Pattern and Perception of Impact of Wearing Face Masks on Communication Among Health Care Workers During COVID-19 pandemic: An Observational Study

Abstract

To assess the impact of wearing masks (KN95, surgical, cloth mask) due to COVID-19 pandemic on interpersonal communication among health care workers and with patients. The present observational study was conducted in tertiary care centre and also included participants from various other health care facilities from all over India over a period of one year from March 2022 to March 2023. 203 health care workers consented to participate in the study. The study was done as an online survey using the questionnaire which was adapted into a Google form consisting of a 15 closed set questions. Participants rated the question using a binary forced choice as either YES or NO. The mean age of participants consenting to the study was 30.9 ± 6.3 SD years,with male predominance (%). Among the choice of use of face mask, 76.35% used surgical mask, 14.77% used KN95 and 8.86% used cloth masks. 15 questions were divided in 5 categories; analysis showed that majority of questions had an affirmative “yes” response. This results of this study indicated that the sudden change in the existing communication situation due to use of face masks in the clinical setup affected interpersonal communication among healthcare workers and with patients, which may also have a bearing on both patient and clinician well being and could have a significant economic impact on health care systems globally. These results provide information about the clinical strain introduced from use of face masks in healthcare settings. Overall, results showed that in healthcare settings, there is increased cognitive load and listening effort for patients and health care providers, as well as changes in clinical efficiency for providers when utilizing masks. These effects are often greater with hearing loss.

Introduction

The corona-virus disease (COVID-19) was defined by the WHO as an infectious disease caused by SARS-COV 2. Precautionary measures such as physical distancing, wearing a mask and hand hygiene to suppress virus transmission necessitated a shift in the communication paradigm [1].

The need for face mask, to decrease the spread of the virus, had a huge toll on interpersonal communication. Facial expressions and gestures play a major role in facilitating the same including the comprehension and delivery of intended message. This has also led to altered communication in health care workers, owing that communication is essential to deliver health care effectively.

Altered acoustic characteristics of speech, absence of lip reading cues, limited facial expression are all challenges that have emerged post wearing a facemask while communicating. The high infectivity of SARS-CoV-2 and the increasing rates of COVID-19 infection pushed physicians and health experts to recommend wearing facemasks during the pandemic. This measure combined with social distancing and hand washing helps in slowing the spread of the virus and decreasing its transmission, especially between people that are designated as asymptomatic carriers. Despite its crucial protective role, the face mask poses challenges on daily face-to-face communications. Interpersonal communication describes the interaction between two individuals or more through oral or physical (gestures) interactions [1, 2].

Proper application of the protective mask involves covering the mouth and the nose, which muffles sound and makes it challenging to understand speech and some higher-pitched voices [2]. Furthermore, face masks eliminate the roles of the middle and lower face in emotional expression, rendering its action units invisible to the receiving individual. Additionally, in the physician–patient setting, positive facial expressions play an important role in decreasing the patient's anxiety. Therefore, the physician–patient relationship is affected by wearing face masks [3].

Covering the face reduces the ability very much of determining the patient's feelings and emotions and affect the physician's measured response to the situation. Likewise, the physician's expression of empathy can be missed by the patient. Furthermore, people with special needs and hearing disabilities, rely on sign language and lip reading to communicate [3]. Covering the lower part of the face (nose, cheeks, mouth, nose, and chin) will adversely affect their understanding of communicated information and make them feel more disabled and ostracized. As a result, emotional perception decreases and the role of the upper face in emotional expression increases in significance [4]. Keeping these perspectives in mind the present study was conducted with the aim to assess the impact of wearing masks (KN95, surgical, cloth) during to COVID-19 pandemic on interpersonal communication among health care workers and with patients.

Materials and Methods

The present observational study was conducted on participants of tertiary centre and also included participants from various other health care facilities from all over India from March 2022 to March 2023. After approval from institutional ethics committee, 203 health care workers consented to participate in the study. The study was done as an online survey using the questionnaire which was adapted into a Google form consisting of a 15 closed set questions, where participants rated the question using a binary forced choice as either YES or NO.

Participants

A total of 203 healthcare workers from all over India participated in the study.

Inclusion Criteria

1. Health care workers (HCW’s) in regular posting during which the use of face mask was mandatory.

2. HCW’s who have prior experience of providing clinical services without masks.

3. HCW’s having prior experience of regular one to one interaction with the patients.

4. No history of infection of Ear, Nose and Throat during the time of data collection.

After applying the inclusion criteria, a total of 203 participants, 105 males, and 98 females, in the age range of 20–51 years participated in the study. Informed consent was obtained from all the participants prior to their enrolment in the study. The questionnaire was taken from the previously done study by Yeshoda et al. 2022 (annexure 1).

The questionnaire was adapted into a Google form consisting of the 15 closed-set questions. Questions on age details, type of preferred mask (KN95, surgical mask, cloth mask) and the consent statement were also added to the initial part of the Google form and were made mandatory. These forms were emailed individually to HCW in different regions of India, via the personal mail id of the author. Participants were requested to choose either a Yes or No response to each of the 15 questions. The responses of all the participants were averaged question-wise and tabulated for statistical analysis.

Statistical Analysis

The Statistical Package for the Social Sciences (SPSS) (Version 20) was used to analyze the data. The binary responses to the questions were summarized by generating crosstabs of the descriptive statistical measures, such as the mean percentage of responses. Additionally, a Chi-square test of association was done to understand any significant relationship between the responses to the questions from the categories of Communication Effectiveness, Visual Cues, Physiological Effects, and Environmental Effects.

Observations

In our study 203 health care workers participated with age range of 21–51 years and following observations were made. Male to female ratio regarding the choice of face mask is given in Table 1.

Table 1.

Choices of face mask

Participants	Total no. (203)	Using N95 (76.35%)	Using surgical mask (14.77%)	Using cloth mask (8.86%)
Male	105	81 (39.9%)	15	9
Females	98	74 (36.4%)	15	9

Among 203 participants, 105 (51.7%) were males. The mean age of presentation was 30.9 ± 6.3 years. 133 (65.5%) participants were below 30 years of age. 155(76.4%) of all participates preferred wearing N95 masks followed by surgical masks in 30(14.8%) and 18 (8.9%) chose cloth masks with no significant gender distribution as seen in Table 1.

The results were scrutinized to understand the impact of facial masks through the questions in the five major categories. It was noted that most questions in all the five categories received a maximum affirmative “yes” response shown in Table 2. The data obtained was analyzed using descriptive statistical methods. Cross tabs of the responses obtained for each question were formulated. The mean percentage scores are given in Table 3 and figuratively represented in Fig. 1.The Chi-square test of association was done to analyze the association between the responses to the questions in the category of communication effectiveness with Visual cues, Physiological Effect, and Environmental Effect (Tables 4).

Table 2.

Percentage of ‘yes’ responses for each question is as follows

S. no	Questions	% age of yes responses
1	Do you feel that the clients find it difficult to follow the instructions of clinicians wearing masks?	93.1
2	Do you feel wearing a mask is a barrier to effective communication as it hinders clear communication and needs multiple repetitions/clarifications?	93.6
3	Do you pay more attention to the suprasegmentals of speaker’s voice?	93.1
4	Do you feel prolonged eye contact necessary to maintain the conversation while wearing mask seems uncomfortable to some people?	97.5
5	Do you feel that communication breakdowns and communication errors (misunderstanding of instructions) are more frequent since subtle facial cues are lost?	97.5
6	Do you find it challenging and time consuming to find innovative ways for rapport building to provide effective assessment and therapy/ intervention to your clients while wearing a mask	96.1
7	Do you feel that the mask hides your facial expressions?	100
8	Do you pay more attention to the talkers’ eyebrows, eye contact, the overall body language and gestures?	96.6
9	Do you experience breathing difficulty/shortness of breath/panting while wearing masks and communicating	97.5
10	Do you feel your voice is strained/ distorted/ muffled while wearing the mask and talking?	98.5
11	Do you use masks for a prolonged duration of time (6–8 h/day)?	100
13	Do you feel you can hear clearly while communicating with the clients wearing masks?	3.9
12	Do the SLPs have a role in supporting communication in context of mask wearing?	96.1
14	Do you feel that the physical background, infrastructure and work environment affect the mask wearing?	91.6
15	Do you use technology and other aids (writing on paper, using signs or gestures, pointing) to facilitate communication	100

Table 3.

Mean percentage of responses for all questions of the five major categories-communication effectiveness, visual cues, physiological, palliative, and environment effect

Categories	Communication effectiveness			Visual cues					Physiological effect				Palliative effect	Environmental effect
Question numbers	1	2	10	3	4	5	8	9	6	7	11	13	12	14	15
Mean % of yes response	93.1	93.5	93.10	92.6	97.5	96.05	100	96.5	97.5	98.5	100	3.95	96.05	91.6	100
Mean % of no response	6.9	6.5	6.9	7.4	2.5	3.95	0	3.45	2.5	1.5	0	96.05	3.95	8.4	0

Fig. 1.

Percentage distribution of "yes–no" responses to questions under the five major categories communication effectiveness, visual cues, physiological, palliative, and environment

Table 4.

Results of Fisher exact test of association between the categories of communication effectiveness and visual cues, physiological and environment effect

	Value	Asymptotic significance (2-sided)
Visual cues	1.473	0.150
Physiological effects	6.671	0.453
Environmental effects	1.299	0.519

No significant association between the groups (asymptotic significance (2-sided) from fishers exact test as the assumptions of chi square were not met)

Discussion

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the virus SARS-CoV-2. The first known case was identified in Wuhan, China, in December 2019. The disease quickly spread worldwide, resulting in the COVID-19 pandemic.COVID-19 is mainly transmitted when people breathe in air contaminated by droplets/aerosols and small airborne particles containing the virus.

The transmission of the virus is carried out through virus-laden fluid particles, or droplets, which are created in the respiratory tract, and they are expelled by the mouth and the nose. There are three types of transmission: “droplet” and “contact”, which are associated with large droplets, and “airborne”, which is associated with small droplets [5]. At the beginning of the pandemic, many experts advised against the use of facemasks by the public due to a sense that their potential risks, such as self-contamination, could outweigh the potential benefits, and that public use would lead to depletion of the supply needed for health-care workers. Experts then shifted their thinking about potential benefits of masks to include protecting others against infection with SARS-CoV-2 (source control), similar to how surgical masks in the operating room protect patients. However, self-protection is the main reason why infection prevention and control experts recommend health-care workers to wear a facemask when entering a patient's room who may have a viral respiratory infection. With COVID-19, however, facemasks were beneficial for protection of both health-care workers and the public.

Face-to-face communication, specifically, was majorly affected by the pandemic. The need for face masks, as an important protective measure to decrease the spread of the virus, had a huge toll on interpersonal communication. Facial expressions and gestures play a major role in facilitating interpersonal communication, comprehension, and the delivery of intended messages. As such, wearing face masks hindered the ability of seeing and understanding people’s expressions during conversations, and decreased the impact of communicated material [6].

In the present study of pattern and perception of impact of wearing masks on interpersonal communication among health care workers during COVID-19 pandemic which was conducted on 203 health care workers regarding the influence of face mask on interpersonal communication during the pandemic of COVID 19. The study was carried out in the form of Google form responses, where questions were in the form of binary forced choice of either Yes or No.

Analysis of the responses of all the questions revealed that the maximum number of questions in all categories received an above-average “yes” response from most participants. This indicated that the sudden change in the existing communication situation, confounded by unfamiliar and prevalent challenges made wearing face masks essential for safeguarding oneself and others, leading to the high affirmative responses. Further, it was noted that for question 13, the physiological category had the least score (3.95%) for “yes” response. However, the speech reception and discrimination abilities may need closer scrutiny using quantitative auditory assessment. 100% of the participants indicated “yes” to the use of other aids to facilitate their communication, and this is in consonance with the findings of Mheidly et al. [3], who advocated the use of telecommunication for interpersonal interactions to facilitate communication while wearing a face mask. When association effects across the major categories were checked, the Fisher Exact test showed no significant association with responses of questions in Communication Effectiveness with the responses to the questions in Visual Cue and Physiological effect groups with Environment Effect. Pearson correlation between 5 categories of communication effectiveness, physiological effect, visual cues, environment effect and palliative effect showed no association and were independent of each other (Table 5).

Table 5.

Result of Pearson correlation between 5 categories of communication effectiveness, physiological effect, visual cues, environment effect and palliative effect

		Communication effectiveness	Physiological effect	Visual cues	Environental effect	Palliative effect
Communication effectiveness	Pearson correlation	1	− 0.091	0.104	− 0.097	0.022
	Sig. (2-tailed)		0.195	0.139	0.170	0.758
	N	203	203	203	203	203
Physiological effect	Pearson correlation	− 0.091	1	0.038	0.122	0.089
	Sig. (2-tailed)	0.195		0.592	0.084	0.206
	N	203	203	203	203	203
Visual cues	Pearson correlation	0.104	0.038	1	0.003	− 0.023
	Sig. (2-tailed)	0.139	0.592		0.967	0.743
	N	203	203	203	203	203
Environmental effect	Pearson correlation	− .097	0.122	0.003	1	0.122
	Sig. (2-tailed)	0.170	0.084	0.967		0.084
	N	203	203	203	203	203
Palliative effect	Pearson correlation	0.022	0.089	− 0.023	0.122	1
	Sig. (2-tailed)	0.758	0.206	0.743	0.084
	N	203	203	203	203	203

No significant association between these 5 groups was seen revealing the categories were independent of each other

The probability of the “McGurk effect’’,wherein the misinterpretation of stimuli occurs when there is a dissonance between the visual and auditory stimuli during the use of facial masks was also emphasized by Campagne DM et al. [7]. Likewise, the speakers experiencing breathing discomforts and use of strenuous voice to be heard through the facial masks and strained listening leading to prolonged communication interaction time (physiological effects) was found to significantly affect the communication effectiveness, which found support from the results of Esmaeilzadeh et al. [8] He reported physiological discomfort like headache, acne, increased facial temperature etc., as the strongest variables affecting the attitude towards mask-wearing. These factors further led to communication failures, disturbing the patient-clinician relational continuity. The majority of the participants in this study preferred surgical masks, followed by N95 masks, and the preference for cloth masks was the least. Preference for the type of the mask may be primarily to safeguard one’s health or a personal choice of the individual for ease of communication and or easy accessibility and warrants further investigation [6].

Overall, the results of the current study showed that the use of face masks in the clinical setup affected interpersonal communication. A report from India on the different nonverbal communication strategies that could be used to establish patient-doctor rapport listed the following: Eye contact, Para linguistics, Body gestures and movements, and being a patient-listener. The need for alternative communication strategies is becoming essential, just like for any other healthcare worker, for effective healthcare delivery, as also suggested by Bandaru et al. [9]. Further, this overall effect of breakdown in communication could hinder a better service delivery, which may also have a bearing on both patient and clinician well-being and could have a significant economic impact on healthcare systems globally.

Conclusion

Wearing face masks impacts overall communication, affects breathing, strains the voice of the talkers, and causes hesitation to converse as the listeners stare at the talkers paying close attention to the upper parts of their faces to comprehend the messages, in turn, prolonging the communication interactions and/ or communication breakdown. This necessitates the Speech-Language Pathologists and Audiologists to facilitate communication to strengthen communication means of clients with communication disorders and fellow professionals. Using alternate communication strategies when using personal protective devices, such as face masks and face shields, should be advocated and encouraged as facilitators for effective communication.

Appendix

Questionnaire.

Funding

Nil.

Declarations

Conflict of interest

None.