International Journal of Public Health Science (IJPHS)

Vol. 12, No. 3, September 2023, pp. 1126~1136

ISSN: 2252-8806, DOI: 10.11591/ijphs.v12i3.22637  1126

Factors affecting non-adherence to the public recommendation

of mask use in Bangladesh: a nationwide survey

Mohammad Aminul Islam1, Md. Kaderi Kibria2, Apon Das3, Md. Monimul Huq2
1
Department of Media Studies and Journalism, University of Liberal Arts Bangladesh (ULAB), Dhaka, Bangladesh
2
Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh
3
Department of Anthropology, University of Delhi, Delhi, India

Article Info ABSTRACT

Article history: Effective communication plays an important role in any uncertain situation
to reduce its risks. The recent coronavirus disease (COVID-19) pandemic
Received Oct 26, 2022 has created uncertainties in human lives around the world. Although
Revised May 20, 2023 infection and deaths rates are decreasing, the need for protective measures
Accepted Jun 11, 2023 and the risk of affecting people by the virus remains high. Moreover, experts
recommend that people wear face masks in public places despite
vaccination. Evidence shows that people in different parts of the world tend
Keywords: not to use face masks in public places, and Bangladesh is no exception to
this phenomenon. Little is known about the topic from the context of the
Bangladesh country. In this study, we explored the factors that influence people for non-
COVID-19 adherence to the public recommendation of using face masks in public
Mask use places. We conducted a cross-sectional survey among 1,868 people across
Public health the country between March 2021 and December 2021. We used a semi-
Public recommendation structured questionnaire to collect the data. The results indicate that the non-
adherence to public recommendation for using face masks is associated with
people’s age, education, and location of residence; risk perception about the
COVID-19; trust in messages from media and public authorities; barriers to
effective communication, religious faith, and cost for buying face masks.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Mohammad Aminul Islam
Department of Media Studies and Journalism, University of Liberal Arts Bangladesh (ULAB)
Dhaka, Bangladesh
Email: aminul.vu@gmail.com; aminul.islam@ulab.edu.bd

1. INTRODUCTION
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, commonly known as
coronavirus disease (COVID-19), first appeared in December 2019 in China, and quickly spread all over the
world. The World Health Organization (WHO) declared the outbreak of the virus as a global public health
emergency concern on January 30, 2020. Later, it declared the outbreak as pandemic on March 11, 2020. The
SARS-CoV-2 pandemic is an unprecedented experience of the human being in the past 100 years. It has
caused havoc in almost all aspects of human life such as health, economy, education, and law and order
around the world. It has altered the very structure and function of human relations at the individual, social,
community, national, and international levels. Lockdown, social distancing, hand washing, vaccination, and
mask use in public places are some of the preventive measures recommended by scientists, experts, and
political leaders around the world. On the other hand, vaccinating the whole population is a costly measure
for low-and middle-income countries like Bangladesh. Moreover, maintaining physical distancing is an
important measure to stop the spread of COVID-19. But it’s almost impossible to keep a distance from others
in crowded public places. So, health experts recommend the use of face masks in such settings. As the

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Int J Public Health Sci ISSN: 2252-8806  1127

countries reopen from stay-at-home orders, the WHO recommends masks for the public to reduce the spread
of COVID-19 [1]. Moreover, it is a low-cost, convenient and effective method to control the outbreak [2],
slow the spread of SARS-CoV-2 [3], and stop the COVID-19 virus from spreading [4]–[7]. The use of a
mask plays a dual role in the prevention of the virus’s negative impact—protecting an individual from getting
infected by the virous and protecting others [5], [8]. According to a study conducted in 69 countries, there is
a strong association between mask use and a reduction in infection, hospitalizations, and death rates [9].
The face mask is a simple fortification tool against COVID-19 with multiple meanings: social,
cultural, political, religious, and medical [10]. Previous studies have shown numerous factors such as socio-
behavioral [11], [12], demographic [13]–[15], psychological [16], [17], faith and religion [18], [19],
contradictory communication and messaging, political and ideological [20], [21], difficulties in
communication while using the mask [22], [23], the technicality of using the mask [24], [25] and trust in
government and science [26] play an influential role in non-adherence of public recommendation of the
masks using in public places. For example, some studies indicated that some socio-behavioural factors
influence people’s not adherence to public health advice such as mask use [12], [20]. The factors include a
lack of public awareness of viral transmission [27], low level of risk perception, lack of trust in government
and science, social pressure and prevalence of altruism, and perceived obstacles to following the advice or
using the mask. Moreover, there are some individual characteristics [28] such as gender, education level,
income level, religion, and political affiliation found to play important roles in this case [13], [29], [30].
Another study done in the United State shows that the tendency of using a mask by the female is higher
compared to the male gender group [31]. People often avoid using face masks in public spaces due to
difficulties in communicative actions while using the mask [23] such as difficulties in recognizing people
while face to face interactions [22], [32]; difficulties in recognizing emotion expressed on the face [33];
problems in being heard or understood [24], [34]; and facing problem in using spectacles. Moreover,
oppositional messages in the media and from people in positions of authority, and not the inclusion of mask
use in early public health recommendations [35] have created confusion among the public. The confusion has
led to lowering trust in government bodies, and ignorance of mask use. Some studies found that public trust
in government plays an influential role in adherence to public health recommendations such as mask use
[36], [37]. Due to the lack of trust, people often see the recommendations as too much government control
over their lives for achieving hidden agendas. As they think that the recommendation of wearing a mask has
been imposed upon them against their will, they tended not to use the mask in a public place. Masks are
psychologically relevant because their use has become a matter of public order, fear, and doubt. Some studies
found that some psychological factors influence an individual’s use of a face mask in a public place [28]. The
factors include an individual’s perception of low risk, a tendency towards risky behaviour, feeling like their
area is safe or has only a few infections, not agreeing that masks help prevent the spread of coronavirus, not
wanting to show fear or vulnerability, behavioural freedom to be under threat [17], [38]. On the other hand,
faith and religion are also found to be influential factors in not adhering to the public recommendation of
mask use [18]. Many people do not believe that COVID-19 can cause serious illness. Rather they believe that
it is only God who can cause illness in the human body, nothing else [19]. Meanwhile, some studies indicate
that due to its very nature and structure the use of non-transparent face masks causes breathing harder,
hampers communication, and compromises the immune system and psychological well-being [23].
As of March 24, 2022, the country has encountered 1.95 million confirmed cases of COVID-19,
while the number of deaths was 29,118. Although the cases of COVID-19 and the death rates are decreasing
gradually, the need for protective measures and the risk of affecting people by the virus remains high.
Moreover, experts recommend wearing is a must despite vaccination. Empirical evidence shows that people
in different parts of the country tend not using masks in public places. So, it is important to understand the
factors that influence people to not adhere to the public recommendation of mask use in the country. Most of
the previous studies have been conducted in the context of western countries, among a small sample of the
profession and geographical location-specific population—physician nurses and community level. Very few
studies explored the phenomenon among the nationwide population. Moreover, some of the studies only
explored the scientific and technical aspects of masks, not the social and behavioural aspects of mask use. A
study found that Bangladeshi participants who were females, Muslims, had education level till graduation,
were employed, and had monthly income had high face mask adherence than Pakistan and India [39]. With
the high density of population, Bangladesh is a country where maintaining social distancing is almost
impossible, and taking other protection measures such as mass vaccination is beyond the capacity of the
government. Well-articulated recommendations for mask use and strict adherence to the recommendation
could be a way out for the county. But there is a lack of knowledge about public perception and reaction to
mask use in the context of the country. To fill the gap, this study aimed to explore why people do not use the
mask and do not adhere to public health advice to use the mask in a public place, and how to deal with people
who refuse to wear a mask in developing countries like Bangladesh.

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2. METHOD
2.1. Study design and participants
This study was a cross-sectional type descriptive research. A nation-wide survey was condeucted to
collect data from individuals living in different parts of the country between March 2021 and December
2021. Individuals with access to internet, and aged above 17 years part took part in the study. A web-based
survey method, using Google Form, was used to collect data from the participants.

2.2. Data collection tools

We used a semi-structured questionnaire to collect information about socio-demography (age,
gender, education, occupation, current residence, religion, marital status, and monthly income), primary
knowledge, attitude, and practice of preventive measures of COVID-19, risk perception, sources of
information, and factors affecting non-adherence to public recommendation to use musk. We measured the
factors affecting non-adherence to public recommendation to use musk using a five-point Likert scale
developed on the basis of literatures review. The scale consisted of 21 questions, and divided into seven
factors—communication and messaging, trust in government, psychological factors, faith and religion,
technicality of mask using, individual features and social factors. For example, communication and
messaging factors were measured asking the respondents to rate statements such as “early public health
recommendations did not include mask use” on the scale where 1=strongly disagree, 2=disagree, 3=neutral
4=agree, and 5=strongly agree. Under the trust in government factors, there were three questions such as
“wearing a mask has been imposed upon by the government”. Psychological factors were measured using
questions such as “I think that my residential area is safe or has only a few infections”; technicality of mask
use was measured using questions such as “using mask make it harder to breathe”; personal factors was
measured on the basis of the questions such as “masks are only needed if someone has COVID-19”; and
questions such as “mask-wearing is a sign of weakness and shame” indicated social factors that influence
mask use in public place. At first, the questionnaire was pretested among 100 individuals. Then, it was
finalized upon an opinion from a panel of experts in media and communication, public health and statistics.

2.3. Procedures
A survey link was distributed through email, WhatsApp messaging tool, and Facebook messenger
among potential 3,200 participants. The link was distributed targeting people living in rural, urban areas and
the capital city Dhaka. We adopted a multistage random sampling method in deciding participants of the
study. Primarily, we selected eight divisions, the administrative structure of Bangladesh. The divisions are
divided into 64 districts. We collected data from two districts from each division at random. From the
randomly selected 16 districts, we aimed to collect 3,200 responses—200 responses from each district.
During the study period, some 2,385 individuals filled up the questionnaire (the response rate was 74.53%).
After removing incomplete and inconsistent responses, 1,868 responses were used for the final analysis. At
the beginning of the questionnaire, the aims, objectives, importance, rights and benefits of taking part in the
study, the right to withdraw at any stage of the survey, the maximum duration of the survey, and declarations
of anonymity and confidentiality of the survey were mentioned. The participants could fill up the
questionnaire only after giving informed consent to take part in the study. No identifiable data or any clinical
evidence were collected. For each participant, the survey lasted for an average of 10 minutes.

2.4. Data analysis

We used descriptive statistics to calculate mean and standard deviation for quantitative variables,
while frequencies and percentages for categorical variables. We applied contingency table and Chi-square
(χ2) test to find out the association between categorical variables. We also performed bivariate logistic
regression to determine the key factors of using face masks in public places during the COVID-19 pandemic,
from which the odds ratio corresponding to each explanatory variable was presented with its 95% confidence
interval (CI) and p-value. The p-value was considered significant at level 0.05. Statistical Package for the
Social Sciences (SPSS, version 26.0) and R (Version 4.2.1) was used to analyze the data. The dependent
variable was the use of face masks in a public place, while independent variables, age, gender, education,
occupation, trust in the newspaper, television social media platforms, health professionals, trust in friends and
relative and trust in government officials.

3. RESULTS
Table 1 presents information about demographic features of the participants of the study. A total of
1,868 individuals from rural and urban areas took part in this study. Of them, 68.6% were male and 31.4%
were female. As shown in the Table 1, the majority of the participants were aged between 19 and 29 years,
and >50 years. Of the participants, 35.2% were from urban areas of upazila level towns, 26.0% rural areas or

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village, 22.5% from city corporations/division level cities. Among the participants 23.8% higher secondary
level of education, 22.3% had graduate level, and 20.3% had post graduate level education. Almost two third
(66.5%) of the participants had have income of more than 20,000. Details are shown in the Table 1.

Table 1. Socio-demographic characteristics of the participants (N=1,868)

Variables Frequency (%)
Gender Male 1,281 (68.6)
Female 587 (31.4)
Age <19 23 (1.2)
19-29 533 (28.5)
30-39 284 (15.2)
40-49 493 (26.4)
>50 535 (28.6)
Residence Rural/Village 486 (26.0)
Urban/Upazila 658 (35.2)
City corporation/Division 420 (22.5)
Capital 304 (16.3)
Education No education 150 (8.0)
Primary 234 (12.5)
Up to class 10 243 (13.0)
Up to class 12 444 (23.8)
Graduate 417 (22.3)
Post graduate 380 (20.3)
Occupation Housewife 290 (15.5)
Agriculture 174 (9.3)
Business 310 (16.6)
Service 549 (29.4)
Student 380 (20.3)
Retired 70 (3.7)
Others 95 (5.1)
Income <20,000 1,242 (66.5)
20,000-40,000 376 (20.1)
>40,000 250 (13.4)
Religion Islam 1,501 (80.4)
Hindu 307 (16.4)
Christian 19 (1.0)
Buddhist 10 (0.5)
Atheist 31 (1.7)
Opinion about COVID-19 Dangerous 400 (56.2)
Like the common flue and fever 216 (30.3)
Not dangerous 96 (13.5)

Table 2 presents information about people’s sources of information about COVID-19, and their trust
in the sources. People get information about COVID-19 from multiple sources—printed newspapers,
television, radio, online news portals, social media platforms, friends and family members, healthcare
professionals, and government officials. Our findings indicate that there is a significant association (p-value
<0.05) between the use of face masks and the level of trust in the information available in the newspapers,
social media platforms, healthcare professionals such as doctors, friend and relatives, and government
officials. Healthcare professionals were found to be most trusted source of information as 65.0% participants
informed that they had strong trust in doctors regarding the source of COVID-19 information. While, the
level of trust in government officials was the lowest as only 26.6% participants had strong trust in the official
when it come a source of information about COVID 19 issues. Details are shown in the Table 2.
Data in Table 3 (see in Appendix) presents information about influencing factors for not using a
mask in public spaces during the COVID-19 pandemic. The results show that multiple factors affect public
decision of not using face masks. The factors are: not inclusion of message on face mask use in the
government’s public health recommendations at the onset of the pandemic (p-value 0.000); presentation of
conflicting messages different mass media outlets (p-value 0.018); the communication of confusing messages
by government officials (p-value 0.000); a perception that the government was imposing to use mask
(p-value 0.000); a feeling that government was trying to control public lives by forcing to use masks
(p-value 0.000); a perception that CODID-19 was not too risky as portrayed by the government and media (p-
value 0.000); a perception that the residential area was safe or had only a few infections (p-value 0.000); an
thinking that the use of face mask may indicate vulnerability to COVID-19 (p-value 0.000); a belief that that
it is only Allah/God who can save from COVID-19, not mask use (p-value 0.000); an experience of using a
face mask made breathing harder (p-value 0.000); difficulties in interpersonal interaction while using a face
mask (p-value 0.000); and creating difficulties to recognize known people (p-value 0.000). Some 63.7%

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participants reported that the government's early recommendations did not include the use of masks in public
places, meanwhile, mass media presented different messages regarding mask-wearing, which confused the
people (p-value <0.05). On the other hand, 47.3% of the participants perceived the recommendation to use a
mask as an imposition from the government. Also, 39.6% of the participants felt that the government was trying
to control their lives by forcing them of wearing a mask. Another influencing factor was that the participants felt
that the face mask use made breathing harder. On the other hand, 52.6% of the participants experienced
difficulties in communicating with others while using a mask. Details are shown the Table 3 (see in Appendix).

Table 2. Sources of COVID-19 information and trust in the sources (N=1,868)

Variables Do not use a mask Use mask Total Chi-square p-value
Trust in the newspaper as a Strong 254 (35.7) 520 (45.0) 774 (41.4) 16.501 0.000
source of information about Neutral 349 (49.0) 471 (40.7) 820 (43.9)
COVID-19 Weak 109 (15.3) 165 (14.3) 274 (14.7)
Trust in television as a Strong 334 (46.9) 587 (50.8) 921 (49.3) 3.713 0.156
source of information about Neutral 280 (39.3) 404 (34.9) 684 (36.6)
COVID-19 Weak 98 (13.8) 165 (14.3) 263 (14.1)
Trust in social media as a Strong 186 (26.1) 372 (32.2) 558 (29.9) 11.204 0.004
source of information about Neutral 362 (50.8) 501 (43.3) 863 (46.2)
COVID-19 Weak 164 (23.0) 283 (24.5) 447 (23.9)
Trust in doctors as a source Strong 423 (59.4) 791 (68.4) 1214 (65.0) 19.862 0.000
of information about Neutral 201 (28.2) 280 (24.2) 481 (25.7)
COVID-19 Weak 88 (12.4) 85 (7.4) 173 (9.3)
Trust in friends and relatives Strong 298 (41.9) 346 (29.9) 644 (34.5) 28.371 0.000
as a source of information Neutral 280 (39.3) 526 (45.5) 806 (43.1)
about COVID-19 Weak 134 (18.8) 284 (24.6) 418 (22.4)
Trust in government officials Strong 154 (21.6) 342 (29.6) 496 (26.6) 20.505 0.000
as a source of information Neutral 285 (40.0) 470 (40.7) 755 (40.4)
about COVID-19 Weak 273 (38.3) 344 (29.8) 617 (33.0)

Data in Table 4 presents information about association between people’s demographic features and
their decision of using or not using masks in public places. The results indicate that the decision of using or
not using face make in public place is strongly associated (p-value >0.01) with an individual’s demographic
features such as age, location of residence, level of education, and occupations. Details are shown in Table 4.

Table 4. Distribution of demographic determinants of using a mask or not using a mask

Variables Use mask Not use mask p-value
(N=1156) (N=772)
Gender
Male 491 (69.0) 790 (68.3) 0.410
Female 221 (31.0) 366 (31.7)
Age
<19 3 (0.4%) 20 (1.7) 0.000
19-29 153 (21.5) 380 (32.9)
30-39 109 (15.3) 175 (15.1)
40-49 208 (29.2) 285 (24.7)
>50 239 (33.6) 296 (25.6)
Location of residence
Rural/Village 249 (35.0) 237 (20.5) 0.000
Urban/Upazila 254 (35.7) 404 (34.9)
City corporation/Division 150 (21.1) 270 (23.4)
Capital 59 (8.3) 245 (21.2)
Education
No education 92 (12.9) 58 (5.0) 0.000
Primary 151 (21.2) 83 (7.2)
Up to class 10 135 (19.0) 108 (9.3)
Up to class 12 191 (26.8) 253 (21.9)
Graduate 98 (13.8) 319 (29.6)
Postgraduate 45 (6.3) 335 (29.0)
Occupation
Housewife 171 (24.0) 119 (10.3) 0.000
Agriculture 102 (14.3) 72 (6.2)
Business 159 (22.3) 151 (13.1)
Service 127 (17.8) 422 (36.5)
Student 88 (12.4) 292 (25.3)
Retired 23 (3.2) 47 (4.1)
Others 42 (5.9) 53 (4.6)

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Table 5 presents results of logistic regression that was performed to determine the multivariate
association between demography, knowledge about COVID-19, social factors, and the probability that the
persons using masks or not in public places. Age group, 30-39 (OR: 24.1%, 95% CI: 0.070-0.830, p<0.05),
40-49 (OR: 20.6%, 95% CI: 0.06-0.701, p<0.05) and >50 (OR: 18.6%, 95% CI: 0.055-0.633, p<0.05) were
comparative significantly higher than age group less than 18 years. Urban (OR: 1.67, 95% CI: 1.318-2.118,
p<0.05), city corporation (OR: 24.1%, 95% CI: 0.070-0.830, p<0.05) and capital (OR: 4.363, 95% CI: 3.120-
6.101, p<0.05) were significantly more using mask than the people who lives in rural area. On the other hand,
people having education up to class 12 (OR: 2.101, 95% CI: 1.143-3.068, p<0.05), graduate level (OR:
5.163, 95% CI: 3.464-7.695, p<0.05) and postgraduate (OR: 11.808, 95% CI: 7.510-18.567, p<0.05) were
more likely to using mask than the no educated participants and which is statistically significant (Figure 1).
The persons who were in service (OR: 2.633, 95% CI: 1.678-4.133, p<0.05), students (OR: 2.630, 95% CI:
1.644-4.207, p<0.05) and retired (OR: 1.619, 95% CI: 0.852-3.079, p<0.05) were more likely to use mask
than the participants in others occupation and there is a significant relationship among them (Figure 1).

Table 5. Factors associated with using masks

Variables Using mask
OR (95% CI) Sig.
Gender (ref: Male)
Female 1.029 (0.842-1.259) 0.779
Age category (ref: <18)
19-29 0.373 (0.109-1.272) 0.115
30-39 0.241 (0.070-0.830) 0.024
40-49 0.206 (0.06-0.701) 0.011
>50 0.186 (0.055-0.633) 0.007
Residence of participants (ref: Rural/Village)
Urban/Upazila 1.671 (1.318-2.118) 0.000
City corporation/Division 1.891 (1.447-2.471) 0.000
Capital 4.363 (3.120-6.101) 0.000
Education (ref: No education)
Primary 0.872 (0.571-1.332) 0.526
Up to class 10 1.269 (0.838-1.921) 0.260
Up to class 12 2.101 (1.1439-3.068) 0.000
Graduate 5.163 (3.464-7.695) 0.000
Postgraduate 11.808 (7.510-18.567) 0.000
Occupation (ref: Others)
Housewife 0.551 (0.345-0.880) 0.013
Agriculture 0.559 (0.338-0.927) 0.024
Business 0.753 (0.474-1.195) 0.228
Service 2.633 (1.678-4.133) 0.000
Student 2.630 (1.644 – 4.207) 0.000
Retired 1.619 (0.852-3.079) 0.141

Figure 1. Forest plot showing odds ratio (OR) and p-value of the associated factors with factor using a mask

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4. DISCUSSION
To reduce the spread of COVID-19 and its associated risks, the use of face masks in public places is
one of the most effective, easy and cost-effective measure recommended by scientists and policy makers
around the world. In this study, we conducted a nationwide survey to understand that factors that influence
non-adherence to the public recommendation of mask use in Bangladesh. We found that at least seven factors
contributed to non-adherence to the public recommendations of mask use in the country. The factors include
socio-demographic features of the people, trust in information sources, appropriate communication and
messaging, trust in government, psychological factors, faith and religion, technical difficulties of using mask,
individual features and socio-economic factors. This finding expands previous works by adding evidence on
factors associated with not adhering to public health advice for mask use during COVID-19 from the context
of a developing country like Bangladesh.
From the overall results, it is evident there is a strong association between the use of face masks and
the level of trust in the information available in the newspapers, social media platforms, healthcare
professionals such as doctors, friend and relatives, and government officials. Healthcare professionals were
found to be most trusted source of information. While, the government officials found to be least trusted
source of information about the issues related COVID-19. From the results, it can be argued that the level of
trust might have influenced people’s decision of not adherence to public recommendation to use face mask.
In such cases, policy makers must put emphasis on engaging more health experts and health professional in
disseminating recommendations instead of government officials.
The results of the study show that more than half of the participants perceive COVID-19 as a very
dangerous virus with life threats. This perception might be associated with exposure to media information,
and social networks in their real life. From our results, it is evident that the use of masks in a public place is
associated with the source of information about COVID-19 and the level of trust in that source, which is
consistent with the findings of several previous studies [40], [41]. People who have strong trust in
newspapers, television, and healthcare professionals such as doctors, close friends, and government officials
tend to use more face masks compared to people with weak trust. So, it can be argued that the
communication of public health recommendations in any emergency like COVID-19 must be done through
trustworthy channels, and public officials must gain the trust of the people of the country, otherwise, people
would not adhere to the recommendation of mask use in public places.
We also found that the decision of using or not using face masks in public places is strongly
associated with an individual’s demographic features such as age, location of residence, level of education,
and occupations, which is similar to the findings of some previous studies [42], [43]. The results show that
the tendency of not using face masks is higher among people who are aged between 19 to 29 years compared
to their tendency of using face mask in public places. Similar tendency was found among service holders and
students. The tendency of using face masks is higher among the people with higher level of education
compared to lower level of education, which is consistent with the findings of another study [44]. From our
results, it can be argued that this tendency might be associated ability to understand the messages from media
and public officials. So, to increase adherence to public advice for using a mask in a public place, the
messages should be crafted in a way so that people with low education can understand it. Consistent with the
findings of previous studies [45], our results show that people of older ages tend to use more masks
compared to younger people. This tendency might be due to their risk perception, comorbidity, and other
health issues. Generally, older people are concerned about their health issues and often suffer from various
health people. So, the communication of health messages during an emergency like the COVID-19 pandemic
should emphasize raising awareness among young people. Consistent with the findings of a study in China
[46], our findings indicate that people living in rural areas are less likely to adhere to public advice to use a
face mask in a public place. The results indicate that the tendency of people living in city corporation areas at
the division level or the capital city of using a face mask in a public place is lower compared to people living
in villages or Upazila town level in Bangladesh. This tendency might be associated with the higher
availability of medical facilities, their control over life, and lower risk perception of COVID-19.
Overall, the non-adherence of public recommendation to use face masks in public places is multi-
faceted. Consistent with the findings of a study in Singapore [47], our results show that people tended not to
adhere to the recommendations as they perceived the public messages about COVID-19 from government
officials were confusing. Moreover, they perceived the recommendation as an imposition from the
government, and the government was trying to control their lives by forcing them to use it. The results also
indicate that a lack of trust in the source of COVID-19 messages is a strong contributing factor to not using a
mask in a public place as the majority of the participants believed that COVID-19 was not too risky as
portrayed by the government and media, and they were living in an area which was safe and had only a few
infections. On the other hand, some personality traits prevent people from adhering to the use of masks in
public places. A majority of the participants of the study reported that they do not use a mask in a public

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Int J Public Health Sci ISSN: 2252-8806  1133

place as they do not want to show that they were vulnerable to COVID-19. Religious faith was found to be an
influential factor in not using a mask as most of the participants believed that it was only Allah/God who can
save them from COVID-19, not mask use. We found that issues related to effective communication also play
an important role in not using a face mask in a public place. People often avoid using the mask as they felt
that it was difficult to breathe, and harder to recognize others and convey messages. Many of the participants
also believed that buying surgical masks has created an economic burden on them.
Our results support some previous studies. For example, a study on European countries [48] argued
that people often do not take proper measures to reduce risk when they are exposed to inaccurate, vague, or
contradictory information from both official and unofficial sources during a crisis. Other studies [49], [50],
found that the perception of risk about the virus is influenced by the sources of the information such as friends
and family, trust in the government, health professionals, and personal and collective efficacy. Although our
study reveals that more than half of the participants perceive the various as dangerous with life risk, the
tendency to use protective measures in a public place is relatively low in the country, which is a paradox.
Our findings are unique from previous studies in many ways. While the previous studies
investigated the phenomenon from a relatively narrower perspective—risk perception, knowledge, and
behaviour, communication barrier, the technicality of mask use, and social, psychological, and religious
dimensions. This study tried to understand the phenomenon from a comprehensive perspective by combining
all possible aspects. Moreover, it generates insight into communicating health and risk issues from a
developing country like Bangladesh. The results of the study would be of interest to public health experts,
public health communication experts, policymakers, and researchers in communication and social science.
However, our study has some limitations. First, this research was conducted among a limited
number of populations in limited geographical areas of a country. So, insights generated in this study may not
reflect the reality of non-adherence to public health recommendations in the whole country and among
people of all levels. Moreover, we did not use a higher level of statistical analysis. So, our interpretation of
the data may not reflect the accurate correlations and causation among the phenomenon.

5. CONCLUSION
Communicating recommendations in public health emergencies is a complex and multidimensional
process. Effective and appropriate communication plays an influential role in gaining trust in government and
public health authorities, and the extent to which people follow public health recommendations in
emergencies and uncertain situations. We found that adherence and non-adherence to public health
recommendations are strongly associated with selecting appropriate communication channels; designing
complete and clear messages; communicating clear recommendations; and gaining public trust in government
and public health authorities. Poor trust in communication from authorities may lead to non-adherence of
public health recommendations in any emergency like COVID-19. So, public health recommendations should
be communicated through trustworthy channels, and public officials must gain the trust of the people of the
country, otherwise, people would not adhere to the recommendation of mask use.

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BIOGRAPHIES OF AUTHORS

Mohammad Aminul Islam Mohammad Aminul Islam is a senior lecturer at the

Department of Media Studies and Journalism, University of Liberal Arts Bangladesh (ULAB).
He received a master’s degree in Mass Communication and Journalism from the University of
Rajshahi, Bangladesh, and a bachelor’s degree in Mass Communication from the same
university. He also received a Post Graduate Diploma in Journalism (New Media) from the
Asian College of Journalism, Chennai, India. His researches focus on communication in
healthcare, communication risk factors for health, public health communication, public health
literacy, social and cultural determinant of health, bio-communicability, mediatization of health,
medicalization of health, medicine, media and market, cyberpsychology, media psychology and
social network analysis. He can be contacted at emails: aminul.islam@ulab.edu.bd (office) and
aminul.vu@gmail.com (personal).

Md. Kaderi Kibria completed his BSc and MSc degrees in Statistics discipline
in 2018 and 2019, respectively, from the Department of Statistics, University of Rajshahi,
Bangladesh. Now, he is working on public health and microbial NGS data analysis. His
interests are in public health, microbial sequence data analysis, and developing corresponding
drug treatments. He can be contacted at email: kibriastat15@gmail.com.

Apon Das is a graduate student at Department of Anthropology at the

University of Delhi, India. He completed his Bachelor of Social Science (BSS) from the
Department of Media Studies and Journalism, University of Liberal Arts Bangladesh
(ULAB). His area of interest in research is media representation and communication in
health. He can be contacted at email: apondas00@gmail.com.

Dr Monimul Huq is a professor at the Department of Statistics, University of

Rajshahi. He received a PhD in statistics from University of Rajshahi. His research interest
includes biostatistics, social determinant of health and mental health. He can be contacted at
email: mhuq75@gmail.com.

Factors affecting non-adherence to the public recommendation … (Mohammad Aminul Islam)

1136  ISSN: 2252-8806

APPENDIX

Table 3. Influencing factors for not using a mask in the COVID-19 situation
Variables Do not use Use mask Total Chi- p-value
a mask square
Communicati Early public health Disagree 415 (58.3) 774 (67.0) 1,189 (63.7) 24.989 0.000
on and recommendations by the Neutral 200 (28.1) 210 (18.2) 410 (21.9)
message government didn't include Agree 97 (13.6) 172 (14.9) 269 (14.4)
factors mask use
Mass media presented Disagree 171 (24.0) 274 (23.7) 445 (23.8) 8.006 0.018
different messages regarding Neutral 143 (20.1) 176 (15.2) 319 (17.1)
mask use Agree 398 (55.9) 706 (61.1) 1,104 (59.1)
Messages from government Disagree 159 (22.3) 391 (33.8) 550 (29.4) 31.337 0.000
officials created confusion Neutral 121 (17.0) 197 (17.0) 318 (17.0)
Agree 432 (60.7) 568 (49.1) 1,000 (53.5)
Trust in The government forced the Disagree 186 (26.1) 459 (39.7) 645 (34.5) 36.721 0.000
Government decision of using face masks Neutral 145 (20.4) 194 (16.8) 339 (18.1)
factors Agree 381 (53.5) 503 (43.5) 884 (47.3)
Feel that the government is Disagree 270 (37.9) 596 (51.6) 866 (46.4) 37.581 0.000
trying to control life by Neutral 130 (18.3) 132 (11.4) 262 (14.0)
forcing to use a mask Agree 312 (43.8) 428 (37.0) 740 (39.6)
Think that COVID-19 is not Disagree 350 (49.2) 941 (81.4) 1,291 (69.1) 225.272 0.000
too risky as portrayed by the Neutral 106 (14.9) 95 (8.2) 201 (10.8)
government and media Agree 256 (36.0) 120 (10.4) 376 (20.1)
Psychological Think that my residential area Disagree 211 (29.6) 607 (52.5) 818 (43.8) 99.740 0.000
factors is safe or has only a few Neutral 115 (16.2) 156 (13.5) 271 (14.5)
infections Agree 386 (54.2) 393 (34.0) 779 (41.7)
Think that masks may help to Disagree 142 (19.9) 103 (8.9) 245 (13.1) 161.732 0.000
prevent the spread of the Neutral 171 (24.0) 93 (8.0) 264 (14.1)
COVID-19 virus Agree 399 (56.0) 960 (83.0) 1,359 (72.8)
Do not use a mask as it may Disagree 357 (50.1) 650 (56.2) 1,007 (53.9) 6.924 0.031
indicate vulnerability to Neutral 129 (18.1) 194 (16.8) 323 (17.3)
COVID-19 Agree 226 (31.7) 312 (27.0) 538 (28.8)
Regarding mask use, it is my Disagree 293 (41.2) 896 (77.5) 1,189 (63.7) 254.632 0.000
life, it is a choice Neutral 115 (16.2) 88 (7.6) 203 (10.9)
Agree 304 (42.7) 172 (14.9) 476 (25.5)
Faith and Believe that it is only Disagree 145 (20.4) 587 (50.8) 732 (39.2) 256.050 0.000
religion Allah/God who can save from Neutral 92 (12.9) 223 (19.3) 315 (16.9)
COVID-19, not mask use Agree 475 (66.7) 346 (29.9) 821 (44.0)
Technicality Using a mask makes it harder Disagree 78 (11.0) 394 (34.1) 472 (25.3) 154.236 0.000
of mask use to breathe Neutral 76 (10.7) 155 (13.4) 231 (12.4)
Agree 558 (78.4) 607 (52.5) 1,165 (62.4)
Using mask make it harder to Disagree 116 (16.3) 560 (48.4) 676 (36.2) 224.853 0.000
communicate with others Neutral 80 (11.2) 129 (11.2) 209 (11.2)
Agree 516 (72.5) 467 (40.4) 983 (52.6)
Using mask make it harder to Disagree 75 (10.5) 249 (21.5) 324 (17.3) 41.429 0.000
recognize known people Neutral 92 (12.9) 155 (13.4) 247 (13.2)
Agree 545 (76.5) 752 (65.1) 1,297 (69.4)
Using a mask makes it harder Disagree 93 (13.1) 176 (15.2) 269 (14.4) 35.439 0.000
to use a spectacle Neutral 233 (32.7) 235 (20.3) 468 (25.1)
Agree 386 (54.2) 745 (64.4) 1,131 (60.5)
Personal Think that masks are only Disagree 300 (42.1) 917 (79.3) 1,217 (65.1) 268.304 0.000
factors needed if someone has Neutral 80 (11.2) 52 (4.5) 132 (7.1)
COVID-19 Agree 332 (46.6) 187 (16.2) 519 (27.8)
Think that masks are not Disagree 356 (50.0) 1,009 1,365 (73.1) 318.563 0.000
necessary for the general (87.3)
public health safety Neutral 98 (13.8) 62 (5.4) 160 (8.6)
Agree 258 (36.2) 85 (7.4) 343 (18.4)
Do not use a mask as suffering Disagree 303 (42.6) 833 (72.1) 1,136 (60.8) 196.311 0.000
from an illness that makes it
difficult to use it
Using a face mask may indicate Disagree 370 (52.0) 1,012 1,382 (74.0) 292.544 0.000
weakness, and it is a matter of (87.5)
shame
Neutral 105 (14.7) 61 (5.3) 166 (8.9)
Agree 237 (33.3) 83 (7.2) 320 (17.1)
Social and Buying a surgical mask has Disagree 90 (12.6) 338 (29.2) 428 (22.9) 92.175 0.000
economic created an economic burden
factors
Neutral 230 (32.3) 396 (34.3) 626 (33.5)
Agree 392 (55.1) 422 (36.5) 814 (43.6)

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