Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that causes COVID-19 and can spread quickly through droplets from the mouth or nose when breathing, coughing, sneezing, or speaking [1]. It first emerged from Wuhan, Hubei Province, China, in December 2019 and rapidly spread throughout the world, prompting the World Health Organization (WHO) to declare a pandemic on March 12^th, 2020 [2]. The COVID-19 outbreak also had an impact on Malaysia, where the Ministry of Health reported 4,450,566 COVID-19 cases as of November 15, 2022, including 36,554 deaths and 4,885,228 cases of recoveries [3].

WHO recommended a few precautions for the public to follow in order to prevent the transmission of COVID-19, including wearing a face mask, avoiding crowded places, frequent hand hygiene, physical distance, and observing coughing and sneezing etiquette [4]. However, there was inconsistency in the recommendation of wearing a face mask in the community [5]. Initially, face mask wear was restricted to healthcare workers and those with flu-like symptoms during the first wave of COVID-19 cases [6, 7]. Later, once it was discovered that asymptomatic carriers may spread the virus, it was recommended that everyone wear a face mask in public [8]. Due to these reasons, Malaysia has made the wearing of a face mask required in public spaces beginning August 1^st, 2020, in compliance with WHO guidelines. Those who fail to comply with the regulations may face fines of up to MYR 1000 (approximately USD 200) under the Preventive and Control of Infectious Disease Act 1988 [9].

Even though wearing a face mask in public places has become compulsory, there have been occasions where people have defied this new face mask mandate. The perceptions received from the face mask may have an impact on this health behaviour [10, 11]. According to a recent meta-analysis study, self-reported perceptions of face mask wearing in the community may differ across countries or regions during the pandemic [12]. For example, in comparison to other regions, communities in the West Pacific had a higher perception rate that the face mask could reduce COVID-19 virus transmission. In Canada, there has been significant ambiguity, inconsistency, and mistrust surrounding public health messages regarding face masks due to frequent changes in recommendations regarding their usage and a lack of information regarding their proper use, effectiveness, and benefits [13]. Moreover, they experienced feelings of embarrassment and guilt when wearing medical-grade masks in non-medical contexts, despite their prioritization for healthcare workers during the initial shortage of personal protective equipment.

Sociodemographics, socioeconomics, COVID-19 infection, and face mask use have been investigated as factors and correlates of face mask use in the general population. The important determinants of face mask use in relation to sociodemographic characteristics include older age, female gender, living in an urban area, higher education levels, and married individuals [14–18]. Previous research also found that socioeconomic characteristics were significantly associated with wearing a face mask, which was indirectly linked to moral beliefs [19, 20]. For example, the likelihood of wearing a mask was found to be substantially related to those in the high-income group, who engaged more in self-protecting behaviours [21]. In terms of COVID-19 infection status, it showed that those who were worried about getting COVID-19 infection and the need to protect others from COVID-19 infection were significant predictors of wearing the face mask in public [22]. In addition, a study in Japan reported that more than half of their study population wore masks if they had close contact with COVID-19 patients [23]. Past experience with virus infection may also contribute to the individual’s decision to wear a face mask in public [24]. The type of face mask used and the length of time it was worn may influence the public’s perception of face mask wearing [25]. Based on this empirical evidence, we hypothesized that,

1. sociodemographic and socioeconomic are associated with face mask wearer perception based on six domains such as comfort, efficacy doubts, inconvenience, attention, appearance, and access.
2. the COVID-19 infection status is associated with face mask wearer perception based on six domains such as comfort, efficacy doubts, inconvenience, attention, appearance, and access.
3. the face mask practice is associated with face mask wearer perception based on six domains such as comfort, efficacy doubts, inconvenience, attention, appearance, and access.

With the emergence of a new variant of COVID-19 and more relaxed COVID-19 protocols in Malaysia, a surge in cases is almost inevitable, and the face mask-wearing mandate may be re-imposed on the general population. Prior to this, it was necessary to investigate the public’s perception of their face mask wearing because their perceptions may differ and be influenced by several factors, including sociodemographics, socioeconomics, COVID-19 infection, and face mask practice. By examining these factors, we can obtain a better understanding of their perceptions and be better equipped to prevent the spread of the COVID-19 virus. Thus, we aimed to measure public perception based on specific domains in Face Mask Perception Scale (FMPS) and identify the factors that may influence it in Malaysia, particularly during the COVID-19 pandemic.

Materials and methods

Results

A total of 1024 respondents participated in this study. Table 1 shows the background characteristics, COVID-19 status, and face mask practice. Respondents had a mean age of 29.7 (standard deviation, SD = 12.6) years. Out of 1024 respondents, the majority were women (73.2%), Malay (96.5%), had a high education (89.1%), were single or had ever married (65.2%), were unemployed, pensioners, or students (58.7%), and lived in an urban area (61.3%). A greater proportion of the respondents (48.4%) had a B40 household income (<USD 1031), then a M40 household income (USD 1031–2330) (35.7%), and finally a T20 household income group (>USD 2330) (15.8%). Most of the respondents had never been diagnosed with COVID-19 (92.7%), had never attended any areas associated with a known COVID-19 cluster (85.8%), and had no close contact with a COVID-19 patient (76.2%).

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Table 1. Background characteristics, COVID-19 status, and face mask practice (N = 1024).

https://doi.org/10.1371/journal.pone.0303031.t001

Most respondents (94.9%) were also concerned that they or a family member could get infected with COVID-19. A small number of the respondents (13.5%) wore tight-fitting respirators (N95 and/or K94) only. Half of respondents (52.6%) wore face masks for four hours or more in public. Almost all (96%) of those surveyed were aware that a face mask needed to be fitted to the face. Overall, the Malay version of the questionnaire was deemed clear, straightforward, and simple to understand by the participants (S1 Table). The Cronbach’s alpha coefficients were satisfactory for comfort (0.83), efficacy doubts (0.65), inconvenience (0.87), attention (0.92), appearance (0.95), and accessibility (0.75) (18) (S2 Table).

Table 2 illustrates the responses regarding face mask perception. The average comfort score was 4.17 (1.44). More than half of the respondents (>60%) reported discomfort wearing a face mask due to difficulty breathing and facial overheating; however, they disagreed that face masks become too hot when worn. Additionally, they expressed no doubts about the efficacy of wearing face masks, with the majority disagreeing that face masks merely provide a false sense of security (70.6%), are ineffective (87.4%), or are unsafe (70.8%). The average efficacy doubt score was 3.35 (0.85). The average scores for inconvenience, attention, and appearance were 2.34 (1.16), 2.68 (1.44), and 1.26 (1.2) respectively. The majority did not believe that wearing a face mask caused inconvenience (>75%), bothered them with attention (>58%), or affected their appearance (>91%). Accessibility to obtain face masks was not an issue among the respondents, with an average score of 1.19 (1.23). The majority knew where to purchase a face mask (97.4%), where to buy the appropriate face mask (86.3%), found it easy to obtain a face mask (96.7%), and did not consider face masks to be too expensive to purchase (73.4%).

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Table 2. Face mask perception responses.

https://doi.org/10.1371/journal.pone.0303031.t002

Several independent factors potentially associated with facemask perception domains were examined in simple linear regression. These factors were organized into three categories: background characteristics, COVID-19 status, and face mask practices. Marital status demonstrated a significant association with comfort; married individuals reported feeling more comfortable wearing a facemask compared to their counterparts (B = -0.27, 95% CI = -0.45, -0.09). Employment status also exhibited a significant association with comfort; respondents classified as unemployed, pensioners, or students (B = 0.27, 95% CI = 0.09, 0.45) reported experiencing more discomfort compared to employed respondents (see Table 3).

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Table 3. Factors associated with comfort, efficacy doubts and inconvenience.

https://doi.org/10.1371/journal.pone.0303031.t003

It also revealed that those who had visited the COVID-19 cluster had no doubts about the mask’s efficacy (B = -0.18, 95% CI = -0.33, -0.03) compared to those who had never visited the affected area. Those wearing the facemask in public for four hours or more indicated that they were confident in the facemask’s efficacy (B = -0.13, 95% CI = -0.24, -0.03). It also appears that those who were concerned about protecting their families and themselves from the infection found it convenient to wear the facemask in public (B = -0.41, 95% CI = -0.74, -0.09). Those who wore a face mask for at least four hours (B = -0.16, 95% CI = -0.09, -0.21) and were aware that facemasks needed to be fitted (B = -0.47, 95% CI = -0.84, -0.11) perceived that wearing facemasks was convenient (Table 3).

The results presented in Table 4 show that a higher education level (B = -0.43, 95% CI = -0.71, -0.15) and belonging to the middle-income group (M40) (B = -0.21, 95% CI = -0.41, -0.02) were independently associated with the attention domain. Furthermore, individuals in the highest income group (T20) reported no difficulty in obtaining facemask supplies (B = -0.04 log-transformed units, 95% CI = -0.08, -0.01), whereas those who were aware that facemasks needed to be properly fitted reported easy access to facemask supplies (B = -0.09 units of log-transformed, 95% CI = -0.15, -0.03).

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Table 4. Factors associated with attention and accessibility.

https://doi.org/10.1371/journal.pone.0303031.t004

Table 5 demonstrates that individuals with a low level of education (B = -0.08 units of log-transformed, 95% CI = -0.12, -0.03) and those who are married (B = 0.06 units of log-transformed, 95% CI = 0.03, 0.08) expressed concerns about their appearance while wearing a face mask. However, individuals who were cautious about protecting their families and themselves from infection did not perceive any issues with the appearance (B = -0.08 units of log-transformed, 95% CI = -0.14, -0.03). Additionally, those who wore a face mask for four hours or longer in public were not concerned about the appearance created by the face mask (B = -0.03 units of log-transformed, 95% CI = -0.05, -0.001).

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Table 5. Factors associated with appearance.

https://doi.org/10.1371/journal.pone.0303031.t005

After adjusting for the multiple linear regression model, all variables were no longer significant for the comfort, efficacy doubts, inconvenience, attention, and accessibility domains (S3–S5 Tables). However, the results with Bonferroni correction were consistent in appearance domain (Table 5). The only statistically significant difference and small effect (f² = 0.04) were observed for those who are married (B = 0.07 units of log-transformed, 95% CI = 0.03, 0.09) and concerned about the safety of their family from getting infected (B = - 0.09 units of log-transformed, 95% CI = - 0.15, - 0.04). Both associated factors explained 4.7% of the variance in the case of facemask appearance. The married respondents were reported to be reluctant to wear the facemask due to the appearance it created compared to their counterparts. In contrast, those who worried about their family being infected by the virus had no issue with the appearance created by wearing a facemask.

Discussion

Before the emergence of COVID-19, the use of face masks was not common in Malaysian society. As COVID-19 imposed serious threats, wearing a face mask as a preventive measure played a key role in reducing and controlling the infection. Our findings indicate that the respondents felt uncomfortable when wearing facemasks. As Malaysia is a hot and humid country, wearing a face mask may cause irritation due to sweating, restricted breathing, and the urge to remove it. Several previous studies corroborate our findings. For instance, if the mask was worn for an extended period of time, the increased pressure on the face may create heat, skin irritation, or even pressure marks [35–37]. This was mostly because of the confined space behind the mask, which allows nasal air to warm the sides of the cheeks and aggravate the sensations of heat and humidity [38, 39]. Our respondents, on the other hand, indicated that the facemask did not get excessively hot while they were wearing it. These claims could be attributed to the type of facemask material used. When the breathing resistance of a facemask is high, its surface temperature is low [39]. The heat transfer from the skin to the environment through the mask should be controlled to achieve an equilibrium of heat loss. It implies that masks that quickly remove heat and moisture from the face are anticipated to be more comfortable to use [40]. In addition, we discovered that marital and work status may influence the comfort of wearing a facemask, but they were no longer significant in multivariable analysis. In agreement with previous studies, marital and work status were not identified as determinants of facemask comfort [41, 42].

Our respondents expressed no doubts regarding the efficacy of face masks, except for the belief that they would provide few health benefits. Most of them refuted the claim that face masks create a false sense of security and found them to be effective and non-harmful. One possible explanation for this mixed response was that wearing face masks in public was mandatory during the pandemic and strictly enforced by health authorities. Furthermore, the inconsistency of guidelines on the necessity of wearing face masks from global health organizations may create confusion among the community [5, 8, 43]. They may be overwhelmed with information from numerous public health information sources, making it difficult to justify the recommended measures of facemask use [44, 45]. Therefore, the news and health information provided by health authorities should be succinct and easy to comprehend for all individuals. They must keep the public informed about the facts and benefits of face mask use. It is critical because facts and deceptions provided to individuals can influence their judgments of efficacy [26]. Although previous studies have shown that individuals who are confident in consistently wearing face masks in public, even in COVID-19 cluster areas, can reduce the transmission of COVID-19 infections [46, 47], our study reported no significant results in multivariable analysis.

Despite several of our respondents indicating that wearing a facemask could be uncomfortable, most of them claimed that it was convenient to wear. This indicates that they had no trouble developing the habit of wearing face masks. The findings may possibly be related to public social norms to use facemasks during the pandemic, as facemask wearing was positively influenced by social norms [48, 49]. Likewise, prior research has demonstrated that respondents who were particularly concerned about their family members getting infected during the pandemic were more inclined to accept face masks as a societal norm [50, 51]. A desire to shield themselves and their family members from COVID-19 may have impacted their willingness [52]. This also reflected their views on the convenience of wearing the facemask for more than four hours and being aware that the facemask should be fitted well when worn. Consequently, it implies that individuals preferred to wear a facemask with a good fit for virus transmission protection [53, 54]. However, our findings in multivariable analysis are inconsistent with these previous findings.

Additionally, our respondents perceived that wearing a face mask did not attract negative social attention, suggesting that it had no influence on visual attention or perceived trustworthiness [55, 56]. Conversely, when queried about the accessibility of face masks, most respondents reported no difficulty in purchasing them. This indicated that face masks were readily available and accessible due to initiatives implemented by the Malaysian government during the pandemic, such as setting a maximum retail price of Malaysian Ringgit (MYR) 1 (USD 0.20) per unit for disposable three-ply face masks on August 15, 2020 [57] and increasing production and supply [58]. This price setting and guarantee of demand were taken to ensure the public incurs a lower burden of out-of-pocket expenses for facemask compliance during the pandemic. The multivariable analysis did not show any significant results, but our bivariate analysis did show that people in the high-income group (T20) who knew how important it was to get a facemask fitted, had a significant relationship with how easy they thought it was to get a facemask on.

Previous research findings have reported that in low- and middle-income countries, the underprivileged group often faces challenges in affording face masks due to financial constraints [59–61]. Conversely, the high-income group is more likely to purchase face masks without hesitation, which can be attributed to their stable financial resources and perceived personal behavioral control [62]. In addition, individuals who engage in protective behaviors and are aware of the risks associated with COVID-19 are more likely to have easy access to face masks [32].

Lastly, we observed that our respondents thought the face mask was appealing. This may be observed among those concerned about infecting themselves and their families with COVID-19, who did not allow the mask’s appearance to deter them from wearing it. They may consider the rationale for wearing a face mask to be more important than their feelings or appearance [57]. This demonstrates that appearance was not the primary reason for avoiding public face mask use. However, married respondents in our study were more concerned with their appearance when wearing the facemask in public. There was a common belief that married individuals might not care about their appearance because they had more responsibilities and priorities in their lives than their physical appearance [58]. Other studies suggest that facial attractiveness is an important indicator of marital behavior, with both spouses behaving more favorably in relationships where wives are more appealing than their husbands and more unfavorably in relationships where husbands are more attractive than their wives [58]. Additionally, previous research has shown that wearing a facemask may diminish perceived attractiveness when only the upper face is visible [59, 63].

To our knowledge, this is one of the few studies undertaken on the public’s perception of face mask use in Malaysia’s general population. The use of an online survey during the COVID-19 pandemic that relied more on the internet gave our study an advantage in achieving a large sample size. However, sharing the survey link through the online platform might limit accessibility among those with no internet connection; as a result, our findings might not be generalizable. Our study had the advantage of exploring the perception of facemask wearing in public, which was mandatory during the pandemic in Malaysia. However, social desirability might also be introduced in our study because they might intentionally try to omit their own violation of social norms. Besides, self-reported responses in our survey might lead to reporting and recall bias.

The non-random sampling approach used in our study may also have potentially resulted in self-selection bias. There is a possibility that the random errors will be greater than those resulting from analysing the sample as a simple random sample. In addition, interactions across associated factors make it difficult to interpret values from multivariable regression. It is important to consider factors identified in this study only as factors associated with perceptions of face mask wearing during COVID-19 rather than causal factors. The results should be evaluated with caution to avoid the Table 2 fallacy, which implies that all contributory factor estimates can be interpreted similarly [60].

Conclusion

In general, our findings indicate that most respondents found wearing a face mask to be uncomfortable. Our study also suggests that marriage influences the appearance of wearing a face mask. The COVID-19 experience also played a vital role in determining face mask wearing perception, especially on the appearance created from wearing the facemask. Consequently, when using the facemask mandate as an implementation prevention strategy, we would recommend health authorities and policymakers consider the significant determinants of background characteristics and COVID-19 status identified in our study when establishing a new evidence-based policy.

Public health authorities should focus on improving communication and education regarding the importance of wearing face masks, particularly addressing concerns about discomfort. Strategies could include providing information on different types of masks, proper fit and adjustment techniques, and the importance of mask-wearing for protecting oneself and others from COVID-19. Understanding that marital status influences perceptions of wearing face masks suggests that interventions may need to be tailored to specific demographic groups. For example, educational campaigns could be designed to target married individuals, addressing any unique concerns or barriers they may face in adopting mask-wearing behaviors.

Given that perceptions of appearance play a role in mask-wearing behavior, public health messaging should emphasize the importance of viewing mask-wearing as a responsible and socially beneficial behavior rather than a hindrance to appearance. Highlighting the role of masks in preventing the spread of COVID-19 and protecting vulnerable populations may help shift perceptions and reduce stigma associated with mask-wearing. With the possibility of a new COVID-19 wave in the future, the potential benefits of facemask wearing in the community to reduce the risk of COVID-19 transmission should be emphasized as an adjunct to other preventive measures such as social distancing, isolation, hand hygiene, and vaccination, but not as a replacement for other public health measures. Future work could also explore the effectiveness of risk communication factors in influencing the perception of the face mask.

Supporting information