The impacts and implications of the community face mask use during the Covid‐19 pandemic: A qualitative narrative interview study

Abstract Introduction A range of nonpharmaceutical public health interventions has been introduced in many countries following the rapid spread of Covid‐19 since 2020, including recommendations or mandates for the use of face masks or coverings in the community. While the effectiveness of face masks in reducing Covid‐19 transmission has been extensively discussed, scant attention has been paid to the lived experience of those wearing face masks. Method Drawing on 40 narrative interviews with a purposive sample of people in the United Kingdom, with a particular focus on marginalised and minoritized groups, our paper explores experiences of face mask use during the pandemic. Results We find that face masks have a range of societal, health and safety impacts, and prompted positive and negative emotional responses for users. We map our findings onto Lorenc and Oliver's framework for intervention risks. We suggest that qualitative data offer particular insights into the experiences of public health interventions, allowing the potential downsides and risks of interventions to be more fully considered and informing public health policies that might avoid inadvertent harm, particularly towards marginalised groups. Patient or Public Contribution The study primarily involved members of the public in the conduct of the research, namely through participation in interviews (email and telephone). The conception for the study involved extensive discussions on social media with a range of people, and we received input and ideas from presentations we delivered on the preliminary analysis.


| BACKGROUND
The use of face masks during the Covid-19 pandemic has been the subject of much scientific debate and discussion, largely around their effectiveness in breaking the transmission of the severe acute respiratory syndrome coronavirus 2. 1,2 Masks first became mandatory in England in mid-June 2020, with wider mandating across the United Kingdom during the summer of 2020, and while mandates have come and gone with successive waves and variants, masks have become a routine part of living with and through a pandemic for many. 3 The World Health Organisation recommended that masks be used as part of a range of nonpharmaceutical interventions against Covid-19. 4 Not everyone will be able to wear a face mask, for various reasons (including physical and mental health conditions and disabilities), although the criteria for and approach to granting exemptions varies across countries and jurisdictions, 5 in some cases changing through time. 6 Masks and other forms of face covering already had a longstanding use in some East Asian countries and appeared to be adopted more readily in these settings during the onset of the Covid-19 pandemic. 7 However, in the United Kingdom, where the use of masks in daily life isor was-not common practice, the introduction of face masks generated significant public debate and discussion. 8 In healthcare settings, face masks have been reported to cause physical issues for users, such as headaches and shortness of breath, which could be problematic for those with existing health conditions. 9 Some work around gendered perceptions of mask use has also been published, suggesting men are more likely to see masks as compromising their independence, whereas women are more likely to report discomfort. 10 However, beyond these studies, there has been little attention to experiences of the use of masks in the community and people's perceptions of this public health intervention.
Given this limited evidence base, concern has been raised regarding the impact of face masks on particular groups during the pandemic, 11 notably those with disabilities who may face social exclusion as a result of mandatory mask policies. 12 Bakhit et al. identified 37 studies in their systematic review on the possible downsides of mask use, concluding that greater research is urgently needed to explore these downsides and strategies to mitigate against them. 13 Given the likelihood of future pandemic events, 14 and the need for ongoing community containment of Covid-19 face masks are likely to be a feature of the public health toolkit across the world for the foreseeable future, and so understanding the experience of their use is vitally important. Our study examines the experiences of a diverse sample of face mask users, with a particular focus on those who may be at risk of negative impacts, as well as those who are exempt from mask-wearing, to explore the lived experience of face mask use.

| Materials
The aim of the study was 'to understand the lived experience of face masks during the Covid-19 pandemic across different groups' in the United Kingdom. We were interested in understanding the personal experience of an intervention that was new and unfamiliar in this context. Narrative interviewing was identified as an appropriate method to address the aims and objectives of the study. We selected a core interview question to guide the narrative interviews. The question was as follows: 'Tell me about your experiences of face masks since they were made mandatory on public transport and in healthcare settings on the 15 June 2020'. We then used unstructured prompting as necessary to provide further clarification or detail to that overall interview question. At the time of the study, face-to-face interviews were prohibited by law. We were conscious of the potential to omit the experiences of some groupsincluding, for example, those who are D/deaf or neurodiverse-if interviewing took place exclusively through telephone/video calls. We, therefore, offered a choice of email or telephone interviews to participants to maximise inclusivity. Interviewing was conducted by (K. F., P. C., A. C., G. M. and E. H.). All telephone interviews were transcribed verbatim to produce written transcripts, then analysed alongside the written email interview accounts. The National Institute for Health and Care Research Equality in research checklist informed the design of the study (https://mk0qebimerabt73npg13.kinstacdn.com/wpcontent/uploads/2020/07/Checklist_COVID_BME_v2.pdf). An easy-read participant information sheet, with visual cues and simplified text, was produced to complement the traditional information sheet for the study. The study received ethical approval from De Montfort University.

| Participants
We sought a theoretically informed sample, based on the developing categories and emerging theory 15 of our preliminary engagement in and monitoring of the developments in academic and public discourse around face masks and Covid-19. We were particularly interested in including those with existing disabilities, hearing issues or learning differences, who identified as Black, Asian or minority ethnic, or who were on a low income. Recruitment for the study was primarily achieved through advertisement on social media (Twitter) and through relevant charities and third-sector organisations which were active with the groups we hoped to include. These included charities supporting those who were D/deaf, such as Deaf Action, and organisations supporting those living with disabilities, such as Shaping our lives and Finding your Feet.
Participants were all aged 18 and over and lived in the United Kingdom. The final sample comprised 40 participants; 15 completed email interviews and 25 telephone interviews. Both forms of data generation elicited rich narrative accounts. As with verbal testimony, the length of email responses varied, but we used follow-up questions to elicit additional information or clarification much as we would within the telephone interviews. Those who were D/deaf or had neurodiversity appeared more likely to request participation via email to make their participation possible and more accessible to them. We offered both options to all participants and did not ask why they had chosen one over the other, as we felt it was important for inclusivity to not make the choice of email conditional on a particular condition or disability. The data were generated between 29 July and 6 October 2020: early in the Covid-19 pandemic, and soon after the introduction of face mask mandates in England and Scotland from June 2020, and in Wales and Northern Ireland from July (https:// www.gov.uk/government/news/new-rules-on-face-coveringscoming-in-on-monday-will-help-keep-passengers-safe). Our work predated both the authorisation of the first Covid-19 vaccine by the UK's Medicines and Healthcare Products Regulatory Agency in December 2020 and the spread of more infectious variants of the virus from winter 2020 onward. At the time of the interviews, the United Kingdom had experienced one 'lockdown' which then was followed by a partial reopening of some businesses and facilities during the summer months. A further lockdown then occurred in the autumn of 2020. Covid-19 cases remained high during the period of data generation and knowledge of its transmission was still developing. A £20 high street shopping voucher to thank participants for their time was given on completion of participation.
Participants were asked to complete a short anonymous demographic survey on completion of their interview (via a weblink).
Thirty-nine of the 40 participants completed this (see Table 1).
Twenty-eight were female and 11 were male. Twenty-nine people were identified as disabled, with 11 having a psychological or mental health condition. Almost half the sample was on household incomes of £20,000 per annum or less, with 23% on less than £10,000 pa.
Seventy-five percent of the sample identified as being white, with 16% from a range of minority ethnic backgrounds; 47% were of the Christian faith. Although we did not systematically collect data on their location, recruitment was nationwide, narrative data indicated that participants were from across the United Kingdom and from both rural and urban locations.

| Analysis
Data were analysed using reflexive thematic analysis following the process described by Braun and Clarke. 16 The data were analysed for what was said as well as how it was said, using inductive coding and then the generation of broad themes. E. H. and G. M. conducted the initial coding and naming of themes before the agreement with the wider authorship team. For the purposes of this paper, we focus on three themes: the emotional aspects of face mask use; health and safety issues and the societal impacts of face masks.  The health, safety and communication issues related to mask use were thus varied, ranging from minor inconveniences to problems that caused significant problems in day-to-day life, or even discouraged participants from engaging in their usual activities.

| Societal issues
A range of broader societal issues also arose in participants' Face masks may then have additional implications for other social measures designed to limit the spread of Covid-19. For some, this was a cause for concern, but others felt more relaxed about occasional close proximity to others when faces were covered.
The cost of face masks was also a concern for some participants.
As noted above, 23% of the sample were on incomes under £10,000 per annum, and many were on benefits. Consequently, they had Laundering reusable face masks added to the challenges and costs identified by participants. As one noted, the use of cloth (reusable) face masks 'generates a bit of extra washing' (P2). Some had found ways to manage this, but for others, it remained a concern, particularly the need to wash masks at a high temperature and the cost of doing so: The material ones, they say you have got to wash While concerns were raised by some about the potential unintended consequences of face masks, 11 others have argued that their potential advantages likely outweighed any negative consequences. 19 Our findings demonstrate myriad unintended consequences associated with the use of masks, including areas of concern as varied as physical and mental health, affordability, accessibility, access to washing facilities as well as environmental impacts.
Undoubtedly, some of these issues will be of trivial importance to many; our approach to sampling and recruitment and the nature of our data set mean that we cannot comment on the population-level impact of these problems. For some individuals, however, their consequences are far from insignificant, and their impact could extend into important aspects of their day-to-day lives. Moreover, some of those vulnerable to these impacts were already in marginalised groups, such as those with mental health disorders and those on low incomes. Several participants expressed concern about the affordability of masks, reflecting the large proportion of our sample  where the urgency of the situation precludes this, it is incumbent on researchers and policymakers to investigate them promptly and thoroughly, to inform speedy efforts to mitigate and manage any harm.
Our study has some limitations. While our qualitative approach is helpful in identifying the range of issues that face masks and mask mandates may present, particularly for marginalised groups, it does not offer insight into the prevalence of these problems. Participants were a self-selecting sample who may have had a particular interest in sharing their views on masks. Our narrative approach sought to ensure that interviews were led by participants rather than solely by researcher interests. The study is bound by the geographical context of our participants, and research in other countries would likely have different relationships with face masks given divergent prevailing attitudes towards mask use. 7

| CONCLUSION
Our study provides much-needed evidence about perceptions of and experiences of face masks in the United Kingdom and characterises some of the harms that masks may cause, particularly for groups who may be at risk of marginalisation through mask mandates. Our