Factors associated with the use and reuse of face masks among Brazilian individuals during the COVID-19 pandemic

Objective to identify the factors associated with the use and reuse of masks among Brazilian individuals in the context of the COVID-19 pandemic. Method cross-sectional study conducted in the five Brazilian regions, among adult individuals, via an electronic form disseminated in social media, addressing general information and the use of masks. Bivariate analysis and binary logistic regression were used to identify the factors associated with the use and reuse of masks. Results 3,981 (100%) individuals participated in the study. In total, 95.5% (CI 95%: 94.8-96.1) reported using masks. Fabric masks were more frequently reported (72.7%; CI 95%: 71.3-74.1), followed by surgical masks (27.8%; CI 95%: 26.5-29.2). The percentage of reuse was 71.1% (CI 95%: 69.7-72.5). Most (55.8%; CI 95%: 51.7-60.0) of those exclusively wearing surgical masks reported its reuse. Being a woman and having had contact with individuals presenting respiratory symptoms increased the likelihood of wearing masks (p≤0.001). Additionally, being a woman decreased the likelihood of reusing surgical masks (p≤0.001). Conclusion virtually all the participants reported the use of masks, most frequently fabric masks. The findings draw attention to a risky practice, that of reusing surgical and paper masks. Therefore, guidelines, public policies, and educational strategies are needed to promote the correct use of masks to control and prevent COVID-19.


Introduction
The COVID-19 pandemic, a disease caused by the novel human coronavirus (SARS-CoV-2), has affected people in all continents, with 6,912,751 cases confirmed up to June 8 th , 2020, along with 400,469 deaths (1) . Brazil ranks third in the world in the number of deaths; more than 680,456 cases and 36,151 deaths were confirmed up to the same date in the country (1-2) .
Symptoms among those infected with SARS-CoV-2 range from no symptoms up to severe cases of pulmonary disease. The incubation period that involves the onset of the first symptoms may range from two to 14 days after the infection, though some people do not present any symptoms (3) .
Note that, even if asymptomatic, individuals infected with SARS-CoV-2 have the potential to transmit the virus (3)(4) . Transmission mainly occurs from person to person through respiratory droplets, when an individual coughs, sneezes or speaks near other people, while contaminated surfaces or objects may also be sources of transmission (5) .
Therefore, the general population is advised to wear face masks as a mechanical barrier to prevent the dispersion of droplets, in addition to frequent hand sanitization using soap and water or alcohol-based solutions (3) . Hence, to self-protect against diseases and also prevent the transmission of pathogens between healthy and sick individuals, masks have been used as a popular public health intervention (6) .
In Brazil, given a shortage of personal protective equipment (PPE), especially surgical masks, the Ministry of Health advised the population, through an informative note published on April 2 nd , 2020, to make and wear their homemade masks. It also advises that masks made of vacuum bags, cotton, or antimicrobial pillowcases ensure an effective physical barrier, provided they are properly designed and sanitized (7) .
Note that to ensure masks are effective for what they are proposed, that is, to impede the dissemination of expelled droplets, masks need to completely cover mouth and nose and adjust well to the face, without side clearances. Homemade masks are recommended to be sanitized before reuse (7) . Surgical masks are disposable and should not be sanitized because they lose their filtering capacity. Similarly, N95 respirators should not be washed and the number of times it may be reused is informed by manufacturers (8) .
How frequently the population wears masks increases with the onset of local epidemics. It is, however, necessary to better investigate factors such as the duration of protection and how this piece of PPE is used and reused, considering that inappropriate use, especially of disposable masks, may compromise its protective effect and even raise the risk of infection (9) .
In this sense, considering that the use of masks is not a common practice in the population in general, in times of pandemic, this measure has been strongly encouraged and represents a new reality experienced by the Brazilian people. Therefore, identify how people have used and reused this protective piece of equipment is extremely important to discuss the potential effects of not wearing the different types of masks or wearing them inappropriately in the face of the    reported reusing masks 5-6 times (Table 3).  The confidence intervals concerning the prevalence of reuse according to types of masks are presented in Table 3.
In the association between variations concerning the reuse of surgical masks, sex (p=0.001) was the variable that presented p<0.20 and was thus included in the binary logistic regression model for the outcome variable "reuse of mask" (Table 4). CI: 0.37-0.78; p=0.001) also remained a factor associated with the reuse of surgical masks, though, the reuse of surgical masks was two times less likely among women than in the population (Table 5).

Discussion
This study's findings reveal the pattern of use and reuse of masks in the Brazilian population. Virtually all the participants reported the use of this piece of PPE and fabric masks were the most frequently reported.
As the COVID-19 pandemic increasingly aggravated worldwide, the use of masks has been recommended to the population as a non-pharmacological intervention that plays a vital role in controlling the spread of the disease, mainly because the dissemination of the SARS-CoV-2 from human to human mainly occurs through respiratory droplets (10)(11) .
The recommendation for the population to wear homemade masks during epidemics of respiratory infectious diseases such as the Severe Acute Respiratory Syndrome (SARS) and COVID-19, has been successful as a public health intervention at the global level.
In China, for instance, this practice has been efficacious in combination with other protective strategies to prevent the dissemination of viruses causing these two diseases (12) .
The populations of many countries in all the continents have adhered to the use of masks due to the rapid dissemination of the SARS-CoV-2. People in China, including Hong Kong, and Japan, Thailand, and South Korea, have used different types of masks. The growth of cases of COVID-19 in the Czech Republic, where the government has made its use mandatory, has been slower than in other European countries (13) .
On April 2 nd , 2020 (7) , the Brazilian Ministry of Health recommended the population at a national level to start wearing masks. The adoption of this recommendation is confirmed in a study conducted in the second half of April of the same year, which reports that the prevalence of the use of masks was almost absolute in all Brazilian regions; the South presented the highest prevalence.
Being a woman doubles the likelihood of wearing masks.
One study conducted in China, addressing 10,304 participants during the period of the COVID-19 pandemic, also reports greater adherence to protective measures among women, indicating that sex influences adherence to official recommendations related to health (14) .
In this study, the likelihood of wearing masks almost doubled among those who had contact with individuals with respiratory symptoms, which is in agreement with the World Health Organization's recommendation to those with a confirmed diagnosis or suspected infection and their respective caregivers to wear masks (13) .
One Chinese study, however, verified that this use, regardless of the presence of respiratory symptoms, was associated with lower levels of anxiety and depression, that is, the use of masks has potential psychological benefits, giving a sense of safety (15) . cost, and the possibility to be reused after washing (17) .
As current results show, the use of this type of mask among Brazilian individuals has been prevalent during the COVID-19 pandemic.  (17) . Therefore, investment is needed, especially on the part of public policymakers, to provide educational guidelines on how to reuse masks to the population in general.
The study shows that, even though surgical masks are recommended to be discarded after use, reuse reports were considerably high. Surgical masks are Another noteworthy finding in this study is the considerable number of people who use, and reuse, paper or gauze masks as respiratory protection, even though, this type of masks have not been recommended in Brazil. Another factor is that the reuse of masks is less frequent among women than among men, reinforcing that sex is associated with adherence or lack of adherence to protective practices (14) . Hence, educational actions are necessary to address preventive measures in the context of the COVID-19 among the male population.
This study only addressed the use and reuse of masks in the Brazilian population, however, it is important to stress that masks must be adopted together with other preventive measures. This research draws attention to two concerning facts: the inappropriate use of masks and/or the possibility that people become careless with other preventive measures when wearing masks. Therefore, the set of measures that can decrease the spread of SARS-CoV-2 and flatten the pandemic curve, include social distancing, respiratory etiquette, and handwashing, together with the appropriate use of masks (11) . These are situations that should be carefully assessed by health managers in Brazil to devise more assertive plans and protocols.
The current COVID-19 pandemic remains severe worldwide and is an international source of concern, considering that it is a disease with high contagious potential, so the importance of sensitizing the population, reinforcing control measures (19) .
This study's limitations include the fact that digital illiterates were excluded, the impossibility to clarify doubts when participants did not understand a question and lack of knowledge regarding the circumstances in which the form was completed.

Conclusion
The results show that most of this study's participants reported the use of masks and that fabric masks were more frequently reported. Being a woman and prior contact with individuals with respiratory symptoms were associated with the use of masks, increasing its likelihood. Being a woman was also associated with the reuse of surgical masks though, as women are twice less likely to reuse this type of mask in the population.
This study's findings draw attention to a risk practice, that of reusing paper and surgical masks, which increases the chance of transmission given inefficacious respiratory protection. In this sense, this study presents important contributions in the health field as it provides new scientific evidence regarding the use and reuse of masks, which can be used to support the establishment of guidelines, public policies and educational strategies to promote the adoption of correct practices to control and prevent the COVID-19 in the Brazilian territory.