No one cared who I was till I put on the mask

It will escape few people’s notice that face masks in shops are to be made compulsory from the 24th July in England in an attempt to reduce the spread of COVID19. Inevitably, this has led to a heated debate on social media about the benefits or otherwise of masks, as well as a perceived loss of freedom some people feel as a result of the mandatory measures.

I am not an infectious diseases specialist, so I am not going to consider the effectiveness or otherwise of masks here. From what I have read from people who are experts, masks alone are not going to prevent the spread entirely, but can be a useful additional protection, which when combined with social distancing and hand washing can reduce the spread of COVID19.

What I thought I would talk a little about instead so some thoughts and experiences of wearing masks, and offer a few handy tips for those who have not worn a mask before to lookout for. As a psychiatrist, wearing a mask has not been a typical part of my job, if anything it is a hinderance. But before I started at psychiatry training, I would frequently wear masks as a junior doctor, including working on a respiratory ward during the flu season (when I felt like I was never out of one) and long hours assisting in the operating theatre where I could not wait to get the mask (and other gear) off at the end of the list.

Communication

One of the biggest problems you will experience wearing a mask is that of communicating with other people. There are two aspects to difficulties communicating; muffled speech, and a loss of facial expression.

For those who are hard of hearing, speaking a second language, or like my patients with learning disability who struggle to understand people at the best of times, having a piece of cloth covering the mouth can make it almost impossible to hear what is being said. It is not just the volume which is reduced by having a mask on, it is also the quality of the speech, which is often muffled. Add to this the need to keep a distance from people when the natural instinct would be to lean in closer, and it can be a really challenge for some people to understand what we are saying.

There are several options to make yourself better understood. The most obvious is to start by speaking slowly, a little louder (without shouting) and annunciating as best you can. By starting with clear speech behind the mask, it will hopefully mitigate any problems the mask might cause. Make sure as you speak with someone who might struggle that they are understanding. There is no point giving a long list of instructions only to find out at the end they have not been following you. Stop and check regularly, and summarise and repeat yourself as much as possible.

It can also be useful to add gestures in when you are speaking. We will speak in a moment about a loss of facial expressions, but you can certainly mitigate this by using your hands and body language to help get your message across. Simple gestures like a thumbs up, or counting numbers on your fingers can add much needed context to the person listening to you, and reduces the chances of a misunderstanding.

When it comes to communicating with other people, you might expect the majority of information is transmitted in the words we say, but if you think how hard getting meaning across for example on the phone is and you will see this is not true. It is estimated that only around 30-40% of information is in the words we say and how we say them, the remaining information is non-verbal, with facial expressions being a significant part of this.

Put in a mask covering half of your face, and facial expression becomes more difficult to convey. Several times I have found myself smiling in response to something positive a patient has said to me, only to realise they cannot see me smile and probably think I am just staring at them in silence.

Not all facial expression is lost with a mask. Your eyes, eyebrows and forehead can carry a lot of meaning, so it is important to make sure you are showing how you feel as much as possible in your eyes. Exaggeration is your friend here. If you are smiling, make it the cheesiest grin you have ever given. Looking surprised? Then open those eyes wide. They might be small gestures, but they can make a big difference when a lot of meaning is otherwise lost.

Identity

It probably goes without saying that much of our identity is in our face. With the exception of some twins and triplets, or faces are unique, and a big part of how we identify ourselves, and how others recognise us. There is no doubt that putting a mask over your face strips away some of that identity. There is a reason someone up to no good covers their face after all. The face is not the only way we identify people (build, movements etc play a part as well) but it is an important one.

In hospitals, I have seen examples of colleagues writing their name or job role on to their mask as a way to get around the restrictions the mask imposes. In my team, several members have printed and laminated photos of themselves to wear around their neck when wearing a mask to offer some help to patients identifying them.

When out shopping it is probably not essential for you to be identified to that degree. The person serving you at the checkout is not going to struggle if they do not know exactly what you look like. So for general purposes issues with identity are going to be a personal issue, and it is not something to be laughed at. Who we are as a person is important, and can affected by even the smallest changes. If you are someone who struggles with their identity to begin with, adding a mask is going to be an additional difficulty.

The obvious solution is to find a mask which has some meaning to you. Wearing a surgical mask which is identical to every other person in the shop is not going to help. Buying a mask in a particular colour or design can bring back a little bit of individuality. Decorating the mask yourself means you can add more of you, making a mask yourself is even better. There are plenty of how to guides for mask making online, and if you are handy with a needle and thread you can probably come up with a fetching number.

Wellbeing

It might sound silly to consider your wellbeing when wearing a mask, after all the whole point is to reduce the spread of the virus, which will improve everyone’s wellbeing if it is successful. But while you are wearing a mask, especially for a prolonged period of time, there are a few things it is useful to consider.

Hydration: wearing a mask, even for a short time, will dry your mouth out. It is important to keep well hydrated when wearing a mask. If you are going shopping for a long period, make sure you have breaks outside to take of the mask, have a drink and some food. The last thing you want is to faint in the middle of the supermarket because you have not had enough to drink. Along the same lines, only wear a mask when you have to (in shops and enclosed spaces). If you are walking to the shops and can keep your distance from people, it is probably best to take off your mask (hygienically, see below) and get some fresh air.

Hygiene: if you are using a reusable mask, make sure you was it regularly. I would think about a mask like underwear, wear once and then wash. This will mean you need a few masks for when one is in the wash, but with the speed with which they can build up dirt and grime, it is for the best.

A second consideration for hygiene is hand washing. If you come into contact with someone with COVID19, there is a chance some of the virus particles are on the mask. If you take the mask off later and do not wash your hands before touching your face again, you might as well have not bothered with the mask. Wash or sanitise your hands whenever you have touched the mask. This might be to readjust it, or when you take it off at the end of the day.

Glasses: finally, for those of you like myself who wear glasses, there is an important practical consideration to make. If you have a poorly fitting mask, especially around the nose, as you breath out you will find your glasses steaming up. At times it has got to the point I could not see at all, so it is important to get a well-fitting mask, or better still a well-fitting mask with an anti-fog strip. Usually this will be a strip of foam which runs along the top of the mask and provides a good seal around the nose and cheeks. I have found one particular surgical mask with a good seal on them where my glasses never fog. Unfortunately to date that is the only mask (other than medical respirators) which has worked, but I will continue my search.

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