https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Knowledge and Practices of Students Regarding the Use of Face Masks to Limit the Spread of Coronavirus Disease (COVID-19) ABSTRACT INTRODUCTION Coronavirus disease is a respiratory infec- tion caused by coronavirus 2 (SARS-CoV- 2) that causes severe acute respiratory syndrome [1]. It first occurred in China in December 2019 and has since spread to almost every country globally, resulting in the coronavirus pandemic of 2019-2020 [2,3]. The virus spreads primarily by Background and Objectives: Many countries are implementing face masks as part of their pandemic prevention strategies. Because the virus is so widespread, incorrect usage and disposal of masks can increase the transmission rate. The purpose of this study was to assess knowledge and practices of students in wearing facemask to prevent the spread of the new coronavirus (COVID-19). Methods: A cross-sectional descriptive study of 365 undergraduate students at Hawler Medical University was conducted from June 15th to October 15th, 2021. The data was gathered through direct interviews using a questionnaire that had been modified include demographic information, ten questions about knowledge, and 17 questions about prac- tices for using surgical face masks to reduce COVID-19 exposure. Result: The result revealed that highest percentage of students were 18 to 20 years old (66.6%). Most of the participants in this study were female (59.5%). Participants demon- strated fair knowledge (N=218, 59.7%). Concerning the using surgical facemask to pre- vent the spread of COVID-19 and good practical knowledge (N=273, 74.8%). The highest levels of practical knowledge were related to wearing face masks in hospital premises to protect against COVID-19 (91.8%) and wearing masks in public spaces to protect against COVID-19 (87.1%). Conclusion: The studied students had a poor understanding of how to utilize face masks. Enhancing one’s knowledge and appropriate use of face masks takes time and effort. It is necessary to implement massive education campaigns at the level of Hawler Medical University to increase the proportion of knowledge about COVID-19 and stop its spread. Keywords: Knowledge; Practice; Students; Face mask; Coronavirus. Burhan Izzaddin Sabir; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: burhan.sabir@hmu.edu.krd) Shahab Ahmad Sideeq; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Yousif Baker Omer; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Nasir Khadir Khalaf; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 01 Erbil Journal of Nursing & Midwifery Received: 14/10/2021 Accepted: 06/02/2022 Published: 30/05/2022 mailto:Burhan.sabir@hmu.edu.krd https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article respiratory droplets, which are released when an infected person coughs or sneez- es, or by touching contaminated surfaces or objects and then touching their mouth, nose, or possibly their eyes [4, 5]. Students are obliged to adopt standard infection control techniques to reduce the risk of infection. The routine usage of a face mask is one of the infection control methods. A face mask is a single-use, loose-fitting mask covering the nose, mouth, and chin. It is a simple, cost-efficient non-pharmaceutical individual intervention for safeguarding oneself and preventing respiratory infec- tions from spreading [6].Incorrect use of face masks may have the opposite effect of reducing the spread of respiratory illness- es. Correct knowledge and practice are re- quired for the appropriate use of face masks. Evaluating these two components can provide helpful information for build- ing health promotion programs to increase face mask efficacy [7]. Students are strong- ly advised to wear a face mask as a stand- ard for transmission-based precaution by the World Health Organization (WHO) and the Centers for Disease Control and Pre- vention (CDC). Furthermore, the correct use of these face masks is critical, especial- ly now that their use is becoming more prevalent [8]. With large student popula- tions, higher education institutions can be- come outbreak hotspots that may nega- tively impact the community [9].Maintaining proper personal hygiene habits and instilling a positive attitude to- ward wearing a face mask during illness is critical to controlling and limiting the spread of coronavirus. The study’s main objective was to assess the knowledge and practices of Hawler Medical University stu- dents about using surgical face masks to prevent the spread of COVID-19. A cross-sectional study was carried out from June 15th, 2021, to October 15th, 2021. The sample size of the study was e- stimated according to the total number of registered students at Hawler Medical Uni- versity (3862) using Power analysis with a 95% confidence interval (CI) and a 5% mar- gin of error [14]. The estimated sample size was 365. All male and female under- graduate students in colleges of Nursing, Medicine, Dentistry, Pharmacy, and Health Sciences were included in the study. The exclusion criteria included those who refu- sed to be interviewed or could not partici- pate in the study. Informed consent was obtained after confirmation of confidentia- lity. Ethical approval was obtained from the research ethics committee at the Col- lege of Nursing (No. 8, dated July 23, 2021). A questionnaire consisting of three parts was developed to collect data. The first part of the questionnaire included sociodemographic characteristics such as age, stage, gender, marital status, and reli- gion. The second part of the questionnaire collected data on the overall knowledge of students regarding the use of surgical face masks using ten items and was divided into three categories: “poor”, “fair”, and “good”. The scores for overall knowledge ranged from 0-10, poor knowledge ranged from 0–3, fair knowledge ranged from 4–7, and good knowledge ranged from 8–10. The third part of the questionnaire in- cluded 17 questions about practices rela- ted to face mask use and was divided into three categories: “poor”, “fair”, and “good”. The overall practical knowledge was ranged from 0-17, poor practical knowledge ranged from 0–5, fair practical knowledge ranged from 6–11, and good practical knowledge ranged from 12–17. Questions were adapted from previously published 02 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Table 2 illustrates the results of students’ knowledge regarding the correct usage of face masks. Most participants (N=158, 43.3%) incorrectly identified the first per- son answered to recommend wearing a mouth mask as Joseph Lister. Johan Miku- licz is the first person who recommended wearing a mouth mask (N=69, 18.9%). Most students correctly answered the questions “Can wearing a surgical face- mask protect you from COVID- 19?” (N=311, 85.2%), “Which is the correct way of using surgical face masks to protect against COVID-19?” (N=277, 75.9%), “How many layers does a surgical mask COVID-19 questionnaires and were filled out by the students using direct interview technique. The data were analyzed using the Statistical Package for Social Sciences (SPSS, Version 23). The association be- tween all sociodemographic variables with students' overall knowledge and practical knowledge was assessed using inferential statistics and the Chi-Square test. A p-value of ≤ 0.05 was considered statistically sig- nificant. Table 1 presents participants’ socio- demographic information. According to the results, the college students in the field of medicine constituted the highest frequency (N=83) and percentage (22.7%). Inc com- parison, the students in health science con- stituted the lowest responses (N=64, 17.5%). The students in their first stage of studies constituted the highest (N=157, 43%) response, while those in their fifth year of study constituted the lowest re- sponse (N=27, 7.4%). Moreover, the high- est responses (66.6%) of students were among the age group 18-20 years old, whereas the 24-26 years old age group had the lowest responses with eight frequen- cies (2.2%). With respect to gender, female students constituted the maximum num- ber of participants in this study (N=217, 59.5%) and were subsequently followed by their male counterparts (N=148, 40.5%). Those students who were single made up most of the participants (N=346, 94.8%), followed by those who were married (N=19, 5.2%). The majority of the partici- pants (N=358, 98.1%) identified as Mus- lims, followed by others (N=4, 1.1%), and then Christians (N=3, 0.8%). 03 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Socio-demographic data of study participants Variables n =365 College Nursing 71 (19.5) Medicine 83 (22.7) Dentistry 76 (20.8) Pharmacy 71 (19.5) Health science 64 (17.5) Stage First 157 (43) Second 76 (20.8) Third 73 (20) Forth 32 (8.8) Fifth 27 (7.4) Age group 18-20 243 (66.6) 21-23 114 (31.2) 24-26 8 (2.2) Gender Male 148 (40.5) Female 217 (59.5) Marital Status Single 346 (94.8) Married 19 (5.2) Religion Christian 3 (0.8) Muslim 358 (98.1) Others 4 (1.1) Total 365 (100) https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article have?” (N=237, 64.9%), and “Which layer acts as a filter media barrier?” (N=246, 67.4%). A majority of students incorrectly responded to the “Which type of masks actually protect against COVID- 19?” (N=116, 31.8%) choosing 99% BFE & PFE. The correct answer for this question is 95% BFE & PFE (N=87, 23.8%). A significant number of participants (N=98, 26.8%) indi- cated eight hours as a correct answer to the question “How long can you wear a surgical mask?”. The majority (N=267, 73.1%) correctly answered the question “For proper wearing, to what extent should the surgical mask cover the face?”, with Nose, Mouth, and Chin being the correct answer. Many of the participants (N=256, 70.1%) correctly answered “yes” to the statement “Wearing a mask for an extend- ed period time can lower O2 levels and raise CO2 levels in the body”. When asked if the cloth facial mask was as effective as a standard surgical facial mask, many partici- pants (N=237, 64.9 percent) correctly an- swered “no”. Table 3 shows the practical knowledge of students regarding the correct usage of face masks. According to the results, a significant number of the student (N=271, 74.2%) correctly answered the question “During clinics, if there is a need to talk to the patient, will you remove your mask?”. However, a substantial num- ber of the students (N=200, 54.8%) incor- rectly indicated “yes” to the question “If you are not sick, do you store the used sur- gical mask in a bag for later use?”. Most of the participants correctly responded to the questions such as “Do you wear a mask in public places to protect yourself against COVID-19?” (N=318, 87.1%), “Do you wear a mask on hospital premises to protect yourself against COVID-19?” (N=335, 91.8%), and “Is it necessary to clean hands before wearing a mask?” (F=303, 83%). Participants correctly responded to the statements “identify the inside and outside of a mask before wearing it on” (N=275, 75.3%), “It's important to confirm the met- al nose band on the top (N=283, 77.5%), “You should place the loop around on the ear” (N=290, 79.5%), “Extending the folds by pulling the top and bottom of the mask” (N = 293, 80.3%), “It is necessary to press the nose band (N=285, 78.1%)”, “you should not touch mask (N=283, 77.5%), “Whilewearing the mask, avoid eating, drin king, and smoking (N=224, 61.4%). Partici- pants also correctly responded to the statements “Remove the mask from your face, only touching the bands” (N=277, 75.9%), and “Avoid pulling the mask over the forehead or down over the chin” (N=269, 73.7%). Participants correct- ly responded to the statements “You should dispose of the mask when soiled or wet” (N=308, 84.6%), "You should clean your hands after taking off” (N=307, 84.1%), and “You should not reuse a single -use mask” (N=284, 77.8%). The overall results for knowledge and practical knowledge of the students are displayed in table 4. Based on total score the overall knowledge is scored as fair (N=218, 59.7%), while overall practical knowledge is scored as good (N=273, 74.8%). Table 5 explores the association between socio- demographic data and overall knowledge of the participants. There was a significant association between good knowledge of the students and the two groups of socio- demographic variables: college group of students (50.7% for pharmacy students, 31.6% for dentistry students, 29.7% for health sciences students, 27.7% for medi- cine students, and 19.7% for nursing stu- dents, P = 0.010) and stage of students (53.1% for forth stage, 51.9 % for fifth stage, 28.8% for third stage, 27.6% for sec- ond stage, and 27.4 % for first stage, P = 0.015). There was no significant difference between good knowledge of the students with the other variables of 04 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 05 Erbil Journal of Nursing & Midwifery Socio demographic; age group (P = 0.097), gender (P = 0.756), marital status (P = 0.584) and religion (P = 0.792).Table 6 ex- hibits the association between sociodemo- graphic data and overall practical knowledge. A significant association be- tween good practical knowledge and col- lege group of students (85.9% for pharma- cy students, 31.6% for dentistry students, 75% for health sciences students, 68.7% for medicine students, and 67.6% for nursing students, P= 0.042), age group (84.2% for 21-23 years old, 71.6% for 18- 20 years old, and 37.5% for 24-26 years old, P= 0.010) and gender(79.3% for females vs. 68.2% for males, P = 0.021). There was no significant association between practical knowledge with the stage of students (P= 0.766), marital status (P = 0.935) and religion (P = 0.828). Items N (%) In 1897, he was the first person to recommend wear- ing a mouth mask. Johan Mikulicz (correct) 69 (18.9) Carl Flugge 54 (14.8) Joseph Lister 158 (43.3) Louis Pasteur 84 (23) Can wearing a surgical mask protect you from COVID- 19? Yes (correct) 311 (85.2) No 54 (14.8) Which way should a surgical face mask be used to protect against COVID-19? Whiteside facing in (correct) 277 (75.9) Whiteside facing out 88 (24.1) A surgical mask consists of how many layers? Two 117 (32.1) Three (correct) 237 (64.9) Four 11 (3) Which layer serves as a filter media barrier? First 96 (26.3) Middle (correct) 246 (67.4) Last layer 23 (6.3) What types of facemasks are effective against COVID- 19? 95% BFE & PFE (correct) 87 (23.8) 97% BFE & PFE 97 (26.6) 91% BFE & PFE 65 (17.8) 99% BFE & PFE 116 (31.8) How long may a surgical mask be worn? 2 Hours 98 (26.8) 4 Hours 169 (46.4) 8 Hours (correct) 98 (26.8) To what extent should the surgical mask cover the face? Mouth only 27 (7.4) Mouth and Nose 71 (19.5) Nose, Mouth, and Chin 267 (73.1) Wearing a facemask for an extended period of time leads to the body’s O2 level dropping and CO2 level rising? Yes (correct) 256 (70.1) No 109 (29.9) Is a cloth facial mask as effective as a standard surgi- cal mask? Yes 128 (35.1) No (correct) 237 (64.9) Total 365 (100) Table 2: Knowledge of students about correct usage of face masks https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 06 Erbil Journal of Nursing & Midwifery Table 3: Practical knowledge of students regarding correct usage of face mask Items Correct Incorrect Will you remove your mask during clinics if you need to talk with a patient? 271 (74.2) 94 (25.8) If you are not sick, do you store the used surgical mask in a bag for later use? 165 (45.2) 200 (54.8) Do you protect yourself from COVID-19 by wearing a mask in pub- lic places? 318 (87.1) 47 (12.9) Do you wear a mask in hospital premises to protect yourself against COVID-19? 335 (91.8) 30 (8.2) Is it necessary to clean hands before wearing a mask? 303 (83) 62 (17) Identify the inside and outside of a mask before wearing it on. 275 (75.3) 90 (24.7) It’s important to confirm the metal noseband on the top. 283 (77.5) 82 (22.5) You should place the loop around on the ear. 290 (79.5) 75 (20.5) Extending the folds by pulling the top and bottom of the mask. 293 (80.3) 72 (19.7) It is necessary to press the nose band. 285 (78.1) 80 (21.9) You should not touch the mask. 283 (77.5) 82 (22.5) While wearing the mask, avoid eating, drinking, and smoking. 224 (61.4) 141 (38.6) Remove the mask from your face, only touching the bands. 277 (75.9) 88 (24.1) Avoid pulling the mask over the forehead or down over the chin. 269 (73.7) 96 (26.3) You should dispose of the mask when soiled or wet. 308 (84.6) 56 (15.4) You should clean your hands after taking off. 307 (84.1) 58 (15.9) You should not reuse a single-use mask. 284 (77.8) 81 (22.2) Overall N (%) Knowledge Poor 31 (8.5) Fair 218 (59.7) Good 116 (31.8) Practical Knowledge Poor 2 (0.5) Fair 90 (24.7) Good 273 (74.8) Total 365 (100) Table 4: Overall Knowledge and Practical Knowledge of the students https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 07 Erbil Journal of Nursing & Midwifery Variables Overall Knowledge P Value Poor Fair Good N (%) N (%) N (%) College Nursing 8 (11.3) 49 (69) 14 (19.7) 0.010 Medicine 10 (12) 50 (60.2) 23 (27.7) Dentistry 7 (9.2) 45 (59.2) 24 (31.6) Pharmacy 2 (2.8) 33 (46.5) 36 (50.7) Health science 4 (6.3) 41 (64.1) 19 (29.7) Stage First 17 (10.8) 97 (61.8) 43 (27.4) 0.015 Second 8 (10.5) 47 (61.8) 21 (27.6) Third 3 (4.1) 49 (67.1) 21 (28.8) Forth 3 (9.4) 12 (37.5) 17 (53.1) Fifth 0 (0) 13 (48.1) 14 (51.9) Age group 18-20 25 (10.3) 151 (62.1) 67 (27.6) 0.097 21-23 6 (5.3) 62 (54.4) 46 (40.4) 24-26 0 (0) 5 (62.5) 3 (37.5) Gender Male 13 (8.8) 85 (57.4) 50 (33.8) 0.756 Female 18 (8.3) 133 (61.3) 66 (30.4) Marital Status Single 29 (8.4) 205 (59.2) 112 (32.4) 0.584 Married 2 (10.5) 13 (68.4) 4 (21.1) Religion Christian 0 (0) 2 (66.7) 1 (33.3) 0.792 Muslim 30 (8.4) 214 (59.8) 114 (31.8) Others 1 (25) 2 (50) 1 (25) Table 5: Association between Socio demographic data with Overall Knowledge https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 08 Erbil Journal of Nursing & Midwifery Table 6: Association between Socio demographic data with Overall Practical Knowledge Variables Overall Practical Knowledge P- Value Poor Fair Good N (%) N (%) N (%) College Nursing 2 (2.8) 21 (29.6) 48 (67.6) 0.042 Medicine 0 (0) 26 (31.3) 57 (68.7) Dentistry 0 (0) 17 (22.4) 59 (77.6) Pharmacy 0 (0) 10 (14.1) 61 (85.9) Health science 0 (0) 16 (25) 48 (75) Stage First 2 (100) 42 (46.7) 113 (41.4) 0.766 Second 0 (0) 21 (27.6) 55 (72.4) Third 0 (0) 14 (19.2) 59 (80.8) Forth 0 (0) 7 (21.9) 25 (78.1) Fifth 0 (0) 6 (22.2) 21 (77.8) Age group 18-20 2 (0.8) 67 (27.6) 174 (71.6) 0.010 21-23 0 (0) 18 (15.8) 96 (84.2) 24-26 0 (0) 5 (62.5) 3 (37.5) Gender Male 2 (1.4) 45 (30.4) 101 (68.2) 0.021 Female 0 (0) 45 (20.7) 172 (79.3) Marital Status Single 2 (0.6) 85 (24.6) 259 (74.9) 0.935 Married 0 (0) 5 (26.3) 14 (73.7) Religion Christian 0 (0) 1 (33.3) 2 (66.7) 0.828 Muslim 2 (0.6) 89 (24.9) 267 (74.6) Others 0 (0) 0 (0) 4 (100) https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article the college, stage, and age of the students, but there was no significant relationship between gender, marital status, and reli- gion and overall knowledge of the use of face masks. This result is like the findings of a descriptive study conducted by Imtaz Ahmed et al. on 60 students at the Univer- sity of Raiwind Road, Lahore [6]. There was a significant relationship between college, age, and gender of the students with over- all practice knowledge regarding the usage of face masks in the resent study. There was no significant relationship between the stage, marital status, and religion of the students with the overall practice of using face masks. Face masks are necessary to implement for prevention in mass gatherings due to the rising number of cases of COVID-19 and the threat of respiratory infection. The study concluded that the knowledge and practice of students regarding the use of surgical face masks were found to be inad- equate. According to the findings of the study, during this pandemic crisis, there is an urgent need to implement periodic edu- cational interventions and training pro- grams on infection control techniques and the use of protective equipment among Hawler Medical University students. Regu- lar instructional webinars with guidelines and content to enhance student aware- ness are necessary for them to be healthy and safeguard our society from diseases like COVID-19. The authors would like to express their heartfelt gratitude to all the students at Hawler Medical University who participat- ed in the study. The highest percentage of the study sam- ple were from Medicine College in the first stage and ranged from 18- 20 years old. This result is similar to the results of a descriptive study done on 592 students who found that most students were in medicine but in the second stage [10]. The findings are consistent with those of a cross-sectional study of 104 students, which found that most students were between the ages of 18 and 25 [11]. More than half of the study sample were females, and the remainder were males. This study agrees with the study done by Hamed Alzoubi, in 2020, which reported more than half of the sample were fe- male [10]. The current study found that the highest percentage of the students were single and Muslims. Concerning the knowledge of students about the correct usage of face masks, most questions were answered correctly. The present study revealed that majority of students answered all questions correctly except one question (“If you are not sick, do you store the used surgical mask in a bag for later use?”). The result of the present study agrees with the findings of the study by Hamed Alzoubi et al. which re- ported a positive practical attitude to- ward COVID-19 [10]. Joshi et al. conduct- ed a cross sectional study on 407 stu- dents which revealed that around 95.58% were knowledgeable about face mask usage while going out duringthe pandemic [12]. The current study showed that the more than half of the sample were at a fair level of overall knowledge and most of the sample were at a good level of practical knowledge. In terms of the relationship between socio- demographic data and overall knowledge, the study found that there was a significant relationship between 09 Erbil Journal of Nursing & Midwifery DISCUSSION CONCLUSION ACKNOWLEDGEMENTS https://doi.org/10.15218/ejnm.2022.01 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [9] Akan H, Gurol Y, Izbirak G, Ozdatlı S, Yilmaz G, Vitrinel A et al. Knowledge and attitudes of university students toward pandemic in- fluenza: a cross-sectional study from Turkey. BMC Public Health. 2010;10(1). [10] Alzoubi H, Alnawaiseh N, Al-Mnayyis A, Abu- Lubad M, Aqel A, Al-Shagahin H. COVID-19 - Knowledge, Attitude and Practice among Medical and Non-Medical University Stu- dents in Jordan. Journal of Pure and Applied Microbiology. 2020;14(1):17-24. [11] Olum R, Chekwech G, Wekha G, Nassozi D, Bongomin F. Coronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teach- ing Hospitals, Uganda. Frontiers in Public Health. 2020;8. [12] Joshi K, Madhura L, Jamadar D. Knowledge and awareness among nursing students re- garding the COVID-19: a cross sectional study. International Journal Of Community Medicine And Public Health. 2020;7(7):2518. DOI: http://dx.doi.org/10.18203/2394- 6040.ijcmph20202536. [13] AHMAD, Imtiaz; ALTAF, Sehar; AHMAD, Hafiz M. Assessment of knowledge, practice and barrier in use of facemask among university students. Pakistan Journal of Medical & Health Sciences, 2017, 11.4: 1657-58. doi:10.11622/smedj.2014037. [14] Ho HS. 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