The influence of gender and ethnicity on facemasks and respiratory protective equipment fit: a systematic review and meta-analysis

Abstract

IntroductionBlack, Asian and minority ethnic (BAME) people are disproportionately affected by COVID-19. Respiratory protective equipment (RPE) has conventionally been developed for a predominantly white male population that does not represent the healthcare workforce. The literature was reviewed to determine the protection offered to female and BAME users.MethodsFive databases were searched. Eligible studies related to respirator fit in the context of anthropometrics, gender and ethnicity. Meta-analysis was performed for gender-based anthropometric differences. A priori protocol registration was not performed.Results32 studies were included and anthropometric data was extracted from 15 studies. Meta-analysis revealed 14 anthropometric measurements were significantly smaller for females. Mean differences ranged from 0.37 mm to 22.05 mm. Gender-based anthropometric differences did not always translate to lower fit factor scores, with 12 studies reporting worse performance and fit for females and 10 reporting no gender effect. No studies provided disaggregate anthropometric data by ethnic group. Pass rates (PR) were low or moderate in 12 BAME or mixed-ethnicity cohorts. 14 studies reported associations between facial dimensions (FD) and respirator fit. Three comparative studies showed lower PR among selective BAME people. 18 studies reported RPE performance differed with model and design. Most studies did not prespecify inclusion/exclusion criteria. Small sample size and lack of justification or power calculations was a concern. Significant heterogeneity in study designs limited comparisons, particularly relating to respirator selection or availability and defining study outcomes relating to RPE performance.ConclusionThe literature reports on largely Caucasian or single ethnic populations, and BAME people remain under-represented, limiting comparisons between ethnic groups. Facial anthropometrics vary between gender and likely between ethnicity, which may contribute to lower PR among females and ethnic minorities, particularly Asians. There is a need for studies including a broader spectrum of ethnicities and for consideration of female and BAME users during RPE development.

Investigation of the Role of Face Shape on the Flow Dynamics and Effectiveness of Face Masks

“…Hariharan et al were also interested in the effect of anthropometric differences on the fit of respirators and found that the fit varied between faces, therefore, resulting in a different distribution of leakage through the respirator's perimeter [26]. Chopra et al studied a compilation of literature on the effects of anthropometric differences on mask leakage and found that gender-based anthropometric differences are associated with lower mask efficacy in half of the studies [27]. Anthropometric difference is also significant across ethnicities, and Chopra et al stated that, although minority groups are disproportionately affected by the COVID-19 pandemic, they are under-represented in literature [27].…”

“…Chopra et al studied a compilation of literature on the effects of anthropometric differences on mask leakage and found that gender-based anthropometric differences are associated with lower mask efficacy in half of the studies [27]. Anthropometric difference is also significant across ethnicities, and Chopra et al stated that, although minority groups are disproportionately affected by the COVID-19 pandemic, they are under-represented in literature [27].…”

N95 respirators for health care workers: the importance of fit, comfort, and usability

“…In the study by Ng and colleagues, ethnic background was known for only 493 participants (23%: European background, 13%; non‐European, 10%), which could have implications for interpreting the study. The authors of a recent systematic review found that Black, Asian, and people with minority ethnic backgrounds are under‐represented in respirator research 10 . Their findings were limited by small sample sizes, heterogeneity, and inadequate reporting in the included studies, but some people with non‐European ethnic backgrounds, who comprise a large proportion of health care workers, have facial features that can affect respirator fit 10 …”

“…The authors of a recent systematic review found that Black, Asian, and people with minority ethnic backgrounds are under-represented in respirator research. 10 Their findings were limited by small sample sizes, heterogeneity, and inadequate reporting in the included studies, but some people with non-European ethnic backgrounds, who comprise a large proportion of health care workers, have facial features that can affect respirator fit. 10 Ng and colleagues report considerable differences in the performance of the included respirators, including their fit test pass rates: 96.4% for the three-panel, flat-fold respirator, 65.0% for the semi-rigid cup respirators, 32.4% for the flat-fold respirator, and 59.2% for the duckbill respirators.…”

“…10 Their findings were limited by small sample sizes, heterogeneity, and inadequate reporting in the included studies, but some people with non-European ethnic backgrounds, who comprise a large proportion of health care workers, have facial features that can affect respirator fit. 10 Ng and colleagues report considerable differences in the performance of the included respirators, including their fit test pass rates: 96.4% for the three-panel, flat-fold respirator, 65.0% for the semi-rigid cup respirators, 32.4% for the flat-fold respirator, and 59.2% for the duckbill respirators. Although the assessment of usability and comfort was subjective, marked differences in performance and user-reported results indicated a strong preference for the three-panel flat-fold respirator, consistent with other reports.…”