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 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 225-227  

Rational use of face mask in a tertiary care hospital setting during COVID-19 pandemic: An observational study

1 Postgraduate Student, Master of Public Health, School of Public Health, AIIMS, Rishikesh, Uttarakhand, India
2 Senior Resident, Department of Microbiology, AIIMS, Rishikesh, Uttarakhand, India
3 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
4 Assistant Professor, Department of Microbiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission30-Apr-2020
Date of Decision12-May-2020
Date of Acceptance14-May-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Meenakshi Khapre
Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_493_20

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Masks play a role in the protection of health-care workers (HCWs) from acquiring respiratory infections, including coronavirus disease 2019 (COVID-19) in health-care settings. This observational study was conducted among 382 HCWs in a tertiary care setting over a period of 1 month. Descriptive analysis was done to assess the rational and recommended use of masks/respirators during COVID-19 pandemic using a structured observation checklist as a survey tool. A total of 374 HCWs were included, 64.9% of whom were using face masks rationally as mentioned per risk area categorization with a predominance of triple-layered mask during all 4 weeks. Overall, 64.1% used masks correctly. Clear guidelines and strategies can help to increase the compliance of HCWs with rational use of face masks.

Keywords: Compliance, coronavirus, COVID-19, masks, pandemic, rational

How to cite this article:
Supehia S, Singh V, Sharma T, Khapre M, Gupta PK. Rational use of face mask in a tertiary care hospital setting during COVID-19 pandemic: An observational study. Indian J Public Health 2020;64, Suppl S2:225-7

How to cite this URL:
Supehia S, Singh V, Sharma T, Khapre M, Gupta PK. Rational use of face mask in a tertiary care hospital setting during COVID-19 pandemic: An observational study. Indian J Public Health [serial online] 2020 [cited 2022 Dec 5];64, Suppl S2:225-7. Available from:

   Introduction Top

The emergence of coronavirus disease 2019 (COVID-19) pandemic has led to a common practice of wearing masks among health-care workers (HCWs). HCWs need to be vigilant and prepared to incorporate infection control measures as per the recommended guidelines. Thus, training and supporting HCWs regarding infection control practices including the use of masks is vital.

Masks and respirators are commonly recommended by health-care organizations to protect HCWs from acquiring respiratory infections.[1] Although government and individual organizations may release somewhat different guidelines for the use of masks, actual clinical practice may vary quite a bit. Adherence with face mask and respirator use is traditionally low as compared to other personal protective equipment despite expert recommendations. In a systematic review by Gammon et al., the mean compliance rate for masks was reported as 30% (range: 4%–55%), while suboptimal compliance was not only reported during routine patient care but also during outbreaks and pandemics.[2]

Mere formulation of guidelines for use of masks in health-care settings does not ensure that those would be followed. To ensure the rational use of face masks and respirators by HCWs during this COVID-19 pandemic, they need to be continuously supervised and monitored to assure adherence. We assessed the compliance of HCWs toward rational and recommended use of masks/respirator in health-care settings in the context of the ongoing COVID19 pandemic; the novelty of this study is its observational approach to collect comprehensive data for the rational use of face mask.

   Materials and Methods Top

A hospital-based nonparticipatory covert observational study was done over a period of 1 month among all the HCWs including faculty members, resident doctors, nursing officers, hospital attendants, housekeeping staff, security guards, administrative, and other staff in a tertiary care setting. The risk classification of area was adapted from the Kayakalp scheme of the Ministry of Health and Family Welfare including (i) very high-risk areas (screening, isolation, trauma, and emergency area); (ii) high-risk areas (operation theatres, intensive care units, microbiology laboratories, and labor rooms); (iii) moderate-risk areas (outpatient departments and pharmacies); and (iv) low-risk areas (administrative area, library, and staff rooms)[3]

Simple random sampling with a lottery method was used to select areas which were further divided into three duty shifts: “morning,” “evening,” and “night”. Observations were made by two trained investigators (SS and TS) using a validated structured checklist, as recommended by the “WHO guidelines on the use of masks in the context of COVID-19.”[4] Prior to observation, it was ensured that in a particular area, a minimum of five persons were present to be part of the study, if not, it was replaced by the next randomly selected area. Each area was observed for 1 h. If a person was lost to observation within 10 min, then that person was excluded from observation in the final analysis. These observations were done without the knowledge of observant (covert).

Data quality was assured by the weekly review of data forms for completeness and accuracy by Hospital Infection Control Team (HICT) (MK and PKG). Data were entered using the data validation feature of MS Excel 2013 to maintain the data quality and exported to IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA) for the analysis. All variables were analyzed using frequency and proportion. Week-wise appropriate usage of mask was analyzed using Chi-square statistics. P < 0.05 was considered to be statistically significant. Field notes were also additionally taken. Noncompliant HCWs were immediately corrected by the investigators. Ethical committee clearance was obtained before the start of the study by HICT with reference letter number-XXX/IEC/20/191 dated April 11, 2020. Rational use of a face mask was defined as wearing a specific type of face mask according to our institute's infection control policy which was prepared considering the WHO and national guidelines for the use of masks.[4] The correct manner of mask use was defined as the use of medical masks/respirators in health-care settings as per the training conducted by HICT for preparedness of infection control as per the WHO guidelines.[4]

   Results Top

A total of 382 observations were completed over a period of 4 weeks with a mean observation time of 42 (±11) min. Three hundred and seventy-four observations were included in our final results, as eight observations of <10 min were excluded. Among the different HCWs, 106 (28.3%) were resident doctors, 71 (19%) were nursing officers, 55 (14.7%) were others including office staff and nonadministrative staff, 44 (11.8%) hospital attendants, 48 (12.8%) were guards, 27 (7.2%) were housekeeping staff, and 23 (6.1%) were faculty members.

Overall, compliance for wearing a face mask/respirator was good. During the 1st week, 74 (81.3%) were wearing triple-layered mask with an increased use of respirators and double-layered masks; in the 4th week, it was 19 (21.8%) and 9 (10.3%), respectively. It had been observed that 17 (15.3%) were using cloth mask during the 3rd week. The week-wise frequency distribution of observations in various areas and type of masks is presented in [Table 1].
Table 1: Week-wise distribution of categories of risk areas and type of masks among all health-care workers in a tertiary care setting (n=374)

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Of 374, 60 did not wear any type of mask. Among 314 observations of those using face mask/respirators, 204 (64.9%) used face masks as per the risk area categorization. None of the HCWs wore dirty/soiled/torn masks or masks facing the reverse side or upside down. Details of week-wise observations of different practices are illustrated in [Table 2]. Seventy-nine HCWs were observed at the time of wearing mask; among whom, only 7 (8%) followed proper guidelines for putting on a face mask. Fifteen HCWs disposed of their masks during the observation time and discarded those in yellow bins. Two hundred and thirty-four HCWs were observed during activities such as eating and drinking; among them, 33 (14.1%) hung their masks around the neck and 9 went to washroom wearing their masks. Of the 42 HCWs who were observed wearing masks during other activities, only 2 HCWs (4.77%) secured their masks at a safe place prior to other activities.
Table 2: Week-wise observation of different practices of face masks (n=314)

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   Discussion Top

Appropriate use of face mask is essential to avoid the risk of transmission of any associated respiratory infection. By covert observation, we assured that the behavior of HCW was not altered (limit Hawthorne effect) and the duration of observation was kept to 1 h to assure good data quality. All the issues noticed during observation were corrected at the end of the observation period.

After training the HCWs for the preparedness for infection control as per our institute's policy, the practices of adequate use of facemask during the 1st week of observation were satisfactory; however, it significantly decreased in 2nd and 3rd weeks but increased in the 4th week. This change in behavior may be due to apprehension about the pandemic in its initial phase that decreased in later weeks due to less number of reported COVID cases in our during observation time leading to low perceived risk of infection. Practice again improved in the last week due to continuous supervision and monitoring of HCWs. A similar finding was reported by Ferng et al. that the use of masks increased when the risk was perceived to be high.[5]

On the basis of the type of mask, 60.16% of the HCWs were using triple-layered mask as compared to N95 (12.03%). This may be due to nonavailability of N95 masks due to its short supply or strict implementation of rational use policy.

It was observed over a 4-week study period that the usage of N95 masks in low-risk area was considerably high despite training to the contrary. Similar findings were exemplified by Chugtai et al. and Gammon et al.[1],[2] This may be attributed to the belief that N95 respirators are superior to surgical masks in protecting HCWs against transmissible acute respiratory infections in clinical settings.[6]

In our study, only 1.26% of the HCWs working in very high-risk area were observed to use more than one mask together (on top of one another) which was low when compared to the study by Chughtai et al.[1] The HCWs were responding well to the training and following the guidelines, as was observed over a period of 4 weeks. To achieve full adherence to guidelines, regular training is needed as also exemplified by Chau et al.[7]

Adeleke et al and Akshaya et al also reflected on the views of participants of their studies that absence of training for use of masks limited their ability to use masks correctly.[8],[9],[10]

The study highlights that clear guidelines need to be formulated and reinforcement done through appropriate information, motivation by senior staff members, strict monitoring, auditing, and disciplinary measures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Chughtai AA, Seale H, MacIntyre CR. Availability, consistency and evidence-base of policies and guidelines on the use of mask and respirator to protect hospital health care workers: A global analysis. BMC Res Notes 2013;6:216.  Back to cited text no. 1
Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs 2008;17:157-67.  Back to cited text no. 2
Swachhta Guidelines for Public Health Facilities. Available from: [Last accessed on 2020 May 08].  Back to cited text no. 3
World Health Organization. Advice on the Use of Masks in the Context of COVID-19: Interim Guidance, 6 April, 2020. Geneva, Switzerland: World Health Organization; 2020. p. 1-5.  Back to cited text no. 4
Ferng YH, Wong-McLoughlin J, Barrett A, Currie L, Larson E. Barriers to mask wearing for influenza-like illnesses among urban hispanic households. Public Health Nurs 2011;28:13-23.  Back to cited text no. 5
Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of masks and respirators against respiratory infections in healthcare workers: A systematic review and meta-analysis. Clin Infect Dis 2017;65:1934-42.  Back to cited text no. 6
Chau JP, Thompson DR, Twinn S, Lee DT, Lopez V, Ho LS. An evaluation of SARS and droplet infection control practices in acute and rehabilitation hospitals in Hong Kong. Hong Kong Med J 2008;14 Suppl 4:44-7.  Back to cited text no. 7
Adeleke O. Barriers to the implementation of tuberculosis infection control among South African healthcare workers: emerging public health practitioner awards. S Afr Health Rev 2012;2012:197-203.  Back to cited text no. 8
Akshaya KM, Shewade HD, Aslesh OP, Nagaraja SB, Nirgude AS, Singarajipura A, et al. Who has to do it at the end of the day? Programme officials or hospital authorities?” Airborne infection control at drug resistant tuberculosis (DR-TB) centres of Karnataka, India: A mixed-methods study. Antimicrob Resist Infect Control 2017;6:111.  Back to cited text no. 9
Tan NC, Goh LG, Lee SS. Family physicians' experiences, behaviour, and use of personal protection equipment during the SARS outbreak in Singapore: Do they fit the Becker Health Belief Model? Asia Pac J Public Health 2006;18:49-56.  Back to cited text no. 10


  [Table 1], [Table 2]

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