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Face Mask Utilization in the Era of COVID-19: Nigeria Experience


 Background: The use of face masks has been accepted and recommended globally as a tool for COVID-19 protection. The government of Nigeria made wearing of face masks compulsory in public places. However, no evidence has shown user compliance or knowledge. This study investigated the knowledge and utilization of face masks among the Nigerian population. Methods: This was a web-based cross-sectional survey conducted from July 2 to August 28, 2020 using a convenience sampling technique. This was in adherence to the Nigeria Centre for Disease Control (NCDC) guideline of physical/social distancing. Data was collected using a pre-tested questionnaire. Descriptive statistics of frequency with percentage were used to present responses.Results: A total of 811 respondents participated in the survey with the mean age of 36.93±12.17 years, out of which 43.8% were male and 56.2% were female. Christians were 94.6%, those employed were 84.7%, 61.1% attained tertiary education and 50.8% belonged to a household size of 3-5 persons. Almost all the respondents 91.9% and 94% were aware that face masks can reduce the spread of COVID-19 and should be worn in the public respectively. 95.3% of the participants had used a face mask as a protection against COVID-19. Furthermore, 90.2% used face masks in the public, 53% used it when entering restricted places, 45.5% when with a suspected case and 30.7% used a mask due to fear of arrest/punishment. The majority of respondents used homemade masks (70%) and 71.2% reused their masks.Conclusion: This study demonstrated adequate knowledge and utilization of face masks among the population. The homemade mask was mostly used. However, there was a poor cleaning culture of the mask among the population. There should be intensive public awareness campaigns through social and mass media on how to clean reusable face masks.


Introduction
The use of face masks has been accepted and recommended globally as a tool for COVID-19 protection since the outbreak in China [1][2]. Though, there was an earlier debate whether to use face masks or not. This debate stemmed from the previous guidelines issued by the World Health Organization (WHO) that asymptomatic persons need not wear face masks when in public. It also advocated that the general population should not wear medical masks unless they were caregivers or had close contact with sick persons. [3][4][5]. But, on 6 April 2020 WHO relaxed its stand on the use of face masks in the healthy population [6].
The Federal Government of Nigeria, through the Presidential Task Force and Nigeria Centre for Disease Control (NCDC) had introduced several measures to curtail the spread of COVID-19 virus and protect the health of the people since the index case was reported in Nigeria. This included an initial lockdown of non-essential activities, closure of schools and ban on international ights [7,8]. Such measures were designed to minimize person-toperson exposures, reduce the reproduction number, and thus the growth rate of the epidemic [9]. Other measures by NCDC were physical/social distancing, use of face masks at public places and frequent handwashing with soap or the use of an alcohol-based sanitizer where water was unavailable [8,10].
Face masks provide a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment [11]. The fact that there is no approved vaccine or medication for the treatment of COVID-19 infection means that the population has to rely upon the precautionary guidelines provided by the WHO and NCDC, such as the wearing of face masks in the public to mitigate the spread of the virus. Since the President of the Federal Republic of Nigeria made the wearing of face mask compulsory in the public places [12], there is no documented evidence to show the citizen's knowledge of face mask, its use and the compliance to the directive on its utilization. Therefore, this study investigated the knowledge and utilization of face masks among the Nigerian population.

Study design and participants
The study utilized a web-based cross-sectional survey which was conducted from July 2 to August 28, 2020. In adherence to the NCDC guideline for physical/social distancing, a convenience sampling technique was used to recruit respondents, and data was collected online via email and social media. At present, there is no documented prevalence on face mask use in Nigeria. A minimum sample size of 600 was calculated based on an estimated adult population of 100 million [13], 4% error margin and 95% con dence level using an online sample size calculator [14].

Data collection
Data was collected with the use of a pre-tested questionnaire. The questionnaire was developed and validated by the authors. The questionnaire was divided into three sections namely, socio-demographic, knowledge on face masks use and practice relating to the use of face masks.
The socio-demographic section contained information on gender, age as at last birthday, area of residence, religion, occupation, marital status, education level, number of people in a household and average income per month. The knowledge section contained nine questions, while the practice section contained ve questions. Another six questions which were multiple options were related to the perception of the respondent on the use of a face mask.

Statistical analysis
Data was downloaded from the google form and exported into STATA version 15 (Stata Corp, College Station, TX, USA) for statistical analysis. Descriptive statistics of frequency with percentage were used to present responses for categorical variables and mean with standard deviation for age.

Results
The mean age of the 811 respondents was 36.93±12.17 years. About two-third (43.8%) of the respondents were males. Almost all the respondents were Christians (94.6%), employed (84.7%), 61.1% had tertiary education and 50.8% were from households with 3 to 5 members. This is shown in Table 1. Table 1 also showed that 95.3% of participants had used a face mask as a protection against COVID-19, and a high prevalence of face mask utilization across the background characteristics. Male and female gender had almost the same prevalence of face mask utilization (95.5% vs 95.4%), the same for married and not married (95.0% vs 95.9%). Also, there was a higher prevalence of face mask use among age group 20-30 years (96.0%), residing in the urban against rural areas (97.6% vs 92.9%), employed against unemployed (96.1% vs 91.9%), and tertiary against below tertiary (96.8% vs 93.3%). Those who reside in a household of more than ve residence had a higher prevalence of face mask utilization (97.3%) compared to other household sizes, and those who earned more than 100,000NGN monthly all used a face mask (100%) compared to others who earned 100,000NGN or less monthly.    Table 4, the assessment of the perception of the respondents about face mask showed that 78.3% of the respondents felt that face mask can prevent the wearer from spreading COVID-19 if he or she already had it, 66% suggested that face mask will protect the wearer from being infected by COVID-19 even if social distancing is not observed. Also, 79.5% of them felt that face mask and social distancing were both necessary to avoid the spread of COVID-19 and persons can be prosecuted if they fail to wear a face mask in a public place (42.1%).

Discussion
This study aimed at assessing the knowledge and level of face mask utilization in Nigeria as a preventive and protective strategy for the spread of coronavirus. This study was anchored on documented evidence that wearing masks can prevent or slow the spread of COVID-19 pandemic [1,2,15,16]. There is little documented work on community knowledge and utilization of face masks for COVID-19 protection in Nigeria and abroad.
In this study, the respondents demonstrated signi cant knowledge and awareness about the use of face masks for the prevention of COVID-19. This was evident from the fact that over ninety percent of the respondents indicated that face masks can reduce COVID-19 spread when properly used, particularly when used in the public place. This nding is higher than the result of a similar study in Pakistan that showed low use of face masks for COVID-19 protection [11]. The setting of our study might have contributed to the high level of knowledge about face masks found among the respondents.
The study revealed that a very signi cant proportion of the respondents used a face mask and this cuts all the participants irrespective of background characteristics. Our result might be in uenced by increased COVID-19 awareness among the Nigerian population [17], and as evident in this study. These ndings can be attributed to locations/a liation of the researchers. Most of the researchers reside in the Southern part of Nigeria where the literacy rate is high [18,19]. Study has shown that educational level in uences the community knowledge on coronavirus [17].
Most of the participants suggested that di culty in breathing dissuaded them from wearing a face mask always and some of the participants felt that coercion could play a role in the use of face masks. The use of face masks in certain places is compulsory in Nigeria according to government policy [12]. The policy is aimed at protecting the uninfected population, those caring for the ill and/or infected persons as well as healthcare workers [20]. Like knowledge, there was a high and positive perception about the use of face masks. This study demonstrated that most of the respondents were aware of the usefulness of wearing a face mask and the danger of not wearing it. Therefore, the government regulation was only a contributing factor for its usage.
Some respondents wore it when entering restricted places that were marked "no face mask, no entry" to avert arrest and punishment. The possible explanation might be that our study was dominated by literate persons and those who worked where these government directives were enforced to the letter.
Furthermore, most of the respondents used cloth or fabric face masks rather than the medical face mask. The face masks were also reused by some of the respondents. The high rate of cloth or fabric face mask usage against the medical face mask may be attributed to the high cost and shortage of medical/surgical face masks [15]. The design of homemade masks in Nigeria has also aided the mass distribution and access to masks, which of course accounted for the high proportion of face mask use in this study. Despite the signi cant knowledge demonstrated by the respondents about the coronavirus, results showed that there was poor cleaning and disinfecting culture among the population. A practice that can expose the respondents to the virus and other infections they were trying to mitigate.
The major limitation of the study is the utilization of self-reported web-based cross-sectional study design which reduced the reach to mostly educated and the rich who could afford a smartphone from which data was collected. Hence a study that will reach out to the generality of the population with a larger sample size should be carried out.

Conclusion
This study demonstrated adequate knowledge and utilization of face masks among the population. Homemade masks were mostly used, although there was poor cleaning and disinfecting culture of the reused mask among the population. We suggest that measures on COVID-19 should be sustained. Also, there should be public awareness campaigns to emphasize the need to clean and disinfect the face mask before reusing it using social and mass media. We hope these would mitigate the spread of the COVID-19 virus in the Nigerian population.

Declarations
Competing Interests

None
Funding Sources None Ethical Approval The study was approved by the Rivers State Health Research Ethics Committee with registration number-RSHMB/RSHREC/11.20/VOL.8/063.