The mask paradox between perception of discomfort and reality of physiological effects in healthy college students in China: a panel study | BMC Public Health | Full Text

BMC Public Health volume 24, Article number: 2845 (2024) Cite this article Metrics details During the COVID-19 pandemic, masks proved to be an effective measure in preventing virus transmission.

BMC Public Health volume 24, Article number: 2845 (2024) Cite this article

Metrics details

During the COVID-19 pandemic, masks proved to be an effective measure in preventing virus transmission. However, many people have reported discomfort and negative perceptions toward wearing masks, especially during physical activity. This study aims to evaluate the discomfort and adverse perceptions related to various mask types among young, healthy adults during light exercise, including sitting, stationary stepping, and stair climbing. The study also examines the extent to which masks influence physiological indicators of physical well-being.

The study was conducted in two stages at the campus hospital of Shantou University. In Stage 1, 20 healthy college students (10 males, 10 females) were recruited to identify the mask with the most substantial physiological and psychological impact among four types: KN95 respirators, surgical masks, cloth masks, and 3D medical masks. These specific types were chosen due to their widespread use and varying levels of filtration and breathability. In Stage 2, 14 healthy college students (7 males, 7 females) were included to examine the effects of the identified mask across various levels of physical exertion. Subjective perceptions were measured using the Mask-Related Discomfort and Perception Score (MRDPS), and physiological parameters such as body temperature, blood pressure, pulse rate, and vital capacity were recorded.

The KN95 respirator and cloth mask were associated with the highest MRDPS, indicating significant discomfort among wearers (p < 0.05). The use of KN95 respirators had the largest impact on MRDPS during stair stepping (β = 10.357, 95% CI [5.755, 14.959]). Physiological parameters showed minor variations across different masks, with KN95 respirators significantly associated with reduced diastolic blood pressure (β=-7.806, 95% CI [-12.294, -3.318]) and pulse rate (β=-10.661, 95% CI [-18.896, -2.425]) in Stage 1. However, after controlling for exercise pace in Stage 2, wearing a KN95 respirator did not significantly affect these parameters.

KN95 respirators and cloth masks were found to cause the most discomfort during light physical activity, with males reporting higher discomfort levels than females. While these masks are associated with varying levels of perceived discomfort, their impact on physiological indicators is relatively modest. Future research should include larger and more diverse samples , continuous monitoring of physiological parameters during exercise, and exploration of the underlying mechanisms of gender differences in mask discomfort.

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At the end of 2019, a novel coronavirus disease (COVID-19) was first detected in Wuhan, China, then spread to countries all over the world and caused nearly 7 million deaths globally by 21st June 2023 [1, 2]. The main mode of transmission of COVID-19 is through respiratory droplets that are released into the air when infected individuals breathe, speak, cough, sneeze, or sing [3]. During the pandemic, masks were shown to be a highly effective measure in preventing the transmission of the virus from infected individuals and minimizing the risk of infection for uninfected individuals [4, 5]. In addition to COVID-19, masks are also beneficial for reducing the risk of other airborne infectious disease transmission and in mitigating exposure risk from aerosol and air pollution hazards [6]. Therefore, the US Centers for Disease Control and Prevention (CDC) strongly advocated for the use of masks as a critical measure for achieving any degree of protection [7].

Despite the benefits of wearing masks, many people showed a negative attitude toward masks and some were even anti-mask [8]. A common reason for negative feeling about masks comes from physiological discomfort and a perception of possible harm from wearing masks [9,10,11,12,13]. For instance, a study found that 78.4% of the participants reported discomfort when wearing disposable surgical masks, and the discomfort mainly came from impairment to breathing and communication difficulties [14]. Different kinds of masks have different levels of discomfort on breathability and tightness. Surgical masks are loose-fitting, disposable masks designed to block large particles and droplets. Made from various fabrics, cloth masks can vary widely based on the type of fabric, the number of layers, and the mask’s fit. N95 respirators are tight-fitting masks designed to achieve a very close facial fit and very efficient filtration of airborne particles, including viruses and bacteria [7]. In general, N95 respirators are less comfortable than surgical masks or cloth masks [15]. For example, a study by compared the use of N95 respirators with surgical masks among healthcare workers and found that participants reported more discomfort and breathing difficulties with N95 respirators [16]. Similarly, a systematic review by Smith et al. (2016) highlighted that while respirators offer better protection, they are associated with higher levels of discomfort and adverse skin effects compared to surgical masks [17]. However, very few studies have compared the discomfort levels among non-N95 masks, which are more commonly used in daily life than N95 respirators [18, 19]. It remains unclear how mask-associated discomfort and adverse perceptions differ between these mask types.

During physical activity, the body’s demand for oxygen increases, and the respiratory system works harder to meet this need [20]. Low-intensity exercises may not significantly increase respiratory demand, allowing individuals to comfortably wear masks with minimal impact on breathing. However, high-intensity exercises drastically increase the need for oxygen and the rate of carbon dioxide expulsion, potentially making mask-wearing more challenging due to restricted airflow and increased resistance to breathing [21]. Although some studies have examined the influence of wearing a mask on physiological outcomes among healthy adults when exercising, the conclusions were not consistent because of different exercise protocols and physiological parameters [22]. A systematic review has found that wearing either surgical or N95 respirators had no discernible effect on exercise performance, but when wearing an N95 respirator, there was a slight increase in end-tidal CO2 (the level of carbon dioxide that is released at the end of an exhaled breath) levels and heart rate [23]. Fukushi et al. found that cloth face masks can increase pulse rate during intense exercise, while surgical masks do not affect pulse rate at any level of exertion [24]. Driver et al. indicated that the use of cloth face masks resulted in a 14% decrease in exercise time and a 29% reduction in VO2 max, which was primarily due to the discomfort perceived by individuals wearing the masks [25]. These findings underscore the importance of considering mask type and exercise intensity when evaluating masks’ impact on physiological responses and performance.

Regardless of the reported increased discomfort experienced by young people during physical activity with masks, a disparity may exist between subjective perceptions and objective markers, potentially attributable to their robust health status and rapid recovery capabilities [14, 26]. Subjective perceptions are based on personal feelings, such as a sense of discomfort while wearing a mask, which can vary greatly between individuals. Objective markers, however, are quantifiable data such as heart rate or oxygen saturation levels that provide unbiased evidence of physical effects. The distinction between the two hinges on individual variability versus measurable consistency.

The primary objective of this study is to evaluate the discomfort and adverse perceptions related to various mask types among young and healthy adults. Furthermore, we aim to determine the extent to which masks substantially influence physiological indicators of physical well-being.

We hypothesize that the physiological impact of mask-wearing during exercise will vary by mask type, with KN95 respirators masks potentially leading to more pronounced subjective measures of discomfort compared to surgical or cloth masks. In addition, we hypothesize that while young, healthy adults may report subjective discomfort while wearing different types of masks, this discomfort may not significantly correlate with measurable objective markers of physical stress.

The study was conducted at the campus hospital of Shantou University. During Stage 1, a total of 20 healthy college student volunteers (10 males and 10 females) were recruited, while in Stage 2, 14 healthy college student volunteers (7 males and 7 females) were included. The participants in these two stages were not the same.

The exclusion criteria were having respiratory system diseases or related symptoms, smoking or staying up late during the study period. Pre-existing respiratory diseases can impair breathing and increase discomfort while wearing a mask, potentially distorting the study’s assessment of masks’ impact [27, 28]. Smoking, which impairs lung function and exacerbates respiratory symptoms [29], might cause smokers to perceive greater discomfort with mask use, affecting the study’s outcomes. Sleep deprivation affects physiological and psychological responses, influencing baseline health metrics and perceptions of discomfort; excluding those with irregular sleep patterns helps isolate the effects of mask-wearing from sleep-related variations [30].

Participants were given an informed consent form before the experiment, which outlined the study’s purpose, procedures, benefits, and risks. Participants were entitled to request information and opt out of the study at any point following commencement, without being subjected to any adverse outcomes.

In the study, a total of four representative types of masks were used, including KN95 respirators conform to China’s GB2626 standard [31](Tuoren, Tuoren Best Medical Device Co., Xinxiang, China, cup-shaped ear-hanging type), surgical masks (Taienkang, Taienkang Medical Technology Co., Shantou, China, TNK-WKA ear-hanging type), cloth masks (Huameidun, Caijun Knitting and Processing Factory, Tai’an, China, CMB type), and 3 dimensional (3D) medical masks (Doctor.Roo, Xianghe Weicai Medical Material Co., Xinxiang, China, C type).

KN95 and N95 respirators both filter 95% of airborne particles, but N95 respirators are certified by U.S. regulators while KN95 respirators are certified in China [32]. Our study conducted in China used KN95 respirators due to their local availability and alignment with Chinese regulatory standards.

A self-designed questionnaire by the authors was developed to measure the subjective perception of masks among participants. The questionnaire was based on the US Occupational Safety and Health Administration’s guidelines and existing literature sources [33, 34]. The questionnaires are divided into two stages, with details provided in Table S1 and Table S2, respectively. Collectively, they include a total of 18 questions that cover personal information, discomfort, and negative effect. The first stage (Table S1) includes questions about general comfort, inspiratory/expiratory effort, overall breathing discomfort, facial and body heat, thermal comfort, ear discomfort, and various other factors when wearing different types of masks. The second stage (Table S2) focuses on similar aspects but in different physical conditions such as sitting and rest, march in place, and stair exercise. These questions are designed to gauge the subjective perception of discomfort and negative effects associated with mask usage in various scenarios.

The Mask-Related Discomfort and Perception Score (MRDPS) was derived from participants’ responses to the questionnaire. This cumulative score aims to reflect the subjective perception of discomfort and the negative effect of wearing masks under different conditions. Questions including: breathing effort, breathing discomfort, facial and body heat, ear discomfort, interference with glasses/goggles/contact lenses, vision obstruction due to fogging, field of vision is blockage, difficulty donning, interference with duties, perceived harm of masks, pressure or pain contribute to the total MRDPS, with the scoring scale varying based on the nature of the question - for example, comfort levels and discomfort intensity are measured on scales from “Very comfortable” to “Very uncomfortable” and “No discomfort” to “Extreme discomfort,” respectively. The maximum total score that can be achieved across all questions is 56, indicating the highest degree of mask-related discomfort and negative effect perceived by the participant. It is implied that each question contributes to the MRDPS, although the exact scoring weight of each question is based on its scale and responses. A higher MRDPS signifies a greater degree of perceived discomfort and negative effects, providing valuable insights into the subjective experiences of mask wearers.

Upon arrival at the study location, participants were required to secure an ID number, and their height and weight was recorded. This ensured that the data of each participant could be precisely tracked and correlated with their corresponding vital sign measurements. Participants were then asked to rest (upright seated) for an initial 15 min before commencing any activities related to the experiment. A fifteen-minute rest period is primarily aimed at ensuring that participants start from a similar baseline, designated as a state of rest. According to literature on standardized blood pressure measurement, resting for 5–10 min on a chair with a backrest is considered sufficient to achieve a state of rest [35, 36]. This resting period was essential for better control and accuracy of the initial vital sign measurements.

The study was conducted in two primary locations: outdoors near a staircase and indoors within an air-conditioned room. The choice of the locations was driven by the need for ease of access and the ability to monitor short-term changes in participants’ vital signs. The photos of these two locations are presented in supplementary materials (Figure S3).

The investigation was divided into two independent stages. In the first stage, the goal was to identify the mask that had the most substantial physiological and psychological impact on the human body from the four types of masks tested. Measurements were categorized into two groups, dictated by the location they were taken. The first group, recorded near the staircase outdoors, included measurements of body temperature and pulse. The second group of measurements was conducted indoors in an air-conditioned room and included assessments of blood pressure and vital capacity. Vital capacity was measured using a spirometer, which is a device that measures the volume of air inhaled and exhaled by the lungs. In our study, the participants removed their masks when undergoing spirometry measurements. This decision was made to ensure the accuracy and reliability of the vital capacity measurements, as wearing a mask during spirometry could introduce additional resistance and potentially affect the results. Participants were instructed to ascend the stairs at a regular pace and follow a predetermined route. They were asked to complete the task without wearing any mask, as well as wearing different types of masks including a surgical mask, a cloth mask, a 3D medical mask, and an KN95 respirator. After the exercise routine, the research staff conducted measurements and administered a subjective perception questionnaire based on personal experiences.

In the second stage, the objective was to examine the physiological and psychological implications of the masks that were identified in the initial stage across various levels of physical exertion. We chose exercises that represent daily activities with different intensity levels, as supported by previous literature. For example, studies have used sitting, treadmill running, and strength training to assess the physiological responses to various activities [23, 24]. Additionally, we aimed to select exercises where the pace could be controlled to ensure consistency across participants. Based on these criteria, we ultimately chose sitting, marching in place, and stair stepping as the activities for our study. Participants underwent a series of tests, which involved sitting outside without a mask and then wearing the mask identified in the initial stage, performing stationary stepping for five minutes with and without the mask, and performing stair exercise for five minutes on a one-step staircase with and without the mask. We chose a five-minute period based on findings from previous studies. Research has shown that five minutes of stair climbing can lead to significant increases in heart rate and oxygen uptake, indicating a sufficient duration to elicit cardiovascular responses [37]. After the exercise routine, the research staff assessed participants’ body temperature, blood oxygen saturation, pulse, blood pressure, and vital capacity. The participants recruited in each stage were not the same.

To ensure the reliability of data and minimize carryover effects between the different stages and tests, participants were granted a 20-minute rest period between each stage of measurements. This interval was implemented to allow sufficient time for any immediate physiological effects from the previous measurements to normalize. A flowchart (Fig. 1) is presented to show the study design.

Flowchart of the two stages study design

The study was conducted in a real-world environment (the campus hospital at Shantou University) and involved physical activities (like stair stepping) that most people would normally do. This increases the external validity of the study.

Each questionnaire was examined for completeness and consistency prior to the analysis. Cronbach’s alpha was used to verify the internal consistency of the items. To describe the characteristics of personal information, subjective perception of masks, and physiological indicators, descriptive analysis was employed. Mean and standard deviation were used to analyze the continuous variables, while frequency was used to analyze the categorical variables. Analysis of Variance (ANOVA) was used to compare the means of variables across different types of masks and exercises. The power analysis was calculated and presented in supplementary materials (Table S4 and Table S5).

To assess the impact of masks on subjective perception and physiological indicators, we adopted mixed effect models adjusted by covariates. The model is as follows:

Where:

y is the vector of the dependent variable (i.e., the observations).

X is the design matrix for the fixed effects.

β is the vector of fixed-effect coefficients.

Z is the design matrix for the random effects.

μ is the vector of random-effect coefficients

ε is the vector of residual errors.

Since all participants within each study location (outdoors near a staircase and indoors within an air-conditioned room) were exposed to consistent temperature conditions during the study, environmental factors such as temperature were considered constants within each location’s statistical models. Therefore, we did not include them in the models and presented them in supplementary materials. Wearing glasses might affect how well the masks fit on participants’ faces. Glasses can interfere with the seal of the mask, especially around the nose bridge area, which could lead to discomfort or air leakage. When wearing masks, exhaled breath can sometimes escape upwards and cause glasses to fog up. This fogging effect could be more pronounced with certain types of masks or during physical activity. Fogged glasses might cause discomfort or visual impairment for participants, which could affect their subjective perception scores. Therefore, we adjusted for ‘wearing glasses’ when estimating the effects of masks on MRDPS.

To address the possible overfitting problem, we examined the significance of each variable in the model and removed those that did not contribute significantly to the model’s explanatory power. For example, we tested the significance of ‘age’ in the model and found that it may not impact the results because most of the participants are junior college students. Therefore, we removed the ‘age’ variable to reduce the risk of overfitting and to make the model more parsimonious.

The fixed effects represent the population-level relationships between the predictor variables and the dependent variable, while the random effects account for the variability in these relationships across different levels of the grouping variable (e.g., participants, groups). The random effects were modeled as random intercepts, allowing for subject-specific baseline levels of the dependent variable [38, 39].

In Stage 1, where we aimed to identify the most uncomfortable masks, the outcome is MRDPS and the fixed effects included in the model were mask types (no mask, medical mask, 3D medical mask, cloth mask, KN95 respirator), gender (male, female), Body Mass Index (BMI, continuous), glasses (yes, no), and exercise time (continuous). The random effect was the participant, which accounted for the individual variability and repeated measures within each participant.

For Stage 2, the outcomes include MRDPS and physiological indicators. The fixed effects in the model were mask conditions (no mask, KN95 respirator), exercise types (sitting, march in place, stair stepping), gender (male, female), and BMI (continuous). We controlled for glasses (yes, no) additionally when estimating the effects of KN95 respirators on MRDPS. Similar to Stage 1, the random effect was the participant.

The adjusted estimated coefficients (\(\:\beta\:\)) with a 95% Confidence Interval (CI) and p-value ≤ 0.05 in the multivariable model were used. All statistical analyses were performed using R version 4.2.2. The statistical analysis was performed using the ‘lme4’ packages and the plots were generated using the ‘ggplot2’ package.

Table 1 presents the participant characteristics across two distinct stages of the study. In stage 1, the study recruited a balanced gender sample of 20 participants, comprising an equal distribution of 10 males and 10 females. The second stage maintained this gender balance, with 7 males and 7 females among the 14 participants. The participants in both stages displayed remarkable similarity in terms of average age, weight, and height, thereby ensuring a consistent demographic profile. Additionally, the proportion of participants who wore glasses remained approximately equal across both stages. This parity in participant characteristics ensures comparative validity across the stages of the study.

Table 2 presents a comparison of Mask-Related Discomfort and Perception Score (MRDPS) and various physiological parameters across different types of masks, including no mask, medical mask, 3D medical mask, cloth mask, and KN95 respirator. The ANOVA results show that MRDPS significantly differed across mask types (p < 0.001). Specifically, the KN95 respirator (16.95 ± 7.77) and cloth mask (16.70 ± 8.43) had the highest MRDPS, indicating greater discomfort and negative perceptions compared to the medical mask (11.65 ± 6.59) and no mask (3.60 ± 2.82) conditions. However, there were no statistically significant differences in the physiological parameters across mask types. The p-values for exercise time (p = 0.965), body temperature (p = 0.420), systolic blood pressure (p = 0.905), diastolic blood pressure (p = 0.856), pulse (p = 0.708), and vital capacity (p = 0.998) were all greater than 0.05, suggesting that the type of mask did not significantly influence these physiological measures during the stair exercise.

Table 3 reflects MRDPS and various physiological parameters in response to different exercise types, while wearing an KN95 respirator or no mask, in Stage 2 of the study. The ANOVA results indicate that MRDPS significantly increased with exercise intensity for both the no mask (p = 0.002) and KN95 respirator (p = 0.005) conditions. The highest MRDPS was reported during stair-stepping with the KN95 respirator (20.00 ± 7.62), suggesting that this combination of exercise and mask type led to the greatest perceived discomfort. For the physiological parameters, body temperature showed a statistically significant decrease with increasing exercise intensity for both the no mask (p = 0.014) and KN95 respirator (p < 0.001) conditions. Pulse rate also significantly increased with exercise intensity in both mask conditions (p < 0.001). Systolic blood pressure significantly increased with exercise intensity only in the KN95 respirator condition (p = 0.007), while the increase was not statistically significant in the no mask condition (p = 0.053). Diastolic blood pressure and vital capacity did not show significant changes across exercise types in either mask condition (all p > 0.05). It is important to recognize that while the data may demonstrate statistical significance for specific physiological parameters, cautious interpretation is warranted when assessing the practical implications and real-world magnitude of these observed physiological changes.

Figure 2 shows the effects of different types of masks on the overall MRDPS of masks when doing exercise on stairs (left), and the effects of wearing KN95 respirators on MRDPS in various exercise types (right) adjusted for gender, BMI, and wearing glasses. Compared to not wearing a mask, wearing a KN95 respirator was significantly associated with the highest increase in MRDPS (\(\:\beta\:=\:7.963,\:95\%\:CI\:[4.791,\:11.125]\)), and wearing a medical mask was related to the lowest MRDPS (\(\:\beta\:=13.441\:,\:95\%\:CI\:[10.224,\:16.658]\)). The effects of wearing a cloth mask on MRDPS was close to KN95 respirator. The use of KN95 respirators had the largest impact on stair stepping (\(\:\beta\:=10.357\:,\:95\%\:CI\:[5.755,\:14.959]\)). The effects of wearing KN95 respirators when sitting were slightly higher than marching in place, with an estimated coefficient with 95% CI of (\(\:\beta\:=6.857,\:95\%\:CI\:[4.336,\:9.381]\)) and (\(\:\beta\:=6.214\:,\:95\%\:CI\:[3.870,\:8.558]\)) respectively.

The effects of wearing masks on Mask-Related Discomfort and Perception Score (MRDPS) in different scenarios. (Left: The effects of different types of masks on the overall MRDPS of masks when doing exercise on stairs adjusted for gender, BMI, and wearing glasses. Right: The effects of wearing KN95 respirators on MRDPS in various exercise types adjusted for gender, BMI, and wearing glasses.)

Figure 3 depicts the relationship between the wearing diverse types of masks and physiological indicators including body temperature, systolic blood pressure, diastolic blood pressure, pulse, and vital capacity adjusted for gender, BMI and exercise time with the reference of no mask. The findings indicate that there was no significant impact of any mask type on body temperature, systolic blood pressure, and vital capacity. The body temperature demonstrating an inverse relationship with exercise intensity may be due to sweat evaporation which is a significant mechanism for the transfer of heat from the body to the environment. In addition, the vital capacity was not significantly affected by the exercise. However, the utilization of KN95 respirators exhibits a significant association with reduced levels of diastolic blood pressure (\(\:\beta\:=-7.806,\:95\%\:CI\:[-12.294,\:-3.318]\)) and pulse (\(\:\beta\:-10.661,\:95\%\:CI\:[-18.896,\:-2.425]\)).

The effects of wearing diverse types of masks on physiological indicators adjusted for gender, Body Mass Index (BMI), and exercise time. Reference: No mask

Figure 4 shows the impact of wearing a KN95 respirator on physiological indicators including body temperature, systolic blood pressure, diastolic blood pressure, pulse, and vital capacity adjusted for exercise types, gender and BMI with the reference of no mask. Wearing a KN95 respirator was only significantly associated with higher body temperature when doing stair stepping (\(\:\beta\:=0.114\:,\:95\%\:CI\:[0.012,\:0.217]\)) compared with no mask.

The effects of wearing a KN95 respirator on physiological indicators adjusted for gender, BMI and exercise types. Reference: No mask

In this study, we compared the discomfort and negative perception level of various masks when doing light exercise. Our study, designed in two stages, demonstrated that the KN95 respirator and the cloth mask resulted in the highest MRDPS, indicating a notable discomfort among wearers (Table 2). While these masks were associated with varying levels of discomfort, their actual impact on physiological indicators was relatively modest compared to participants’ perceptions (Figs. 3 and 4).

Regarding the discomfort level of different masks, our results showed that participants ranked the masks in the following order: KN95 respirators, cloth masks, 3D medical masks, and surgical masks. Regarding KN95 respirators and surgical masks, our findings are consistent with prior research. In particular, N95 respirators were reported to be more uncomfortable due to their tight fit, higher breathing resistance, and increased heat buildup within the mask [16, 40]. The MRDPS of cloth masks were higher than surgical masks and 3d medical masks, suggesting the discomfort level of cloth masks is greater. This may be due to the their thicker and less breathable material, less secure fit, potential for skin irritation, and higher tendency to slip down during use [41, 42].

In addition, the discomfort level of masks among males are higher than females, suggesting that males are more sensitive to masks when doing light exercise. Males generally have a higher metabolic rate than females, which could lead to increased heat production [43]. This may result in more difficulty breathing or feeling hotter due to reduced airflow. On the other hand, research indicates that females tend to have a higher pain tolerance than males [44]. Consequently, females may perceive less discomfort from mask use in the same context, which may explain the observed gender disparity in mask discomfort reports.

In the first stage, we demonstrated that wearing an KN95 respirator during stair-stepping was significantly associated with lower diastolic blood pressure and pulse compared with no mask wearing (Fig. 3), which was not consistent with previous findings. Wearing a surgical facemask did not increase pulse rate during less vigorous exercise [24]. Brisk walking with a surgical mask did not affect the mean pulse rate and blood pressure significantly [45]. A previous systematic review and meta-analysis indicated that wearing either a surgical mask or an N95 respirator during exercise did not show any significant differences in systolic or diastolic blood pressure compared to not wearing a mask [23]. The study also showed that surgical nor cloth masks had a significant impact on heart rate during exercise, while the use of N95 respirator increased heart rate compared to not wearing a mask, although this effect was no longer significant when studies with a high risk of bias were excluded [23]. In addition, another systematic review and meta-analysis also indicated no significant change in heart rate when a mask was worn during exercise [46]. Besides variations in study design and mask materials, the discrepancy could also be attributed to the lack of exercise pace control in stage 1, allowing participants to adjust their own pace. This variability could have led to inconsistencies in the intensity of exercise, which in turn could have influenced heart rate and blood pressure measurements. Later in stage 2, after controlling the pace, wearing an KN95 respirator did not significantly affect diastolic blood pressure and pulse (Fig. 4). In conclusion, while previous research on this topic has produced mixed results, our study suggests that both the type of mask and the pace of exercise can influence the cardiovascular effects of mask-wearing during exercise.

In the second stage, we found that the wearing of KN95 respirator was associated with lower pulse, which was counterintuitive. The possible reason might be that wearing an KN95 respirator can alter breathing patterns, possibly leading to slower, deeper breaths. This may be an unconscious adaptation to the increased resistance to airflow imposed by the mask [47]. Slower, deeper breathing could potentially lead to a reduction in heart rate, as the body may be able to more efficiently exchange gases and maintain adequate oxygen levels with fewer breaths per minute [48]. This effect may be more pronounced at rest when breathing demands are lower. Further research is needed to confirm the phenomenon.

While the paired sample design provided high power for detecting differences in MRDPS, we acknowledge that the study may have been underpowered for some of the secondary physiological outcomes. Future studies with larger sample sizes may be warranted to further examine potential subtle effects of mask-wearing on parameters such as exercise time, body temperature, and pulse. However, the current findings provide an important initial investigation into these relationships using a rigorous within-subjects design. Second, all participants were healthy college students, potentially limiting the generalizability of the findings to other age groups, people with underlying health conditions, or people from different demographic or socioeconomic backgrounds. Third, the use of a self-designed questionnaire to measure the subjective perception of mask discomfort could be susceptible to bias. Participants’ responses might have been influenced by factors such as social desirability or recall bias. Fourth, the physiological measurements were taken only pre- and post-exercise. Continuous monitoring during exercise might have provided more comprehensive data. Fifth, while the study had a 20-minute washout period between different stages, it is unclear whether this was sufficient time to eliminate potential carryover effects from one stage to the next. However, setting a long washout period may not be feasible because of the limited availability of participants. Future studies could use randomization to improve this limitation. Last, although the measurements were taken immediately upon completion of the exercise protocol, the assessment of multiple indicators could lead to a delay between exercise completion and measurement, which might impact the physiological variables of interest.

Our study offers important insights into the discomfort and negative perceptions associated with different types of masks during light physical activity. Notably, KN95 respirators were found to cause the most discomfort among the mask types tested. In addition, the discomfort level of masks among males are higher than females. Manufacturers could take this information into account to design masks that cater to the different needs of males and females. Besides, understanding these gender differences in mask discomfort during light exercise could inspire further research into potential physiological or psychological factors that contribute to the disparity.

While these masks were associated with varying levels of discomfort, their actual impact on physiological indicators was relatively modest compared to participants’ perceptions. Interestingly, our findings related to blood pressure and pulse during exercise while wearing an KN95 respirator differed from some previous research, possibly due to variability in exercise intensity. Despite limitations, our study underscores the importance of considering comfort, gender differences, and exercise conditions in mask-wearing guidelines, relevant in the ongoing fight against respiratory diseases, including COVID-19.

Further research is needed for a more comprehensive understanding of mask-wearing impacts during physical activity. A larger and more diverse sample size, including various age groups, people with underlying health conditions, and individuals from different demographic or socioeconomic backgrounds, could provide a more comprehensive understanding of the physiological and psychological impacts of mask-wearing. In addition, the physiological effects from recovery from exercise could have masked the effects. In order to avoid training effects, the participants could have returned another day to finish the study. Furthermore, continuous monitoring of physiological parameters during exercise, as opposed to only pre- and post-exercise measurements, could provide more in-depth insights into the dynamic changes in response to mask-wearing.

No datasets were generated or analysed during the current study.

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This study was supported by Shenzhen One Foundation Public Welfare Foundation ‘Chaoshan Mother’s Charity Fund - Rural Revitalization Research Service, and Shantou University Scientific Research Foundation for Talents (NTF23005).

Songtao Wang and Jiayuan Hao contributed equally to this work.

School of Public Health, Shantou University, Shantou, Guangdong Province, China

Qianyi Ruan, Xuanxuan Hong, Zicheng Yu, Jiawen Huang, Jiayi Li, Dongna Gao & Suyang Liu

Rural Revitalization Research Center, Business School, Shantou University, Shantou, Guangdong Province, China

Songtao Wang

Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Jiayuan Hao

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JHao conducted data analysis and drafted the paper; QR, XH, ZT, JHuang, and JL conducted the experiment and collected data; DG did proof-reading, SW and SL provided funding, conceived the study and did proof-reading.

Correspondence to Suyang Liu.

This study was approved by the Ethics Committee at Shantou University Medical College (Approval number: 202303022). For both stages of the study, all participants provided written informed consent before taking part. In Stage 1, 20 participants consented to wear four types of masks (KN95 respirators, surgical masks, cloth masks, and 3D medical masks) while performing stair exercises, and to undergo physiological measurements including body temperature, blood pressure, pulse rate, and vital capacity. In Stage 2, a separate group of 14 participants consented to wear KN95 respirators during various activities (sitting, marching in place, and stair stepping) and to undergo the same physiological measurements. All participants were informed about the study’s purpose, procedures, potential discomfort from mask-wearing and exercise, and their right to withdraw at any time without consequence. Participants also agreed to complete questionnaires about their subjective perceptions of mask discomfort.

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Wang, S., Hao, J., Ruan, Q. et al. The mask paradox between perception of discomfort and reality of physiological effects in healthy college students in China: a panel study. BMC Public Health 24, 2845 (2024). https://doi.org/10.1186/s12889-024-20127-2

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Received: 03 December 2023

Accepted: 18 September 2024

Published: 16 October 2024

DOI: https://doi.org/10.1186/s12889-024-20127-2

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