Journal of Occupational
Health and Epidemiology
Rafsanjan university Of medical sciences
Volume 11, Issue 1 (Winter 2022)
J Occup Health Epidemiol 2022, 11(1): 23-31 |
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Arasteh A, Mostafavi S, Mirza-Aghazadeh-Attari M, Alizadeh M, Mostafavi Montazeri S M, Hejazian S M et al . Associations between Wearing Masks, Hand Washing, and the Risk of COVID-19 Contraction: A Case-Control Study in the Northwest of Iran. J Occup Health Epidemiol 2022; 11 (1) :23-31
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Amin Arasteh1 
, Soroush Mostafavi2 , Mohammad Mirza-Aghazadeh-Attari3 , Mahasti Alizadeh4 , Seyedeh Mina Mostafavi Montazeri5 , Seyyedeh Mina Hejazian * 6, Seyede Saba Mostafavi Montazeri*7
, Soroush Mostafavi2 , Mohammad Mirza-Aghazadeh-Attari3 , Mahasti Alizadeh4 , Seyedeh Mina Mostafavi Montazeri5 , Seyyedeh Mina Hejazian * 6, Seyede Saba Mostafavi Montazeri*7
1- Resident Student in Ophthalmology, Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.
2- MD Student, Student Research Committee, Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
3- MD Student, Dept. of Radiology, Medical Radiation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
4- Professor, Social Determinants of Health Research Center, Dept. of Community and Family Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
5- Resident Student in Internal Medicine, Clinical Research Development Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
6- MSc in Medical Biotechnology, Student Research Committee, Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. ,s.mina.hejazian@gmail.com
7- MD Student, Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran. , sabamst26@gmail.com
2- MD Student, Student Research Committee, Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
3- MD Student, Dept. of Radiology, Medical Radiation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
4- Professor, Social Determinants of Health Research Center, Dept. of Community and Family Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
5- Resident Student in Internal Medicine, Clinical Research Development Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
6- MSc in Medical Biotechnology, Student Research Committee, Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. ,
7- MD Student, Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran. , sabamst26@gmail.com
Article history
Received: 2021/11/5
Accepted: 2022/02/28
ePublished: 2022/03/25
Accepted: 2022/02/28
ePublished: 2022/03/25
Subject:
Epidemiology
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Table 1. Participants' demographic information
Table 2. History of underlying diseases among the participants
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
Full-Text: (86 Views)
Itroduction
In December 2019, a new coronavirus (Severe Acute Respiratory Syndrome Coronavirus-2) (SARS-CoV2) was discovered in Wuhan, China, which caused novel coronavirus disease 2019 (COVID-19) [1]. Due to its high virulence rate and rapid spread, the World Health Organization (WHO) considered it a pandemic health threat [1-3]. From the beginning of the pandemic until February 2022, 6,543,837 confirmed cases were identified in Iran, of whom 132,745 cases died [4]. Although no virus particles were found 2-5 meters away from patients’ beds in the ICU in the study by Seyyed Mahdi et al [5], most studies demonstrated that human-to-human transmission of the virus occurred through droplets, or it was airborne [6, 7]. There are two alternatives for dealing with the virus and preventing the incidence of the virus-induced infection. The first one is pharmaceutical methods, like vaccines or drugs, and the second one is non-pharmaceutical interventions [8]. Wearing masks and hand hygiene are the two proven ways, as non-pharmaceutical interventions, for appropriately preventing the virus spread [9-11]. Given that COVID-19 is still unknown and there are many unanswered questions, it is necessary to investigate this issue more accurately [12]. Since the use of vaccines and definitive drugs is not agreed upon by some individuals suspicious of their efficacy, it seems that the use of non-pharmaceutical methods is more logical [13]. However, European countries still keep employing preventive protocols, including wearing face masks and hand washing to control the incidence of COVID-19 [14].
Wearing facemasks and hand washing, as preventive methods, have reduced the incidence of the disease in some countries, like Singapore and South Korea [15]. Evidence shows that facemasks not only prevent viral infections by reducing virus particles, but they also induce immunity among individuals [16]. In contrast, in countries, such as Iran and Italy in which these protocols were not strictly observed, no reduction occurred in the incidence of the disease [17]. In a study by Peyrony et al, it was observed that SARS-CoV2 remained on light switches, door knobs, or closets in the hospital [18]; therefore, it is necessary to use disinfectants to prevent COVID-19 contraction. However, some people refused to regularly follow the protocols of wearing masks and hand washing for asymptomatic, political, medical, or other reasons [19]. There were similar studies in the literature review on the relationship between personal hygiene protocols of COVID-19 and prevention of COVID-19 contraction or mortality (20, 21). Nevertheless, to our knowledge, no study was found to have been conducted among the population of Tabriz, Iran. In this context, this study aimed to determine the role of hand washing and wearing facemasks in preventing COVID-19 contraction and its relationship with other factors
among the population of Tabriz, Iran.
Materials and Methods
Data collection for this descriptive non-interventional study was performed from July 22, 2020 to August 20, 2020. To this end, a total of 360 people (120 cases and 240 controls) who participated in the study were selected via non-randomized convenient sampling. The sample size was determined via G-power software, where p = 0.95, d = 0.405, α-error = 0.05, and allocation ratio N2/N1= 2. These individuals received and completed the questionnaire in person, by phone, or online. The inclusion criteria were having a history of periodic care by the health centers of Tabriz, Iran, and being willing to participate in the study. On the other side, the exclusion criteria were incomplete questionnaires, treatment staff, and unwillingness to participate in the study. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1399.116).
During this study, some individuals were employed for collecting the required information via a questionnaire that contained multi-optional questions. In addition, the individuals were free to select one of the options for each question. The questionnaire utilized in this study consisted of four parts. The first part included sociodemographic characteristics, including age, gender, education, occupation, smoking habits, history of underlying diseases, and caring for a child under 7 or a person over 60 years old; the second part included information on COVID-19, whether they or anyone around them had been infected with the disease, and the current status of infected acquaintances; the third part included mask-wearing behaviors, such as whether they wore facemasks, the type of the masks, reuse of the masks, washing the masks, and the reason for not wearing them; and the fourth part included hand washing habits, such as carrying disinfectants outdoors and regularly washing hands after coming home. It is worth noting that the questionnaires utilized were designed by professors at Tabriz University of Medical Sciences, whose reliability and validity were determined at the beginning of the study based on calculations in a study by Firouzbakht et al [22].
Data analysis was performed by SPSS 19.0. In addition, data distribution of quantitative variables was controlled in terms of normality by the Shapiro-Wilk test. The results obtained were reported as mean ± standard deviation or the median (min-max) for normal or non-normal data
distribution, respectively. In addition, after determining frequencies of qualitative variables, the relationship between them was evaluated by the Fisher’s exact test. Additionally, correlations were assessed by the Spearman's test, and p-values were considered significant at 0.05.
Results
A total of 360 individuals were included in this
study, of whom 120 cases had a history of COVID-19 contraction, yet 240 individuals had not experienced COVID-19. The mean ages of individuals with and without COVID-19 were 43 ± 13 and 44 ± 15 years old, respectively. In addition, distributions of demographic and clinical parameters, including gender, education, and COVID-19 contraction were similar among the groups assessed (Table 1).
In December 2019, a new coronavirus (Severe Acute Respiratory Syndrome Coronavirus-2) (SARS-CoV2) was discovered in Wuhan, China, which caused novel coronavirus disease 2019 (COVID-19) [1]. Due to its high virulence rate and rapid spread, the World Health Organization (WHO) considered it a pandemic health threat [1-3]. From the beginning of the pandemic until February 2022, 6,543,837 confirmed cases were identified in Iran, of whom 132,745 cases died [4]. Although no virus particles were found 2-5 meters away from patients’ beds in the ICU in the study by Seyyed Mahdi et al [5], most studies demonstrated that human-to-human transmission of the virus occurred through droplets, or it was airborne [6, 7]. There are two alternatives for dealing with the virus and preventing the incidence of the virus-induced infection. The first one is pharmaceutical methods, like vaccines or drugs, and the second one is non-pharmaceutical interventions [8]. Wearing masks and hand hygiene are the two proven ways, as non-pharmaceutical interventions, for appropriately preventing the virus spread [9-11]. Given that COVID-19 is still unknown and there are many unanswered questions, it is necessary to investigate this issue more accurately [12]. Since the use of vaccines and definitive drugs is not agreed upon by some individuals suspicious of their efficacy, it seems that the use of non-pharmaceutical methods is more logical [13]. However, European countries still keep employing preventive protocols, including wearing face masks and hand washing to control the incidence of COVID-19 [14].
Wearing facemasks and hand washing, as preventive methods, have reduced the incidence of the disease in some countries, like Singapore and South Korea [15]. Evidence shows that facemasks not only prevent viral infections by reducing virus particles, but they also induce immunity among individuals [16]. In contrast, in countries, such as Iran and Italy in which these protocols were not strictly observed, no reduction occurred in the incidence of the disease [17]. In a study by Peyrony et al, it was observed that SARS-CoV2 remained on light switches, door knobs, or closets in the hospital [18]; therefore, it is necessary to use disinfectants to prevent COVID-19 contraction. However, some people refused to regularly follow the protocols of wearing masks and hand washing for asymptomatic, political, medical, or other reasons [19]. There were similar studies in the literature review on the relationship between personal hygiene protocols of COVID-19 and prevention of COVID-19 contraction or mortality (20, 21). Nevertheless, to our knowledge, no study was found to have been conducted among the population of Tabriz, Iran. In this context, this study aimed to determine the role of hand washing and wearing facemasks in preventing COVID-19 contraction and its relationship with other factors
among the population of Tabriz, Iran.
Materials and Methods
Data collection for this descriptive non-interventional study was performed from July 22, 2020 to August 20, 2020. To this end, a total of 360 people (120 cases and 240 controls) who participated in the study were selected via non-randomized convenient sampling. The sample size was determined via G-power software, where p = 0.95, d = 0.405, α-error = 0.05, and allocation ratio N2/N1= 2. These individuals received and completed the questionnaire in person, by phone, or online. The inclusion criteria were having a history of periodic care by the health centers of Tabriz, Iran, and being willing to participate in the study. On the other side, the exclusion criteria were incomplete questionnaires, treatment staff, and unwillingness to participate in the study. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1399.116).
During this study, some individuals were employed for collecting the required information via a questionnaire that contained multi-optional questions. In addition, the individuals were free to select one of the options for each question. The questionnaire utilized in this study consisted of four parts. The first part included sociodemographic characteristics, including age, gender, education, occupation, smoking habits, history of underlying diseases, and caring for a child under 7 or a person over 60 years old; the second part included information on COVID-19, whether they or anyone around them had been infected with the disease, and the current status of infected acquaintances; the third part included mask-wearing behaviors, such as whether they wore facemasks, the type of the masks, reuse of the masks, washing the masks, and the reason for not wearing them; and the fourth part included hand washing habits, such as carrying disinfectants outdoors and regularly washing hands after coming home. It is worth noting that the questionnaires utilized were designed by professors at Tabriz University of Medical Sciences, whose reliability and validity were determined at the beginning of the study based on calculations in a study by Firouzbakht et al [22].
Data analysis was performed by SPSS 19.0. In addition, data distribution of quantitative variables was controlled in terms of normality by the Shapiro-Wilk test. The results obtained were reported as mean ± standard deviation or the median (min-max) for normal or non-normal data
distribution, respectively. In addition, after determining frequencies of qualitative variables, the relationship between them was evaluated by the Fisher’s exact test. Additionally, correlations were assessed by the Spearman's test, and p-values were considered significant at 0.05.
Results
A total of 360 individuals were included in this
study, of whom 120 cases had a history of COVID-19 contraction, yet 240 individuals had not experienced COVID-19. The mean ages of individuals with and without COVID-19 were 43 ± 13 and 44 ± 15 years old, respectively. In addition, distributions of demographic and clinical parameters, including gender, education, and COVID-19 contraction were similar among the groups assessed (Table 1).
Table 1. Participants' demographic information
| Variables | COVID-19 | P-value | ||||
| No | Yes | |||||
| Count | % | Count | % | |||
| Gender | Men | 123 | 51.2% | 67 | 55.8% | 0.435 |
| Women | 117 | 48.8% | 53 | 44.2% | ||
| Education | Illiterate | 11 | 4.6% | 0 | 0% | 0.04 |
| Lower than high school diploma | 52 | 21.7% | 27 | 22.5% | ||
| High school diploma | 53 | 22.1% | 32 | 26.7% | ||
| Undergraduate | 87 | 36.3% | 35 | 29.2% | ||
| Graduate and higher | 37 | 15.4% | 26 | 21.7% | ||
| Occupation | Jobless | 14 | 5.8% | 7 | 5.8% | 0.092 |
| Housewives | 54 | 22.5% | 31 | 25.8% | ||
| Clerks | 57 | 23.8% | 23 | 19.2% | ||
| Students | 11 | 4.6% | 8 | 6.7% | ||
| Health workers | 5 | 2.1% | 11 | 9.2% | ||
| Retired | 32 | 13.3% | 11 | 9.2% | ||
| Self-employed | 62 | 25.8% | 28 | 23.3% | ||
| Workers | 5 | 2.1% | 1 | 0.8% | ||
| Family members | Care seekers | 122 | 50.8% | 71 | 59.2% | 0.061 |
| Older than 60 | 45 | 18.8% | 15 | 12.5% | ||
| Younger than 7 | 48 | 20% | 29 | 24.2% | ||
| Both | 25 | 10.4% | 5 | 4.2% | ||
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
Table 2 shows correlations between the presence of underlying diseases and the incidence of COVID-19 contraction among the participants.
In this study, most of the participants suffered from hypertension (n = 40), obesity (n = 30), and diabetes mellitus (n =22). In addition, 9 individuals had respiratory disorders, 8 had cardiovascular diseases, 5 had neurological or psychological problems, 5 had thyroid problems, 2 had allergies, 2 had autoimmune disorders, and one person had chronic kidney disease. However, the frequency of the individuals infected with COVID-19 was not affected by any of the underlying disorders (p > 0.05).
In this study, most of the participants suffered from hypertension (n = 40), obesity (n = 30), and diabetes mellitus (n =22). In addition, 9 individuals had respiratory disorders, 8 had cardiovascular diseases, 5 had neurological or psychological problems, 5 had thyroid problems, 2 had allergies, 2 had autoimmune disorders, and one person had chronic kidney disease. However, the frequency of the individuals infected with COVID-19 was not affected by any of the underlying disorders (p > 0.05).
Table 2. History of underlying diseases among the participants
| Underlying diseases | COVID-19 | P-value | |||
| No | Yes | ||||
| Count | % | Count | % | ||
| Hypertension | 40 | 16.7% | 16 | 13.3% | 0.445 |
| Obesity | 30 | 12.5% | 16 | 13.3% | 0.867 |
| Diabetes mellitus | 22 | 9.2% | 13 | 10.8% | 0.706 |
| Respiratory disorders | 9 | 3.8% | 6 | 5.0% | 0.584 |
| Cardiovascular diseases | 8 | 3.3% | 8 | 6.7% | 0.177 |
| Others | 8 | 3.3% | 7 | 5.8% | 0.273 |
| Neurological/psychological problems | 5 | 2.1% | 2 | 1.7% | 1 |
| Thyroid problems | 5 | 2.1% | 2 | 1.7% | 1 |
| Allergies | 2 | 0.8% | 2 | 1.7% | 0.603 |
| Autoimmune disorders | 2 | 0.8% | 1 | 0.8% | 1 |
| Chronic kidney disease | 1 | 0.4% | 1 | 0.8% | 1 |
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
|
*
|
Table 3. Daily behaviors possibly affecting COVID-19 contraction
| Related behaviors | COVID-19 | P-value* | ||||
| No | Yes | |||||
| Count | % | Count | % | |||
| Smoking | No | 176 | 73.3% | 111 | 92.5% | < 0.001 |
| Second-hand smokers | 30 | 12.5% | 3 | 2.5% | ||
| Smokers | 34 | 14.2% | 6 | 5.0% | ||
| Using antibacterial sanitizers | Never | 17 | 7.1% | 6 | 5.0% | 0.002 |
| If available | 31 | 12.9% | 11 | 9.2% | ||
| Always | 192 | 80.0% | 103 | 85.8% | ||
| Hand washing | No | 1 | 0.4% | 4 | 3.3% | 0.584 |
| Yes | 239 | 99.6% | 116 | 96.7% | ||
| Wearing masks | Never | 11 | 4.6% | 8 | 6.7% | 0.011 |
| After COVID-19 incidence | 4 | 1.7% | 10 | 8.3% | ||
| Always | 225 | 93.8% | 102 | 85.0% | ||
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
Table 3 shows daily behaviors affecting COVID-19 contraction. Accordingly, it was revealed that the individuals smoking (p < 0.001), using antibacterial sanitizers (p = 0.002), and wearing facemasks (p = 0.011) were at a low risk of COVID-19 contraction. Although the incidence of COVID-19 contraction was reduced among individuals washing their hands, the difference observed was not statistically significant (p = 0.584).
In addition, observations of personal protection against COVID-19 contraction were compared among the individuals with different genders, education levels, occupations, and family
members. The results showed that education remarkably determined if the individuals wore a facemask (p = 0.016); gender and occupation were significantly effective in determining the frequency of hand washing (p = 0.033 and 0.028, respectively); and education and occupation significantly affected the use of antibacterial sanitizers among the individuals (p = 0.001 and 0.02, respectively). However, having a care seeker, a male elder, or a baby did not statistically affect protective behaviors among the individuals (p > 0.05) (Table 4).
In addition, observations of personal protection against COVID-19 contraction were compared among the individuals with different genders, education levels, occupations, and family
members. The results showed that education remarkably determined if the individuals wore a facemask (p = 0.016); gender and occupation were significantly effective in determining the frequency of hand washing (p = 0.033 and 0.028, respectively); and education and occupation significantly affected the use of antibacterial sanitizers among the individuals (p = 0.001 and 0.02, respectively). However, having a care seeker, a male elder, or a baby did not statistically affect protective behaviors among the individuals (p > 0.05) (Table 4).
Table 4. Observations of personal protection against COVID-19 contraction among the general population
| Parameters | Wearing masks | P-value | Hand washing | P-value | Using antibacterial sanitizers | P-value | ||||||
| Never | After the pandemic |
Always | No | Yes | Never | If available | Always | |||||
| Gender | Male | 11 | 10 | 169 | 0.309 | 5 | 185 | 0.033 | 11 | 27 | 152 | 0.277 |
| Female | 8 | 4 | 158 | 0 | 170 | 12 | 15 | 153 | ||||
| Education | Illiterate | 3 | 0 | 8 | 0.016 | 0 | 11 | 0.177 | 3 | 1 | 7 | 0.001 |
| Lower than high school diploma | 7 | 5 | 67 | 1 | 78 | 12 | 3 | 64 | ||||
| High school diploma | 6 | 4 | 75 | 0 | 85 | 1 | 13 | 71 | ||||
| Undergraduate | 2 | 4 | 116 | 1 | 121 | 4 | 17 | 101 | ||||
| Graduate and higher | 1 | 1 | 61 | 3 | 60 | 3 | 8 | 52 | ||||
| Occupation | Jobless | 3 | 0 | 18 | 0.343 | 1 | 20 | 0.028 | 2 | 0 | 19 | 0.02 |
| Housewives | 3 | 3 | 79 | 0 | 85 | 9 | 5 | 71 | ||||
| Clerks | 2 | 2 | 76 | 1 | 79 | 1 | 11 | 68 | ||||
| Students | 0 | 0 | 19 | 2 | 17 | 0 | 1 | 18 | ||||
| Health workers | 1 | 2 | 13 | 0 | 16 | 1 | 2 | 13 | ||||
| Retired | 2 | 5 | 39 | 1 | 42 | 1 | 5 | 37 | ||||
| Self-employed | 7 | 0 | 78 | 0 | 90 | 8 | 16 | 66 | ||||
| Workers | 1 | 14 | 5 | 0 | 6 | 1 | 2 | 3 | ||||
| Family members | Care seekers | 9 | 6 | 178 | 0.363 | 3 | 190 | 0.357 | 14 | 18 | 161 | 0.736 |
| Older than 60 | 4 | 1 | 55 | 2 | 58 | 3 | 7 | 50 | ||||
| Younger than7 | 6 | 5 | 66 | 0 | 77 | 5 | 12 | 60 | ||||
| Both | 0 | 2 | 28 | 0 | 30 | 1 | 5 | 24 | ||||
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
Table 5 shows the effect of underlying diseases on personal hygiene. The results obtained showed that patients with cardiovascular diseases and a history of COVID-19 contraction wore facemasks more frequently than the others (p = 0.021 and 0.044, respectively). In addition, individuals with a history of COVID-19 contraction and neurological/psychological problems used more antibacterial sanitizers (p = 0.002 and 0.046, respectively); however, none of the two patients with chronic kidney disease used antibacterial sanitizers (p = 0.003). Nevertheless, other underlying diseases had no effect on observations of personal protection against COVID-19 contraction (p > 0.05).
Table 5. Observations of personal protection against COVID-19 contraction among individuals with underlying diseases
| Underlying diseases | Wearing masks | P-value | Hand washing | P-value | Using antibacterial sanitizers | P-value | |||||
| Never | After the pandemic | Always | No | Yes | Never | If available | Always | ||||
| Hypertension | 3 | 3 | 50 | 0.744 | 0 | 56 | 1 | 5 | 8 | 43 | 0.448 |
| Obesity | 1 | 4 | 41 | 0.107 | 1 | 45 | 0.497 | 1 | 6 | 39 | 0.508 |
| Diabetes mellitus | 2 | 2 | 31 | 0.711 | 1 | 34 | 0.402 | 2 | 3 | 30 | 0.936 |
| Respiratory disorders | 2 | 1 | 12 | 0.193 | 0 | 15 | 1 | 1 | 2 | 12 | 0.872 |
| Cardiovascular diseases | 1 | 3 | 12 | 0.021 | 1 | 15 | 0.204 | 1 | 0 | 15 | 0.316 |
| Others | 1 | 0 | 14 | 0.769 | 2 | 13 | 0.015 | 0 | 2 | 13 | 0.755 |
| Neurological/psychological problems | 1 | 0 | 6 | 0.489 | 0 | 7 | 1 | 2 | 1 | 4 | 0.046 |
| Thyroid problems | 0 | 1 | 6 | 0.279 | 0 | 7 | 1 | 0 | 0 | 7 | 0.749 |
| Allergies | 1 | 0 | 3 | 0.317 | 0 | 4 | 1 | 0 | 1 | 3 | 0.541 |
| Autoimmune disorders | 0 | 0 | 3 | 1 | 0 | 3 | 1 | 0 | 1 | 2 | 0.441 |
| Chronic kidney disease | 0 | 0 | 2 | 1 | 0 | 2 | 1 | 2 | 0 | 0 | 0.003 |
| COVID-19 history | 11 | 11 | 152 | 0.044 | 1 | 173 | 0.373 | 3 | 23 | 148 | 0.002 |
Results obtained from the Fisher’s exact test; p-value < 0.05 was considered statistically significant.
The results of the study were divided into the following two categories:
1. Associations between demographic findings and COVID-19 contraction: The individuals never wearing a mask were older than other groups. In addition, illiterate people were significantly less likely to wear a mask, and people with lower education levels used hand sanitizers less frequently. The risk of COVID-19 was significantly higher in the infected people's acquaintances. Those who had an elderly person (> 65 years) at home and cared for them were significantly less likely to contract COVID-19 (p = 0.010). Smokers had a lower risk of contracting the virus than healthy people (p = 0.009). Besides, health workers were at a higher risk of contracting the virus than other employees (p = 0.002). People with underlying neuropsychological diseases and chronic kidney disease (CKD) used hand sanitizers less frequently. In addition, the use of hand sanitizers was lower among those not having been
infected with the virus. The frequency of hand washing and wearing masks was lower in people with underlying cardiovascular diseases as well. Furthermore, the frequency of wearing masks was higher in the non-affected group, while it was higher after contracting the disease in the affected group.
2. Associations between different behaviors and COVID-19 contraction: The use of surgical masks was associated with a higher risk of contracting COVID-19 than cloth masks (p = 0.003). In addition, there was no significant relationship between mask washing behaviors, mask reuse, and the frequency of mask washing with contracting COVID-19.
The main reason for not wearing a mask in the infected people was the lack of trust in the effectiveness of masks; however, in healthy people who did not wear a mask, the feeling of shortness of breath and intolerance to masks were mentioned as the main reasons. The incidence of
COVID-19 was significantly higher among those who had not been wearing masks at least for a period of time (p = 0.007).
The highest and lowest rates of regular hand washing after getting home were observed among women and students, respectively. Besides, failure to wash hands after getting home was more significantly common in people infected with the virus than in others. In the meantime, those who did not use hand sanitizers used masks less frequently.
Discussion
Airborne transmission is considered the main method of COVID-19 contraction [23]. Therefore, wearing a mask reduces the risk of the viral infection. This study aimed to determine risk factors for COVID-19 contraction and the way personal behaviors inhibit COVID-19 contraction.
In this study, an inverse relationship was found between contracting the virus and smoking, which was consistent with a study by Tsigaris et al [24]. However, as mentioned in that study, the association does not assign a therapeutic and prophylactic role to smoking in COVID-19 [24]. Simons et al observed that novice smokers were less exposed to SARS-CoV-2 contraction than professional smokers experiencing severe COVID-19 and even death [25]. In addition, ecological research among European :union: countries revealed that frequent smoking led to a lower COVID-19 contraction rate. This might be justified by the downregulation of the angiotensin-converting enzyme (ACE-2) via nicotine [26]. Miyara et al observed severe COVID-19 among ambulatory and hospitalized heavy smokers. They believed that nicotine and nicotinic receptors could be involved in the pathways of viral infections, so this issue could be investigated in an experimental study for more confirmation [27]. In fact, although some studies confirm that smoking may protect people against COVID-19 contraction or at least reduce severity of the disease, toxic effects of nicotine on health should be carefully investigated [28]. Controversially, other studies have reported higher rates of COVID-19 severity and mortality due to COVID-19 among smokers [29, 30]. However, scientists do not advise using nicotine to prevent COVID-19 or to decrease its severity [31].
The lower incidence of COVID-19 among individuals living with the elderly in our study may confirm that they were more adherent to protective protocols for the fear of contracting the disease. COVID-19 is more severe and deadly in elder patients due to their weak immune system and alterations in the ACE-2 receptor, which require more self-protection [32]. Nevertheless, it was observed that the rate of wearing facemasks decreased in elder individuals because there were lower rates of employment at older ages, so they were not required to leave home.
By a decrease in wearing masks, an increase was observed in the COVID-19 incidence among people of low level jobs and low literacy levels. According to Rollston et al, unfavorable conditions at home, less frequent use of healthy foods, inappropriate access to health services, and inability to buy personal protective equipment lead to the possibility and complications of disease transmission [33].
There was no significant difference between the effectiveness of surgical masks and cloth masks. Thus, due to the global shortage of disposable masks and the evidence implying that they are almost equally effective, it is appropriate to use cloth masks and wash them daily [34].
Although the severity of COVID-19 was higher among people with cardiovascular diseases in our study, people with cardiovascular diseases were less likely to wash their hands and wear masks [35]. COVID-19 is associated with several cardiovascular complications that increase the overall mortality rate [36]. This makes it even more important for cardiovascular disease patients to follow hand hygiene and mask-wearing guidelines.
In this study, health care workers were more likely to contract SARS-CoV-2. Proper use of personal protective equipment and adherence to other infection control measures are effective in reducing the incidence of COVID-19 among healthcare providers [37]. The association between hand-washing habits and the incidence of COVID-19 contraction mainly depends on the places where the patients commute. According to Goldman's study, wearing gloves and disinfecting surfaces seem to be reasonable in hospital settings, while in the general population with low virus loads on surfaces, transmission through the surface does not appear to be serious [38]. Zare et al studied COVID-19 contraction in Shahroud County and concluded that COVID-19 re-contraction would be preventable by wearing masks and social distancing [39]. Two studies reported that 50% of the Iranian population did not exhibit approved preventive behaviors of hand washing as well as wearing masks and gloves [40, 41]. Shiraly et al reported that wearing masks prevented touching mucosal zones of the face and infection transmission [41].
Shamsalinia et al reported that among Iranians, women and healthcare workers considered these behaviors excessive, and that all people accepted the rules against COVID-19 contraction only for the first two months [42]. Consistent with these results, the present study showed that among women, housewives were more involved with COVID-19 than other occupations. Suen et al reported that females had higher compliance with hand washing requirements. In this study, being female was considered an effective factor in improving hand washing knowledge [43]. Several studies have shown that healthcare workers are more prone to contract COVID-19, and that there are more preventive strategies for them to be adopted [42, 44, 45]. Sabetian et al observed that in hospitals of the Fars Province, Iran, healthcare workers were more prone to contract COVID-19, with an incidence rate of 5.62% [45]. A systematic review by Fouladi Dehaghi et al revealed that in addition to wearing N95 respiratory masks, it is important to frequently wash hands and use disinfectants to prevent COVID-19 contraction among healthcare workers [46]. In their study in the hospitals of Birjand City, Iran, Zangoue et al reported that although healthcare workers were more exposed to COVID-19 contraction due to their occupational conditions, the prevalence of antibodies against infections, including COVID-19, was very low due to not fully meeting protective protocols, according to seroconversion studies [47]. In another study by Nasrabadi et al, it was reported that masks were the most frequently used tool against COVID-19 contraction, yet the use of face shields was not prevalent among healthcare workers in surgical wards of Tehran hospitals, Iran [48].
The results of this study could help epidemiologists plan for giving necessary training to the population. However, this study had some limitations. Accordingly, our study was based on a limited number of patients, and the individuals included in this study either had not contracted the disease or had recovered from it after contraction. In addition, severely ill patients and patients who died were not included in this study. Another limitation of the study was recalling behaviors, such as wearing face masks and hand washing at the time of contraction (at least two weeks before acquiring the disease), which caused time bias that could confuse the results. In future studies, it is recommended to evaluate how individuals consider social distancing during their COVID-19 contraction period. In addition, it is important to determine how some people keep following protocols like the beginning days of contraction.
Conclusion
In conclusion, this study found that wearing masks, among protective behaviors, was more effective in
preventing COVID-19 contraction than hand washing and using antiseptics. In addition, those who did not wear masks were at a higher risk of COVID-19 contraction. Behaviors, such as reusing masks and washing surgical masks, did not affect the contraction risk. Moreover, this study showed that wearing masks, washing hands, and using disinfectants would significantly depend on individuals’ occupation, education, and underlying diseases.
Acknowledgement
We would like to extend our gratitude to all participants for their valuable cooperation in this study.
Conflict of interest: None declared.
1. Associations between demographic findings and COVID-19 contraction: The individuals never wearing a mask were older than other groups. In addition, illiterate people were significantly less likely to wear a mask, and people with lower education levels used hand sanitizers less frequently. The risk of COVID-19 was significantly higher in the infected people's acquaintances. Those who had an elderly person (> 65 years) at home and cared for them were significantly less likely to contract COVID-19 (p = 0.010). Smokers had a lower risk of contracting the virus than healthy people (p = 0.009). Besides, health workers were at a higher risk of contracting the virus than other employees (p = 0.002). People with underlying neuropsychological diseases and chronic kidney disease (CKD) used hand sanitizers less frequently. In addition, the use of hand sanitizers was lower among those not having been
infected with the virus. The frequency of hand washing and wearing masks was lower in people with underlying cardiovascular diseases as well. Furthermore, the frequency of wearing masks was higher in the non-affected group, while it was higher after contracting the disease in the affected group.
2. Associations between different behaviors and COVID-19 contraction: The use of surgical masks was associated with a higher risk of contracting COVID-19 than cloth masks (p = 0.003). In addition, there was no significant relationship between mask washing behaviors, mask reuse, and the frequency of mask washing with contracting COVID-19.
The main reason for not wearing a mask in the infected people was the lack of trust in the effectiveness of masks; however, in healthy people who did not wear a mask, the feeling of shortness of breath and intolerance to masks were mentioned as the main reasons. The incidence of
COVID-19 was significantly higher among those who had not been wearing masks at least for a period of time (p = 0.007).
The highest and lowest rates of regular hand washing after getting home were observed among women and students, respectively. Besides, failure to wash hands after getting home was more significantly common in people infected with the virus than in others. In the meantime, those who did not use hand sanitizers used masks less frequently.
Discussion
Airborne transmission is considered the main method of COVID-19 contraction [23]. Therefore, wearing a mask reduces the risk of the viral infection. This study aimed to determine risk factors for COVID-19 contraction and the way personal behaviors inhibit COVID-19 contraction.
In this study, an inverse relationship was found between contracting the virus and smoking, which was consistent with a study by Tsigaris et al [24]. However, as mentioned in that study, the association does not assign a therapeutic and prophylactic role to smoking in COVID-19 [24]. Simons et al observed that novice smokers were less exposed to SARS-CoV-2 contraction than professional smokers experiencing severe COVID-19 and even death [25]. In addition, ecological research among European :union: countries revealed that frequent smoking led to a lower COVID-19 contraction rate. This might be justified by the downregulation of the angiotensin-converting enzyme (ACE-2) via nicotine [26]. Miyara et al observed severe COVID-19 among ambulatory and hospitalized heavy smokers. They believed that nicotine and nicotinic receptors could be involved in the pathways of viral infections, so this issue could be investigated in an experimental study for more confirmation [27]. In fact, although some studies confirm that smoking may protect people against COVID-19 contraction or at least reduce severity of the disease, toxic effects of nicotine on health should be carefully investigated [28]. Controversially, other studies have reported higher rates of COVID-19 severity and mortality due to COVID-19 among smokers [29, 30]. However, scientists do not advise using nicotine to prevent COVID-19 or to decrease its severity [31].
The lower incidence of COVID-19 among individuals living with the elderly in our study may confirm that they were more adherent to protective protocols for the fear of contracting the disease. COVID-19 is more severe and deadly in elder patients due to their weak immune system and alterations in the ACE-2 receptor, which require more self-protection [32]. Nevertheless, it was observed that the rate of wearing facemasks decreased in elder individuals because there were lower rates of employment at older ages, so they were not required to leave home.
By a decrease in wearing masks, an increase was observed in the COVID-19 incidence among people of low level jobs and low literacy levels. According to Rollston et al, unfavorable conditions at home, less frequent use of healthy foods, inappropriate access to health services, and inability to buy personal protective equipment lead to the possibility and complications of disease transmission [33].
There was no significant difference between the effectiveness of surgical masks and cloth masks. Thus, due to the global shortage of disposable masks and the evidence implying that they are almost equally effective, it is appropriate to use cloth masks and wash them daily [34].
Although the severity of COVID-19 was higher among people with cardiovascular diseases in our study, people with cardiovascular diseases were less likely to wash their hands and wear masks [35]. COVID-19 is associated with several cardiovascular complications that increase the overall mortality rate [36]. This makes it even more important for cardiovascular disease patients to follow hand hygiene and mask-wearing guidelines.
In this study, health care workers were more likely to contract SARS-CoV-2. Proper use of personal protective equipment and adherence to other infection control measures are effective in reducing the incidence of COVID-19 among healthcare providers [37]. The association between hand-washing habits and the incidence of COVID-19 contraction mainly depends on the places where the patients commute. According to Goldman's study, wearing gloves and disinfecting surfaces seem to be reasonable in hospital settings, while in the general population with low virus loads on surfaces, transmission through the surface does not appear to be serious [38]. Zare et al studied COVID-19 contraction in Shahroud County and concluded that COVID-19 re-contraction would be preventable by wearing masks and social distancing [39]. Two studies reported that 50% of the Iranian population did not exhibit approved preventive behaviors of hand washing as well as wearing masks and gloves [40, 41]. Shiraly et al reported that wearing masks prevented touching mucosal zones of the face and infection transmission [41].
Shamsalinia et al reported that among Iranians, women and healthcare workers considered these behaviors excessive, and that all people accepted the rules against COVID-19 contraction only for the first two months [42]. Consistent with these results, the present study showed that among women, housewives were more involved with COVID-19 than other occupations. Suen et al reported that females had higher compliance with hand washing requirements. In this study, being female was considered an effective factor in improving hand washing knowledge [43]. Several studies have shown that healthcare workers are more prone to contract COVID-19, and that there are more preventive strategies for them to be adopted [42, 44, 45]. Sabetian et al observed that in hospitals of the Fars Province, Iran, healthcare workers were more prone to contract COVID-19, with an incidence rate of 5.62% [45]. A systematic review by Fouladi Dehaghi et al revealed that in addition to wearing N95 respiratory masks, it is important to frequently wash hands and use disinfectants to prevent COVID-19 contraction among healthcare workers [46]. In their study in the hospitals of Birjand City, Iran, Zangoue et al reported that although healthcare workers were more exposed to COVID-19 contraction due to their occupational conditions, the prevalence of antibodies against infections, including COVID-19, was very low due to not fully meeting protective protocols, according to seroconversion studies [47]. In another study by Nasrabadi et al, it was reported that masks were the most frequently used tool against COVID-19 contraction, yet the use of face shields was not prevalent among healthcare workers in surgical wards of Tehran hospitals, Iran [48].
The results of this study could help epidemiologists plan for giving necessary training to the population. However, this study had some limitations. Accordingly, our study was based on a limited number of patients, and the individuals included in this study either had not contracted the disease or had recovered from it after contraction. In addition, severely ill patients and patients who died were not included in this study. Another limitation of the study was recalling behaviors, such as wearing face masks and hand washing at the time of contraction (at least two weeks before acquiring the disease), which caused time bias that could confuse the results. In future studies, it is recommended to evaluate how individuals consider social distancing during their COVID-19 contraction period. In addition, it is important to determine how some people keep following protocols like the beginning days of contraction.
Conclusion
In conclusion, this study found that wearing masks, among protective behaviors, was more effective in
preventing COVID-19 contraction than hand washing and using antiseptics. In addition, those who did not wear masks were at a higher risk of COVID-19 contraction. Behaviors, such as reusing masks and washing surgical masks, did not affect the contraction risk. Moreover, this study showed that wearing masks, washing hands, and using disinfectants would significantly depend on individuals’ occupation, education, and underlying diseases.
Acknowledgement
We would like to extend our gratitude to all participants for their valuable cooperation in this study.
Conflict of interest: None declared.
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