Use of facemasks during the covid-19 pandemic in southeastern Nigeria: an observational study

Methods Using a two-stage sampling technique, a total of 3100 participants were observed from both and Frequency distribution tables were used to categories and describe the observed variables, Chi-square (X 2 ) test was used to check for the association between categorical variables.


Background
The use of facemask for the control of the spread of COVID-19 virus among the population has been recommended by the health authorities. This observational study was carried out to assess the use of facemask in Southeastern Nigeria.

Methods
Using a two-stage sampling technique, a total of 3100 participants were observed from both rural and urban settings. Frequency distribution tables were used to categories and describe the observed variables, Chi-square (X 2 ) test was used to check for the association between categorical variables.

Results
Among the observed participants, 46.4% made use of facemask. The most common facemask used was cloth mask (28.6%). About 16.0% of the participants correctly used their facemasks. The highest usage was observed in the urban location (49.2%). A statistically signi cant association was found between facemask usage and study location (p < 0.001), also between the appropriateness of usage and age category (p < 0.001).

Conclusions
The observed rate of mask usage may not be able to protect the population against the spread of COVID-19, therefore adequate sensitization on the need for proper use of face masks by the public should be prioritized.

Background
Coronavirus disease 2019 , caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), was rst reported in Wuhan, China, in December of 2019 [1]. Since then, the virus had spread to the other parts of the world. Report from the Africa Centers for Disease Control and Prevention (ACDC) con rmed that cases of COVID-19 had risen to almost 8 million in the African region, and over 190,000 deaths [2]. As of 4th September 2021, the West African sub-region accounted for about 8.7% of cumulative COVID-19 prevalence in Africa [2]. By the 4th of September 2021, Nigeria had recorded 197,088 con rmed cases of COVID-19 with a total of 2,495 mortality [3]. These gures have been projected to increase, due to the reproduction number (R0) of SARS-CoV-2 [3].The R0 estimates ranges from 1.4 to 6.49.3 [4,5]. Globally, serious response had been instituted against the disease as a result of its high infectivity and high case fatality rate especially in Europe and America [6].
The virus spreads from an infected person's mouth and nostrils in form of droplets or droplet nuclei to a susceptible host when the infectedperson coughs, sneezes, speaks, and breathe [7]. Current evidence suggests that the virus spreads mainly between people who are in close contact with each other, typically within 1 metre [8].
The fact that the currently approved vaccine does not confer absolute protection against COVID-19 infection means that the population have to rely upon the precautionary guidelines provided by the WHO and the NCDC, including the wearing of facemasks in the public to mitigate the spread of the virus [9].
Facemasks provide physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment including from his own hands [10]. Unfortunately, there is a wide-spread misuse and abuse of facemasks in Nigeria [11]. The Nigeria media is inundated with images of members of the general public, including healthcare workers and government o cials, wearing facemasks on their jaws and necks, without covering their mouth and nostrils. Some only cover their mouths with the masks while their nostrils are left wide opened [12]. Many people who use facemasks are commonly observed to pull down their mask to their jaw to talk and then pull it back over their mouth and nose after talking. In African countries,most especially in Nigeria, different varieties of cloth masks of doubtful e cacy are being hawked and sold on the streets; these facemasks are rst tried on by different wearers before deciding on purchase [12].
People are also observed to repeatedly touch the front of their facemasks in a bid to adjust the mask, to remove it, or during re ex touching of the face [12]. Some wear one mask for prolonged periods, without replacement even, when it became wet or soiled. The rising spate of misuse and abuse of facemasks is a source of worry for the Nigerian COVID-19 Presidential Task Force who had observed the improper, unhygienic and ill-advised use and sharing of masks, especially multiple ttings before buying from vendors [13].
The use of facemasks for COVID-19 prevention is important, as recent studies indicated that a signi cant proportion of people who have COVID-19 do not show symptoms (asymptomatic), and these people can shed the virus and spread it even before they realize that they are infected [14,7].
There is evidence that the correct use of facemasks reduces the risk of COVID-19 infection [15,1]. In the light of the established importance of facemask usage in curbing the spread of COVID-19, it is, therefore, important that facemask usage and everything surrounding it (quality and mode of use) among the people be accessed. This assessment will inform health education material development and help identify policy direction for infection control.

Study Design
The study employed an observational cross-sectional study design. Observational studies, also called epidemiological studies, are conducted in such a way that the researcher has no in uence on the study phenomenon [16].

Study Area
The study was conducted in Owerri, Imo state, Nigeria. Owerri is the capital of Imo State, located in the

Study Population
The populations surveyed were members of the public in both urban and rural communities in Owerri, Imo state, Nigeria. This population cuts across several sectors of the economy. Some are in civil service and other cooperate professions (white collar), the rest are students, traders, and artisans. Owerri is known as an entertainment hub; tourists and travelers always troop into the city.Thissituation is an important driver of the transmission and spread of COVID-19.
All obviously sane adult and youth members of the study area who are present at the selected study sites at the time of data collection were all included in the study.

Sample Size
After the population of each of the settings were been estimated, sample size determination table was then used to determine the required sample for each of the sites [18]. Table 1 shows the estimated numbers of people in the various study sites and the corresponding sample sizes as determined with the sample size determination table.

Sampling
Owerri was purposively selected as the study site for being the Imo State capital,therefore a true representation of the situation in the state. Owerri west and Owerri North were, however, included as study sites because of their proximity to Owerri municipal (State capital) and for their being rural areas. In each of the study areas, one setting each (bank, hospital, school, commuter motor part, church and market) was selected as the study site.
In the various study sites, every eligible individual that visited were observed for the variables of interest, making sure not to observe an individual twice. This was done until the required sample size was arrived Page 5/19 at.

Data Collection Tool
The study data was collected using a standardized observation checklist (OCL). The OCL was designed to obtain information on the location, setting, time, gender, age category, facemask use, type of facemask, condition of the facemask and mode of facemask use of people in the study area.
On the checklist, location was described as urban and rural; and study sites were: churches, market/business premises, school, commuter park, bank, and health facilities. The time options included morning, afternoon and evening. Age groups observed were adolescent, adults and the elderly. The different types of facemasks listed were surgical mask, cloth mask and ltered mask. However, a space for others was added. Another important component of the checklist was the mode of facemask use which included: correct use, uncovered mouth and nose, uncovered nose, inside out and upside down.
After the OCL had been checked for relevance to the subject matter, clarity and appropriateness of language, the instrument was pre-tested in a setting and condition that is similar to that of the research study area. This was done not to report results but rather to check for glitches in wording, ambiguousness, lack of clarity of instructions etc. The structure and contents of the tool were later re ned in the light of weaknesses spotted during the pretesting.

Data Collection
The research assistants positioned at strategic places around the study sites, careful enough not to allow the study candidates to be aware that they are being observed, the researchers also ensured that no single individual was observed twice as they went about their normal businesses. The observers then ticked the checklist based on what they observed in each location.

Demographic Characteristics and Frequency of the Use of Facemask
A total number of 3100 participants were observed in terms of facemask usage in Imo state ( Table 2). Rate of facemasks usage by location, settings, time, gender and age group Table 3 depicts the rate of facemasks usage by location, settings, time, gender and age group in the study area. The overall observed facemask usage was 46.4%. More facemask usage was observed in the urban area (49.2%) compared to the rural areas (39.0%). The health facility was the study site in which highest frequency of facemask usage was observed (74.4%), while the least facemask usage was observed in market/business premises (20.2%). Highest rate of facemasks usage was observed in the morning (52.0%) while it was lower in the evening (21%). Males (48.6%) used facemasks than the female (43.5%).
Also, adolescents (47.8%) usedfacemasks more than other age group with the lowest usage observed among the children (20.5%).
Association between facemask usage and the demographic characteristics of candidates Association between facemask usage and the demographic characteristics of respondents is depicted in table 4. A statistically signi cant association was found between facemask usage and location (p<0.001) as more candidates in the urban location made use of facemasks (49.2%) compared to candidates in the rural locations (39.0%).
Study sites were also found to be signi cantly associated with facemask usage (p<0.001), where more people in the bank made use of the facemasks (71.7%), and least usage was found in the market/business premises (20.2%).
More facemask usage was observed in the morning time (52.0%), the least usage was observed in the evening (21.2%), the association between time period and facemask usage was found to be statistically signi cant (p<0.00).
Age category was also found to be signi cantly associated with facemask usage (p< 0.001), as more adolescents (47.8%) made use of their facemasks compared to the elderly (46.8%) and the children (20.5%).
Association between modes of facemask usage with demographic characteristics of candidates Table 5 shows the association between modes of facemask usage with demographic characteristics of study candidates. Study candidates from the rural location (61.9%) and the urban location (64.7%) who made use of facemasks wore them wrongly. The association between location and mode of facemask usage was, however, not signi cant (p> 0.005). In the banks, only 41.3% of the candidates with facemasks wore them correctly, this situation of correct facemask usage was 35% in the church, 34.4% in the commuter park, 37.8% in the market places, and 20.0% in the health facility. Also, no signi cant association was found between study sites and the mode of facemask usage (p> 0.005).More children (75.0%) wore their facemasks correctly compared to the adults (33.4%) and the elderly (33.2%). A statistically signi cant relationship was found between age categories of the study candidates and their mode of facemask usage (p< 0.005). Also, more males (37.3%) than females (33.9%) made use of their facemasks appropriately. The association between gender and facemask usage was not signi cant (p> 0.005).Meanwhile appropriate facemask usage was observed more in the evening (40.0%) than in the afternoon (34.3%) and in the morning (36.8%).The association between time of the day and mode of facemask usage was not statistically signi cant (p > 0.005).

Association between the condition of facemasks and thedemographic characteristics of study candidates
The association between the conditions of facemasks used and demographic characteristics of study candidates is shown in table 6. More people from the urban area had clean (35.9%) and new (22.1%) facemasks compared to people from the rural areas who had 30.7% and 19.7% clean and new facemasks respectively. More people from the urban area also had dirty (15.7%) compared to people in the rural areas (11.6%). The association between the condition and the quality of the facemask worn and the location of the candidates were found to be statistically signi cant (p< 0.001).
It was also found that the church had more people with clean (34.2%) facemasks, while the bank had more people with facemasks (27.1%). More individuals with worn-out facemasks were found in the market/business premises (40.0%). Overall, the association between the study sites and the condition of facemasks used was signi cant (p< 0.001).
More people were observed to put on clean facemasks in the afternoon (37.6%) compared to in the morning (34.6%) and in the evening time (16.5%). Whereas, more people were observed to put on new facemasks in the evening (28.2%) compared with in the morning (24.0%) and in the afternoon (17.0%).
Worn-out facemasks were observed more in the evening (40.0%) compared to in the morning (26.1%) and in the afternoon (31.5%). The association between time of the day and the condition of the used facemask was found to be statistically signi cant (p<0.001).
More female had clean facemasks on (36.3%) compared to the males (33.6%). Ironically, more female had dirty facemasks on (17.0%) compared to the males (13.2%). More males, however, had worn-out facemasks on (32.3%) compared to the female (24.2%). The relationship between gender and the conditions of the facemasks was not signi cant (p> 0.005).
In the age category, the adults had more clean facemasks on (36.4%) compared to the other age categories. The elderly had more dirty facemasks on (21.3%) compared to the other age categories. The children had more new facemasks on (62.5%) compared to the other age categories, while the adolescents had more worn-outfacemasks on (36.6%) compared to the other age groups. The association between age category and the condition of the facemasks was also found to be signi cant (p<0.001)

Discussion
This study was conducted to observe the facemask usage habits of the Owerri residents in the light of the ravaging COVID-19 that is far from being over. Currently, COVID-19 has spread across many countries and territories leading to an ongoing pandemic which has claimed the lives of at least 4.5 million individuals worldwide; and which presents an unprecedented challenge to global public health [19].

One effective way to prevent the spread of this virus is through the proper use of facemask [8]. The
Federal Government of Nigeria in 2021, therefore, enacted a law on the compulsory use of facemask in public places like schools, banks, market, hospitals, motor parks and places of religious worship [20].
This study then became imperative following the identi cation of proper facemask usage as an important measure that can help in the prevention and control of the disease [8], most especially in resource limited setting like Nigeria where the vaccination may not be able to reach more than 50% of the population [15].
The rate of use of facemasks found in this study was very low. This may be as a result of such factors as individual differences, feeling of inconvenience resulting from facemask usage, and beliefs that the COVID-19 is no more in existence [12]. Others responsible factors may include demographic and cultural characteristics of the observed participants, low implementation of the law on the use of facemask in public places, and the differences in the persceived prevalence of COVID-19 in the various places of data collection. Studies in countries inSouth Asia including [21].Singapore,India, United Arab Emirate and Saudi Arabia [22], found much more usage rate of facemasks during the COVID-19 pandemic. Thisindicatesthe possibility of also upscaling facemask usage in the study area and the rest ofNigeria as in other parts of the world if appropriate sensitization and enforcements are put in place.
The highest rate of facemasks usage/adherence was observed amongst the adolescentsthan people in other age categories. This is in contrast with previous studies which found adults to use facemasks more than adolescents [9,23]. Access to COVID-19 information especially through the internet is more common among the adolescents; this may have played an important role in in uencing the facemasks usage among them [9].
It was also found that the rate of facemasks usage was more in the urban area compared with the rural areas;this is similar toprevious report of more facemask usage in the urban areas [9]. This difference in facemask usage between the rural and the urban residentscould be mostly due to the difference in the socioeconomic statusesof people in the urban and the rural areas. There is also better access to health information by the urban dwellers; access to information has been shown to in uence behavior [24].
Facemaskusage was lowest in the business/market premise. Although, this study was unable to capture the educational level of the observed candidates, but it is usually the case for the market traders to be of relatively low educational attainment [25]. If that be the case,it can explain the apathy towards use of facemasks as in other diease control protocolsas obseved among them. This is beacuseon the contrary, highly educated individuals have been shown severally to have better disposition towards disease control measures often occasioned by their being better informed [26].
Facemask usage was found to be higher in the mornings. This may be as a result of atmospheric conditions which are usually humane during the morning hours. Lowest rate of facemask usage were observd in the afternoons, improper usageof facemasks was also observed more the afternoons. This may be attributed to atmospheric condition which is usually hot and harsh in the afternoon, and which induces the feeling of discomfort while wearing the facemask. Again, [9], observed that the feeling of hotness as well as di culty in breathing discouraged wearing facemasks always and suggested that more convenient alternatives such as face shield should be should be recommended during the afternoon.
Facemask usagewas signi cantly higher in males than in females in this study. This is in contrastwith a study in Saudi Arabia and in south Asian countries where there was higher usage amongst females than males [21,23]. This contrast may be as a result of difference in cultural orientation particularly among femalesin the respective parts of the world.

Declarations Ethics approval
Ethical approval for this study was given by the ethical committee of the School of Health Technology, FederalUniversity of Technology, Owerri, Nigeria.

Consent for publication Not Applicable
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. conciousness imbibed as a result of previous experiences with u like illnesses, as well as appropriate sensitization on use of facemasks.
Among the different settings were observations were made, correct use of facemasks was observed more in the banks, not even in the health facilities.The banks are more enclosed and compact and therefore enforcement of use of face masks and other protocols is easier compared to other settings which are more open, without enforcement precautionary protocols. Signi cant relationship was found in the use of facemask and the location, settings, time, gender, and age groups, indicating that these factors are major determinants of facemask usage in the study population.

Limitations
The study, being and observational study could not assess some major demographic data like age, educational level, occupation and income. Also the study do not assess peoples reasons for not wearing a face mask. The ages of the participants were grouped according to children, adolescence and adult. A non-differential miss-classi cation could occur in the age grouping.