“Eyes don’t say it all” – Communication challenges while wearing facemasks in class Katarina Paunović 1 , Danka Vukašinović 2 , Katarina Đurđević 3 , Ana Jovanović 4 , Maja Milorado- vić 5 University of Belgrade, Faculty of Medicine, Institute of Hygiene and Medical Ecology Dr Subotića 8, 11000 Belgrade, Serbia

ABSTRACT Facemasks are personal protective equipment worn to reduce the risk of the transmission of Covid- 19. University students and teachers/lecturers in Serbia are required to wear facemasks in class at all times. However, such practice may cause challenges in student-teacher communication. We pre- sent students’ experiences regarding speech intelligibility in the educational setting. We distributed an anonymous online questionnaire among students from various universities. Speaking with a facemask in class creates communication challenges for teachers and students alike. Students claim that teachers often have difficulties understanding students who speak wearing masks; teachers of- ten ask students to repeat the sentence, and teachers often ask students to speak louder. Similarly, when teachers talk with their facemasks, students often report not hearing or understanding teach- ers back. In turn, students would ask teachers to repeat the sentence and raise voices. Students pay more attention to teachers’ facial expressions, hand gestures, body language, and tone of voice. Students tend to engage their non-verbal interaction skills more often to facilitate communication. We further discuss the differences regarding students’ gender and the type of facemask typically worn. We express concern that the inability to communicate clearly may cause annoyance and frus- tration in the academic setting. 1. INTRODUCTION

The COVID-19 pandemic rendered many mental health challenges for children, adolescents, and young adults across the globe. During the lockdown, children in China suffered from anxiety, sleeping difficulties, and poor appetite; they were described as being distracted, irritable, worried, and in constant fear for their health and the health of others [1]. Adolescents in Spain spent the lockdown at home, which provided security and covered their essential needs but negatively af- fected their mental wellbeing. Adolescents complained about stressful living conditions at home, engaged in unhealthy activities, experienced impaired relationships with their parents and siblings, and criticized their families’ dysfunctional parenting styles [2]. 1 katarina.paunovic@med.bg.ac.rs

2 danka.djorovic@med.bg.ac.rs

3 katarina.djurdjevic@med.bg.ac.rs

4 ana.s.jovanovic@ med.bg.ac.rs

5 maja.miloradovic92@gmail.com

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Students worldwide faced restrictions regarding their education, which may have triggered wor- ries for their health and families during the pandemic as well as fears about their careers, financial situation, and social relationships [3]. Many students displayed anxiety and depression symptoms and social dysfunction during the lockdown [4], up to the point of being classified as clinically de- pressed [5]. Fortunately, students found meaningful ways to cope with the situation by adopting healthier lifestyle habits, such as having a good sleep, reducing alcohol consumption [5], increasing physical activity [6], and using mobile applications for mental health support [3]. Fortunately, there is evidence that students’ mental health improved after the lockdown, with their depressive and anxiety symptoms reduced [7].

In Serbia, the school system struggled to maintain consistency throughout the spring and sum- mer of 2020 and the whole year 2021. During the winter semester in 2021, i.e., from October 2021 to February 2022, university teachers and students were obliged to wear facemasks during face-to- face classes. Under the new circumstances, teachers experienced several challenges in communica- tion, as they had to hold lectures, seminars, and practical activities while wearing facemasks and maintaining social distance. From the authors’ experience as teachers, wearing facemasks nega- tively affected our teaching style. For example, we consciously forced ourselves to speak more loudly, clearly, and comprehensively, and we needed more time to present, explain, and discuss top- ics in class. At the same time, we felt that students struggled to hear and understand and made an effort to support us by keeping quiet in class and speaking clearly and loudly as well. We hypothe- size that students experienced communication challenges in class and that wearing facemasks af- fected their behaviour and attitudes regarding communication with the teachers and other persons.

This survey explores the communication challenges in class from the students’ perspective, their behaviour and attitudes related to communication while wearing facemasks in class.

2. METHODS

2.1. Study participants

A cross-sectional self-reported online survey of challenges in communication in class was deliv- ered online from December 2021 to March 2022 using Google Forms software. The authors shared the survey link through various social network platforms. Target participants were students from various faculties across the country, instructed to post the link on their social media accounts or share it directly with their friends and colleagues. Therefore, the sampling was a combination of convenience, snowballing, and purposive recruitment.

The questionnaire was designed purposefully for this survey in the Serbian language. The anonymous questionnaire included age, gender, academic status (student vs. teacher), the frequency of communication challenges occurring in class, participants’ behaviours and attitudes towards wearing facemasks in class, and the type of facemask used. Respondents had an option to skip ques- tions if necessary, review and change their previous responses, and provide feedback, comments, examples on the issues brought up by the survey. The questionnaire was anonymous and logging from a unique IP address and the same device was only allowed once.

For this survey, we include the responses obtained from students and exclude teachers and in- complete responses. Students reported how often certain communication challenges happened in class while students or teachers wore facemasks and their behaviour regarding their communication partner wearing a facemask. We graded the responses on a 3-point scale, ranging from 0–‘rarely or never’, to 1–‘sometimes’, to 2–‘often or always’.

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Furthermore, students reported their attitudes regarding communication in class while wearing facemasks. We used the 3-point grading scale, ranging from 0–‘disagree, to 1–‘neutral attitude’, to 2–‘agree’. Finally, students reported the type of facemask they would most often wear in class, in- cluding surgical, cotton, and KN95 mask. We estimated subjective noise sensitivity using a single question on a numerical scale from 0–‘not at all’ to 10–‘extremely’. Highly noise-sensitive partici- pants reached scores above the median value for the whole sample.

2.2. Statistical analysis

We present descriptive statistics as percent (relative number) for categorical variables. We com- pared students’ perception of the frequency of communication challenges in class, their behavior and attitudes to communication while wearing facemasks by gender, the type of facemask worn, and noise sensitivity level using Pearson’s chi-square test. We considered p values less than 5% (p<0.05) statistically significant. We performed the analysis using SPSS for Windows statistical software (Version 22.0, SPSS Inc. Chicago, IL). 3. RESULTS

The survey comprised 351 students, 270 women (77%) and 81 men (23%), aged 18 to 30 years, selected out of 395 fulfilled questionnaires. The majority of students wore surgical facemasks in class (79%), followed by KN95% facemasks (14%), and cotton masks (7%).

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Figure 1 presents the frequency of communication challenges in class occurring when the stu- dent wears a facemask.

Teacher asks me to speak louder

34%

34%

32%

Teacher asks me to repeat text

28%

42%

30%

Teacher struggles to understand me

35%

41%

24%

Teacher gets n e rvous when I wear facemask

84%

9%

7%

Teacher asks me to take facemask off

81%

14%

5%

Teacher asks me to write instead of speaking

95%

3%

2%

0% 20% 40% 60% 80% 100%

Rarely or never

Sometimes Often or always

Figure 1: Students’ perspective on the communication challenges in class when the student speaks

wearing a facemask

Students frequently report the following communication challenges in class while wearing face- masks: teachers ask students to speak louder or to repeat the text (31% of students reported this happening often or always), and students feels that teachers struggle to understand them (in 24% of students this is happening often or always). Less than 10% of teachers get nervous because they do not hear or understand what students say with their facemask. Only a small proportion of teachers would ask students to remove facemask or express themselves in writing to improve communica- tion (Figure 1).

Figure 2 presents the frequency of communication challenges in class occurring when the teacher wears a facemask.

I struggle to realize who is talking in a group

46%

24%

30%

I struggle to hear what the teacher is saying

30%

42%

28%

I struggle to understand what the teacher is saying

37%

38%

25%

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I ask teacher to repeat the text

31%

41%

28%

I ask teacher to speak louder

38%

36%

26%

I ask teacher to remove facemask

72%

15%

13%

0% 20% 40% 60% 80% 100%

Rarely or never

Sometimes Often or always

Figure 2: Students’ perspective on the communication challenges in class when the teacher speaks

wearing a facemask

When teachers wears facemasks, students frequently report the following communication chal- lenges in class: students struggle to identify the person talking in a group, students struggle to hear or understand what the teacher is saying, students ask teachers to speak louder or repeat the text (almost one-third of students reported this happening often or always). One in ten students would often ask the teacher to remove the facemask in class to improve communication (Figure 2).

Figure 3 presents the frequency of students’ behaviours in communication when the other person wears a facemask.

I pay attention to their body language

12%

22%

66%

I pay attention to their hand gestures

15%

20%

65%

I pay attention to their voice / intonation

20%

20%

60%

I pay attention to their facial expression

21%

21%

58%

I get nervous when they wear facemask

55%

26%

19%

I require silence when they wear facemask

75%

13%

11%

0% 20% 40% 60% 80% 100%

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Rarely or never

Sometimes Often or always

Figure 3: Students’ behaviour with communication partner who speaks wearing a facemask

Students frequently report the following behaviours in communication with a partner who wears a facemask: students pay attention to their partner’s body language, hand gestures, voice tone, and facial expression (57-66% of students reported this happening often or always). One in five students would frequently get nervous when they do not hear or understand what the other person says. One in ten students would often or always require silence in their surroundings to listen to what the other person is saying (Figure 3).

Students frequently report the following attitudes regarding their communication skills: students use hand gestures more often, and they feel they need more time to explain things since they wear a facemask (37-41% of students agree with this statement). 31% of student feels they misunderstand the context of communication with the person whose face they cannot see. One in four students is not at ease talking to others when they cannot see their faces. One in seven students would even give up asking questions because of fear that the communication partner would not understand them (Figure 4).

Figure 4 presents the frequency of students’ attitudes regarding their communication skills while wearing facemasks.

I use hand gestures more often since I wear facemask

38%

20%

42%

I need more time to explain things with facemask on

49%

14%

37%

I misunderstand context when I don't see one's face

45%

24%

31%

I am not at ease talking to others when I don't see their

59%

16%

25%

face

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I give up asking questions because I fear they will not

73%

13%

14%

understand me

0% 20% 40% 60% 80% 100%

Disagree

Neutral attitude Agree

Figure 4: Students’ attitudes regarding their communication skills wearing facemasks

Figure 5 presents the frequency of students’ attitudes regarding attention and motivation in class with facemasks.

Students’ attitudes regarding attention and motivation in class were ambiguous. Many students express opinion that facemasks impair their attention and motivation and the overall working at- mosphere in class (35-42% of students agree with this statement). One-third of students believe that facemasks impair teachers’ attention and motivation in class (Figure 5).

Facemasks impair working atmosphere in class

39%

19%

42%

Facemasks impair students' attention in class

38%

20%

42%

Facemasks impair students' motivation in class

42%

23%

35%

Facemasks impair teachers' attention in class

39%

27%

34%

Facemasks impair teachers' motivation in class

42%

26%

32%

0% 20% 40% 60% 80% 100%

Disagree

Neutral attitude Agree

Figure 5: Students’ attitudes regarding attention and motivation in class with facemasks

Concerning gender, female students were more likely to pay attention to the other person’s facial expression, hand gestures, body language, and voice tone in communication.

Highly noise-sensitive students were more likely to report the following communication chal- lenges: they were often unable to hear or understand what the teacher was saying in class; they would often give up asking questions to teachers for fear of not being understood; they would often get nervous when they do not hear or understand what the other person is saying; and they would often ask their communication partner to repeat what they said while wearing a facemask. Highly noise-sensitive students also often complained that teachers did not understand them and asked them to repeat or speak more loudly while wearing facemasks. Highly noise-sensitive students also more often believed that facemasks affect students’ and teachers’ motivation and attention and the overall working atmosphere in class.

As for the type of facemask worn by students (surgical, cotton, KN95), we observed no differ- ences regarding reported communication challenges, students’ behaviours, and attitudes in class.

3. DISCUSSION

The present study reveals university classroom communication problems when students and teachers wear facemasks. From the students’ perspective, person-to-person lectures were challeng- ing as both parties could not hear and understand each other. To facilitate communication, students would ask teachers to repeat the sentence and raise their voices, and vice versa. Furthermore, stu- dents pay more attention to teachers’ mimic and body language when a teacher speaks with a face- mask and engage their own non-verbal interaction skills while speaking with a facemask. Students express concern that wearing facemasks in classes may disrupt students’ and teachers’ attention and motivation and the overall working atmosphere.

Several experiments tested the effect of speaking with facemasks on speech intelligibility. In the first study, healthy volunteers listened to speeches when the speaker wore different facemasks, ad- dressed various speaking styles, and spoke with background noises [8]. Authors reported that dis- posable and transparent facemasks worn by the speaker and background noises decreased speech intelligibility in listeners compared to situations when the speaker wore no facemask. However, speech became more comprehensible when speakers intentionally articulated clearly, slowed their speech rate, and amplified their voice and intonation [8]. Authors recommend using transparent facemasks, which enable listeners to perceive visual information accompanying the verbal one. Fur- thermore, they recommend speakers improve their talking style (articulate clearly, raise voice, speak slowly) to intensify emitted acoustic signals and promote speech intelligibility in mask- wearing and noisy conditions [8].

In the second study, volunteers listened to speakers talking with and without facemasks in three speech styles, i.e., casual, clear, and positive-emotional [9]. Listeners rated the face-masked speech less intelligible than non-face-masked speech when the speaker presented emotionally (i.e., speak- ing, smiling, and expressing positive emotions at the same time). To their surprise, listeners report- ed that the face-masked speech was more intelligible than the non-face-masked speech when the speaker presented in a clear speaking style (clear pronunciation with emphasizing words) [9]. When the speaker presented in the casual manner (just like in everyday communication), listeners ob- served no difference in intelligibility regarding the use of facemasks. The results likewise illustrate the need for speakers to deliberately adjust their voice and verbal expression to overcome the acous- tic distortion caused by the facemask [9].

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The third experiment tested the impact of age on speech comprehension in quiet and noisy con- ditions while speakers wore different types of facemasks [10]. Results show that speaking with cot- ton and transparent facemasks negatively affected listeners’ comprehension and subjective listening effort independently from the background noise levels, whereas speaking with surgical facemasks had the slightest influence on speech intelligibility. Older adults had poorer intelligibility and re- quired more effort to process information than the younger ones [10]. Researchers criticize trans- parent facemasks for rapidly getting opaque from condensation, which obscures the transmission of visual information by lip-reading. However, listeners with impaired hearing who rely considerably on observing the speaker’s mouth could benefit from transparent masks worn by their communica- tion partners [10].

From the authors’ experience, we intuitively adjusted our speaking style and presentation in class to improve speech intelligibility. British medical practitioners recognized communication problems in the healthcare settings and proposed several recommendations for effective conversation among patients and staff. In summary, health staff should try to improve their vocal abilities, minimize background noise and distractions, and practice supporting verbal information with non-verbal ex- pression (facial, hand, and body signals) [11]. We strongly believe that these recommendations are applicable in the academic setting as well.

During the pandemic, many students and teachers highly appreciated replacing the classical in- person education with digital learning methods. A flipped classroom model, i.e., teaching through access to lectures, slides, and other resources on online educational platforms, increased students’ self-perceived motivation and self-autonomy in learning during the academic year 2020-21 in Spain [12]. Undergraduate dentistry students in Indonesia perceived distance learning as a more efficient learning method than classical learning as it provided them more time to study and review study materials. However, most students still opted for classroom learning for group discussions and complained about technical challenges with digital learning [13]. Similarly, postgraduate students and their teachers were satisfied with web-based lectures in the spring of 2020, regarding them more effective than traditional classroom lectures. The study pointed out that students were more affirmative of web-based learning than teachers and that older students benefitted more than the younger ones. Teachers, on the contrary, found online lecturing more challenging than in-person teaching, as they were exhausted by dealing with technical issues (internet speed and quality, video and audio effects) and the inability to maintain good interaction with the audience [14].

As medical university teachers, we believe that medical studies differ significantly from studies in other fields, particularly regarding the specific training in a clinical setting. During the pandemic, many medical schools and universities suspended clinical rotations involving contact with patients [15]. Nevertheless, medical students across the United States were eager to continue with their usu- al clinical training even during the pandemic; they were willing to accept the risk of infection in the clinical setting if provided with adequate personal protective equipment [15].

A systematic review identified the strengths and weaknesses of virtual medical teachings during the pandemic [16]. The advantages of virtual teachings include teaching sessions with world- renowned medical specialists, examination of virtual patients, learning flexibility, and access to teaching materials and medical publications, which may further encourage self-directed learning and students’ motivation. Most weaknesses of virtual teaching comprise technical challenges, con- fidentiality issues, lack of student engagement, and loss of assessments. Furthermore, virtual learn- ing could negatively affect students’ mental health and well-being by losing social interactions and support from peers and tutors and feelings of isolation [16].

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The long-term effects of virtual learning on students’ mental health are under investigation. In a survey among Kazakhstan medical students, burnout, depression, anxiety, and somatic symptoms decreased during the early stages of the pandemic (online learning), compared with the pre- pandemic period (classical in-person learning) [17] . The authors explain this by students’ high mo- tivation for self-education, fewer spatial and temporal learning barriers, and lower financial burden (travel and accommodation costs) during the lockdown. However, they observed that students con- cerned with their academic performance still conveyed symptoms of depression and anxiety [17] .

On the other side, the mental health of medical students in Cyprus deteriorated during the lock- down when the clinical training stopped and switched to a virtual setting [18]. One in five medical students suffered from burnout during the lockdown, particularly those in the final (sixth) year. In contrast, fourth-year students were less often affected by burnout than in the pre-pandemic period. Cynicism levels increased among most students, which authors interpret as mounting doubt over the significance and usefulness of their studies and loss of interest and enthusiasm for the medical pro- fession [18]. Authors claim that virtual teaching and the lack of clinical experience negatively affect students’ confidence, which may have consequences on the choice of profession in the subsequent years. Authors strongly dispute against virtual training for medical students in their last year [18].

Similarly, a large multi-centric online survey comprising more than two thousand medical stu- dents across 148 medical schools in Brazil, Chile, Colombia, Germany, Italy, Japan, Mexico, Spain, and Venezuela confirmed that the shift in teaching environment from bedside to virtual learning had negative effects on students’ physical and mental health [19]. Students complained about head- aches, ocular tiredness, backache, and suffered from insomnia, emotional irritability, emotional in- stability, anhedonia, and depressed mood in relation to the time spent in front of the computer screen. Authors advise limiting daily screen time for students in online education setting [19]

One of the important findings of our study was the positive association between students’ com- munication challenges, behaviour, and attitudes with noise sensitivity. Highly noise-sensitive stu- dents were more likely to report being unable to hear or understand the teacher who was wearing the facemask; they complained about teachers not understanding them while speaking with face- masks. Highly noise-sensitive were more likely to withdraw from communication for fear of not being understood, get nervous when they failed to hear or understand the other person, and ask their partner to repeat the phrase. Overall, highly noise-sensitive students reported a negative attitude to- ward the overall working atmosphere in the facemask-wearing classes.

The presented study has several limitations. Firstly, this is a cross-sectional study, and therefore, we cannot make direct etiological assumptions. Second, the online design and selection of partici- pants carry bias and can be considered less reliable. Third, female medical students dominated the study population, which is standard gender distribution in our faculty. However, we also tried to gather students from other faculties and universities across the country to decrease professional and gender disproportion. Fourth, although we know that students from various universities responded to our questionnaire, their anonymity prevents us from comparing the findings between medical and non-medical professions. Fifth, we did not consider students’ personality traits that may play a role in perceiving the communication challenges in class. Sixth, we assessed students’ noise sensitivity using a non-standardized numeric scale and classified them according to the median value. A recent study showed that the threshold for high noise sensitivity is set at a much higher level when estimat- ing the influence of noise sensitivity on perceived annoyance [20] . Finally, we did not evaluate the way the facemask is worn. As researchers report that only three-quarters of medical students wear facemasks by covering their mouths and nose [21], we can only hope that the surveyed students and

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teachers wore them correctly. We were, however, able to demonstrate that the type of facemask made no difference in the perceived communication challenges.

If possible, further studies should compare the challenges, behaviours, attitudes, and practice of wearing facemasks among students of different fields to understand whether our results can be gen- eralised to other young adults. It would be interesting to study communication challenges with facemasks in bilingual teaching setting, i.e., among international students or students learning a se- cond language [22]. Longitudinal studies should further provide definite response how the pan- demic and the new teaching methods affected students’ physical and mental health.

4. CONCLUSIONS

In summary, speaking with a facemask in class creates communication challenges for teachers and students alike. Both communication parties have difficulties hearing and understanding each other when any of them speak wearing masks. Students and teachers often ask each other to repeat the text, raise voices, and speak clearly. Students rely on their own and teachers’ facial expressions, hand gestures, body language, and tone of voice to facilitate communication. The type of facemask typically worn had no effect on the occurrence of the presented communication challenges in class. However, students’ subjective noise sensitivity proved to modulate perceived problems, behaviours, and attitudes toward communication with facemasks. We express concern that the inability to communicate clearly may cause frustration in the academic setting . We strongly appeal that aca- demic institutions implement the anti-epidemic measures in class as well as provide technical, pedagogical, and psychological support to teachers and students under the new circumstances. 5. ACKNOWLEDGEMENTS

This research is financially supported by the Ministry of Education, Science and Technological De- velopment of the Republic of Serbia, Project No. 175078. 6. REFERENCES

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