Inaccurate risk perception

Overall, HCP compliance with protective measures such as universal masking often correlates with the level of risk they perceive. Individuals are more likely to comply with recommended prevention measures if they perceive themselves to be at higher risk of harm in a particular situation or setting. ^{Reference Fakih, Sturm and Fakih5} HCPs commonly perceive their risk of contracting COVID-19 from an infected patient to be higher than the risk of exposure to an asymptomatic coworker. Ironically, HCPs spend more time in close proximity to their coworkers than infected patients. A recent study demonstrated that <5% of exposed HCPs tested positive for SARS-CoV-2 despite exposure to an infected patient without adequate personal protective equipment (PPE), although most HCP attribute greater risk to this type of exposure. ^{Reference Baker, Rhee and Fiumara6} The propensity among HCPs to perform inaccurate risk assessments has been seen with other basic infection prevention measures such as hand hygiene. ^{Reference Chen, Carriker and Staheli7}

Inconsistent messaging from public health authorities

Earlier this year, public health authorities pointed out a lack of evidence related to the use of universal masking by the general public to prevent acquisition of SARS-CoV-2. Later, a member of the World Health Organization (WHO) stated in June 2020 that asymptomatic spread of SARS-CoV-2 is ‘very rare.’ The WHO quickly modified and clarified this statement by stating that asymptomatic spread is incompletely understood even though it actually occurs, contributing to ongoing confusion. Furthermore, a few high-ranking political leaders and millions of citizens routinely ignore the current recommendation to use face coverings in indoor settings and when in close proximity with others. Inconsistent, contradictory and unclear advice from public health authorities has contributed to widespread confusion about the utility of universal masking in preventing the spread of SARS-COV-2 (response efficacy). ^{Reference Fakih, Sturm and Fakih5}

The CDC recently updated their exposure guidelines and issued a new “frequently asked question” on May 29, 2019, recommending the use of eye protection when caring for patients in areas of “moderate to substantial community transmission [of SARS-Cov-2],” even if COVID-19 is not suspected. ^8,9 In our opinion, this guidance is confusing and adds an unnecessary emphasis on the use of additional PPE by HCPs when in direct contact with patients and does not place emphasis on the need for universal masking of patients when staff are in close proximity to patients.

COVID-19 fatigue

COVID-19 fatigue, a term that describes drift in following preventative measures as this pandemic goes on, is an important cause of poor compliance with policies related to universal masking. ^{Reference Lee, Lam and Chan10} This “fatigue” among HCPs may be potentially related to their long work hours, required interactions with other team members throughout the day, the burden of wearing additional eye protection and uncomfortable or poor-quality masks.

Future strategies related to universal masking

For effective behavioral change, wearing a mask must become a habit for HCPs in all shared spaces inside and outside the workplace, outside of their immediate household and when appropriate physical distancing is not possible. ^{Reference Mergelsberg, Mullan, Allom and Scott11} We need to work closely with HCPs to better understand the root causes for poor masking compliance and to identify and remove barriers to doing the right thing. Simple solutions such as educational campaigns on the rationale for masking, creation of a mask committee comprised of key stakeholders from various worker types to serve as champions, making physical changes to the environment to facilitate distancing, offering better quality masks, as well as suitable and accessable alternate locations that allow for physical separation to occur while HCPs are unmasked during breaks, will likely lead to improved compliance.

Finally, we need clear, simple, and consistent messaging from public health authorities for successful implementation of universal masking policies. Our goal should be to focus on the simple message of universal masking to prevent the transmission of SARS-CoV-2. Healthcare epidemiologists and public health professionals need to learn the art of salesmanship during these times because the message itself, though important, is only as good as the leader that presents it to the public. ^{Reference Sexton12}