Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Public Health 219 (2023) 154e156 Contents lists available at ScienceDirect Public Health journal homepage: www.elsevier.com/locate/puhe Short Communication Who wears the face mask? Preventive measures against COVID-19 in Latin America before vaccination E. Rentería a, *, A. Go  mez-Casillas a, P. Zueras a, b a Centre D'Estudis Demogra fics, C/Ca N'Altayo  Edifici E2, 08193, Bellaterra, Spain b University of Essex and Centre D'Estudis Demogra fics, C/Ca N'Altayo Edifici E2, 08193, Bellaterra, Spain a r t i c l e i n f o a b s t r a c t Article history: Objectives: We analyze the profile of adults who used a mask in the context of the COVID-19 pandemic in Received 21 February 2023 Latin America, between October and November 2020, right before the mass vaccination campaigns. Received in revised form Study design: Based on the Latinobarometer 2020 data, we assess the individual, regional, cultural and 29 March 2023 political factors of people who used a mask in the context of the COVID-19 pandemic in 18 countries of Accepted 3 April 2023 Available online 10 April 2023 Latin America. Methods: We applied a logistic regression to model the probability of using the mask regularly to avoid being infected with the COVID-19 virus. Keywords: Sanitary face mask Results: Women, older people, those with higher education, those being employed and not working in COVID-19 temporarily jobs, retirees, students, people with a centrist political ideology, and Catholics had a higher Latin America chance of using a face mask on a regular basis. People living in Venezuela, Chile, Costa Rica and Brazil Preventive measures were the most likely to use face masks. Socio-economic status Conclusion: These results highlight the need to understand the social forces behind the willingness to Political ideology adopt non-pharmacological preventive measures to make them more effective in health crisis emergencies. © 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Introduction The use of the face mask was related to the individual percep- tion of risk, the feeling of responsibility and solidarity, cultural and The World Health Organization (WHO) recommended the use of religious traditions, and the need to express their own identity in face masks as one of the main measures to prevent COVID-19 an earlier study.5 In relation to the adoption of protective attitudes transmission. However, the medical discourse about preventive against respiratory epidemics, a study before COVID-19, found that measures is mediated by a range of factors that affect their women were more inclined to adopt non-pharmacological pre- implementation, such as gender constructions in health care,1 risk ventive measures (such as the use of mask, washing hands and perception related to age and care attitudes linked to educational avoiding public transport), whereas men were more prone to level2 and also political orientation and religious affiliation.3 In the pharmacological measures such as vaccination and antiviral specific context of COVID-19, the role of national governments in medication.6 Regarding political ideology, being of right-wing recognizing the magnitude of the pandemic and their willingness ideology in the United States (US) was correlated with the belief to implement the WHO health recommendations were also critical. that the use of mask would not prevent the spread of the COVID-19 The latter has been especially relevant in Latin America, where virus,7 and accordingly, the US was the only country where gov- political instability, low levels of investment in public health sys- ernment supporters were less likely to follow health prevention tems, and the idiosyncrasy of each government defined different guidelines against COVID-19 in a cross-country study,3 showing the public interventions and prevention messages sent to the importance of the government position for individual prevention population.4 attitudes. Previous studies analyzing mask wearing determinants in Latin America have been conducted at the national level, but cross- * Corresponding author. Centre d’Estudis Demogra fics, C/Ca n’Altayo  Edifici E2, country comparisons are important to put into perspective the 08193, Bellaterra, Spain. Tel.: þ34 93 5813060. diversity of individual attitudes and governmental responses to the E-mail address: erenteria@ced.uab.es (A. Gomez-Casillas). https://doi.org/10.1016/j.puhe.2023.04.002 0033-3506/© 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. mez-Casillas and P. Zueras E. Rentería, A. Go Public Health 219 (2023) 154e156 pandemic. Moreover, the use of a face mask during the COVID-19 Table 1 pandemic has not been a trivial act, and it is important to under- Logistic regression over the regular use of face mask in Latin American countries. stand the determinants that influence this decision to obtain les- Variables Odds Ratio Std. err. sons and design more effective preventive campaigns to manage Sex (Men) future health crises. A transnational analysis in Latin America can Women 1.488 (0.087)*** allow us to understand the different levels of influence that are Age (18-25) interconnected in the individual decision to wear a mask as a 26-40 1.186 (0.086)* 41-60 1.580 (0.127)*** protective measure against the COVID-19 virus. This study aims to 61þ 1.576 (0.166)*** develop a descriptive analysis of the profile of people who wear Education (Illiterate) masks and to understand the importance of the cultural and so- Basic 1.110 (0.111) ciopolitical context of individuals in Latin America. We carried out Secondary 1.401 (0.147)** Tertiary 2.102 (0.256)*** logistic regression models controlling for all the demographic, Labor activity (self-employed) socio-economic and country variables, relevant to understand the Employee 1.431 (0.117)*** determinants of preventive behaviors. Unemployed 1.317 (0.135)** Retired 1.723 (0.286)** Inactive 1.039 (0.075) Data and methods Student 1.388 (0.21)* Social Class (High) The Latinobarometer [Latinobaro metro] is a representative Medium 1.215 (0.129) Low 1.046 (0.105) population survey conducted between October 26 and November Missing 0.906 (0.132) 17, 2020, in 18 Latin American countries. The sample includes Religion (Evangelical) 20,204 people, ranging from 1000 to 1200 adults interviewed by Catholic 1.292 (0.094)*** country. We eliminated 127 minors, 89 people who did not answer Other 1.060 (0.148) the question about the use of masks, and three people who did not None 0.820 (0.072) Missing 0.624 (0.112) report their educational level. Political ideology (Right) We performed a logistic regression of the binary-dependent Center-Right 1.443 (0.156)** variable created from the question about the use of mask on a Center 1.508 (0.15)*** regular basis to not get infected with the COVID-19 virus. The model Center-Left 1.097 (0.109) Left 0.870 (0.091) included as independent variables the gender (male/female), age None 1.235 (0.152) (18e25, 26e40, 41e60, and 61 years), educational level (illiterate, Missing 1.386 (0.161)** basic education completed, completed high school, completed Country (Brazil) higher education), current occupational status (self-employed, Argentina 0.617 (0.121)* salaried, retired or pensioned, unemployed and student), political Bolivia 0.180 (0.03)*** Chile 1.385 (0.327) ideology (left, center left, center, center right, right), religion Colombia 0.505 (0.093)*** (Catholic, Evangelical, others, none) and the country of residence Costa Rica 1.259 (0.283) (see Table 1). Survey's interviews were conducted face-to-face. Dominican Rep. 0.524 (0.097)*** Ecuador 0.915 (0.187) El Salvador 0.933 (0.191) Results Guatemala 0.997 (0.202) Honduras 0.678 (0.128)* Mexico 0.191 (0.032)*** Table 1 shows the results of the multivariate regression model, Nicaragua 0.350 (0.062)*** indicating women use more the mask than men (odds ratio Panama 0.663 (0.128)* [OR] ¼ 1.488; P value <0.001). Younger people are less likely to use Paraguay 0.402 (0.072)*** a mask, although a greater correlation is not observed among the Peru 0.663 (0.126)* population aged >60 years (OR ¼ 1.576; P value <0.001) compared Uruguay 0.789 (0.156) Venezuela 2.094 (0.541)** with those aged between 41 and 60 years (OR ¼ 1.580; P value Constant 5.736 (1.286)*** <0.001). Those with higher educational level, have a higher chance N 19988 of wearing a mask, and differences are significant for people with *** P<0.001; ** P<0.01, * P<0.05 higher education (OR ¼ 2.102; P value <0.001) and secondary ed- ucation (OR ¼ 1.401; P value <0.01). Employees, temporarily un- employed people, retirees and students use the mask to a greater the reference category, the only country where the use of masks is extent than people who are self-employed. Self-perceived social significantly higher is Venezuela (OR ¼ 2.070; P value <0.01), class in the bivariate analysis (results not shown here) indicates although Chile and Costa Rica also showed non-significant higher that the middle class is more likely to use masks than the upper rates. In contrast, the use of the mask is lower in Bolivia, Colombia, class but this is not significant in the multivariate analysis. the Dominican Republic, Honduras, Mexico, Nicaragua, Panama, Regarding religion, Catholics have a higher chance of wearing Paraguay, and Peru. the mask than Evangelicals (OR ¼ 1.292; P value <0.001), whereas other religions and people who declare no religion show no sig- nificant difference. The results on political ideology indicate that Discussion people from the center right (OR ¼ 1.443; P value <0.01) and center (OR ¼ 1.502; P value <0.001), as well as those with missing values Here we profile individuals who commonly used a mask be- (OR ¼ 1.386; P value <0.01) use the mask to a greater extent than tween October and November 2020 before the vaccination right-wing people. However, there are no significant differences campaign started in Latin America. The results of this analysis are between people who is on the right with respect to those on the consistent with previous studies showing that men are more prone left, center left or without political ideology. Compared with Brazil, to risky behaviors than women.2 Although young people are less 155 mez-Casillas and P. Zueras E. Rentería, A. Go Public Health 219 (2023) 154e156 likely to use masks, both the middle-aged and oldest-age groups Author statements showed similar propensity, suggesting that the age perception of risk started earlier than the actual risk. The finding that higher Ethical approval levels of education are associated with greater use of masks is consistent with previous studies where higher educational levels This article adheres to ethical standards and complies with are associated with healthier behaviors.2 relevant guidelines for using secondary survey data. Data on the Regarding occupational status, the fact that retirees or pen- research is done are freely available and ensure the confidentiality sioners are more likely to use face masks than those who are self- and privacy of the participants in accordance with relevant laws employed is related to the fact that older people are the most and regulations. The analysis presented here are available upon vulnerable group to the virus.8 In addition, students might be more request. likely to use them because of the mandatory use of face masks in educational centers. We also find that the employees and the un- employed are more likely to wear a mask than the self-employed. In Funding this sense, it should be noted that although we control for the current occupational situation, the survey does not have variables This work was supported by the Spanish Ministry of Science and that allow us to control which people can perform their daily lives Innovation, through the Ramon y Cajal grant number [RYC-2017- without having to leave their homes, where the use of a face mask 22586]”, and the project of the National R&D&I Plan COMO- would not be so necessary. Social class does not show significant RHEALTHSES [PID2020-113934RB-I00]; the Economic and Social results, but this may be a limitation of the self-perceived question Research Council (ESRC) through the Research Centre on Micro- to capture this dimension. Unlike countries such as the US, where Social Change (MiSoC) at the University of Essex, grant number political orientation shapes prevention behaviors,3 the results of ES/S012486/1; and support from CERCA Programme Generalitat de our study indicate that there is no left-right polarization of mask Catalunya. use in Latin America. Interestingly, centrist people are the most likely to wear a mask. In this sense, religion, which has also been present in discussions about the pandemic,9 also shapes prevention Competing interests behaviors. Those belonging to the Evangelical religion wear a mask to a lesser extent than Catholics. These findings raise many ques- None declared. tions about the role of religions in promoting health behaviors and the arguments that certain religions make against medical discourse. Finally, Venezuela, Chile, Costa Rica and Brazil are the References countries in Latin America where the use of a mask is highest. In the case of Brazil, the lack of rapid and equitable responses from the 1. Dean K. Self-care components of lifestyles: the importance of gender, attitudes and the social situation. Soc Sci Med 1989;29(2):137e52. government might have led the population to increase their pre- 2. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by vention attitudes against the virus.10 Regarding Venezuela, the education. J Health Econ 2010;29(1):1e28. country has deepened its political and economic crisis since COVID- 3. Becher M, Stegmueller D, Brouard S, Kerrouche E. Ideology and compliance 19, and there has been a lack of credibility from the citizenship in with health guidelines during the COVID-19 pandemic: a comparative perspective. Soc Sci Q 2021;102(5):2106e23. the reported cases because of the shortage of virus tests.11 4. García PJ, Alarco n A, Bayer A, Buss P, Guerra G, Ribeiro H, et al. COVID-19 The study presents some limitations that should be noted. First, response in Latin America. Am J Trop Med Hyg 2020;1. the sample size may be too small for some big countries such as 5. Martinelli L, Kopilas V, Vidmar M, Heavin C, Machado H, Todorovi c Z, et al. Face masks during the COVID-19 pandemic: a simple protection tool with many Brazil or Mexico, which can limit the generalization of findings. meanings. Front Public Health 2021;8. Second, the cross-sectional nature of the survey does not allow to 6. Moran KR, Del Valle SY. A meta-analysis of the association between gender and establish causal relationships between variables. Finally, it is an protective behaviors in response to respiratory epidemics and pandemics. PLoS One 2016;11(10):e0164541. inherent limitation of surveys that participants provide socially 7. Bir C, Widmar NO. Societal values and mask usage for COVID-19 control in the desirable responses, which cannot be overcome considering that US. Prev Med 2021;153:106784. the survey does not include questions that allow to control for this. 8. Sorensen RJ, Barber RM, Pigott DM, Carter A, Spencer CN, Ostroff SM, et al. (COVID-19 Forecasting Team) (2022). Variation in the COVID-19 infec- Future research should aim to address these limitations. tionefatality ratio by age, time, and geography during the pre-vaccine era: a The use of face mask to prevent COVID-19 infection was uneven systematic analysis. Lancet 24 de February de 2022. https://doi.org/10.1016/ across individual, regional, cultural and ideological factors in Latin S0140-6736(21)02867-1. 9. Barmania S, Reiss MJ. Health promotion perspectives on the COVID-19 America. The analysis showed the importance of understanding the pandemic: the importance of religion. Global Health Promotion 2020;28(1): demographic and socio-economic profile of those individuals more 15e22. prone to use preventive measures to stop the spread of the pandemic 10. Castro MS, Kim S, Barbeira L, Ribeiro AF, Gurzenda S, Ribeiro KB, et al. in the region, and the critical role of social forcesdthrough religion Spatiotemporal pattern of COVID-19 spread in Brazil. Science 2021;372(6544): 821e6. and political ideasdin shaping health-related attitudes in a health 11. Rodriguez-Morales AJ, Figuera ME. COVID-19 in Colombia and Venezuela: two emergency crisis. sides of the coin. Am J Publ Health 2022;112(56):5581e4. 156