INTRODUCTION:

COVID 19 virus continues to spread globally, posing a serious threat to mankind and caused challenges to health care professionals.¹ The pandemic also changed lifestyle and hygienic practices among people.² The interventions such as using face masks, hands washing, lockdowns, physical distancing and other hygiene measures are considered as major preventive strategy.^3,4

In this regard many countries have mandated the use of face masks among the public and health care workers.^5,6 Face masks have traditionally been used in general infection control.⁷ Improper disposal of face mask is a great environmental threat and shall be considered as biomedical hazard.^8,9 Pandemic has increased the demand, usage and disposal of face masks. Community had not faced such huge use of face mask use in recent hundred years.Disposal of facemask in health care settings by the healthcare professional might be easy and manageable but it may not be properly done by the non-healthcare individuals in public due to lacuna in knowledge and regulations. The knowledge on household waste and medical waste disposal among the public is low in the selected population.^10,11 By considering this, public awareness and practice on proper disposal of face mask is a great question mark.¹² The rational use of face masks requires an appropriate knowledge and awareness and it may vary between the health care and non-health care individuals. Therefore, it is essential to explore the existing knowledge, awareness and practice towards the rational use and disposal of face masks between health care and non-health care individuals.^13,14 Thus the current study was designed to compare the knowledge, awareness and practice among health care and non-health care individuals towards rational use and disposal of face masks.

MATERIALS AND METHODS:

Study design and sample:

It is a cross sectional questionnaire based study conducted among the selected towns of five different states of south India. The study duration was three months between July and August 2020. The current study utilised the non-probabilistic convenient sampling technique. The subjects those who were 18 years and above were included in the study. Participants from both the gender were invited to participate in the survey irrespective of their demographic characteristics. The electronic survey was created using google forms and was circulated through various social media platforms. Grouping: The participants in the survey were grouped into health care professionals and non-healthcare individuals based on their response. The health care professionals included both healthcare students and the practicing physicians, nurses, pharmacists and physiotherapists (128 subjects – Group 1) and non-health care individuals included common public (301 subjects - Group 2).

Questionnaire and data collection:

The questionnaire assessed the knowledge and attitude on usage and disposal of face masks which was distributed in local regional languages (Tamil, Telugu, Kannada, and Malayalam) and English as well. The questionnaire was prepared by referring to various published literatures and world health organization guidelines. The pilot study was conducted to estimate the content validity. The questionnaire was originally prepared in English and was translated to regional languages in south India. The language validation was done by using back translation method. The items included in the questionnaire were mixed model. Total of 31 items were included along with one item dedicated for informed consent. The sections included in the questionnaire are demographic characteristics (9 items), type of face mask use (1 item), attitude on usage of face mask (12 items) and knowledge and attitude on disposal of face mask (9 items).

Ethical considerations:

The study was approved by institutional review board of Balaji college of pharmacy and the approval # is IRB/2020/BCP-PD/32. The data are kept confidentially and all the subjects were free to participate or not to participate in the study by providing an electronic consent.

Statistical analysis:

The data were downloaded from the google survey as excel file and was exported to statistical package for social sciences (SPSS), version 22.0 for Windows for statistical analysis. The descriptive statistics were used to illustrate the demographic characteristics. The comparison between healthcare and non-healthcare individuals for the frequency of correct responses to the questionnaire was tested by using χ2 test. P value was considered significant if < 0.05.

RESULTS:

Overall 442 subjects responded the survey. Out of which only 429 responses were included for the final analysis. Remaining responses were excluded due to incomplete data or disagreement with the consent. The study included 128 health care professionals and 301 non health care individuals. The scale reliability coefficient was found to be 0.56 for comparison of appropriate usage of face masks among health care professionals and non-health care individuals. The majority of the study subjects were in the age group of 18 – 25 years (43.8 % and 65.1 % in group 1 and group 2 respectively). The majority of the participants in group 2 were females. The distribution of gender was equal in group 1. Overall, 91 % of study subjects from both the groups were living with their families. 100% and 95.7 % of study subjects from group 1 and 2 had completed their college /university level education. Among all the participants, around 50.8% of the study subjects were students and 37.8 % of subjects were salaried workers. In group 1, more than 40% of the subjects were earning 20,000 Indian rupees and above per month, whereas in group 2, majority of the subjects were earning an monthly income of 10,000 – 20,000 Indian rupees per month (37.9%) and around one quarter (28.6 %) of the respondents’ income was less than 5000 Indian rupees per month. Table 1.

Table 1. Demographic characteristics of the study subjects

Characteristics		Group 1 (HCP) Frequency (%) N=128	Group 2 (Non-HCP) Frequency (%) N=301	Total Frequency (%)
Age in years	18-25	56 (43.8)	196 (65.1)	252 (58.7)
	26-35	43 (33.6)	46 (15.3)	89 (20.7)
	36-45	23 (18.0)	38 (12.6)	61 (14.2)
	46-50	3 (2.3)	8 (2.7)	11 (2.6)
	>50	3 (2.3)	13 (4.3)	16 (3.7)
Gender	Male	64 (50.0)	92 (30.6)	156 (36.4)
Gender	Female	64 (50.0)	209 (69.4)	273 (63.6)
Living Status	Alone	27 (21.1)	12 (4.0)	39 (9.1)
Living Status	With Family	101 (78.9)	289 (96.0)	390 (90.9)
Education	No formal education	0 (.0)	1 (.3)	1 (0.2)
	Primary school	0 (.0)	2 (.7)	2 (0.5)
	Secondary school	0 (0.0)	10 (3.3)	10 (2.3)
	College / University	128 (100.0)	288 (95.7)	416 (97)
Occupation	Student	33 (25.8)	185 (61.5)	218 (50.8)
	Home maker	1 (.8)	23 (7.6)	24 (5.6)
	Farmer	0 (0)	2 (.7)	2 (.5)
	Salaried	89 (69.5)	73 (24.3)	162 (37.8)
	Not working	5 (3.9)	18 (6.0)	23 (5.4)
Monthly Income (Indian Rupees)	Less than 5000	15 (11.7)	86 (28.6)	101 (23.5)
	5000-10000	20 (15.6)	46 (15.3)	66 (15.4)
	10000-20000	38 (29.7)	114 (37.9)	152 (35.4)
	More than 20000	55 (43.0)	55 (18.3)	110 (25.6)
Familial Covid history	No	110 (85.9)	284 (94.4)	394 (91.8)
	Yes	18 (14.1)	17 (5.6)	35 (8.2)

Table 2: knowledge and attitudes on appropriate usage of Face mask

Items	Response	Group 1 Frequency (%)	Group 2 Frequency (%)	Total Frequency (%)	P value^†
Do you wash your hands before start using face mask?	Correct	105 (82)	241 (80)	346 (81)	0.690
Do you wash your hands before start using face mask?	Wrong	23 (18)	60 (20)	83 (19)	0.690
While using face mask, do you uncover any one of the following? Face or chin or nose.	Correct	87 (68)	203 (67)	290 (68)	1.000
	Wrong	41 (32)	98 (33)	139 (32)	1.000
Do you frequently touch the face mask, preferably on the front side?	Correct	100 (78)	238 (79)	338 (79)	0.897
	Wrong	28 (22)	63 (21)	91 (21)	0.897
When you are using cloth/fabric mask, do you wash the mask with the detergent when you want to reuse it?	Correct	111 (87)	277 (92)	388 (90)	0.106
	Wrong	17 (13)	24 (8)	41 (10)	0.106
How often do you wash your Cloth/Fabric mask?	Correct	86 (67)	198 (66)	284 (66)	0.796
How often do you wash your Cloth/Fabric mask?	Wrong	27 (21)	69 (23)	96 (22)	0.796
Do you wash your hands after removing the face mask?	Correct	115 (90)	276 (92)	391 (91)	0.578
Do you wash your hands after removing the face mask?	Wrong	13 (10)	25 (8)	38 (9)	0.578
Do you wear a loose mask?	Correct	116 (91)	268 (89)	384 (90)	0.731
Do you wear a loose mask?	Wrong	12 (9)	33 (11)	45 (10)	0.731
Do you share your mask with others?	Correct	127 (99)	297 (99)	424 (99)	1.000
Do you share your mask with others?	Wrong	1 (1)	4 (1)	5 (1)	1.000
Do you wear a mask under the nose?	Correct	108 (84)	264 (88)	372 (87)	0.354
Do you wear a mask under the nose?	Wrong	20 (16)	37 (12)	57 (13)	0.354
Do you remove mask when you are talking with unknown person?	Correct	128 (100)	297 (99)	425 (99)	0.322
	Wrong	0 (0)	4 (1)	4 (1)	0.322
Do you remove mask when you are talking with your friends or office colleagues?	Correct	119 (93)	267 (89)	386 (90)	0.220
	Wrong	9 (7)	34 (11)	43 (10)	0.220
Do you reuse the Medical/Surgical mask?	Correct	93 (73)	214 (71)	307 (72)	0.815
Do you reuse the Medical/Surgical mask?	Wrong	35 (27)	87 (29)	122 (28)	0.815
If you use Medical/Surgical mask, do you ensure colored side faces outwards?	Correct	95 (74)	177 (59)	272 (63)	0.003*
	Wrong	33 (26)	124 (41)	157 (37)	0.003*

* P value <0.05 considered significant. ^†Chi square test.

Table 3: Knowledge and attitudes on appropriate disposal of face mask

Items	Response	Group 1 Frequency (%)	Group 2 Frequency (%)	Total Frequency (%)	P value^†
Approximately, How long the Medical/Surgical face masks can be used?	Correct	46 (36)	97 (32)	143 (33)	0.502
	Wrong	82 (64)	204 (68)	286 (67)	0.502
While you remove your mask, will you touch front side of the mask with your bare hands?	Correct	106 (83)	247 (82)	353 (82)	0.891
	Wrong	22 (17)	54 (18)	76 (18)	0.891
Do you use gloves or tissues to remove face mask?	Correct	31 (24)	55 (18)	86 (20)	0.187
Do you use gloves or tissues to remove face mask?	Wrong	97 (76)	246 (82)	343 (80)	0.187
Do you throw your face mask in an open environment or in open trash bin after its usage?	Correct	100 (78)	249 (83)	349 (81)	0.280
	Wrong	28 (22)	52 (17)	80 (19)	0.280
Do you discard the face mask, if it is wet or damaged?	Correct	114 (89)	239 (79)	353 (82)	0.018*
Do you discard the face mask, if it is wet or damaged?	Wrong	14 (11)	62 (21)	76 (18)	0.018*
Do you think improperly discarded face masks has potential health hazards?	Correct	117 (91)	268 (89)	385 (90)	0.602
	Wrong	11 (9)	33 (11)	44 (10)	0.602
Do you think pathogens can survive for long hours in used face masks?	Correct	117 (91)	272 (90)	389 (91)	0.857
	Wrong	11 (9)	29 (10)	40 (9)	0.857
After usage, do you leave your mask within the reach of others?	Correct	120 (94)	273 (91)	393 (92)	0.346
	Wrong	8 (6)	28 (9)	36 (8)	0.346
Do you fold inwards (possibly several folds) and discard your mask to avoid the pathogens being exposed outside?	Correct	74 (58)	175 (58)	249 (58)	1.000
	Wrong	54 (42)	126 (42)	180 (42)	1.000

* P value <0.05 considered significant. ^†Chi square test.

DISCUSSION:

Several published literatures from Asia estimated the knowledge, attitude and practice on COVID 19 and other medical waste management among healthcare and non-healthcare individuals but not specifically about face masks.^15-19To our knowledge, this is the first published research study estimated the knowledge and awareness on rational use of face masks and disposal, among the health care and non-healthcare individuals particularly during this ongoing COVID-19 pandemic in south India. People around the world are driven by their governments to wear face masks along with other precautionary measures to contain the spread of this disease.²⁰

Various awareness and educational programs are being conducted to the public to provide proper guidance on the rational use and disposal of face masks. Moreover, the fundamental healthcare education provides a deep understanding towards the same to the healthcare professionals as it comes as the part of their feature. The current pandemic has narrowed the gap between the healthcare and non-healthcare individuals in combating COVID 19, where the use of face masks become mandatory.²⁰ Hence, evaluation of rational use of face masks and their disposal by the people living in a community was undertaken in the current study by dividing them in to sects, per se, for the sake of deriving an understanding.

It was evident from our results that the non-healthcare individuals use the non-medical face masks including piece of clothes, face veils, hand kerchiefs, scarfs, etc., which reflects their negligence towards battle against COVID 19. The Canadian center for occupational health and safety reiterates that not all the fabrics used to cover the face provide the protection in the same way as the surgical masks do.²¹ Continuous use of non-recommended fabrics may jeopardize the health of the individual, family and the community as they are not up to the standards, and are not designed to fit the face tight enough to provide the required protection against COVID 19.²² Instead, the only advantage of these fabrics, if worn, are that they limit the spread of the droplets when sneezed or coughed in a public area to some extent, where social distancing is not possible,²³ whereas, the spread of the disease is well controlled with medical facemasks than the fabric cloths.²² In this regard, the respirators are given 95% higher ratings in terms of safety and efficiency against protecting the individual who wears it.^21,24,²⁵

Awareness regarding the usage of the face masks among the given participants was at acceptable limit.^26,27In terms of knowledge and awareness on using face masks, the responses were nearly the same in both the groups, except selecting the appropriate front side of the face masks by differentiating the color of the surface and many participants have reflected an idea that they chose to use the facemask even if it is wet or damaged.

While discussing the face masks as a tool for prevention of this pandemic, the disposal of the used face masks should not be neglected. A recent research, which studied the disposal of medical waste in Asian countries in the current pandemic suggested a strict guidelines for medical waste management should be implemented.²⁸ In the current study, though the study subjects have known some ideas on how to dispose the used face masks, there is a shortfall in terms of method of disposal or awareness on existing guidelines with regards to disposal of face masks. Earlier, the guidelines on medical waste management were taught only for the healthcare professionals, but now it is required for common public as well, and at least for the face masks, since the use of face masks is very well increased among common public during the current pandemic, though initially face mask use among public was not preferred by the experts due to the reason of self-contamination.²⁹

In contrast to a Bangladesh study, which ascertained the knowledge and practice on medical waste management was insufficient among health care workers in Bangladesh due to lack of financial support.³⁰ It is satisfying that the healthcare professionals in our study possess an adequate knowledge regarding the disposal of face masks and it can be extended to the non-healthcare individuals with the help of personnel and financial support from the government.

The responses from the participants clearly show that there are some pitfalls in using and disposing the face masks in an appropriate way, which need to be improved. Since the pandemic forced most of the common public and some of the healthcare professionals to wear the face masks without prior experience or practice, it is necessary to conduct awareness programs on “how to use the face masks’ in an appropriate way.

Our study had explored few irrational practices of using face mask. So, the findings of our study will help the healthcare authorities in designing an awareness program with the inclusion of the above discussed issues. Besides, the published studies revealed that the people are willing to change their behavior to combat COVID 19 infection.³¹ In addition it was highly recommended by many of the researchers that a community based awareness program followed by a structured educational leaflets distribution must be taken up to bring the awareness and seriousness regarding the usage and disposal of face masks among both the common public and the healthcare professionals. ^32,33,34

A pandemic with the irrational human intervention with the improper usage and disposal of the after use face masks may act as curse on us leading the mankind to combat the situation without many gains. Maintaining the highest possible sterile environment or controlled situations cannot guarantee the control of spread of infections at community level.³⁵A proper awareness among the public towards the same may create cautious application and develops responsibility towards battling the notorious diseases like COVID – 19. One who lacks the knowledge can gain from a knowledgeable provider for the fruitful outcomes.

CONCLUSION:

The study explored that both health care and non-health care individuals were having enough knowledge and positive attitude towards the appropriate usage and disposal of face masks and found highest among young and college going participants. Still there are areas which need to be focused and improved by educating the general public, which may upgrade their knowledge and awareness regarding facemasks in the prevention of communicable diseases including COVID 19. State government agencies has to develop proper awareness and scientific disposal methods for disposing used face masks. One area of prime most important and needed improvement is the change in the attitude of acceptance of threat and managing it and the awareness programs related to the same must be included in the national health policies.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this research.

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Received on 14.10.2021 Modified on 09.07.2022

Research J. Pharm. and Tech 2023; 16(9):4281-4287.

DOI: 10.52711/0974-360X.2023.00701