively unknown [23]. Understanding facemask usage among local community particularly among those visiting high risk area for cross-contamination such as hospital is one research area that may help to describe the prevalence of respiratory protective device used.
The findings of this research could be used to improve strategic management for public health as well as managing Covid-19 pandemic in community setting.

Aim of the study
This study aims to investigate the prevalence and types of respiratory protective device (facemask) usage among individuals visiting hospital during  pandemic .This study also aims to evaluate the acceptance of the facemask practice worn by individuals.

Ethics Approval
The ethical approval to conduct the study was obtained from the Medical Ethical Review

Study setting
For this study; patients, their companion or visitors entering the hospital will be all be referred to as individuals. This prospective observational study was conducted among individuals visiting Hospital Seri Manjung, Malaysia in April 2020. At the time of writing, this treatment facility practices preliminary screening (body temperature and respiratory symptoms) for visitors before entering the treatment facility with a separate entry point for visitors with respiratory symptoms and those without. The study subject for this study was selected from entry point without respiratory symptoms which provided a representative of the asymptomatic general population where the decision of wearing facemask is a matter of choice rather than a requirement.

Inclusion and Exclusion
Inclusion criteria for this study were any individuals entering the treatment facility from selected entry points (without respiratory symptoms). Exclusion criteria for this study were individuals less than 2 years old, visiting the emergency department, working at the treatment facility, individuals which are suspected of multiple entry and individuals who are exiting the treatment facility entrance.

Data Variables
Individual data were collected by visually observing the type of facemask used and evaluating the garbing practice among visitors entering into the treatment facility. The following demographic data were collected: patient's gender, age group and ethnicity while facemask data such as category and type of the product as well as garbing technique was recorded.
Besides, the time of entrance to the facility was recorded. Gender was categorised as either male or female while patients ethnicity was categorised into Malay or Non-Malay to reflect population distribution [24]. The Visitors age group was recorded as either as children, adult or elderly which was done based on subject's facial and physical feature [25] . The age group was further categorised to low-risk age (children and adult) or high-risk age (elderly) group [26][27][28]. Facemask usage classifies as either "Yes" when any type of respiratory protective device is worn or as "No" when the product is absent. The category of facemask used was described according to their class ; surgical facemask (2 , 3 ply or any medical grade mask) , respirators (all respirator Standard ; FFP1 & P1 , FFP2 & P2 , N95, N99 & FFP3, P3 , N100 ) , cloth or paper mask . The facemask was further categorized as medical-use (Surgical facemask and respirator) or non-medical use (cloth and paper mask).The acceptance level of facemask practice was recorded as acceptable (correct wearable method) or unacceptable (incorrect method). The reason for unacceptable practice was further described as well. Finally, the visit time was categorized to morning session (am until 12 pm) or evening session (1 pm until p.m.) to reflect the elective operational hour of the facility. Additionally, we also collected information on any other type of PPE such as glove, apron, hair cover or any other atypical used.

Statistical analysis
All demographic and categorical variables were presented as number (n) and percentage (%). Pearson's chi-squared test was used to determine the statistically significant difference between the demographic characteristic between age group and the acceptance level of facemask practice. Simple logistic regression was used to screen the independent variable.
Variables with p value <0.25 were included in the multivariate analysis. Binomial logistic regression test was applied to determine the contributing factor to unacceptable facemask garbing practice. Correlation matrix was checked for interaction between the variables. The Hosmer and Lemeshow test, Classification table and the Area under the curve was used to evaluate the model of good fit. The final model was presented with 95% confidence interval (CI) and its corresponding p-value. For all test Two-tailed p-value <0.05 was considered as statistically significant. All statistical analyses were performed using SPSS for Windows (1559) combination of adult and elderly , which is a good representation of the local population . As shown in Table 1, 1574 (96.9%) of individuals had worn facemask. Among them 1269 (72.0%) individuals worn medical grade facemask with a majority of them was wearing surgical type facemask (70.5%). We also observed that 45 (2.8%) individuals had at worn glove, however we did not observe any practice of using of hair cover, boot cover, apron/overall or any other types of atypical PPE among the study population.  The acceptance level were analysed between individuals who have worn facemask. As shown in Table 3, within 1574 individual who worn facemask, 1397 (88.8%) individuals' facemask practice was acceptable while the reaming 177 (11.2%) subject was perceived with unacceptable facemask practice. A significant relationship was found between facemask practice and the following variables; gender, ethnic, age group and session of visit to facility.
Higher proportion of male from unacceptable group (66.1%) and acceptable group (56.2%) was observed compared to female χ2 (1) = 6.306, p =.012. As for ethnicity, higher number of    reported substantial mortality impact [31]. South Korea was one of the hardest hit country during the initial outbreak but had managed to limit their COVID-19 outbreaks without lockdown. The success of Korean government could be attributed to extensive testing, rigorous contact tracing, and strict isolation as well as universally practices facemask in public [32] .
Similarly , Hong Kong with world's highest prevalence of public facemask reported shorter influenza season (5 weeks versus 12-18 weeks) during the first wave of the COVID-19 epidemic [33]. Generally, health care authorities have recommended using facemask and practising social distance to reduce cross-transmission. This had led to a surge of demand for medical facemasks. Notably, China as the epicentre of the outbreak estimated the daily demand of facemask to be >50 million whereas the daily production has now dropped from 20 million to 15 million [33]. These have resulted in shortage of medical facemasks, which appears to be worldwide phenomena [17][18][19]34]. Although Malaysia have reported shortage of facemask during the initial outbreak [35], the high prevalence (96.9%) of individuals had worn facemask and majority (72.0%) of them were using medical grade facemask indicating accessibility of facemask in local community . the wide spread use and availability of the facemask could be due to a few initiatives taken by the Malaysian government , namely ; importation on 10 million facemask from china during the acute shortage phase [36] , increase in manufacturing and establishment of new manufacturing facility to increase in production capacity of local manufacturer [37,38] and handling out 24.6 million facemask to Malaysian household [39].
Although we observed high percentage of medical grade facemask usage in both high-risk age group and low-risk age group, the high proportion among low-risk age group raises the question on the necessity of medical grade facemask use in community setting. The consensus recommended the use of facemask for vulnerable population particularly those older than 65 years and immunocompromised individuals. Evidence that facemasks can protect against infections in the community is relatively scare [40][41][42], as acknowledged by contrasting views on medical facemasks by governments and public health experts [20].  [9,54,55]. Although the current rate of mortality among Malay Ethnic is unknown, comorbidity among Malay ethic [56][57][58][59] predisposed them to increased hazard of death. Non-compliance to facemask practice such as loosely fitted facemask , exposing mouth and nose as observed by us have been reported as main concern in previous by other researches as well [33,53,60]; however the compliance could be improved through targeted public health education [40,41].
While waiting for effective antiviral treatment against Covid-9 , public health agencies should encourage personal hygiene behaviours such as facemask as adjuvant to social distancing and hand hygiene which have been proven to be effective in infection control [41,61]. In addition, pre-emptive action needed to ensure compliance use of facemasks especially vulnerable populations to alleviate the stress on health care system.
Although our study presented the use of facemask among general population, our finding are not generalizable as the prevalence of facemask use from a single centre heavily really on local health care recommendation and the availability of commercial product on market. In addition, our population consist of individuals visiting hospital which is generally considered as high risk area for cross-infection and hence visitors could have taken extra precaution which could have skewed our observation.

Conclusion
Ongoing Covid-19 infection in humans are unprecedented and no single strategy have proven to successfully contain the outbreak. Facing a worldwide public health emergency with limited effective clinical treatment, the inevitable impact public health is of paramount importance.
Extensive use of facemasks coupled with comprehensive campaigns and other environmental hygiene measures is a vital epidemiology strategy which may help to mitigate the COVID-19 epidemic impact. In spite of contradicting opinion on the potential value of facemasks for general population use, targeted personal health education strategy to improve compliance to proper facemask practice among high risk population is needed to achieve maximal protective benefit.