1 INTRODUCTION

In response to the COVID-19 pandemic, various measures were implemented to control the spread of the virus, including social distancing and mask-wearing.¹ Social distancing, a health practice that was frequently scrutinised,² and mask-wearing, which was deemed an essential preventive measure, were both widely enforced in many countries.³ During the postpandemic period of COVID-19, the practice of wearing masks was maintained.⁴ Wearing a mask can help prevent contagion by reducing the spread of virus-loaded droplets, particularly in situations where social distancing is not possible.⁵ Epidemiologic studies have shown that mandatory use of masks is associated with a reduction in COVID-19 cases at the community level.⁶

As part of the action plan for the 2020–2021 school year in Catalonia, Spain, all educational stages began with 100% in-person attendance. Full attendance was only partially reduced in the postmandatory stage between November 2020 and April 2021. Regarding personal prevention measures in educational centres, the main measures were physical distancing and the use of masks. The use of masks in educational centres was mandatory in the 2021–2022 course to prevent the spread of COVID-19.⁷ However, on 19 April 2022, the requirement for masks in all internal spaces was eliminated.⁸

According to Goldstein and Flicker,⁹ research indicates the significance of examining the impact of COVID-19 restrictions on adolescents, including the effects of deteriorated relationships on their mental and emotional health. Several studies have estimated the frequency of face mask use amongst young people, and approximately half of the participants always wore a face mask or covering in public.^{10, 11} Most studies examining the impact of the pandemic or mask-wearing have focused on the period when mask-wearing was mandatory or on the reasons for and facilitators of adhering to the regulations.¹² Research into face mask adherence in the pandemic COVID era reveals intriguing gender-based disparities and in most cases is inconclusive. Studies by Galasso et al.¹³ highlight differing compliance rates between genders, indicating that females tend to exhibit higher adherence to mask-wearing protocols compared to males. Additionally, research by Howard et al.¹² highlights the influence of gender-specific attitudes and perceptions towards mask usage, attributing these differences to varying social norms and perceived susceptibility to viral transmission. However, there is limited knowledge regarding adolescents' experiences with COVID-19 or their use of face masks in the postpandemic period. No study has yet described the factors that influence adolescents to use face masks, even when mask-wearing is no longer mandatory in many countries. This study aims to explore Catalan adolescents' experiences of continuing to wear face masks despite the absence of a mandate.

2 METHOD

This study is based on the COVID-19 Sentinel Schools Network of Catalonia.¹⁴ Its main objective was to monitor and evaluate the epidemiological situation of COVID-19 and its determinants in the educational setting. The aim was to gather evidence for health policies aimed at preventing and controlling severe acute respiratory syndrome coronavirus 2 infection in schools. The study utilised an exploratory qualitative design, which enables a thorough comprehension of a particular phenomenon within a specific context and is suitable for investigating less-known phenomena.¹⁵ The Ethical Committee of the Foundation University Institute for Research in Primary Health Care Jordi Gol i Gurina approved it on 17 December 2020 (code 20/192-PCV).

Study participants were students aged 12–17 years, selected from two high schools in Catalonia. The only inclusion criterion was the wearing of a mask during the removal of restrictions, and they were recruited by the research team in coordination with their educational institution. Participants who were 16 years or older received written and oral information about the study and provided signed informed consent before the interviews. For participants under 16 years old, their parents provided signed informed consent after they were informed about the study. The data were collected by means of face-to-face semistructured interviews, which allowed for the collection of personal information in a guided and trustworthy manner.¹⁵ Sixteen individuals aged 12–17 from two different sociocultural contexts (eight girls and eight boys) were interviewed in May 2022. This sample size was considered sufficient to achieve information saturation.

The interview script was developed based on a prior study¹⁶ and the research interests. It addressed the following topics: reasons for continuing to use face masks, emotions associated with their use and situations in which individuals felt safe without wearing a mask. All interviews were conducted by a female researcher with a PhD and extensive experience in a private and secure location within an educational centre. All participant identities were kept anonymous, and a pseudonym was used throughout the interviews and transcriptions. The transcripts were securely stored on the university campus and protected with a security key, with access limited to the research team.

The collected data were analysed using Braun and Clarke's thematic analysis,¹⁷ which consists of six steps: (1) becoming familiar with the data, (2) coding the data, (3) categorising the data, (4) reviewing the categories, (5) defining and naming the categories and (6) writing the report. To increase the credibility and consistency of the results, two researchers (M. A.-G. and J. M. L.-M.) performed this procedure in parallel. Additionally, Atlas.ti® software was utilised to manage and analyse the textual data, providing increased rigour to the procedure.

Recommendations for Establishing Validity in Qualitative Inquiry¹⁸ were applied throughout the process. Consensus meetings were held with two expert researchers, and regular discussions and debriefing sessions were conducted concurrently. Reflective and critical thinking guided the entire process, providing robustness to the findings. Each data analyst reviewed the codes, themes and interview quotations separately, and all disagreements were resolved through discussion. Finally, the findings were discussed in three sessions with five experts, including two epidemiologists and three nurses, all with previous experience in qualitative methods. No changes were required after the discussions.

3 RESULTS

The thematic analysis identified three main themes: (1) Navigating complex decision-making: balancing safety and self-image, (2) peer influence dynamics and (3) managing the future: weather dynamics and pandemic evolution.

4 DISCUSSION

The study provides insight into the use of face masks beyond health behaviours, as mask-wearing has become optional in many countries. The study demonstrates that perceptions of personal and familial vulnerability are the primary determinants of mask-wearing. This finding is consistent with Martinelli et al.'s¹⁹ research, which also highlights the societal and personal dimensions of wearing masks, such as the perception of infection risk and a sense of responsibility and solidarity. Hanna et al.²⁰ reported that the adult population believes that wearing masks provides personal protection and reduces the transmission of the virus as its primary benefit. Additionally, Warnock-Parkes et al.²¹ found that the strongest predictors of wearing masks are an individual's belief in their ability to protect others and having an underlying health condition. Therefore, individuals' decisions to wear masks or not were influenced by their social connections, personal judgement and perceived susceptibility.²² These findings can be explained by Fineman's theory of vulnerability, which states that people are constantly exposed to multiple biopsychosocial hazards, making them vulnerable to harm and injury due to the ever-present possibility of harm and injury.^23,p.9

The study by Chen and Lei²⁴ employed the Protection Motivation Theory (PMT) to understand adolescents' decisions regarding mask adoption. According to PMT, individuals' protective behaviours are influenced by their perception of the severity and susceptibility of a threat, as well as their belief in the effectiveness of the response (response efficacy) and their confidence in executing the required behaviour (self-efficacy). In this context, adolescents demonstrated adherence to these PMT constructs, as their decision to continue wearing masks was substantiated by various factors. First, their awareness of the improved epidemiological situation did not diminish their belief in susceptibility; they maintained a perception that they or their family members could still fall ill. Second, their conviction in the effectiveness of masks in halting disease transmission remained firm, indicating a belief in the response's efficacy. Lastly, adolescents displayed confidence in their ability to consistently use masks (self-efficacy). This alignment between the PMT constructs and adolescents' persistent mask use illustrates the applicability of PMT in explaining and predicting individuals' decisions to engage in protective behaviours like continued mask-wearing.

Building on Chen and Lei's²⁴ research, our study aims to contribute to the understanding of psychosocial factors that influence mask-wearing behaviour in adolescents. Although adolescents were aware of the improved epidemiological situation, they also had a nuanced understanding of their vulnerability to infection. This statement emphasises the dynamic interaction between external circumstances and individual behavioural choices, enriching the applicability of the variables within the PMT framework. Research suggests that attitudes and policies towards mask use play a critical role in mask adoption and lead to higher adoption rates. Additionally, a more stringent face mask policy is correlated with a higher probability of mask usage.²⁵ The findings of the present study suggest that face masks are used for both personal health protection and the protection of those around the wearer. Additionally, they may provide a sense of security in terms of physical appearance. Previous research has investigated the social representations and significance of wearing face masks during the pandemic.^{19, 22} These studies highlighted the various roles that face masks play in people's lives, extending beyond their primary purpose of protection.

Amongst the participants in this study, female individuals under the age of 14 reported wearing face masks due to self-image reasons. During this stage of adolescence and identity development, self-concept and personal perception are not the only influencing factors; the perceptions of others, particularly their peers, are highly relevant. Adolescents form crucial relationships with their peers in their search for self-identity.²⁶ Therefore, it is possible that adolescents are more concerned with the image they convey than with their actual emotions.²⁷ It is worth noting that many adolescents who reported struggling with self-image began their journey of identity formation while wearing a face mask. This may explain why adolescents may be reluctant to stop wearing masks, despite expressing a desire to do so. Research has shown that gender does not influence the decision to wear a face mask. However, it may affect perceptions of face masks. For example, women may perceive face masks as uncomfortable, while men may view them as a threat to their independence.²⁸

Another reason why some adolescents were hesitant to stop wearing face masks is because of concerns about their self-image and social anxiety. Social anxiety is a health condition in which an individual experiences fear or apprehension in social interactions, particularly those where they may be evaluated by others.²⁹ The present study's results could be explained by Saint and Moscovitch's³⁰ findings, which suggest that mask-wearing can provide a sense of security, particularly for individuals dealing with social anxiety. The use of masks can act as a protective shield, reducing discomfort associated with being exposed to others and the possibility of negative evaluations in social situations. This protective function may have motivated the adolescents in the present study to continue wearing masks beyond the mandatory period.

This study has some limitations that should be taken into account. First, the data were collected in two different sociocultural contexts, but they are limited to the realities, imaginaries, policies and norms present in Barcelona. Consequently, the results may only be transferable (not generalisable) to adolescents in large Western European cities. Second, it is important to note that the study only interviewed participants who volunteered, which may have limited the scope of the experiences considered. Additionally, conducting interviews within schools may have introduced a social desirability bias, despite the interviewees not being affiliated with the educational process. Finally, the interviews were conducted and analysed in Spanish or Catalan. To ensure the accuracy and naturalness of the findings, the translation process was overseen by two bilingual researchers and professional translators proficient in both languages.

5 CONCLUSION

This study found that adolescents, mostly girls, continued to use face masks voluntarily during COVID-19, even though their use was no longer mandatory, for fear of infecting their vulnerable relatives and to protect their self-image. Parents and other family members played a key role in helping them make this decision and reinforcing it. Adolescents reported feeling vulnerable and anxious when not wearing a face mask in places they considered risky.

As previously mentioned, there is limited research on the withdrawal of COVID-19 preventive measures, including mask-wearing, and the potential implications of transitioning from wearing masks to not wearing them beyond the pandemic. Therefore, it is crucial to further investigate the experiences and perceptions related to both mask usage and discontinuation, especially amongst individuals in critical and sensitive stages, such as childhood and adolescence. Furthermore, it is important to examine individuals' attitudes towards those who opt to continue wearing masks after the pandemic, taking into account the possible social implications.

The study results emphasise the significance of investigating the effects and outcomes of implementing strict public health measures, such as those enforced during the pandemic. The findings add to the expanding body of research on mask-wearing behaviour and offer valuable insights into public health interventions during pandemics. These findings could help inform the development of future policies and guidelines that more accurately reflect individuals' experiences and perceptions of mask-wearing, by incorporating psychosocial perspectives into public health directives and addressing fears related to vulnerability and personal image in educational centres. More inclusive and responsive postpandemic guidelines could be developed by creating supportive environments in educational settings, prioritising mental health aspects and including youth perspectives in policy formulation.

AUTHOR CONTRIBUTIONS

Mariela Aguayo-González: Investigation; writing—original draft; writing—review and editing; formal analysis; data curation; conceptualisation. Juan M. Leyva-Moral: Conceptualisation; validation; formal analysis; supervision; writing—review and editing; writing—original draft; methodology. David Giménez-Diez: Conceptualisation; investigation; writing—review and editing; writing—original draft. Andreu Colom-Cadena: Conceptualisation; writing—review and editing. Isabel Martínez: Conceptualisation; writing—review and editing. Carolina Watson: conceptualisation; writing—review and editing. Anna Bordas: Conceptualisation; writing—review and editing. Cinta Folch: Conceptualisation; writing—review and editing. Jordi Casabona: Conceptualisation; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

This study was approved on 17 December 2020 by the Ethical Committee from the Institute for Research in Primary Health Care Jordi Gol i Gurina (IDIAPJGol) (code 20/192-PCV).