An Observational Study of Mask Guideline Compliance In An Outpatient OB/GYN Clinic Population

Abstract

Dear Editor, The preponderance of recent evidence indicates mask usage decreases the risk of SARS CoV-2 transmission [1]. Wake Forest Baptist Health (WFBH), mandated masking by all patients and visitors to our outpatient clinics on June 1, 2020. This was communicated via campaign of digital contact through our healthcare portal, signage outside and inside clinics, billboard and transport advertisements, and telephone communication during appointment reminder calls. Masking/social distancing messaging currently accounts for 70-80% of the WFBH advertising expenditures (WFBH Communications, Marketing & Media, personal communication, September 29, 2020). There was additional advertising by state and municipal governments and other healthcare systems operating in the area. We sought to determine rate and quality of mask compliance and type of mask chosen among patients and visitors to a general OB/GYN and MFM clinical site whose layout allowed unobstructed observation of arriving patients and visitors. One observer (MN) performed 720 minutes of patient/visitor surveillance at a single WFBH MFM and general OB/GYN outpatient clinic between 9/21/2020 and 10/2/2020. A perimeter was defined 30 feet from the entrance to the clinic’s SARS CoV-2 screening lobby. Patients and visitors entering the perimeter were assessed for sex, type of mask, and correct mask use. A second assessment of use was performed at entry into the screening lobby. Mask type was designated cloth (C), paper (P), valved (V), N95/KN95 (E), improvised (I), or None (N). Correct mask usage was defined as lower face coverage per WHO guidelines [2]. Data were compared using Chi-Square and Fisher’s Exact tests as appropriate. Wake Forest University School of Medicine Institutional Review Board approved this project. During surveillance, 187 patients and visitors were assessed. Summary of data is presented in Table 1 . Mask usage rate was high, with 96.8% of subjects masked. 80.1% were using their mask correctly at perimeter. This increased to 93.4% at entry. Mask type was not associated with correct use at perimeter (p = 0.79) or entry (p = 0.12). Males had a non-statistically significant trend towards correct use at perimeter (p=,0.06) but this disappeared at entry (p = 0.46). Table 1 Sex, mask type and adequacy of mask usage. Table 1 n % Sex Female 150 80.2 Male 37 19.8 Mask Type Cloth 107 57.2 Paper 53 28.3 Cloth with Valve 13 7.0 Extended 6 3.2 Improvised 2 1.1 None 6 3.2 Adequacy of Mask Coverage Upon Approach 145 80.1 Upon Entry 169 93.4 We demonstrate masking in an outpatient setting at WFBH is extremely high. Data estimating rates of consistent masking in the 9 counties surrounding WFBH ranges from 45.8% in Surry County to 70.6% in Forsyth County [3]. Using population data for these 9 counties [4] the authors calculate the average rate of consistent mask use in this area is 61.1%. Our rate of masking is higher than estimated local rates. The high rate of masking and the correction of incorrect mask usage between perimeter and entry suggests high health literacy for proper mask usage. Causation for this high level of masking and correct usage is multifactorial but may include presence of a state mask ordinance [5] and marketing penetration into the target population. We conclude in part the multimedia campaign from WFBH and governmental/non-governmental entities positively influenced masking in the study population. Study limitations include a small sample size and possible introduction of observer bias/error during observation periods. A single observer with a thorough understanding of regulations and a discrete definition of mask adequacy reduced the chance of introducing bias/error. Differences in masking between study population and regional population may be due to selection bias since individuals that pursue health care tend to have different health-promoting habits than those that do not seek health care. This type of selection bias reduces generalizability of the findings but does not invalidate the observations within the targeted study population. Study limitations notwithstanding, our findings indicate compliance with mask usage in the obstetric clinic patient population is very good and suggest that the multifaceted campaign promoting mask usage in this population has been successful thus far. Disclosure of Funding No external funding sources. Disclosure of Ethical Review Approved by Wake Forest University School of Medicine Institutional Review Board September 19, 2020. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.