The Use of Facemasks To Prevent Respiratory Infection: A Literature Review in The Context of The Health Belief Model
The Use of Facemasks To Prevent Respiratory Infection: A Literature Review in The Context of The Health Belief Model
The Use of Facemasks To Prevent Respiratory Infection: A Literature Review in The Context of The Health Belief Model
O riginal A rticle
doi:10.11622/smedj.2014037
Introduction Acute respiratory infections are prevalent and pose a constant threat to society. While the use
of facemasks has proven to be an effective barrier to curb the aerosol spread of such diseases, its use in the local
community is uncommon, resulting in doubts being cast on its effectiveness in preventing airborne infections during
epidemics. We thus aimed to conduct a literature review to determine the factors that influence the use of facemasks
as a primary preventive health measure in the community.
Methods A search for publications relating to facemask usage was performed on Medline, PubMed, Google, World
Health Organization and Singapore government agencies’ websites, using search terms such as ‘facemask’, ‘mask’,
‘influenza’, ‘respiratory infection’, ‘personal protective equipment’, ‘disease prevention’, ‘compliance’ and ‘adherence’.
Findings were framed under five components of the Health Belief Model: perceived susceptibility, perceived benefits,
perceived severity, perceived barriers and cues to action.
Results We found that individuals are more likely to wear facemasks due to the perceived susceptibility and
perceived severity of being afflicted with life-threatening diseases. Although perceived susceptibility appeared
to be the most significant factor determining compliance, perceived benefits of mask-wearing was found to have
significant effects on mask-wearing compliance as well. Perceived barriers include experience or perception of
personal discomfort and sense of embarrassment. Media blitz and public health promotion activities supported by
government agencies provide cues to increase the public’s usage of facemasks.
Conclusion Complex interventions that use multipronged approaches targeting the five components of the
Health Belief Model, especially perceived susceptibility, are needed to increase the use of facemasks in the
community. Further studies are required to evaluate the effectiveness of implemented interventions.
1
Yong Loo Lin School of Medicine, National University of Singapore, 2SingHealth Polyclinics, 3 Duke-NUS Graduate Medical School, Singapore
Correspondence: Ms Shin Wei Sim, Medical student, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, 1E Kent
Ridge Road, Singapore 119228. simshinwei@gmail.com
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Even if the facemasks are ill-fitting, they are still able to interrupt evidence generated within the health community about the
the particles and airborne viruses sufficiently, such that these role knowledge and perception play in personal responsibility,
pathogens do not reach the breathing zones of people nearby.(16,17) the use of HBM to predict more general health behaviours
Outside the hospital environment, the effectiveness of (e.g. the behaviour of the public in their use of facemasks in
facemasks in containing the spread of airborne diseases in the the community) has been more extensive in recent years. A
general population has been diminished largely due to improper modified version of the HBM that has an additional component
use and lack of user compliance.(7) An Australian study showed (i.e. cues to action) was proposed by Tang et al.(22) This five-
that among the three methods used to handle an influenza component HBM was used to present the results of the
pandemic – vaccination, isolation and mask-wearing – willingness present review. HBM allows the organised classification of the
to comply with mask-wearing was the lowest.(18) Another determinants of mask-wearing behaviour. At the same time,
Australian study found that while adherence to mask-wearing it is also able to show the interdependent relationship shared
significantly reduced the risk for influenza-like infections, less among its components. HBM provides a clear frame-work for
than 50% of the participants in their study wore facemasks planning interventions and has been widely used to explain
regularly.(19) In a study conducted in Singapore during the SARS other forms of preventive behaviour and plan prevention
outbreak, only 4% of the respondents had worn a facemask in programmes.
the preceding three days.(20) This highlights a need to uncover
the determinants of mask-wearing, in order to identify the R ES U LT S
issues and overcome the barriers associated with mask-wearing From our literature review, we found that the use of facemasks
compliance. The present literature review aims to evaluate these was associated with the following demographics:
determinants and provide a framework for future interventions
directed at increasing facemask usage as an effective public 1. Age: In Australia, a telephone survey by Taylor et al found that
health measure to curb airborne infectious disease outbreaks. younger people (aged 16–34 years) were less willing to wear face-
masks.(18) In that study, willingness to comply with mask-wearing
METHODS was measured by asking respondents how willing they would
The search for relevant studies and reviews were performed be to wear a facemask. Responses were coded on a five-point
using electronic journal databases, such as PubMed, Medline, Likert scale, with options ranging from ‘not at all’ to ‘extremely
Google and Google Scholar. The following keywords were used willing’. Tang et al evaluated factors influencing the use of
in different combinations: ‘facemask’, ‘mask’, ‘surgical mask’, facemasks to prevent the transmission of SARS in Hong Kong
‘PPE’ or ‘personal protective equipment’, ‘disease prevention’, via telephone surveys, and found that participants aged 50–59
‘respiratory infection’, ‘infection’, ‘influenza’, ‘compliance’, and years were most likely to wear facemasks (68%), while those
‘adherence’. A search was also carried out on the World Health aged 19–29 years were least likely to wear facemasks
Organization website, and Singapore’s government agencies (52.8%).(22) In that study,(22) compliance with mask-wearing was
(e.g. the Ministry of Health of Singapore and Singapore Health measured by asking participants to specify how frequently
Promotion Board) websites. Studies cited by selected articles (in the past week) they wore facemasks to prevent SARS
were also reviewed. transmission. These two studies suggest that younger people
We retrieved 138 articles written in the English language, were less likely to comply with mask-wearing.
published between November 2003 and December 2012,
including systematic reviews, qualitative studies, cross-sectional 2. Marital status: In the same study by Tang et al, a higher level
studies and prospective, randomised trials. The retrieved of compliance with mask-wearing was also found among people
articles were then assessed for relevance. Published studies who were married.(22) This finding is supported by the study by
and reviews that explored reasons for compliance and/or non- Taylor et al, which found that individuals who were never
compliance with mask-wearing, and literature covering factors married had lower compliance levels.(18) However, the authors
affecting facemask use in the community and hospital settings of that study explained that marital status was potentially a con-
were included, with priority given to those conducted in the founder as the likelihood of a person getting married increases
community setting. Using the aforementioned criteria, a total with age. As such, it may not be marital status that predicted
of 51 articles were eventually selected for the present literature mask-wearing adherence, but age itself.
review.
The Health Belief Model (HBM) is a health behaviour 3. Educational level: Our literature review revealed that
change and psychological model developed by Rosenstock higher education was positively associated with mask-wearing
in 1966 to predict behavioural response to treatment received behaviour. In a survey conducted among traditional market
by acutely or chronically ill patients.(21) It consists of four workers and shoppers in Taiwan, participants with a senior high
components – perceived susceptibility, perceived severity, school education or higher were found to be more likely to
perceived barriers and perceived benefits. With the evolving wear facemasks (adjusted OR 6.86).(23) This trend was echoed
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by the results of telephone surveys conducted in Hong Kong times more likely to wear facemasks,(22) and Lau et al found that
by Lau et al,(24) and in Australia by Taylor et al.(18) shortly after an imported case of H1N1 to Hong Kong, increasing
numbers of confirmed H1N1 cases was one of the two most
4. Gender: In several studies, it was observed that women commonly mentioned factors that affected a respondent’s
were more likely to don facemasks than men. During the SARS decision to use facemasks in public places (49.3%).(31) Lau et al
outbreak in Hong Kong, women were reported to be more likely found that a few months after the start of the outbreak, respondents
to wear facemasks to prevent SARS (OR 1.810, 95% CI with symptoms of influenza-like illness (ILI) were more likely to
1.445–2.268).(22) This was similarly observed during the H1N1 wear facemasks when going out if they had been exposed to live
outbreak, with women found to be more likely to wear birds or poultry within the last three months (OR 4.84, 95%
facemasks regularly in public areas (OR 1.94, p < 0.001) and CI 1.16–20.19, p < 0.05) or if they perceived H5N1 to have
when going out while experiencing influenza-like symptoms symptoms similar to those of influenza (OR 4.79, 95% CI 1.49–
(OR 2.44, p < 0.001).(25) In a study of two metro stations in 15.39, p < 0.01).(31) In the Taiwan traditional market survey,
Mexico City, it was observed that more females wore facemasks Kuo et al found that AI preventive behaviour was more likely
during the H1N1 outbreak.(26) In that study, the authors stated to be performed by participants who had been informed of
that this finding is consistent with the higher rate of risk-taking local AI outbreaks (adjusted OR 2.24).(23) Higher risk perception
behaviour among men when compared to women in many scores concerning influenza were also associated with mask-
situations. wearing behaviour in a study of a Hispanic population in Northern
Conversely, the survey conducted among traditional Manhattan, which had predominantly female participants.(29)
Taiwanese market workers and shoppers found that the
adherence of workers and shoppers to avian influenza (AI) 2. Perceived benefits: In the present context, perceived benefits
preventive behaviour, such as wearing facemasks and washing refer to how effective facemasks are believed to be in preventing
hands after contact with poultry, was not significantly affected the spread of diseases by the community and/or individual.
by gender.(23) Taylor et al also found that gender had no Positive correlations have been found to exist between
statistically significant effect on mask-wearing compliance.(18) perceived benefits and the likelihood that an individual would
In the latter study, however, the demographics of the study’s be willing to wear a facemask.(22,24,25,32) In Hong Kong, Tang et al
sample population were not available for further comment. found that individuals who had strong beliefs in the effective-
ness of wearing facemasks were 1.4 times more likely to wear
5. Ethnicity: Ethnicity may have a role in mask-wearing facemasks during SARS.(22) Lau et al found that during the H1N1
compliance. An Australian study by MacIntyre et al found that outbreak, those who perceived wearing facemasks in public
Caucasians appeared to be more likely to wear facemasks,(19) areas to be a very effective self-protection measure were more
and a cross-sectional survey conducted in the Singapore military likely to wear facemasks (OR 1.90, p < 0.001).(25) In the study
by Yap et al found that Malays were more likely to practise of the Hispanic group with predominantly female participants,
preventive behaviour (e.g. mask-wearing and hand-washing) increased perception of the effectiveness of mask-wearing was
than other ethnic groups.(27) also associated with mask-wearing behaviour.(29)
6. Location of residence: The articles reviewed also suggested 3. Perceived severity: Perceived severity refers to how much
a possible association between the location of residence and an individual fears a disease or an outbreak, and how worried
mask-wearing compliance. Taylor et al found that people living he/she is that his/her place of residence would become a
in rural areas were more likely to wear facemasks.(18) The study quarantine city.(22) During the early SARS outbreak in Hong
conducted in Taiwan found that people living in northeastern Kong, the results of a telephone survey showed that perceived
Taiwan were more likely to practise AI preventive measures susceptibility, perceived benefits and cues to action were
compared to those living in central Taiwan (adjusted OR 6.01).(23) significant predictors of facemask use. Perceived severity was
In the points below, we present the findings of our literature not found to be a significant predictor of the use of facemasks.(22)
review according to the aforementioned five components The authors, Tang et al, attributed this finding to the individuals’
of HBM: underestimation of the disease’s potential to become a global
epidemic. During the early stage of the local outbreak, the
1. Perceived susceptibility: Perceived susceptibility refers to the disease mainly affected healthcare workers, a few index
extent to which one believes he or she is at risk of contracting an patients, and the close contacts of the two mentioned groups.
infectious disease. It has been well established as a major force The dire outcome of the disease with increasing prevalence
driving adherence to mask-wearing, with a higher perception and fatalities could have been overlooked.(22)
of susceptibility being linked to higher compliance with mask- In contrast, shortly after an imported case of H1N1 to
wearing.(2,22,24-26,28-30) Tang et al found that individuals who Hong Kong, Lau et al found that reports of deaths of local H1N1
personally felt very vulnerable to contracting SARS were 2.5 patients affected the decision to use facemasks in public areas
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(13.1%).(25) The authors found that over the duration of the from using facemasks. In a cluster-randomised trial by
H1N1 outbreak, those who perceived that H1N1 infection had MacIntyre et al, households in Australia were given either (a) P2
a very high fatality rate were more likely to wear facemasks masks, which are the equivalent of N95 masks; (b) surgical masks;
regularly in public areas (OR 1.64, p < 0.01).(25) However, or (c) no facemasks.(19) Households given facemasks (either
perceived severity did not affect the wearing of facemasks P2 masks or surgical masks) were instructed that the facemasks
when going out in cases of ILI. Although 88.7% of the were to be worn at all times in the presence of a child infected
respondents had initially stated they would wear facemasks with respiratory infection. In that study, more than half of the
when having symptoms of ILI, only 36.6% of respondents mask-wearers voiced concerns about the discomfort associated
self-reported that they had often or always worn facemasks with mask-wearing. Other barriers to compliance were that
in public areas when having symptoms of ILI, a few months the children of mask-wearers disliked their parents wearing
after the outbreak.(33) Among those with symptoms of ILI, facemasks, forgetfulness, ill fit of the facemasks provided, and
respondents were found to be more likely to wear facemasks the impracticality of wearing facemasks in certain situations, such
when going out if they perceived the impact of bird-to-human as during meal times and while sleeping. Other than that, the
H5N1 to be worse than that SARS (OR 3.21, 95% CI 1.21–7.91, study found that participants with three or more adults in the
p < 0.05). house were less likely to wear facemasks.(19)
In a study by Syed et al, the authors described their journey Ferng et al’s study, which aimed to evaluate the barriers
from the United Kingdom to Thailand during the 2003 SARS to mask-wearing among Hispanic households of Northern
scare.(34) They observed that the prevalence of mask-wearers Manhattan, involved ‘think-aloud’ activities and focus group
in Thailand rose during the outbreak and hypothesised that discussions.(29) The study found that discomfort resulted from
the perceived severity of SARS as a threat to the economy poor fit of the facemasks, which was due to certain facial
and public health was associated with the increased social structures of the wearer. For instance, facemasks tend to slide
acceptance of facemasks.(34,35) In Australia, Taylor et al found that down the faces of wearers with low cheekbones and small nose
individuals who reported to be extremely or very concerned bridges. In addition, it was reported that ill individuals might find
for self and/or family in the event of a pandemic influenza were it unpleasant to wear facemasks, especially if the user suffers
more willing to wear facemasks (OR 1.94, p < 0.001).(18) A 2009 from nasal congestion or rhinorrhoea. Facemasks also tend to
study by Eastwood et al, in which interviews were conducted become damp after a period of time in warm environments,
with adult Australians, found that an increase in anxiety further contributing to the discomfort of mask-wearing.(29) In a
was associated with an increase in the willingness to wear study by Weiss et al, the authors identified four barriers that may
facemasks.(15) discourage individuals from wearing facemasks: (a) discomfort,
A lack of adequate knowledge about a disease may also especially in hot weather; (b) the presence of chronic lung
hinder mask-wearing compliance. The street survey in Taiwan disease; (c) inconvenience, due to the need to remove facemasks
traditional markets by Kuo et al found that individuals who when eating or drinking; (d) young age, as facemasks are
lacked correct knowledge about the fatality rate of avian generally not designed for children, and even if they were,
influenza were four times less likely to practise appropriate children were found to be unlikely to wear them for long periods
AI preventive behaviour, including mask-wearing.(23) Factors of time.(36)
associated with correct AI preventive behaviour included In Hong Kong, Tang et al found that perceived barriers was
having correct knowledge about the fatality rate of AI (adjusted not a significant factor affecting mask-wearing compliance
OR 4.18) and having knowledge of severe cases of AI (adjusted during SARS.(22) During epidemics, perceived susceptibility and
OR 2.13). perceived severity outweighed the effect perceived barriers had
In a cross-sectional survey conducted in Singapore in 2009, with regard to facemask use. The authors postulated that since
influenza patients were shown to be more compliant with facemasks are relatively easy to put on and remove, as well
mask-wearing than the general population, contacts of influenza as cheap and accessible (except during the early stages of the
patients and healthcare workers.(27) Healthcare workers and SARS outbreak), they present as less of a barrier, despite the
contacts of influenza cases were, however, more compliant discomfort and inconvenience associated with their use.
with preventive measures (e.g. mask-wearing and vaccination) The cost of facemasks was a factor that was not thoroughly
than the general population. This was likely because these covered in any of the studies that investigated the determinants
individuals, unlike the general population, had more first-hand of mask-wearing compliance. Nevertheless, monetary cost to
experience with influenza.(27) The survey also found that there the individual has been found to affect compliance with other
was a strong correlation between the level of knowledge about health measures. In a study by Campbell et al, which studied
the disease and likelihood of practising preventive behaviour.(27) the effect of asthma medication price changes on asthma
medication use, the authors found that even a slight increase in
4. Perceived barriers: In the present context, perceived barriers medication costs led to a severe decline in medication use.(37)
refer to factors that potentially prevent or discourage individuals In Taiwan, it was reported that N95 masks that originally
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Individual
Environment
Fig. 1 F l ow c ha r t sh ows t h e f a c to r s t hat inf lu e n c e c o mp lia n c e wit h ma sk- we a r ing , in t h e c o ntex t of t h e H e a lt h B e lief M o d e l .
cost 85 cents each were sold for USD 20 each during the SARS Social acceptance was another key factor in increasing or
outbreak in 2003.(38) However, the report did not elaborate on decreasing the rate of compliance. In Japan, a street survey
the impact of cost on an individual’s decision to don masks, showed that most Japanese agreed that healthy individuals are
which may be significant, particularly during outbreaks when being ‘respectful’ towards one’s health in a positive way by
the demand for masks may outstrip the supply. wearing facemasks. Hence, mask-wearing had not only become
a normalised practice, but a desirable one.(2) In a qualitative
5. Cues to action: Other than individual beliefs, one’s choice of study involving students of an Australian university, Seale et al
whether or not to comply with mask-wearing is also impacted established embarrassment to be a contributing factor to
by environmental factors. The family, society, media and noncompliance.(32) Respondents in the study voiced concerns
government play important roles in providing cues to encourage about mask-wearers being perceived as ‘dangerous’ and
people to take preventive measures (e.g. the use of facemasks), attracting unwanted attention.(32) Syed et al observed how peer
particularly during a disease outbreak in the community. In the pressure could significantly influence the use of facemasks.(34)
Hong Kong survey conducted by Tang et al during the SARS Passengers who arrived in Bangkok without facemasks,
outbreak, participants were asked to rate the degree to which bought and wore them before boarding their next flight
the local government and their family members encourage after witnessing all staff at the Bangkok airport donning
them to don facemasks.(22) Participants who were more aware facemasks. This occurred despite the fact that there was no clear
of environmental cues were found to be 2.4 times more likely recommendation for these passengers to do so.(34)
to wear facemasks. Pressure from the media, in the form of impactful advertising
Japan is a country well-known for its prevalent use of campaigns (e.g. by mask manufacturers) and the appearance of
facemasks in the community, even during periods when news reporters donning facemasks on national television during
outbreaks are not prevalent. Burgess et al theorised that the epidemics, has been shown to contribute to the high levels of
spate of epidemics in Japan (e.g. the avian flu in 2004 and the adherence to mask-wearing in Japan.(2) Such advertisements,
swine flu in 2009) played key roles in heightening residents’ which portray the mask-wearing individual as the ideal
perceived susceptibility, triggering a surge in the use of employee and family person, may have helped to mould the
facemasks and perpetuating the use of facemasks in the local mindset of the Japanese. The increase in the use of facemasks
community.(2) Burgess et al also attributed part of Japan’s in Thailand during the SARS outbreak was also partly attributed
mask-wearing culture to the fact that some employees in Japan to media influence.(34)
experience pressure from their bosses to don facemasks.(2) In Official public policies have been shown to have a significant
other words, in cases where the failure to don facemasks role in promoting the use of facemasks. The frequency of
adversely affected one’s income and/or employment, compliance facemask usage in the community has been shown to increase
with mask-wearing seemed to improve. This is further supported after governments and public health officials promoted
by the study conducted in Mexico City, where the authors the use of facemasks, especially during periods of disease
observed that taxi drivers who wore facemasks during the outbreak.(2,22,26) Condon and Sinha carried out an observational
H1N1 outbreak were preferred by people hailing taxis, possibly study during the severe third wave of the H1N1 epidemic in
contributing to the higher rate of facemask use among taxi Mexico City, during which there was paucity of official publicity
drivers than bus drivers.(26) regarding the outbreak.(26) The authors observed that the paucity
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of official publicity resulted in the scarce use of facemasks The trend that individuals with a higher level of education
(quantification of the use of facemasks was based on the are more likely to be compliant with preventive behaviours may
computation of the number of facemask users in the subway). be explained by these individuals’ increased awareness of
This contrasted with the higher prevalence of facemask users diseases and disease consequences, which allow them to have
during the first wave of the H1N1 outbreak, during which the a more severe perception of the risks associated with non-
local official agencies encouraged the use of facemasks, and compliance. As these individuals might also have a better
mandated drivers in the public transport system to wear face- understanding of public health measures and their effectiveness,
masks and gloves.(26) In the hospital setting, Chor et al found and consequently a higher perception of the benefits of these
that differences in the guidelines stipulated by the health preventive behaviours, they are more likely to be compliant to
authorities of different countries correlated with the differences these measures.
in facemask usage rates observed in the respective hospitals of A possible reason as to why individuals who are currently
the countries.(39) or previously married have been found to be more adherent to
Other than the environmental factors mentioned, preventive behaviour than those who have never been married
Burgess et al found that the reason why some Japanese donned is that those who are, or have been, married feel responsible,
facemasks was due to perceived pressure from one’s family and perhaps anxious, for the health of not just themselves, but
members, doctors and school, suggesting that these environ- also their loved ones (e.g. their spouse and children). This might
mental factors may also aid in improving compliance with have led to increased perceived severity and susceptibility,
mask-wearing.(2) A summary of the five HBM components that resulting in increased compliance.
determine compliance with mask-wearing is presented in Fig. 1. Although it is evident from the literature reviewed that cues
to action played a crucial role in influencing mask-wearing
D I S C U SS I O N compliance, it is important to note that this may only hold true
Based on our literature review, we observed that perceived when there is sufficient trust between the individual and the
severity was not a significant factor influencing mask-wearing environmental factors. In the H1N1 study by Condon and Sinha
compliance in the study by Tang et al.(22) However, Tang et al in Mexico City, the effectiveness of mandatory and voluntary
reported that as the study was carried out during the early stages public health measures set by the government was diminished
of the SARS outbreak in Hong Kong, there was a relative lack by the lack of trust in the government.(26) Likewise, one can
of understanding of the disease and its potential to become a expect healthcare professionals to have little or no impact in
serious threat to the community at that time. In other words, influencing a person’s decision to comply with public health
there is the possibility that perceived severity may become measures if the person does not trust or value the advice given
a significant predictor of facemask usage with increased by these healthcare professionals.
awareness of the disease. With the findings mentioned, we propose that healthcare
Studies investigating other forms of preventive behaviour policy-makers intervene using factors derived from the
and disease control measures, such as handwashing and multipronged HBM, which focuses on increasing the public’s
covering one’s mouth when coughing or sneezing, have perceived susceptibility, perceived severity and perceived
findings that are similar to those of the aforementioned studies benefits; decreasing perceived barriers; and increasing the cues
evaluating the determinants of mask-wearing compliance. These to appropriate actions. From our literature review, perceived
studies showed that the following were significant predictors susceptibility appears to be the most significant factor
of improved compliance with other forms of preventive influencing compliance with mask-wearing. To increase the
behaviour: higher perceived susceptibility, higher perceived public’s perceived susceptibility, there should be increased
severity, higher perceived benefits, older age, female gender, education on respiratory infections (e.g. mode of transmission,
higher education level, presently or previously married, higher serious implications of infection and preventive measures).(15)
level of awareness of a disease or health measure, and provision There should also be timely updates about outbreaks. By making
of information by health professionals.(18,24,40-42) information about new outbreaks more easily available to the
With regard to gender, it has been postulated that women are public, and at an earlier time, awareness and understanding
generally less willing to take risks, and are thus more compliant of the emergent epidemic would improve. This would, in turn,
with preventive behaviour than their male counterparts. Such increase the public’s perceived susceptibility and severity, hence
differences in risk-taking have been attributed to evolutionary potentially improving compliance. In addition, promoting the
differences between the two genders.(43) In order to ensure use of facemasks and educating the public about mask-wearing
that they are able to care for their offspring, females tend to as an effective tool in disease prevention may also help to
avoid risky activities. In contrast, males need to take more increase the public’s perceived benefits, which may then also
risks in order to fulfil their roles – to hunt, to protect their contribute to increasing mask-wearing compliance.
mates and offspring, and to increase their chances of attracting Healthcare professionals also play an important role
a mate. in reiterating the preventive measures provided by official
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healthcare agencies and in motivating their patients toward Table I. Summary of the literature review on the use of face-
masks to prevent respiratory infection.
appropriate behaviour change. Good doctor-patient relationships
based on trust and mutual respect is a key element to effecting • Facemasks play an important role in the prevention and
control of infectious respiratory disease transmission.
change. In a telephone survey conducted in 2007, it was
However, compliance issues reduce the effectiveness
found that Australians were more likely to seek information of mask-wearing as a public health measure.
about the outbreak from general practitioners and other • Factors that influence mask-wearing compliance can be
healthcare professionals than the public health department.(44) categorised according to the five components of the Health
The participants in that study were reviewed two years later, Belief Model – perceived susceptibility, perceived benefits,
perceived severity, perceived barriers and cues to action.
and the results obtained were consistent with that of the 2007
• Perceived susceptibility appears to be the most significant
telephone survey.(15) Thus, it is not only important to keep factor determining compliance. Low compliance rates are
healthcare providers updated on outbreaks and methods of often observed when risk perception is low (e.g. no
disease prevention, it is also crucial to encourage healthcare outbreaks imminent).
providers to play an active role in educating the public on such • A concerted effort by healthcare policy makers and workers,
educational institutions and the mass media is paramount in
topics. Aside from sharing facts about disease transmission and
improving mask-wearing compliance. Efforts should be made
prevention, Yap et al proposed the use of narratives and case to decrease perceived barriers, and to increase perceived
illustrations by healthcare workers, as this may aid in improving benefits, perceived severity, cues to action, and in particular,
compliance with preventive measures like mask-wearing since it perceived susceptibility.
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