Knowledge, attitude and practice of wearing mask in the population presenting to tertiary hospitals in a developing country.

BACKGROUND: In the era of COVID-19 where there is emphasis on the importance of wearing a mask, wearing it rightly is equally important. Therefore, the purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at three major tertiary care hospital.
MATERIALS AND METHODS: Participants of this cross-sectional study were patients and attendants at three major tertiary care hospital of Karachi Pakistan. Selected participants, through non-probability convenient sampling technique, were interviewed regarding knowledge, attitude, and practice of wearing mask using an Urdu translated version of a questionnaire used in an earlier study. Three summary scores (0 to 100) were computed to indicate participants' mask wearing practice, technique of putting it on, and technique of taking if off. Collected data were analyzed with the help of IBM SPSS version 19.
RESULTS: A total of 370 selected individuals were interviewed, out of which 51.9% were male and mean age was 37.65±11.94 years. For more than 90% of the participants, wearing a face mask was a routine practicing during the pandemic. The mean practice score was 65.69±25.51, score for technique of putting on a face mask was 67.77±23.03, and score of technique of taking off a face mask was 51.01±29.23. Education level of participant tends to have positive relationship with all three scores, while presence of asthma or chronic obstructive pulmonary disease (COPD) as co-morbid had negative impact on mask wearing practice.
CONCLUSION: We have observed suboptimal knowledge, attitude and practice of wearing mask among the selected individuals. There is a continued need to spread awareness and educate general population about the importance of using a face mask, as well as the proper technique of wearing and taking off a face mask.

Introduction

Face masks are a one-time use, affordable means to form a mechanical barrier from irritants and contagious diseases like airborne infections, hence, protecting from respiratory illnesses. They have demonstrated a pivotal role in curtailing the spread of the current Coronavirus Disease 2019 (COVID-19) pandemic. COVID-19, a respiratory disease caused by increased acute respiratory coronavirus syndrome 2 (SARS-CoV-2), initially appeared in China in December 2019 and has since spread to most countries worldwide, culminating in the COVID-19 pandemic [1]. As of today COVID-19 facts about Pakistan are as following; according to official figures total confirmed reported cases are 1,291,467, deaths are 28,878, and 60,043,930 individuals are fully vaccinated with the recommended dose of available COVID-19 vaccine [2].

The virus spreads primarily through respiratory droplets formed when an infected person coughs or sneezes, or by contacting contaminated surfaces or items, and then touching his or her mouth, nose, or possibly eyes. In their pandemic strategies, several nations, including Pakistan, have employed the use of face masks. The face mask works by creating a physical barrier in the immediate environment between the wearer’s mouth and nose and possible pollutants [3]. In terms of the viral infectious dose, the reduction in exposure by wearing a mask could reduce the risk of infection [4] and, as a result, the transmission of the virus in the general population. Masks can play at least two roles in the prevention of viral transmission in the general population. Firstly, masks affect the formation of turbulent gas clouds and the emission of respiratory pathogens [5]. Research shows that masks can either block fast turbulent jets produced by coughing or redirect jets in much less harmful ways to manage airborne infections [6]. Secondly, the mask material can filter viral particles, like aerosols or droplets [7]. Appropriate donning and doffing steps should be followed to make the face mask more effective, as improper usage could increase the toll of these infections [8].

The proportion of people wearing masks during a pandemic depends on various factors, with society playing a crucial role in deciding the coverage of masks around the world [9]. In East Asia, wearing a mask is popular and has been culturally appropriate for a long time [9]. People wear masks for several purposes such as pollution, allergies, and winter safety, not just when they are sick. According to a recent Mintel survey, 63% of Japanese citizens wear face masks in public during the spread of COVID-19 [10]. However, public health authorities in North America and Europe have prevented safe people from wearing masks [9]. Previous studies across five countries highlighted a significant gap between willingness (71%) and real action (8%) to wear a mask in the United States [11]. One particular study advised imposing mandates to reinforce mask-wearing amongst the general population [12]. It could be an effective measure to control the surge in COVID-19 cases [12]. Furthermore, a study conducted in Civil Hospital, Karachi among healthcare workers showed limited knowledge, attitude, and practice of wearing a face mask [13].

The best way to wear a surgical mask is to wear the colored side facing out, independently of your health status, according to Nawhen, a columnist for Medical Myth busters Malaysia, a non-governmental organization that aims to address misconceptions and misleading evidence on medical matters. The hydrophobic outer layer is fluid-repelling, and its primary purpose is to keep germs from adhering to it. In contrast, the inner layer is a hydrophilic layer that absorbs moisture from the air that is exhaled. The moisture from the air will bind to it if worn the other way round, thereby making it possible for germs to linger there. A middle layer directly filters the microorganism [14]. Thus, proper knowledge of how to wear a mask and its importance is imperative among the general population. A very limited literature are available on comprehension level of the information on importance and use of face mask among general population of developing and under-developing countries. In the era of COVID-19 where there is emphasis on the importance of wearing a mask, wearing it rightly is equally important. Therefore, the purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at three major tertiary care hospital.

Material and methods

Study design and setting

This cross-sectional study was conducted after the approval of the ethical review committee of National Institute of Cardiovascular Disease (NICVD), Karachi, Pakistan. This multicenter study was conducted at three major tertiary care hospital of Karachi Pakistan, namely Jinnah Postgraduate Medical Centre (JPMC), NICVD, and Dow University of Health Sciences (DUHS), between March 2021 and May 2021.

Study population

Participants of this cross-sectional study were patients and attendants at three major tertiary care hospital of Karachi Pakistan. Intercept study participants were recruited through non-probability convenient sampling technique from the waiting area of the outpatient clinics. Verbal informed consent was obtained from all the participants. All the individuals fulfilling the inclusion criteria were taken to a dedicated booth for the interview. Inclusion criteria for the study were either gender, aged ≥ 18 years, and presented in hospital premises as patient or attendants, hospital employees were not included in this study. Face to face interviews were conducted by the trained healthcare workers and both interviewer and respondents were strictly adherent to the COVID-19 standard operating procedures (SOPs) which included hand sanitization, wearing a face mask, and keeping a safe distance.

Study instrument

An interview regarding knowledge, attitude and practice of wearing a mask was conducted with all the participants using the Urdu translated and regional adopted questionnaire used by Lee LYu et al. [15]. The Urdu translated version of the questionnaire was internally validated for the validity and relevance of the content to the context of mask wearing habit in local scenario of Pakistani population. The questionnaire consisted of three domains, first domain was regarding assessment of participants’ practice of wearing a face mask in given scenarios where wearing a face mask was declared necessary. Each scenario was defined in a statement and participant’s adherence to the mask wearing practice in given scenario was rated on three-point frequency scale as “never”, “sometimes”, and “always”. ‘Not applicable’ indicated that the participants did not encounter a situation that required wearing a face mask. An aggregated percentage score was computed by assigning percentage point to each of the response as “0” to never, “50” to sometimes, and “100” to always rating. Response “not applicable” was excluded from the calculation of aggregated percentage score.

Second domain was regarding assessment of face mask wearing technique in which 12 face mask wearing steps were outlined and response of the participant was recorded as “yes” and “no”. The final domain was regarding assessment of face mask taking off technique in which 8 steps were outlined and participant response was recorded as “yes” and “no”. Aggregated mask wearing technique and mask taking off technique score were computed by assigning 100 points to each “yes” response and 0 points to each “no” response. Dataset along with the detailed questionnaire (in English and Urdu) are provided as S1 Data and S1 Questionnaire respectively.

Data analysis

In the absence of relevant literature on mask wearing habit it our population, the sample size for the study was calculated with anticipated proportion of mask wearing practice as 50%, at 95% confidence level, and 5% error margin the required sample size of 384 was calculated. Statistical Package for the Social Sciences (IBM SPSS) Version 21.0 was used for data analysis. No missing value imputation methods were used and analysis were performed on complete dataset of 370 responses after excluding 14 responses due to missing values. The common method bias in the responses to the attitude and practice related attributes was assessed by conducting Harman’s single factor test and Kaiser–Meyer–Olkin (KMO) test. Collected data were summarized with the help of descriptive statistics such as mean ± standard deviation (SD) or percentage (frequency). Face mask wearing practice and non-practicing group of participants were compared for various demographic and clinical characteristics and mask wearing practice and techniques attributed by applying Chi-square test. Differences in the mean score of three domains by various demographic characteristics were assessed with the help of independent sample t-test. The significance level was ≤ 0.05.

Results

A total of 370 participants successfully completed the interview questionnaire. 51.9% were male and the mean age of the participants was 37.65 ± 11.94 years, the majority (74.9%) of whom were under 45 years of age. More than 90% of the participants were practicing face mask wearing in their day to day life during the COVID-19 pandemic. A mask wearing habit positively associated with the participants’ education level and negatively associated with the presence of asthma or Chronic Obstructive Pulmonary Disease (COPD) as co-morbid conditions. Demographic characteristics and risk profile stratified by the face mask wearing habit of the respondent are presented in (Table 1).

Table 1

Demographic characteristics and risk profile stratified by the face mask wearing habit of the respondent.

Characteristics	Total	Mask wearing habit during COVID-19 pandemic		P-value
		No	Yes
Total (N)	370	30 (8.1%)	340 (91.9%)	-
Gender
Male	51.9% (192)	8.3% (16)	91.7% (176)	0.869
Female	48.1% (178)	7.9% (14)	92.1% (164)
Age (years)	37.65 ± 11.94	39.6 ± 15.94	37.48 ± 11.54	0.482
18 to 45 years	74.9% (277)	7.6% (21)	92.4% (256)	0.522
> 45 years	25.1% (93)	9.7% (9)	90.3% (84)
Residence
Urban	65.4% (242)	6.6% (16)	93.4% (226)	0.147
Rural	34.6% (128)	10.9% (14)	89.1% (114)
Socioeconomic class (PKR/month)
Low (≤ 25000)	54.3% (201)	9.5% (19)	90.5% (182)	0.440
Middle (25000–50000)	40.8% (151)	6% (9)	94% (142)
High (≥ 50000)	4.9% (18)	11.1% (2)	88.9% (16)
Education
Low (primary or less)	37.6% (139)	13.7% (19)	86.3% (120)	0.010 *
Middle (up to 10th grade)	49.2% (182)	4.9% (9)	95.1% (173)
High (12th grade or higher)	13.2% (49)	4.1% (2)	95.9% (47)
Hypertension
No	58.1% (215)	9.8% (21)	90.2% (194)	0.168
Yes	41.9% (155)	5.8% (9)	94.2% (146)
Diabetes
No	61.6% (228)	9.6% (22)	90.4% (206)	0.169
Yes	38.4% (142)	5.6% (8)	94.4% (134)
Current Smoker
No	74.6% (276)	7.2% (20)	92.8% (256)	0.298
Yes	25.4% (94)	10.6% (10)	89.4% (84)
Asthma/COPD
No	89.2% (330)	7% (23)	93% (307)	0.021 *
Yes	10.8% (40)	17.5% (7)	82.5% (33)
Ischemic heart disease
No	84.1% (311)	9% (28)	91% (283)	0.148
Yes	15.9% (59)	3.4% (2)	96.6% (57)
Family COVID-19 history
No	81.9% (303)	7.9% (24)	92.1% (279)	0.779
Yes	18.1% (67)	9% (6)	91% (61)
Exposed to COVID-19 patients
No	79.5% (294)	6.8% (20)	93.2% (274)	0.070
Yes	20.5% (76)	13.2% (10)	86.8% (66)

*significant at 5%.

COPD = chronic obstructive pulmonary disease, COVID-19 = coronavirus disease.

The KMO measure of sampling adequacy was 0.676 with Harman’s single factor test for common method bias showing 20.96% variance explanation ensuring both adequacy and bias free information for the analysis. Participants were found to adhere more to face mask wearing practices while visiting hospitals (88.1% respondent reported frequency of ‘Always’) and clinics during the pandemic (69.5% respondent reported frequency of ‘Always’). The practice of wearing a mask was lesser reported for situations like taking care of family members with fever (34.3% respondent reported frequency of ‘Never’) and taking care of family members with a respiratory infection (28.1% respondent reported frequency of ‘Never’). The distribution of the practice of using a face mask specific to various situations is reported in (Fig 1).

Fig 1

Distribution of practice of using face mask specific to various situations and technique of putting on and taking of face mask.

The stepwise techniques of putting on and taking off a face mask followed by the respondents are reported in Fig 1. Hand hygiene before wearing (31.1%) and before taking off a face mask (21.9%) were the least followed steps. Less than 50% of the participants reported performing hand hygiene after disposing off the face mask.

Mean percentage score of practice of mask wearing in various situations and technique of putting on and taking off face mask by various demographic and baseline characteristics are presented in (Table 2).

Table 2

Mean percentage score of practice of mask wearing and technique of putting on and taking off face mask by various demographic and baseline characteristics.

Demographic characteristics	Practice of mask wearing	Technique of putting on face mask	Technique of taking off face mask
Gender
Male	69.42 ± 25.69	66.25 ± 22.9	50.52 ± 28.48
Female	61.68 ± 24.76	69.42 ± 23.12	51.54 ± 30.08
P-value	0.003 *	0.185	0.737
Age (years)
18 to 45 years	65.26 ± 25.75	67.94 ± 23.13	51.17 ± 29.66
> 45 years	66.97 ± 24.87	67.28 ± 22.84	50.54 ± 28.07
P-value	0.577	0.812	0.856
Residence
Urban	66.31 ± 25.99	67.49 ± 23.73	52.17 ± 28.86
Rural	64.52 ± 24.62	68.3 ± 21.73	48.83 ± 29.9
P-value	0.522	0.748	0.296
Socioeconomic class (PKR/month)
Low (≤ 25000)	63.73 ± 26.86	67.45 ± 22.96	51.24 ± 30.9
Middle (25000–50000)	68.32 ± 23.38	68.34 ± 24.02	50 ± 26.77
High (≥ 50000)	65.65 ± 26.55	66.67 ± 14.7	56.94 ± 30.69
P-value	0.248	0.918	0.628
Education
Low (primary or less)	60.64 ± 26.49	65.16 ± 24.99	47.12 ± 30.26
Middle (up to 10th grade)	68.21 ± 23.45	68.08 ± 22.5	51.1 ± 29.12
High (12th grade or higher)	70.68 ± 28.08	74.05 ± 17.66	61.73 ± 23.99
P-value	0.010 *	0.065	0.010 *
Hypertension
No	69.88 ± 26.77	68.06 ± 21.64	52.67 ± 29.63
Yes	59.89 ± 22.47	67.37 ± 24.89	48.71 ± 28.6
P-value	0.001 *	0.777	0.198
Diabetes
No	67.64 ± 27.4	67.13 ± 23.73	51.1 ± 30.31
Yes	62.58 ± 21.86	68.81 ± 21.9	50.88 ± 27.52
P-value	0.063	0.494	0.945
Current Smoker
No	65.74 ± 25.81	69.62 ± 22.77	52.45 ± 29.48
Yes	65.56 ± 24.75	62.36 ± 23.06	46.81 ± 28.22
P-value	0.953	0.008 *	0.106
Asthma/COPD
No	66.87 ± 25.75	68.85 ± 22.38	51.82 ± 28.79
Yes	56 ± 21.34	58.93 ± 26.52	44.38 ± 32.27
P-value	0.011 *	0.010 *	0.128
Ischemic heart disease
No	67.25 ± 26.21	68.23 ± 22.78	50.4 ± 29.48
Yes	57.5 ± 19.67	65.38 ± 24.34	54.24 ± 27.91
P-value	0.007 *	0.384	0.356
Family COVID-19 history
No	66.76 ± 26.53	69.17 ± 22.85	51.16 ± 29.39
Yes	60.86 ± 19.7	61.48 ± 22.97	50.37 ± 28.7
P-value	0.086	0.013 *	0.843
Exposed to COVID-19 patients
No	66.9 ± 26.18	69.06 ± 22.66	52.13 ± 29.53
Yes	61.03 ± 22.29	62.78 ± 23.91	46.71 ± 27.79
P-value	0.074	0.034 *	0.150

*significant at 5%.

COPD = Chronic Obstructive Pulmonary Disease, COVID-19 = Coronavirus Disease 2019.

Mean percentage score of practice of mask wearing in various situations was 65.69 ± 25.51, mean percentage score for technique of putting on face mask was 67.77 ± 23.03, and mean percentage score for technique of taking of face mask was 51.01 ± 29.23. Education level of the respondent tends to have positive relationship with all three scores, while presence of asthma or COPD as co-morbid had negative impact on mask wearing practice.

Discussion

The general population presenting to tertiary care hospitals in Karachi, Pakistan were not using face masks optimally. The importance of hand hygiene as an essential step in wearing and taking off a mask was deeply undervalued. Considered the importance of subject matter, both practice and technique related to face mask use were suboptimal in our population. Education level of participant tends to have positive relationship towards face mask practice and technique while presence of some co-morbid conditions such as asthma or COPD had negative impact on mask wearing practice. Although, no prior literature regarding mask wearing practice are available for our population, but the lack of adherence to the protocols of mask wearing in our populations was same as the observation made by Lee LY et al. [15] among adult population of Hong Kong. A separate discussion on each of the findings is presented in the following sections.

Gender and mask wearing

The practice of wearing a mask and gender were found to be statistically significant, whereas the technique of putting on and taking off a mask were not significant. This outcome has been supported by multiple studies in the past which state that males are more knowledgeable about wearing a mask than female participants [16, 17]. In a survey conducted on the general public of Pakistan, males were found to gather socially more often than females; a possible explanation of why they are more likely to wear a mask [17]. However, other research revealed that female respondents were more likely to wear a mask in their day-to-day life when going outside [18] and that women were more likely to have good practices regarding masks and other preventive measures [19]. Amongst a cross-section of young adults in Pakistan, females were more prone to overestimate the fatality of coronavirus and demonstrated more knowledge-seeking behavior than their male counterparts, reasons that could explain a higher likelihood of females wearing a mask [20].

It is important to note that men are more susceptible to coronavirus infection than women due to physiologic differences such as sex hormones and a higher expression of coronavirus receptors in males, as well as lifestyle differences such as increased tobacco and alcohol consumption by men [21]. Thus, the emphasis on wearing a mask, especially for the male population, is crucial and strict implementation measures must be taken worldwide.

Level of literacy, socioeconomic status and mask wearing

A statistically significant relationship was noted between education levels and the practice of wearing a mask (p = 0.01), as well as technique of taking off a mask (p = 0.01). This notion has been well demonstrated in many past studies [16-18]. It is obvious that the use of the internet, digital and print media to spread awareness about COVID-19 is better understood and thus, practiced by the literate population. Additionally, these informative channels are more affordable for and accessible to the educated masses. Limited access to all sources of information makes vulnerable populations such as rural families more susceptible to having poor knowledge and inadequate practices towards the COVID-19 pandemic [18].

Moreover, other precautionary measures such as hand hygiene are also more prevalent in participants with a higher level of education [22]. Those using masks or practicing appropriate hand hygiene more than four times a day have been shown to have greater knowledge about coronavirus [23]. Lower education levels have also been highlighted as a predictor of poor practices of coronavirus prevention measures [16].

No statistical significance was noted between socioeconomic status and the prevalence of wearing a mask. However, it has been previously established that participants with higher income levels use N95 and surgical masks, while respondents belonging to lower income groups are more likely to wear cloth masks [17].

Co-morbid conditions and mask wearing

Several co-morbid conditions namely Hypertension, Diabetes, Asthma, COPD and Ischemic Heart Disease (IHD) were included. On analysis, a statistically significant relationship between hypertension and wearing a mask, asthma and COPD and wearing a mask as well as technique of putting on a mask, and IHD and wearing a mask was discovered.

Surprisingly, there was a negative association between wearing a mask and the presence of asthma or COPD. One possible explanation for this may be that wearing a mask causes respiratory difficulties in those with already compromised pulmonary function. It has been proven that, in those suffering from COPD, the heart rate, breathing frequency and end-tidal PCO2 were significantly higher after a 6-minute walk test while wearing an N95 mask versus without an N95 mask, whereas the SPO2 levels were significantly lower [24]. Based on these findings, it is advised that those suffering from COPD who have Medical Research Council dyspnea scale (mMRC) scores ≥ 3 or Forced Expiratory Volume in 1 second (FEV1) < 30% predicted should use N95 masks with caution due to an increased risk of inducing respiratory failure [24]. However, when using a surgical face mask, subjects with COPD have not shown significant physiologic changes in gas exchange measurements after a 6-minute walk test [25].

Patients with controlled or mild asthma can safely wear a surgical mask for four continuous hours during their usual activities [26]. The Asthma and Allergy Foundation of America state that patients with mild and/or well-controlled asthma are likely to wear a face mask comfortably, while for those with severe disease and frequent asthma-related issues, wearing a mask may cause issues [27]. Therefore, for those who are unable to wear a mask due to breathing difficulties, it is advised that they practice other coronavirus preventive measures such as staying at home, avoiding contact with sick individuals, maintaining a 6 feet social distance in public and practicing hand hygiene [27].

Similarly, a negative association between hypertension and the practice of wearing a mask, as well as IHD and the practice of wearing a mask was also revealed. This is alarming as it is unequivocal that increased blood pressure and cardiac injury put individuals at a higher risk of COVID-19 complications and mortality [28]. Therefore, it is essential to spread awareness about the importance of wearing a mask and practicing other coronavirus precautionary measures in these high-risk patient populations.

Exposure to COVID-19 patients, family history of COVID-19 and mask wearing

Participants who had been exposed to COVID-19 patients were less likely to wear a mask. Additionally, those with a positive family history of COVID-19 also wore a mask less frequently than those with a negative family history.

The incubation period of COVID-19 before the manifestation of symptoms is between 2 days to 15 days [29]. It is hypothesized that people are most infectious at this stage, when symptoms are absent or mild [30]. Individuals who have been in close contact with a COVID-19 patient are most likely to fall in this category of asymptomatic people and hence, should be extra cautious to wear a mask. In a study conducted in Beijing, China, face masks proved to be 79% effective in reducing the transmission of coronavirus when used by the patient and their family contacts [31].

Even though this the first study of its kind in our population, main limitation of the study was limited sample size and hospital setup. Hence generalizability of study results to the entire general population may be limited.

Conclusion

We have observed suboptimal knowledge, attitude and practice of wearing mask among the selected individuals. There is a continued need to spread awareness and educate general population about the importance of using a face mask, as well as the proper technique of wearing and taking off a face mask. Those with co-morbid conditions who are at the highest risk of COVID-19 mortality should be especially vigilant about following preventive measures. Moreover, individuals with limited access to news outlets as well as those with low literacy rates living in remote areas should receive special training in their own languages through the government on the use of face masks, especially in developing countries such as Pakistan.

Dataset in SPSS format.

(SAV)

Click here for additional data file.

Questionnaire with Urdu translation in PDF format.

(PDF)

Click here for additional data file.

13 Dec 2021

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I would like to draw attention of authors on following:

1. The language of the purpose of the study must be same both in the abstract and in the end of introduction.

Abstract: "The purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population presented to three major tertiary care hospitals of a developing country."

Introduction: "The purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at two major public sector and one private sector hospital."

Methodology: Authors have mentioned "regional adopted questionnaire used"; they have to clarify with regard to the region.

Figures (1 and 2) are not properly labelled.

Conclusion: The sentence mentioned in the conclusion in abstract is not included in conclusion of text of manuscript. Authors have taken sample of the people (patients and others) visiting the hospitals but not the sample of the people in general population; the conclusion must be focused on people (patients and others) visiting the hospitals as hospitals usually don't allow the people enter into hospital without wearing mask. People visiting hospitals are bound to wear the mask but general public usually don't follow the instruction in Pakistan as observed.

Authors have also mention the limitation of the study.

Reviewer #2: Abstract: This needs to be written again, in its current form it is poorly written. In the background, the authors require to highlight the importance of wearing a mask before explaining the purpose. In material and methods authors needs to mention which sampling approach and analysis tool have been used. Results need correction such [technique of putting on was 67.77±23.03, and technique 36 of taking off was 51.01±29.23] shown incomplete sentence.

Introduction The flow of the introduction is generally poorly structured. They have not provided some evidence regarding COVID-19 cases, vaccines delivered in developing countries. In addition, there is a needs to report the research gap and why this study is needed. What are the contributions of the study?.

Methods: This section needs to be sub-divided into the sampling and data collection, recruitment of the respondents, measures of the study (what questions have been asked), and data analysis. Furthermore, there can be critiques on the items used whether those are validated or not. There are several other issues in this part of the study such as how data was collected (i.e., face to face, online), participants have been approached and sampled. Why did they only select 370 participants, how the sample was calculated, did they use any calculation formula, if the authors employed it, there is a need to be reported. Proper justification needs to be added.

Results: This section has several issues as well. Such as which analytical tools and techniques have been used. Why authors did not use hierarchal regression. In addition, there can be common method bias, there is a need to report Harman’s single factor, and KMO test to ensure data is free from any bias.

Discussion: In this section, there is a need to give more importance to insignificant results, general results have been discussed less attention has been given to prior studies. For instance, whether work is consistent or inconsistent with previous studies.

Conclusion: This section needs to be sub-sectioned into implications (general/practical and government/policymakers), limitations, and future directions of the study.

Apart from the above, there are several grammatical errors into the study such as refer line 36, taking of needs to be taking off.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Rano Mal Piryani

Reviewer #2: Yes: Sikandar Ali Qalati

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

30 Dec 2021

Pathiyil Ravi Shankar

Academic Editor

PLOS ONE

30th December 2021

Dear Dr. Pathiyil Ravi Shankar,

We are respectfully submitting our revised manuscript titled “Knowledge, Attitude and Practice of Wearing Mask in the Population Presenting to Tertiary Hospitals in a Developing Country” [PONE-D-21-33953] - [EMID:9854e2ba05706459] for publication consideration in PLOS ONE. We appreciate the insightful editorial and reviewer comments, all of which have been specifically addressed in this revised version of the paper. Please find below the reviewer comments in bold and the author responses in non-bold. We believe these changes have strengthened the quality of our manuscript and that you will find it suitable for publication in the Journal.

All authors had access to all the study data, take responsibility for the accuracy of the analysis, and had authority over manuscript preparation and the decision to submit the manuscript for publication. The manuscript represents original work that has not been published and is not under consideration for publication in any other journal. All authors meet the criteria for authorship and instructions to the author were read. We accept all conditions and publication rights. We have no conflicts of interest to declare and no funding sources to declare.

Thank you for your consideration, and we hope that you find our revised manuscript suitable for publication in PLOS ONE.

Thank you,

Yours sincerely,

Shumaila Furnaz, Manager at Research Department, National Institute of Cardiovascular Diseases, Karachi, Pakistan.

E-mail: shumailafurnaz41@gmail.com

Mobile: +923452093086

Fax: +92-21-99201287

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: Formatting of the title page and body of the text as well as file naming are updated as per the PLOS ONE's style requirements

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

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We will update your Data Availability statement on your behalf to reflect the information you provide.

Response: There are no restrictions data availability, a minimal anonymized data set is uploaded in “.sav” format along with the revised manuscript

3. One of the noted authors is a group or consortium MSc, and MBBS. In addition to naming the author group, please list the individual authors and affiliations within this group in the acknowledgments section of your manuscript. Please also indicate clearly a lead author for this group along with a contact email address.

Response: There are no group authors and title page is updated accordingly

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: captions for supporting information files are provided at the end of revised manuscript

5. In your Supporting Information, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Supporting Information to reflect the information you provide in your cover letter.

Response: Reference to the supporting information is added to the methodology section at appropriate position

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Response: Methodology section is updated to address the technical aspects of the study design

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Response: Statistical aspects are elaborated in the methodology section.

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Response: Data availability statement is updated and a minimal anonymized data set is uploaded in “.sav” format along with the revised manuscript.

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Response: Typographical or grammatical errors are corrected throughout the manuscript

________________________________________

5. Review Comments to the Author

Reviewer #1: It seems "authors have worked hard in conducting this study and writing the manuscript of study.

I would like to draw attention of authors on following:

1. The language of the purpose of the study must be same both in the abstract and in the end of introduction.

Abstract: "The purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population presented to three major tertiary care hospitals of a developing country."

Introduction: "The purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at two major public sector and one private sector hospital."

Response: Study objective mentioned in the introduction section and abstract section are updated as per the suggestion

Methodology: Authors have mentioned "regional adopted questionnaire used"; they have to clarify with regard to the region.

Response: Details on regional adoption of questionnaire are added to the methodology section

Figures (1 and 2) are not properly labelled.

Response: Updated as per the suggestion

Conclusion: The sentence mentioned in the conclusion in abstract is not included in conclusion of text of manuscript. Authors have taken sample of the people (patients and others) visiting the hospitals but not the sample of the people in general population; the conclusion must be focused on people (patients and others) visiting the hospitals as hospitals usually don't allow the people enter into hospital without wearing mask. People visiting hospitals are bound to wear the mask but general public usually don't follow the instruction in Pakistan as observed.

Response: Updated as per the suggestion

Authors have also mention the limitation of the study.

Response: Study limitations are added as per the suggestion

Reviewer #2:

Abstract: This needs to be written again, in its current form it is poorly written. In the background, the authors require to highlight the importance of wearing a mask before explaining the purpose. In material and methods authors needs to mention which sampling approach and analysis tool have been used. Results need correction such [technique of putting on was 67.77±23.03, and technique 36 of taking off was 51.01±29.23] shown incomplete sentence.

Response: Abstract is updated as per the suggestion

Introduction The flow of the introduction is generally poorly structured. They have not provided some evidence regarding COVID-19 cases, vaccines delivered in developing countries. In addition, there is a needs to report the research gap and why this study is needed. What are the contributions of the study?.

Response: As per the suggestions, statistics regarding COVID-19 cases and vaccines delivery in the local context are added to the introduction section with rationale of study highlighting the need of this study in our population.

Methods: This section needs to be sub-divided into the sampling and data collection, recruitment of the respondents, measures of the study (what questions have been asked), and data analysis. Furthermore, there can be critiques on the items used whether those are validated or not. There are several other issues in this part of the study such as how data was collected (i.e., face to face, online), participants have been approached and sampled. Why did they only select 370 participants, how the sample was calculated, did they use any calculation formula, if the authors employed it, there is a need to be reported. Proper justification needs to be added.

Response: As per the suggestions, methodology section is divided into sub-sections as study design and setting, study population, study instrument, and data analysis. Details on regional adoption of questionnaire are added to the methodology section. Details and assumptions used for the calculation of sample size are added.

Results: This section has several issues as well. Such as which analytical tools and techniques have been used. Why authors did not use hierarchal regression. In addition, there can be common method bias, there is a need to report Harman’s single factor, and KMO test to ensure data is free from any bias.

Response: As per the suggestions, Statistical method section is updated regarding assessment of bias in the responses and results of Harman’s single factor test and Kaiser–Meyer–Olkin (KMO) test are provided in results section.

Discussion: In this section, there is a need to give more importance to insignificant results, general results have been discussed less attention has been given to prior studies. For instance, whether work is consistent or inconsistent with previous studies.

Response: Updated as per the suggestion

Conclusion: This section needs to be sub-sectioned into implications (general/practical and government/policymakers), limitations, and future directions of the study.

Apart from the above, there are several grammatical errors into the study such as refer line 36, taking of needs to be taking off.

Response: Updated as per the suggestion

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

1 Mar 2022

Knowledge, Attitude and Practice of Wearing Mask in the Population Presenting to Tertiary Hospitals in a Developing Country

PONE-D-21-33953R1

Dear Dr. furnaz,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Pathiyil Ravi Shankar

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Rano Mal Piryani

Reviewer #2: Yes: Sikandar Ali Qalati

3 Mar 2022

PONE-D-21-33953R1

Knowledge, Attitude and Practice of Wearing Mask in the Population Presenting to Tertiary Hospitals in a Developing Country

Dear Dr. Furnaz:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Pathiyil Ravi Shankar

Academic Editor

PLOS ONE