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Citation: Cordero Franco, H.F.;
Salinas Martínez, A.M.; Martínez
Martínez, D.L.; Santiago Jarquin, B.R.;
Guzmán de la Garza, F.J. Cessation of
Face Mask Use after COVID-19
Vaccination in Patients with Diabetes:
Prevalence and Determinants. Int. J.
Environ. Res. Public Health 2023,20,
2768. https://doi.org/10.3390/
ijerph20042768
Academic Editor: Osuagwu
L. Uchechukwu
Received: 11 January 2023
Revised: 30 January 2023
Accepted: 1 February 2023
Published: 4 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Article
Cessation of Face Mask Use after COVID-19 Vaccination in
Patients with Diabetes: Prevalence and Determinants
Hid Felizardo Cordero Franco 1, * , Ana María Salinas Martínez 1,2 , Diana Laura Martínez Martínez 3,4, Blanca
Reyna Santiago Jarquin 4and Francisco Javier Guzmán de la Garza 1,5
1Epidemiologic and Health Services Research Unit/CIBIN, Mexican Institute of Social Security,
Monterrey 64360, Mexico
2School of Public Health and Nutrition, Autonomous University of Nuevo Leon, Monterrey 64460, Mexico
3Vice-Rectory of Health Sciences, University of Monterrey, San Pedro Garza García 66238, Mexico
4Family Medicine Clinic No. 26, Mexican Institute of Social Security, Monterrey 64360, Mexico
5School of Medicine, Autonomous University of Nuevo Leon, Monterrey 64460, Mexico
*Correspondence: dr_hid_cordero@hotmail.com; Tel.: +52-811098-3303
Abstract:
Studies on the cessation of face mask use after a COVID-19 vaccine in patients with diabetes
are not available, despite their greater predisposition to complications. We estimated the prevalence
of cessation of face mask use after receiving the COVID-19 vaccine in patients with diabetes and
identified which factor was most strongly associated with non-use. This was a cross-sectional study
in patients with diabetes 18–70 years with at least one dose of vaccine against COVID-19 (n= 288).
Participants were asked to respond face-to-face to a questionnaire in a primary care center. Descriptive
statistics, chi-square tests, and multivariate binary logistic regression were used for analyzing the
association between vulnerability, benefits, barriers, self-efficacy, vaccine expectations (independent
variables), and cessation of use (dependent variable), controlling for sociodemographic, smoking,
medical, vaccine, and COVID-19 history. The prevalence of cessation of face masks was 25.3% (95%
CI 20.2, 30.5). Not feeling vulnerable to hospitalization increased the odds of non-use (adjusted
OR = 3.3
, 95% CI 1.2, 8.6), while perceiving benefits did the opposite (adjusted
OR = 0.4
, 95% CI 0.2,
0.9). The prevalence was low, and only two factors were associated with the cessation of face mask
use after COVID-19 vaccination in patients with type 2 diabetes.
Keywords: COVID-19; vaccines; masks; health belief model; health behavior
1. Introduction
During the COVID-19 pandemic, the use of face masks showed to be effective in
reducing the spread of the disease and, secondarily, in decreasing hospitalization and
mortality due to the disease [
1
–
5
]. On the other hand, the greatest benefit of the vaccines
was observed in the reduction in disease severity and, therefore, in the decreased need
for hospital care and death from COVID-19 [
6
,
7
]. Mexico was one of the countries with
the highest percentage of face mask use; 9 out of 19 Mexicans wore them as of May 2022
(one year after mass vaccination started) [
8
]. Moreover, 12,409,086,286 vaccines had been
applied worldwide as of August 2022; 209,673,612 correspond to Mexico [
9
], and 63% of
Mexican adults had completed a full vaccination scheme [
10
]. Patients with diabetes were
at increased risk of severe COVID-19 disease and had priority to be vaccinated [
11
–
15
].
However, institutions such as the World Health Organization [
16
], the Centers for Disease
Control and Prevention [
17
], and the American Diabetes Association [
18
] maintained the
recommendation of keeping a healthy distance and the use of face masks, even after
vaccination, because the risk of severe illness and death continued to exist.
Various theoretical models have been proposed to explain health behaviors. The
Health Belief Model considers vulnerability, benefits, and barriers [
19
–
21
], which together
Int. J. Environ. Res. Public Health 2023,20, 2768. https://doi.org/10.3390/ijerph20042768 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023,20, 2768 2 of 13
with self-efficacy help explain the use of COVID-19 preventive measures [
22
–
26
]. Expecta-
tions also play a key role in maintaining a healthy behavior, and continuing the use of face
masks may depend on the expected benefits of the vaccine; if the result does not occur in
the way it was anticipated, the behavior may be abandoned or replaced [
27
]. Furthermore,
unrealistic expectations can be a source of the false security of not getting sick, accompanied
by wrong decisions in the use of preventive measures. Hence, expecting 100% protection
against COVID-19 infection by the vaccine could lead to perceived invulnerability and the
cessation of the use of face masks. The intention to maintain the behavior of mask use after
vaccination has not been consistent in general populations. Studies from China [
28
,
29
],
Italy [
30
], the United Kingdom [
31
], and the United States [
32
,
33
] show that vaccinated
people tend to maintain preventive recommendations, suggesting that the perception of
risk of the disease remains. However, some others indicate the opposite [
34
–
37
]. A survey
from the US revealed that 5–6 out of 10 adults intended to continue wearing a face mask or
using other preventive measures after receiving the first dose [
38
]. Studies on the cessation
of the use of masks in patients with diabetes after being vaccinated against COVID-19
are not available, despite the importance of discontinuing the use of face masks in any
population, and even more, in patients with diabetes because of their greater predisposition
to complications and risk of dying from COVID-19 [
39
]. Although today the use of masks
is no longer mandatory in Mexico and other regions, the study of the cessation of mask use
still provides essential and valuable information. Lessons from the past allow for correct
planning. The recognition of factors that influenced the initiation and maintenance of the
use of masks makes it possible to foresee strategies that would favor their utilization in the
event of a resurgence of this or another infectious disease that warrants this type of measure.
The objective of the present study was to estimate the prevalence of cessation of face mask
use after receiving the COVID-19 vaccine in patients with diabetes. Additionally, to identify
which factor (vulnerability, benefits, barriers, self-efficacy, or vaccine’s expectations) was
most strongly associated with non-use.
2. Materials and Methods
This was a cross-sectional study conducted from September 2021 to February 2022 in
Monterrey, Mexico. The study population consisted of patients with diabetes between 18
and 70 years with at least one dose of vaccine against COVID-19 (n = 288). The sampling
technique was non-random. The participants were invited to respond to a structured
questionnaire in a primary care center of the Mexican Institute of Social Security. The face-
to-face survey lasted 10 to 15 min and was conducted in a private room during morning
and evening shifts (8 a.m. to 8 p.m.). Collaboration was entirely voluntary, and withdrawal
was allowed at any time without the need to justify the decision; no participant withdrew.
The sample size was enough for 5% precision and a 95% confidence level because the
post-vaccine face mask cessation prevalence was 25%, using the free statistical software
Epidat 3.1 [40]; this was corroborated with the formula [41]:
N=(Zα)2(p)(q)
δ2
where, N = sample size, Zα=1.96, p = 0.25, q = 0.75, δ=0.05.
The research protocol was approved by the Local Committee of Ethics and Health Re-
search (R-2021-1909-104). Written informed consent was obtained from all participants, and
the Declaration of Helsinki for Research on Human Subjects’ Guidelines were followed [
42
].
2.1. Dependent Variable
Cessation of Face Mask Use after Receiving the COVID-19 Vaccine
Five questions were included. They were adapted from Schoeni et al. [
43
]. We
identified the frequency of face mask use before receiving the vaccine: (1) inside the car,
the bus, or the subway, (2) while walking outdoors, (3) while talking inside the house
with someone with whom he/she does not live, (4) while talking outside the house with
Int. J. Environ. Res. Public Health 2023,20, 2768 3 of 13
someone with whom he/she does not live, and (5) while waiting for food in a restaurant
(1 = never, 5 = always); 5 items, Cronbach’s alpha = 0.80. The questions were asked again,
but now after receiving the COVID-19 vaccine (5 items, Cronbach’s alpha = 0.85). Pre-
and post-vaccine responses to each question were paired. If the pre-vaccine response was
always or almost always and the post-vaccine response was sometimes, rarely, or never
worn, the face mask use was coded as 1 = cessation of use. If the opposite occurred or
remained the same, the face mask use was coded as 0 = no cessation of use. The positive
items were then summed (possible range of 0 to 5). A score greater than or equal to
3 defined the category of overall cessation of face mask use.
2.2. Independent Variables
2.2.1. COVID-19 Vulnerability before and after Receiving the COVID-19 Vaccine
Four questions were included. They were adapted from the literature [
44
–
48
]. We
identified vulnerability before receiving the vaccine: (1) for getting infected, (2) for devel-
oping symptoms, (3) for being hospitalized, and (4) for dying from the disease (
1 = not any
,
5 = very high; 4 items, Cronbach’s alpha = 0.92). The questions were asked again, but now
after receiving the COVID-19 vaccine (4 items with Cronbach’s alpha = 0.88). Pre- and
post-vaccine responses to each question were paired. If the pre-vaccine response was high
or very high and the post-vaccine response was low, very low, or not any, the vulnerability
was coded as 1 = stopped feeling vulnerable. If the opposite occurred or remained the same,
the vulnerability was coded as 0 = did not stop feeling vulnerable. The positive answers
were not added up; they were analyzed individually.
2.2.2. Use of Face Masks Benefits
Ten questions were included. They were adapted from the Health Belief
Model [19,20,49]
.
We identified the benefits of wearing face masks (e.g., it keeps you safe from coronavirus)
(
−
1 = no, 0 = do not know, +1 = yes; 10 items, Cronbach’s alpha = 0.78). The positive
responses were coded as 1 = did perceive the benefit; negative and do not know responses
were regrouped and coded as 0 = did not perceive the benefit. The positive items were then
summed (possible range of 0 to 10). A score greater than or equal to 6 defined the category
of the overall perception of the benefits of wearing face masks.
2.2.3. Use of Face Masks Barriers
Ten questions were included. They were adapted from the Health Belief
Model [19,20,49]
for identifying barriers to wearing face masks (e.g., the use of a face mask is uncomfortable)
(
−
1 = no, 0 = do not know, +1 = yes; 10 items, Cronbach’s alpha = 0.72). The positive
responses were coded as 1 = did perceive the barrier; negative and do not know responses
were regrouped and coded as 0 = did not perceive the barrier. The positive items were then
summed (possible range of 0 to 10). A score greater than or equal to 6 defined the category
of the overall perception of barriers to wearing face masks.
2.2.4. Use of Face Masks Self-Efficacy
Seven questions were included for identifying the self-confidence for wearing face
masks: (1) While partying or gathering with family/friends, (2) while waiting for food
in a restaurant, (3) while being inside of a crowded place, (4) despite keeping it on it is
annoying, (5) despite being difficult to breathe with the mask on, (6) despite keeping it on
it is uncomfortable, and (7) despite there being people who think face masks are useless
(
0 = not any
, 4 = very high; 7 items, Cronbach’s alpha = 0.92). The answers high and very
high were regrouped and coded as 1 = did perceive self-efficacy. The answers low, very
low, and not any were regrouped and coded as 0 = did not perceive self-efficacy. The
positive items were then summed (possible range of 0 to 7). A score greater than or equal
to 5 defined the category of the overall perception of self-efficacy for wearing face masks.
Int. J. Environ. Res. Public Health 2023,20, 2768 4 of 13
2.2.5. Vaccine’s Realistic Expectations
Three questions were included for identifying the realistic expectations of the
COVID-19
vaccine: (1) It will reduce virus transmission, (2) it will reduce the risk of hospitalization,
and (3) it will reduce the risk of dying from the disease (
−
1 = no, 0 = do not know,
+1 = yes
;
3 items, Cronbach’s alpha = 0.52). The positive responses were coded as 1 = did have
realistic expectations; negative and do not know responses were regrouped and coded as
0 = did not have realistic expectations. The positive items were then summed (possible
range of 0 to 3). A score greater than or equal to 2 defined the category of the overall
perception of vaccines’ realistic expectations.
2.2.6. Vaccine’s Unrealistic Expectations
Three questions were included for identifying unrealistic expectations of the
COVID-19
vaccine: (1) It will totally prevent contagion, (2) it will make it possible to stop using the
mask, and (3) it will make it possible to stop using antibacterial gel (
−
1 = no, 0 = do not
know, +1 = yes; 3 items, Cronbach’s alpha = 0.45). The positive responses were coded as
1 = did have unrealistic expectations; negative and do not know responses were regrouped
and coded as 0 = did not have unrealistic expectations. The positive items were then
summed (possible range of 0 to 3). A score greater than or equal to 2 defined the category
of the overall perception of vaccines’ unrealistic expectations.
2.2.7. Other Variables That Can Affect Face Mask Use
Self-report of medical history (hypertension, cardiovascular disease, other), self-report
of personal or family history of COVID-19, number of doses and vaccine type (virus vector,
mRNA, inactivated virus), smoking, age, sex, schooling, marital status, and occupation.
2.3. Procedures
Data were collected by trained personnel (a medical resident and a medical intern). The
questionnaire was designed in Spanish. All items were subject to content validity, and special
attention was paid to avoiding ambiguity and technical vocabulary. The reliability results
have already been provided. Pre-test and pilot tests were carried out to verify the clarity and
ease of understanding. The final version is available in Supplementary Materials File S1.
2.4. Statistical Analysis
Measures of central tendency and dispersion were estimated for the numerical vari-
ables, and proportions and 95% confidence intervals (CI) for the categorical variables. The
chi-square test was used for analyzing the association between study factors (categorized
as yes or no) and cessation of face mask use (categorized as yes or no). Multivariate binary
logistic regression was used for estimating odds ratios (OR) and 95% CI. Vulnerability, ben-
efits, barriers, self-efficacy, and vaccine expectations represented the independent variables;
cessation of use was the dependent variable; and sociodemographic, smoking, medical, vac-
cine, and COVID-19 history were the control variables. Independent and control variables
were entered in a single step (enter method). A p-value < 0.05 was considered significant.
3. Results
3.1. Descriptive Statistics
The mean age was 57.9
±
9.5 years. More than half of the participants were female
with secondary and higher education. The most common medical history was hypertension,
and a high percentage had had COVID-19 him/herself or his/her family. Nearly 94% of
patients had received two or more doses of the COVID-19 vaccine at the time of the survey
(Table 1). There was no significant difference in the type of vaccine and number of doses
between men and women (p= 0.20 and 0.21, respectively).
Int. J. Environ. Res. Public Health 2023,20, 2768 5 of 13
Table 1.
Sociodemographic, smoking, medical, and COVID-19 history in patients with type 2 diabetes
with at least one dose of vaccine against COVID-19 (n = 288).
Characteristic Frequency
n (%)
Sociodemographic
Sex, female 187 (64.9)
Marital status, lives with a partner 227 (78.8)
Occupation, economically active 112 (38.9)
Schooling, high school, or less 151 (52.4)
Smoking 125 (44.4)
Medical history
Hypertension 208 (72.2)
Cardiovascular disease 35 (12.2)
Chronic obstructive pulmonary disease 25 (8.7)
Immunosuppression 7 (2.4)
Chronic kidney disease 7 (2.4)
Cancer 5 (1.7)
Type of vaccine
AZD-1222 (virus vector) 184 (63.9)
BNT162b2 (mRNA) 53 (18.4)
CoronaVac (inactivated virus) 17 (5.9)
mRNA-1273 (mRNA) 17 (5.9)
Ad5-nCoV (virus vector) 4 (1.4)
JNJ-78436735 (virus vector) 2 (0.7)
Unknown 11 (3.8)
Number of doses
One 18 (6.3)
Two 153 (53.1)
Three or more 117 (40.6)
COVID-19 infection
Before the 1st dose 82 (70.1)
Before the 2nd dose 1 (0.9)
After the 2nd dose 34 (29.1)
Needed hospitalization 6 (5.1)
A family member got sick with COVID-19 243 (84.4)
A family member died because of COVID-19 1 (0.4)
The overall prevalence of cessation of face mask use was 25.3% (95% CI 20.2, 30.5),
and most people stopped wearing a mask in their homes (Figure 1).
High and very high vulnerability rates were 80% or higher before receiving the vaccine
and they ranged from 27% to 51%, after vaccination (Figure 2).
The overall frequency of face mask benefits and barriers was 89.2% and 25.3%, respec-
tively (95% CI 85.7, 92.8, and 95% CI 20.3, 30.4, respectively), whereas the overall frequency
of high and very high self-efficacy was 96.2% (95% CI 94.0, 98.4). The overall vaccine’s
realistic expectations frequency was 80.9% and that of unrealistic expectations was 14.6%
(95% CI 76.4, 85.4, and 10.5, 18.7, respectively) (Figures 3–6).
Additionally, the main variables were analyzed according to the number of vaccine
doses received (one dose versus two or more doses), without finding significant differences
(Supplementary Table S1).
3.2. Factors Associated with Cessation of Face Mask Use
Not feeling vulnerable after vaccination for getting the infection (unadjusted
OR = 2.6
,
95% CI 1.5, 4.5, p< 0.001), developing symptoms (unadjusted OR = 2.1, 95% CI 1.3, 3.7,
p< 0.001
), being hospitalized (unadjusted OR = 4.4, 95% CI 2.3, 8.3, p< 0.0001), and dying
from COVID-19 (unadjusted OR = 3.1, 95% CI 1.8, 5.5, p< 0.0001) were associated with
Int. J. Environ. Res. Public Health 2023,20, 2768 6 of 13
cessation of face mask use at the univariate level. Only two factors were related at the
multivariate level, discontinuation of feeling vulnerable for hospitalization increased the
odds of non-use after vaccination (adjusted OR = 3.3, 95% CI 1.2, 8.6), and the perception of
face mask benefits reduced them (adjusted OR = 0.4, 95% CI 0.2, 0.9) (Table 2).
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 6 of 13
Figure 1. Mask use (always or almost always) before and after receiving the COVID-19 vaccine and
cessation of use after vaccination (change from always or almost always to sometimes, rarely, or
never) in patients with diabetes (n = 288).
High and very high vulnerability rates were 80% or higher before receiving the vac-
cine and they ranged from 27% to 51%, after vaccination (Figure 2).
Figure 2. Vulnerability (high and very high) before and after receiving the COVID-19 vaccine and
not feeling vulnerable after vaccination (change from very high or high to low, very low or not any)
in patients with diabetes (n = 288).
The overall frequency of face mask benefits and barriers was 89.2% and 25.3%, re-
spectively (95% CI 85.7, 92.8, and 95% CI 20.3, 30.4, respectively), whereas the overall fre-
quency of high and very high self-efficacy was 96.2% (95% CI 94.0, 98.4). The overall vac-
cine’s realistic expectations frequency was 80.9% and that of unrealistic expectations was
14.6% (95% CI 76.4, 85.4, and 10.5, 18.7, respectively) (Figures 3–6).
Figure 1. Mask use (always or almost always) before and after receiving the COVID-19 vaccine and
cessation of use after vaccination (change from always or almost always to sometimes, rarely, or
never) in patients with diabetes (n = 288).
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 6 of 13
Figure 1. Mask use (always or almost always) before and after receiving the COVID-19 vaccine and
cessation of use after vaccination (change from always or almost always to sometimes, rarely, or
never) in patients with diabetes (n = 288).
High and very high vulnerability rates were 80% or higher before receiving the vac-
cine and they ranged from 27% to 51%, after vaccination (Figure 2).
Figure 2. Vulnerability (high and very high) before and after receiving the COVID-19 vaccine and
not feeling vulnerable after vaccination (change from very high or high to low, very low or not any)
in patients with diabetes (n = 288).
The overall frequency of face mask benefits and barriers was 89.2% and 25.3%, re-
spectively (95% CI 85.7, 92.8, and 95% CI 20.3, 30.4, respectively), whereas the overall fre-
quency of high and very high self-efficacy was 96.2% (95% CI 94.0, 98.4). The overall vac-
cine’s realistic expectations frequency was 80.9% and that of unrealistic expectations was
14.6% (95% CI 76.4, 85.4, and 10.5, 18.7, respectively) (Figures 3–6).
Figure 2.
Vulnerability (high and very high) before and after receiving the COVID-19 vaccine and
not feeling vulnerable after vaccination (change from very high or high to low, very low or not any)
in patients with diabetes (n = 288).
Int. J. Environ. Res. Public Health 2023,20, 2768 7 of 13
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 7 of 13
Figure 3. Perception of benefits of wearing face masks in patients with diabetes (n = 288).
Figure 4. Perception of barriers to wearing face masks in patients with diabetes (n = 288).
Figure 3. Perception of benefits of wearing face masks in patients with diabetes (n = 288).
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 7 of 13
Figure 3. Perception of benefits of wearing face masks in patients with diabetes (n = 288).
Figure 4. Perception of barriers to wearing face masks in patients with diabetes (n = 288).
Figure 4. Perception of barriers to wearing face masks in patients with diabetes (n = 288).
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 7 of 13
Figure 3. Perception of benefits of wearing face masks in patients with diabetes (n = 288).
Figure 4. Perception of barriers to wearing face masks in patients with diabetes (n = 288).
Figure 5. Self-efficacy (high or very high) of wearing face masks in patients with diabetes (n = 288).
Int. J. Environ. Res. Public Health 2023,20, 2768 8 of 13
Int. J. Environ. Res. Public Health 2023, 19, x FOR PEER REVIEW 8 of 13
Figure 5. Self-efficacy (high or very high) of wearing face masks in patients with diabetes (n = 288).
Figure 6. Vaccine’s realistic and unrealistic expectations in patients with diabetes (n = 288).
Additionally, the main variables were analyzed according to the number of vaccine
doses received (one dose versus two or more doses), without finding significant differ-
ences (Supplementary Table S1).
3.2. Factors Associated with Cessation of Face Mask Use
Not feeling vulnerable after vaccination for getting the infection (unadjusted OR =
2.6, 95% CI 1.5, 4.5, p < 0.001), developing symptoms (unadjusted OR = 2.1, 95% CI 1.3, 3.7,
p < 0.001), being hospitalized (unadjusted OR = 4.4, 95% CI 2.3, 8.3, p < 0.0001), and dying
from COVID-19 (unadjusted OR = 3.1, 95% CI 1.8, 5.5, p < 0.0001) were associated with
cessation of face mask use at the univariate level. Only two factors were related at the
multivariate level, discontinuation of feeling vulnerable for hospitalization increased the
odds of non-use after vaccination (adjusted OR = 3.3, 95% CI 1.2, 8.6), and the perception
of face mask benefits reduced them (adjusted OR = 0.4, 95% CI 0.2, 0.9) (Table 2).
Table 2. Multivariate analysis of the vulnerability, benefits, barriers, self-efficacy, vaccine expecta-
tions, and cessation of use of face masks.
Cessation of Use
Unadjusted OR
Adjusted OR a
Yes
(n = 73)
n (%)
No
(n = 215)
n (%)
(95% CI)
(95% CI)
Not feeling vulnerable after vaccination
For getting the infection
39 (53.4)
66 (30.7)
2.59 (1.51, 4.45)
2.07 (0.75, 5.70)
For developing symptoms
39 (53.4)
75 (34.9)
2.14 (1.25, 3.66)
0.93 (0.34, 2.54)
For being hospitalized
59 (80.8)
105 (48.8)
4.41 (2.34, 8.31)
3.26 (1.23, 8.60)
For dying from the disease
52 (71.2)
95 (44.2)
3.13 (1.77, 5.52)
1.18 (0.49, 2.82)
Perception of benefits
61 (83.6)
196 (91.2)
0.49 (0.23, 1.06)
0.36 (0.15, 0.86)
Perception of barriers
13 (17.8)
60 (27.9)
0.56 (0.29, 1.09)
0.62 (0.30, 1.29)
High and very high self-efficacy
71 (97.3)
206 (95.8)
1.55 (0.33, 7.35)
1.17 (0.20, 6.78)
Vaccine’s realistic expectations
59 (80.8)
174 (80.9)
0.99 (0.51, 1.94)
0.91 (0.42, 1.97)
Vaccine’s unrealistic expectations
10 (13.7)
32 (14.9)
0.91 (0.43, 1.93)
1.15 (0.49, 2.70)
a Adjusted for sociodemographic, smoking, medical, number of vaccine doses, and COVID-19 his-
tory. OR: odds ratio. CI: confidence interval.
4. Discussion
This study focused on the cessation of face mask prevalence and factors associated
with wearing a face mask after receiving the COVID-19 vaccine in patients with type 2
diabetes. We found that one in four patients discontinued the use of face masks after
Figure 6. Vaccine’s realistic and unrealistic expectations in patients with diabetes (n = 288).
Table 2.
Multivariate analysis of the vulnerability, benefits, barriers, self-efficacy, vaccine expectations,
and cessation of use of face masks.
Cessation of Use Unadjusted OR Adjusted OR a
Yes
(n = 73)
n (%)
No
(n = 215)
n (%)
(95% CI) (95% CI)
Not feeling vulnerable after vaccination
For getting the infection 39 (53.4) 66 (30.7) 2.59 (1.51, 4.45) 2.07 (0.75, 5.70)
For developing symptoms 39 (53.4) 75 (34.9) 2.14 (1.25, 3.66) 0.93 (0.34, 2.54)
For being hospitalized 59 (80.8) 105 (48.8) 4.41 (2.34, 8.31) 3.26 (1.23, 8.60)
For dying from the disease 52 (71.2) 95 (44.2) 3.13 (1.77, 5.52) 1.18 (0.49, 2.82)
Perception of benefits 61 (83.6) 196 (91.2) 0.49 (0.23, 1.06) 0.36 (0.15, 0.86)
Perception of barriers 13 (17.8) 60 (27.9) 0.56 (0.29, 1.09) 0.62 (0.30, 1.29)
High and very high self-efficacy 71 (97.3) 206 (95.8) 1.55 (0.33, 7.35) 1.17 (0.20, 6.78)
Vaccine’s realistic expectations 59 (80.8) 174 (80.9) 0.99 (0.51, 1.94) 0.91 (0.42, 1.97)
Vaccine’s unrealistic expectations 10 (13.7) 32 (14.9) 0.91 (0.43, 1.93) 1.15 (0.49, 2.70)
a
Adjusted for sociodemographic, smoking, medical, number of vaccine doses, and COVID-19 history. OR: odds
ratio. CI: confidence interval.
4. Discussion
This study focused on the cessation of face mask prevalence and factors associated
with wearing a face mask after receiving the COVID-19 vaccine in patients with type
2 diabetes
. We found that one in four patients discontinued the use of face masks after
vaccination, and the prevalence varied from 20 to 50%. An Israeli study found 10% in the
general population [
34
], a Chinese study identified 22% in a student population [
35
], and
an Ethiopian study documented 31% in a population of health workers [
36
]. The analysis
by location showed cessation was highest at home and lowest in public places. Maybe
because at the time of the study, the use of face masks was mandatory in most public
places. Burger et al. [
50
] indicated the use of face masks had become a new social norm
that helped protect others. As of today, many countries have suspended the mandatory use
of face masks. Recognizing what favors the use and maintenance of the face mask is still
valuable since the COVID-19 pandemic is not over yet. Moreover, it is useful for health
authorities who wish to promote its use to prevent the spread of other highly transmissible
respiratory diseases such as influenza. A notable increase in cases of influenza is expected
due to the relaxation of the use of face masks [
51
]. We must not forget that the severity
of influenza may be greater in people with diabetes [
52
]. Regarding vulnerability, at least
8 out of
10 participants
felt very susceptible to the disease before getting vaccinated, similar
to other reports [
43
,
45
–
48
,
53
]. However, more than 50% stopped feeling vulnerable to
Int. J. Environ. Res. Public Health 2023,20, 2768 9 of 13
dying or being hospitalized after the vaccine. Furthermore, discontinuation of feeling
vulnerable for hospitalization increased three times the possibility of cessation of face
mask use. It is understandable to observe relaxation in those who feel protected by the
vaccine [
54
]. The role played by post-vaccine susceptibility in preventive behaviors has
been controversial. Some reports have confirmed this relationship [
25
,
36
,
55
–
58
], but others
have not [
25
,
36
,
55
–
58
]. More research is needed to analyze the impact of this component of
the health belief model on the maintenance of health measures during an epidemic.
Due to their effectiveness, the use of masks during the COVID-19 pandemic was
strongly recommended for the protection of oneself and others [
59
]. Fortunately, the global
prevalence of perceived benefits was high: 9 out of 10 participants perceived advantages in
the use of face masks. The perception of individual benefits varied from 74 to 97%, figures
that were considerably higher than those reported by Keller et al. [
60
] of 46%. We also
identified that the perception of benefits reduced the possibility of cessation of face mask
use by 64%, which was in accordance with what was documented in a Chinese study [
56
].
Only one in four patients perceived barriers to wearing a face mask. The most frequently
mentioned barrier had to do with the hot weather, typical of the summer in the city where
the study was carried out. Discomfort has been described as a factor against wearing
a face mask [
56
]. The cost and not recognizing the need for its use when there are no
people around are other known barriers [
50
,
61
], which were also present but less frequently.
Notably, the perception of barriers was not associated with the cessation of use or, contrary
to what was expected [
26
,
50
,
56
,
58
], self-efficacy either. One possible explanation is that
the barriers were overcome by the benefits [
62
] and that the prevalence of self-efficacy was
high: 9 out of 10 participants perceived themselves as very confident in wearing a face
mask. Finally, we anticipated a greater interruption of use due to high expectations of the
effectiveness of the vaccine to reduce the risk and spread of the disease [
63
], but this did
not happen. A high percentage of participants correctly expected such outcomes. Mask
fatigue or a lack of energy to wear a face mask after a long time has been described [
64
],
and although 7 out of 10 people expected that the vaccine would completely prevent them
from getting the infection, a reduced frequency of respondents expected to stop wearing
the mask thanks to the vaccine. Thus, the population with diabetes was correctly aware
that the scope of the vaccine was limited and that there was a need to continue with
self-care measures [
16
–
18
]. Health authorities must recognize which factors influence the
maintenance of the use of preventive measures to focus on health education strategies
that are useful not only to deal with emerging diseases but also with chronic-degenerative
diseases [65,66].
Limitations. All the participants were residents of the Monterrey urban area; therefore,
it is not possible to generalize the results to individuals who live in non-urban areas due to
possible socioeconomic differences. Furthermore, they were primary care users. The results
cannot be applied to those who are receiving secondary and tertiary care, because advanced
complications might influence perceptions and expectations. In the future, it would be
desirable to include patients with these characteristics. Another limitation corresponds
to the cross-sectional design of the study; a longitudinal approach will be required in the
future for definitive association results. Finally, the study focused only on patients with
diabetes due to their higher risk and poor COVID-19 prognosis. It is desirable to replicate
the methodology in patients with other health conditions and to analyze determinants of
the use of other preventive measures in populations at higher risk.
5. Conclusions
The prevalence of face mask cessation was low after COVID-19 vaccination in patients
with type 2 diabetes. Two factors were associated: not feeling vulnerable to being hospi-
talized increased the odds of less use, and the perception of the benefits diminished them.
The study of factors that favor the maintenance of preventive measures is important for
all types of diseases, infectious and non-infectious. Undoubtedly, the recognition of what
Int. J. Environ. Res. Public Health 2023,20, 2768 10 of 13
determines the use of face masks would allow specific promotion campaigns to be carried
out with a greater possibility of success in preventing the spread of communicable diseases.
Supplementary Materials:
The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph20042768/s1, File S1: Questionnaire; Table S1. Cessation
of the use of face masks and related variables according to the number of vaccine doses received
against COVID-19.
Author Contributions:
Conceptualization, H.F.C.F. and A.M.S.M.; data curation, D.L.M.M., B.R.S.J.
and F.J.G.d.l.G.; formal analysis, H.F.C.F. and A.M.S.M.; investigation, D.L.M.M., B.R.S.J. and
F.J.G.d.l.G.; methodology, H.F.C.F. and A.M.S.M.; project administration, H.F.C.F., A.M.S.M. and
B.R.S.J.; supervision, F.J.G.d.l.G.; validation, H.F.C.F. and A.M.S.M.; writing—original draft, H.F.C.F.;
writing—review and editing, H.F.C.F., A.M.S.M., D.L.M.M., B.R.S.J. and F.J.G.d.l.G. All authors have
read and agreed to the published version of the manuscript.
Funding:
This research received no external funding. This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-profit sectors.
Institutional Review Board Statement:
The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional Review Board and Ethics Committee of the
Mexican Social Security Institute (Registry number R-2021-1909-104).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Acknowledgments:
The nursing and social work staff of the Family Medicine Clinic No. 26 for the
facilities provided to interview patients.
Conflicts of Interest: The authors declare no conflict of interest.
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