Examining factors influencing public knowledge and practice of proper face mask usage during the COVID-19 pandemic: a cross-sectional study

Introduction

The COVID-19 pandemic in the Kingdom of Saudi Arabia accounted for 841,469 confirmed cases of COVID-19 and 9,646 deaths between 3 January 2020 and 6 September 2023 (World Health Organization, 2023). Global data of almost 180 nations as of July 29, 2020 has revealed the following: 16,558,289 were the positive cases reported; with 656,093 deaths; and 25,127 new cases; with a 4.9% mortality rate; and 180 nations afflicted with COVID-19 (Sawicka et al., 2022). However, despite the fact that the COVID-19 pandemic is no longer a public health emergency of global significance, we still need to maintain vaccination campaigns and epidemiological surveillance because of the infection’s current state. The World Health Organization (WHO) declared the emergency on January 30, 2020, and it ended on May 5, 2023, after 3 years and 3 months (Moraga-Llop & Campins-Martí, 2023). The pandemic caused turmoil and substantially impacted the public, including employment uncertainties, financial instability, mental health issues, educational disruption, family well-being concerns, and loss of loved ones. People protected themselves from the spread of the coronavirus by physical and social distancing, lockdowns, and other health protocols such as facemasks and hand hygiene (Gayatri & Puspitasari, 2022). The primary mode of transmission of COVID-19 was clearly through respiratory droplets from the infected individuals, with both symptomatic or asymptomatic individuals prone to transmitting the infection (Lai et al., 2020; Johansson et al., 2021).

Facemasks have long been used traditionally for general infection control. Generally, any pandemic preparedness involves the implementation of both pharmaceutical (vaccination and antiviral drugs) and nonpharmaceutical countermeasures, such as social and physical distancing, hand hygiene, and the use of facemasks (Brienen et al., 2010). Therefore, interventions such as facemasks uses, hand washing, lockdowns, physical distancing, and other hygiene measures were considered major preventive approaches (MacIntyre et al., 2009; Lepelletier et al., 2020). In this regard, facemasks and respirators were strongly recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) as a standard for transmission-based precaution (Siegel et al., 2007).

The specifications and recommendations regarding how to use facemasks vary across countries, and the use of facemasks has increased after the COVID-19 pandemic, including the use of N95 respirators (without any other protective equipment) (Rahman et al., 2022). Nations worldwide have repeatedly emphasized the necessary measures for the correct utilization of facemasks by the general public. These measures encompass cleansing one’s hands with soap and water or an alcohol-based sanitizer prior to donning the facemask. Additionally, it is important to properly position the facemask to cover the nose, mouth, and chin, ensuring a snug and secure fit. One should refrain from touching the front surface of the facemask while it is being worn, and proper disposal should be conducted (Desai & Mehrotra, 2020; Lee et al., 2020).

The proper facemask removal technique is to hold only the straps, fold the mask inward (possibly several folds) and dispose of it in closed bins with subsequent appropriate hand hygiene (Desai & Mehrotra, 2020; Lee et al., 2020). However, the incorrect use of facemasks might have profound consequences, such as reduced user protection and infection spread to others. In addition, the use of facemasks was unfamiliar, and the public was not accustomed to this practice. Many substandard practices, such as the prolonged use and reuse of facemasks are expected, and there is a paucity of data on this topic (Chughtai, Seale & MacIntyre, 2013). However, it is well known that the appropriate use of facemasks and respirators requires knowledge, training, and supervision (Tang & Wong, 2004; Chughtai et al., 2015). Moreover, individuals’ impudence regarding not being at risk and their lack of awareness concerning the proper use of facemasks might lead to decreased protection against the spread of infections.

The COVID-19 pandemic highlighted the gaps in health surveillance systems, disease prevention, and treatment worldwide (Global Burden of Disease 2021 Health Financing Collaborator Network, 2023). The COVID-19 pandemic has caused significant consequences due to a lack of pandemic preparedness, despite the tremendous research conducted on infectious diseases. This lack of preparedness has resulted in economic damage a substantial loss of human life (Neumann & Kawaoka, 2023).

Past experience demonstrated that many infections reemerge as new outbreaks with and produced high levels of mortality and morbidity. In addition, the identification of new pandemics are being discovered and on the race (Neumann & Kawaoka, 2023).

Facemasks are considered one of the basic preventive measures for any infection transmitted through the respiratory tract. The COVID-19 pandemic has led to increased demand for face masks, particularly the highly infectious omicron variant. Despite vaccinations, most nations still require masks, and the global market for face masks is projected to grow by 4% by 2026. However, improper disposal of masks poses a risk of viral transmission and environmental waste, as they have a limited usage time and must be replaced every 4–10 h (Oludoye et al., 2023). Although facemasks are no longer required during the post-pandemic period, their use has become a new normal among the public (Kaewchutima et al., 2023). The prevention of future pandemics may require preparedness from health care agencies and the public. One feasible option for preventing future pandemics is facemasks, and it is essential to educate the general public on the appropriate use and disposal of facemasks (Missoni, Armocida & Formenti, 2021).

A large number of face masks have been disposed of in the environment in recent years, and these masks could release contaminants and may produce ecotoxicological effect (Oliveira et al., 2023). It is a significant public health concern that the improper use of facemasks may lead to not only spread the diseases but also toxicity to the environment (Shammas et al., 2022). Therefore, appropriate disinfection methods should be followed by the public before they dispose of used facemasks. Local health authorities should develop active mechanisms to collect and dispose of used face masks from the public (Asim, Badiei & Sopian, 2021). Additionally, the effective management of used facemasks is necessary to prevent the reemergence of infectious diseases and the emergence of new pathogens. Therefore, the proper management of used facemasks must be encouraged among the public, and is significantly influenced by knowledge and awareness of the public towards the proper usage and disposal of facemasks (Barloa, Lapie & Cruz, 2016; Seng, Fujiwara & Spoann, 2018; Akkajit, Romin & Assawadithalerd, 2020).

Hence, it is essential to explore the existing knowledge, awareness, and practice regarding the appropriate use and disposal of facemasks and to design effective educational intervention (Pappas, 1994; Liang et al., 1999).

There is a scarcity of literature on the factors associated with the suboptimal use of facemasks, and it is imperative to investigate individuals’ willingness and consistency to comply with the guidelines for facemask use. Hence, the current study was conducted with an objective to explore the factors determining facemask use among individuals during the COVID-19 pandemic. This will equip us with valuable insights that will help us successfully navigate future pandemics considering the knowledge, attitude and practice of common people towards facemask usage and its proper disposal, which stands out to be the primary research question of the study.

Materials & Methods

Results

Discussion

Respiratory infections are not new. From seasonal flu to catastrophic outbreaks such as severe acute respiratory syndrome (SARS) in 2006, H1N1 in 2009, SARS-like disease in the Middle East in 2012 and COVID-19 since the end of 2019, respiratory infections have been a threat worldwide. Their reemergence or evolution of new pathogens may cause future pandemics (Sim, Moey & Tan, 2014). It has been reported that zoonotic events caused by the introduction of viruses into humans from mammals likely to lead to the next pandemic (Neumann & Kawaoka, 2023). Facemasks have been regarded as one of the major strategies to prevent the transmission of respiratory pathogens in the past and at present (Babatola et al., 2023) and they will continue to be used in future. During the COVID-19 pandemic, it was made mandatory to use facemasks in the Kingdom of Saudi Arabia. Extensive use of these facemasks necessitates their appropriate use; otherwise, they could become a biohazard (Al Naam et al., 2021). Hand hygiene ought to be observed prior to putting on the facemask and subsequent to its removal since this practice can reduce inadvertent contact between the face and potentially contaminated hands. Such precautions preserve the cleanliness of our environment and safeguard against other infections (Kampf & Kramer, 2004; Wangchuk et al., 2023). As seen in our study, those aged 26 to 35 years showed excellent handhygiene practices when using facemasks, surpassing the other age groups could be owed to the reason that the younger generation have a better access to the informatin, awareness, education through the technical advancement and social and peer awareness and goes similar in findings with the study published among university students from Abudhabi (Ajaj et al., 2023).

It has been inferred that older adults do not consistently adhere to good hand hygiene practices, which is directly linked to a lack of health literacy (Or, Wong & Chung, 2020). This finding suggest that older individuals may require additional education to ensure they fully understand and practice hand hygiene protocols. Males showed a more positive attitude than females in our study, in contrast with several previous studies that have revealed different obvious gender distinction regarding the perception and effectiveness of hand hygiene (Rubin et al., 2009; Park et al., 2010). Associated with this difference in knowledge levels, it has been postulated that females are less likely to take risks and thus more likely to follow hand-washing recommendations (Sim, Moey & Tan, 2014).

Participants with low monthly income and a history of COVID-19 infection showed a negative attitude toward frequent hand washing before and after using using facemasks. These participants were possibly unaware that hand hygiene is an important health measure before and after facemask use. A similar situation was observed during the SARS outbreak in 2002–2003, whe some hand hygiene behaviors were not respected, even by hospital workers (Lau et al., 2004).

Facemasks use has been recommended worldwide to prevent the spread of COVID-19 infection (Fouladi Dehaghi et al., 2020; Tabatabaeizadeh, 2021). The appropriate use of facemasks is crucial for containing the transmission of respiratory droplets and protecting oneself and others from infectious diseases. It is important to follow recommended guidelines for wearing facemasks correctly and consistently. In this study, the participants aged 26–35 years were found to wear their facemasks properly. However the study finding also suggests that demographic characteristics can negatively influence the appropriate use of facemasks. This might be due to the relatively simple designs of facemasks, leading many people to assume that they know how to use them (Ho, 2012)). This assumption can reduce the public’s desire to learn correct facesmask use protocols. In addition, a lack of knowledge might lead to inappropriate facemask use. The findings of our study are in line with those of a previous study that revealed an association between poor COVID-19 knowledge and a deficiency in facemask use (Al-Hanawi et al., 2020). We also found a significant association between facemask use attitudes and level of education, which is in agreement with similar studies conducted in Saudi Arabia and Bangladesh, that demonstrated that high educational qualifications resulted in positive attitudes toward COVID-19 preventive measures (Ferdous et al., 2020; Al-Hanawi et al., 2020).

Sharing masks can increase the risk of spreading infections between individuals since respiratory droplets containing pathogens can accumulate on the mask’s surface. Therefore, individuals should not share their masks with others and should be cautious about removing facemasks during social and personal meetings (World Health Organization, 2020). In the current study, most of the participants did not share their facemask with others. Participants staying with family, those with a college-or university-level education, and those who were working demostrated negative attitudes toward removing masks during their social or personal meetings. Therefore, information regarding the dangers of sharing masks or removing them during their social or personal meetings and how avoiding these actions helps prevent infection spread must be strognly conveyed to everyone.

It is interesting to note that, participants with a monthly income of SR 6,000–8,000 and a positive history of COVID-19 infection had a highly positive attitude toward not removing facemasks during their social or personal meetings. This finding suggests and effct of their previous experience with the disease or awareness of the dangers of removing masks. The effectiveness of infection control methods may be negatively impacted by sharing or taking off face masks during social or private interactions. People need to be aware of the possible dangers and repercussions that come with these actions. Therefore, it is necessary to post a warning reminding people not to take off their face masks in public areas. Additionally, educational initiatives should be put in place to inform people about the value of adhering to infection control protocols and good hygiene practices. These educational initiatives shallbe augmented by structured information leaflets or printed education materials, as these education materials are frequenlty used resource for education (Easwaran et al., 2023; Vigneshwaran, Padmanabha & Devanna, 2013).

During the COVID-19 pandemic, mask decontamination and reuse have been considered last-resort strategies during periods of mask shortages (Bhattacharjee et al., 2020). Participants belonging to the aged 50 years and older and with higher education had high knowledge regarding disinfection and reuse of facemasks. The most common methods used to disinfect and sterilize masks are decontamination with hot water or steam. Notably, this method may not be effective for all types of masks (Fathizadeh et al., 2020; Ma et al., 2020).

Improper facemask disposal is increasing in frequency, which contirbutes to infections. When worn or discarded incorrectly, facemasks can become contaminated and serve as a potential source of infection (Shetty et al., 2020; Mudenda et al., 2020; Mudenda et al., 2021). The adult population and participants with a high level of education were found to dispose of their used facemasks properly following the appropriate recommended procedures. The proper disposal of used facemasks is important for long-term care facilities or households with elderly and immune-compromised individuals, where improperly discarded masks can lead to severe repercussions (Bhattacharjee et al., 2020; Kaewchutima et al., 2023). The intitiatives from the educational institutions is imperative that they can take the lead in offering instruction on the subject. The incorrect disposal of facemasks poses a risk to the environment and could accelerate the spread of infection among people particulary among young people. According to the current study results, those aged 50 years and older should be targeted for education regarding the proper disposal of used facemasks and trained on how to collect, pack, and dispose of used facemasks correctly.

Our findings highlighted an important problem regarding how to use and/or reuse the facemasks or dispose of the used facemasks correctly. Disinformation, incorrect opinions, and knowledge related to mask use and reuse may increase the infection risk in the community. As reported, incorrectly disposed facemasks could become biohazards and risk new infections and outbreaks (Al Naam et al., 2021). Hence, awareness and information campaigns aimed at the general population are needed to implement the correct use of masks and limit the infection rate as much as possible. This could help in prevent new outbreaks and avoid the reemergence of COVID-19 outbreaks.

Limitations

Recognizing the limitations of facemask usage and disposal evaluation will guide future research, potentially leading to more extensive investigations on these essential infection control issues. The present research used non-probabilistic conveniece sampling, which limits its applicability to the entire population and may under- or overrepresent it. The sampling technique, small sample size and regional differences in Saudi Arabia may potentially limit the generalizability of the findings. This could have an impact on the results’ capacity to be applied to larger populations. Alternative sample techniques should be used in future studies to gain a more thorough insight. The small sample size was due to difficulties recruiting a large number of participants due to time, resources, or the study community. Depending on the research design and analytic methodologies, a small sample size can yield useful insights and statistical significance. Self-reported, voluntary electronic survey data were obtained. Thus, agreement bias may have altered the responses. The current study design limits causal inference. The current study identified determinants of facemask use and disposal but did not evaluate proper use or disposal. Future researchers should adopt stratified or cluster sampling to obtain a sample more representative of the population.

Future researchers can also use Bayesian theory, which provides a mathematical technique for revising probability based on new evidence for future research. This approach relies on conditional probability to incorporate past knowledge or beliefs into the analysis.

Machine learning algorithms can be used alongside Bayesian theory to tackle these challenges. These algorithms can examine enormous datasets and find patterns to correct ratios and fields by considering many aspects and variables.

Conclusions

The present investigation examined a range of demographic factors that impact the accurate use and proper disposal of facemasks. The three main characteristics that are crucial in developing targeted intervention strategies to enhance the prudent use and proper disposal of facemasks are gender, income, and employment. Furthermore, the findings of the present research suggest that it would be beneficial for facemask producers to reconsider the design of their packaging and provide comprehensive instructions pertaining to the appropriate use, and disposal of facemask and accurate application techniques. Critically, alteration of mindset toward recognizing and effectively addressing potential risks requires improvement. Therefore, in order to increase understanding, it is imperative to develop national awareness campaigns and similar initiatives. Health authorities should set up a workable system that allows the general population to gather and discard worn facemasks, beginning with informational campaigns and continuing through the ultimate disposal phase. Moreover, the results of the present study have significant implications for health preventive programs aimed at preparing for future pandemics since they highlight the males, high income and highly educated groups have shown better compliance and females, low income and not high educated groups should be prioritized in the development of such policies. Furthermore, it is advisable to integrate these interventional initiatives into national health policies to improve preparedness for future pandemics.

Supplemental Information