Abstract
Commercially available children’s cloth masks range widely in material type and fabric structures, methods of construction, layering, and shape, and there is a lack of sizing systems, anthropometric data or guidelines specifically targeting the fit assessment and design of cloth face masks for children 4-6 years old. To better identify and understand the cloth face mask fit and functional needs of children ages 4-6 years old, the researchers embarked on interdisciplinary in-depth study to investigate commercial market offerings of children’s face masks, identify consumer perspectives, and explore mask design improvements through design research. By triangulating results from survey feedback, commercial market content analysis, and wear trial observations, the researchers were able to identify important design criteria that can be used in the improvement of children’s cloth face mask design: size, comfort, dexterity, movement, and thermal comfort. These criteria were used to iteratively develop new mask prototypes involving a 3D printed head form, traditional sewing and hand patternmaking skills, and the creation of multiple mask versions to explore the design criteria listed above. The designs were interpreted through Bye’s (2010) Problem-Based Design Research (PBDR) framework, which identifies common design research practices in the field on a spectrum and situates PBDR as a process centered on a problem as impetus for design through which artifacts are developed.
Introduction
As of late October 2021, COVID-19 rates in the US for children under 12 years of age have risen to over 2.85 million cases, with 409 deaths (Centers for Disease Control and Prevention, n.d.-b), and though vaccines are readily available for those aged 12 years old and up, they are not yet approved for use in the younger populations. Further, the Delta variant of the COVID-19 pandemic is more transmissible and affects children and others who are unvaccinated in higher numbers than did the original virus strain (Unicef, 2021), and the number of children affected by a condition associated with COVID-19 called multisystem inflammatory syndrome in children, or MIS-C, has increased to over 5.2 thousand, with 46 deaths (Centers for Disease Control and Prevention, n.d.-a). Outside of vaccinations, methods to help prevent the transmission of COVID-19 include social distancing, hand washing, and the wearing of face masks. Because medical face masks such as N95 respirators are needed for health professionals and fluctuations in the supply chain impact the availability of disposable surgical masks (Gereffi, 2020), it is incumbent upon the general population to rely on cloth face masks as an alternate option for covering the nose and mouth. Cloth face masks are a convenient, cost-effective option that can be washed and re-worn, and made at home or purchased commercially (De Silva et al., 2020).
The Centers for Disease Control and Prevention (CDC) advise the wearing of cloth face mask use in individuals over the age of 2, and for those who the wearing of masks would not impede medical issues. With the current vaccination age set at 12 years old in the US, children ages 2–11 must use masks as a deterrent to transmission, and particularly while indoors during school (Centers for design Control and Prevention, n.d.-c). Limitations surrounding children’s face mask use includes their developing dexterity and subsequent need for adult assistance with donning or doffing, discomfort due to extended wear, and difficulty in breathing while wearing the face masks (Seo et al., 2017). Children ages 4–6 years old have limited ability to carefully handle social distancing, and difficulty in dexterity for the donning/doffing of face masks which can lead to self-contamination and spread of infection in the presence of COVID-19. Compared to older children, young children have increased vulnerability to respiratory epidemics due to the relative weakness of their immune systems and significantly higher respiration rates per minute than adults, that can cause airborne viruses to linger (Kim et al., 2010) and are vulnerable to possible infection while spending time in daycare, schools, and during activities with physical and verbal interactions with other children. Unlike adults, children in this age range cannot adjust the fit of face masks independently or easily, and this population needs frequent adult support for donning, doffing and adjusting of face masks multiple times a day which can increase the possibility of self-contamination and transmission.
In addition, there is no anthropometric data available to be used for the design and sizing of face masks for children in this age range. According to literature review, the fit of a facemask is as important as effectiveness of its filtering materials to protection, and that children ages 4 to 6 years old were identified as particularly in need of assistance with face masks due to a general dearth of information surrounding their specific anthropometries and functional requirements. While adults can easily adjust mask fit using the metal nose bridge or ear elastics, it is extremely difficult to adjust the fit of children’s masks due to their smaller features, which can result in the inhalation of contaminated air such as through the open space around their nose or gaps around the sides of the face or under the chin. Throughout the COVID-19 pandemic there has been a surge in home or community production with those possessing the ability to sew taking on labor required to produce cloth face masks (Snyder et al., 2020). While those with sewing abilities may be able to create or alter cloth face masks for children, many others rely on commercially available options. Vague sizing across commercially available masks for children can create difficulty in sourcing well-fitting options, stemming from a lack of standardization in fit, sizing, materials, and consideration for functional needs of the young wearer.
Study design
Commercially available children’s cloth masks range widely in material type and fabric structures, methods of construction, layering, and shape, and there is a lack of sizing systems, anthropometric data or guidelines specifically targeting the fit assessment and design of cloth face masks for children 4–6 years old. A review of the literature identified a paucity of practical and translative research that can provide the public with comprehensive and clear guidance for the selection of children’s face masks communicating the impact of material types, layering, design, sizing, and fit on the effectiveness of protection and comfort. It was therefore important to explore these areas targeting children ages 4 to 6 years old, as this is an age demographic as-yet excluded from general study and analysis.
To better identify and understand the cloth face mask fit and functional needs of children ages 4–6 years old, the researchers embarked on interdisciplinary in-depth study with a three-pronged approach: (1) investigating commercial market offerings of children’s face masks, identifying consumer perspectives, and exploring mask design improvements through design research; (2) identifying and testing materials and new mask designs for filtration efficiency and air permeability; (3) evaluating anthropometric sizing and fit in the target age range of children ages 4–6 years old. The study is divided into three manuscripts, and this present text represents the perspectives of commercial market offerings, consumer perspectives, and design research outcomes.
The two-part research problem was identified as follows: (1) the lack of clear knowledge, guidance, and standardization about the fit and functional needs of cloth face masks in children ages 4–6 years old, and (2) the lack of well-fitting commercially available cloth face masks for children ages 4–6 years old. The research questions (RQs) guiding the present study are as follows:
RQ1: How do commercially available cloth face masks fit and incorporate functional considerations for children ages 4 to 6 years old?
RQ2: How can cloth face mask design be improved for children ages 4 to 6 years old? The purposes of this multi-method study were (1) to explore the phenomenon to better understand the fit and function of commercial cloth face masks for children and (2) to use qualitative and design research skills to develop improved options for children’s cloth face masks targeted to children ages 4–6 years old. The study addresses the research questions through the following objectives: (1) explore commercially available children’s face masks’ attributes; (2) identify consumer needs for children’s cloth face masks; (3) develop alternative cloth face mask designs for children ages 4–6 years old. Interpreted through Bye’s (2010) Problem-Based Design Research (PBDR) model, the researchers conducted a content analysis of children’s face masks through market research, interpreted survey responses regarding children’s face masks from adults who are either parents/guardians of or work with children ages 4–6 years old, and conducted iterative design research developing mask prototypes to explore alternative and improved designs for children’s face masks.
Literature review
Face mask use
In addition to social distancing, wearing face masks is the predominant guideline for reducing the airborne transmission of the virus that causes COVID-19, SARS-CoV-2. Infected individuals can expel respiratory droplets in a wide range of sizes, but the smaller particles (< 5 μm) are of major importance as they are likely to contain infectious particles (SARS-CoV-2 and other pathogens) and remain suspended in the air for longer residence times (Fennelly, 2020). The protection given by face masks comes from filtration provided through the types and layers of materials used and the way the masks fit to the face over the top of the nose, sides of the face, and at the chin, which help to eliminate air gaps between the wearer and the environment (De Silva et al., 2020). When worn correctly, these masks can help to prevent the spread of the virus. Other commercially available devices worn on the face to help in protecting the wearer include neck gaiters and face shields, however, unclear messaging and conflicting study results have caused confusion surrounding the use of these items. Face shields provide a clear barrier for the wearer, but their design allows for droplets and aerosols to pass around their edges through large air gaps and should be used in conjunction with other measures such as face masks (Lindsley et al., 2021).
Children’s cloth face masks
Eberhart et al. (2021) explored children’s face masks through a review of the literature and in doing so discovered that there was such little information available on the topic that a second round of literature review was necessary, calling for further studies targeting different age groups. Mickells et al. (2021) explored adherence to face mask use in elementary schools and found it to decrease later in the day or at the end of the week and was more challenging for the students after periods of independent work or time such as lunch and recess. They further learned more specifics related to children’s mask wear discomfort, including difficulty breathing, students feeling hot, and “baseline poor fit of the masks as well as masks becoming wet and stretched which led to worsening fit over time” (Mickells et al., 2021, p. 559). These findings reinforce the need for (1) study in this area and (2) importance of design considerations related to comfort and fit.
Children’s face mask design
In February 2021 the CDC issued a report on ways to enhance the fit of face masks for better performance, including double-masking (1 surgical mask next to the face with 1 cloth mask on top) and modifying surgical masks to better fit the face to reduce air gaps including through knotting the ear elastics and folding excess gapping mask edges inward (Brooks et al., 2021). A similar process was undertaken by a team of doctors in Italy with researchers adjusting surgical face masks to fit children’s faces (Lubrano, 2021). While these two studies specifically utilize surgical masks, a common thread between the two is the necessary adjustment of a rectangular pleated mask to better fit the contours of the human face and reduce air gaps or adjust to a more appropriate size, as with children. This adjustment exemplifies the importance of fit to the face with masks overall, and specifically the popular pleated style.
Problem-based design research
In Bye’s (2010) Problem-Based Design Research (PBDR) framework (see Fig. 1), the identification of a problem serves as the root of the design process for the exploration and development of artifacts. This is accompanied by a review of literature and the development of prototypes, which are analyzed in relation to the original problem. Through this process, multiple artifacts are created. In this present study the artifacts were the masks themselves along with their patterns, notes, and photographs. Data gathered from these items were compared with results from the market research content analysis and the survey responses to create a circular process for the development of cloth face mask improvements and modifications for children ages 4–6 years old.
Methods
The present research study was comprised of multiple parts: identifying consumer perspectives related to face masks in children, investigating commercial market offerings of children’s face masks, and exploring design improvements. Methods undertaken include survey research with subjective and objective responses, a market research content analysis, wear observations, and design research through iterative prototyping. Results of the survey research, content analysis, and wear observations were triangulated with subsequent conclusions used as design criteria for mask modifications and improvements in new designs. Data acquired through the study were analyzed through a variety of techniques including content analysis and visual observations, identification of emergent themes and descriptive statistics of quantitative survey responses, pilot wear test observations of commercial masks, and review of artifacts developed through PBDR (Bye, 2010) including mask patterns, prototypes, photographs, and notes.
Online survey
After IRB approval was gained from the researchers’ university, a Qualtrics survey was distributed online by advertising the study on social media. The survey included multiple choice and open-ended questions. Not all participants answered every question as respondents were able to self-select into sub-categories, which helped to customize the survey to the participants and showed only questions that best aligned with their experiences. Participants were asked to select any modifying factors that would affect the children’s mask wearing (e.g., glasses, disabilities, or special needs). Additional questions included experience with different types of masks and mask fastenings, and subsequent ratings of preference, comfort, donning/doffing, and fit, as well as issues they may have faced with their mask of choice. Mask composition-related questions included preference of materials, number of layers, inclusion of filter pockets, bendable metal nose bridges, reversibility, and visual surface design. Descriptive statistical analyses were conducted in Excel.
Market review and selection of test masks
A content analysis of commercially available children’s face masks was conducted for market research. Google searches of “children’s face masks” and “kid face masks” yielded curated lists from Vogue (Schama, 2020), People (Warner, 2020), Today (Boan & Ortiz, 2020), Good Housekeeping (Sachs, 2020), and the She Knows blog (Weiss, 2020) for a total of 113 unique face masks, of which 30 were recommended by two or more sites. Screenshots were captured of each mask listing and PDF reference sheets created for each of the five curated lists, including images of the masks and listing text content. A Microsoft Excel comparison chart categorized each mask’s attributes including style, fastening type, number of fabric layers, material properties, and type of surface design. These attributes were compared within their categories to find the overall most common children’s commercial mask attributes
Wear trials, user observations and fit assessments
After review of these attributes, eight masks (see Fig. 2A) were purchased for observation of users’ wear trials, investigating fit issues and exploring fabrics and overall fit. The selection criteria of these eight masks included fiber/fabric types and number of layers, style, size adjustability, and use of filters, with masks purchased to represent a variety of these attributes. Of these eight test masks, six were recommended by more than one curated list and the remaining two masks were selected to round out the testing across attribute categories. The test masks were further evaluated for design and construction techniques and pattern shapes were traced and digitized to explore shape comparisons (see Fig. 2B), and sizing was measured by hand with a tape measure. Finally, pilot wear tests were conducted with each of the eight test masks.
Due to the difficulty in recruiting children as participants during the ongoing pandemic with adherence to lockdown recommendations, the overarching need for safety and the limited abilities of children to follow a multi-step evaluation process for feedback through numeric ratings, three children ages five (n = 2, one boy and one girl) and six (n = 1, boy) years old from the researchers’ families wore a selection of face masks indoors and outdoors to ascertain real-life responses and observations by members of the research team. Though recognized as a limitation in the research methods, the observations of masks on these three children provided valuable feedback when placed in conversation with survey results. They were interpreted through the lens of the PBDR framework (Bye, 2010), reflecting common issues with the fit and wear of commercially available children’s face masks and providing insights into ways to improve existing mask designs. With IRB exemption approved from Cornell University (IRB No.: 2008009743), observations were recorded using memos and photos, focusing on (1) noticeable/visual fit issues, (2) ease of donning and doffing, and (3) fogging of eyeglasses, which indicates air gaps around the nose.
Design research
Following the PBDR framework (Bye, 2010), design-centered information gained from the triangulated survey findings, market research content analysis, and wear trial observations were used as integral knowledge for the design and refinement of two prototypes to improve children’s face mask designs. These prototypes were developed by the apparel design student researchers and evolved through refinements and discussion with the rest of the research team. The two mask prototypes were named the “Orb” (see Fig. 3), and the “Lobster” (see Fig. 4), based on their shapes’ resemblances to other objects. The “Orb” mask utilized shaping techniques to provide greater space for breathing around the nose and mouth. However, through prototyping it was discovered that the overall silhouette had issues with collapsing at the center, and that the prototype was bulky due to the construction techniques used. The “Lobster” mask included considerations for expansion of the mouth in dynamic movement through the use of pleats and stretch side panels, and did not face the same concerns with bulk or misshaping. As such, it was decided by the research team to move forward with the “Lobster” design for the rest of the research study.
69% of the respondents indicated that commercial masks were too loose and slip down the face, while for the 64% of the respondents’ ears straps were too loose. Other most frequently reported issues were that the mask doesn’t stay in place (45%)—especially during strenuous physical activity (38%) and while talking (33%); discomfort on back of the ear (44%); and mask too large (40%). Further qualitative feedback from the survey provided deeper insights into the difficulties that arise with face mask use in younger children. Some common themes that arose include heat and dampness inside the mask, slippage due to movement or ill fit, the need for alterations or adjustments to improve fit, the need for stowage (such as a neck strap) when temporarily removed, and issues related to the size and sensitivity of children’s ears.
Some direct quotes from the survey feedback include the following. Regarding size and fastenings, “Almost always more difficult if any tying is required. Most store bought masks are too big for smaller children and fall off of the nose.” Pertaining to thermal comfort: “Children get hot under the mask. Masks get damp/wet inside and it makes them less effective and uncomfortable.” And finally, related to size and movement: “Masks that are too loose or tight (so they’re uncomfortable staying on) or not staying on the nose while they talk.” Due to their young age and developing motor skills, children may not have the dexterity required for tying face masks or reaching behind their ears to secure ear loops. There were also several comments that mentioned long hair complicating the donning process and children chewing on the inside of their masks, especially if fitted too close to the mouth.
In the market research content analysis results, comparisons of listings yielded identification of the following physical mask attributes that were considered in the proposed mask designs: style, fastening type, number of layers, materials, fabric structure, and surface design (see Table 1). Add-ons with lower frequencies included the specification of an enclosed metal nose piece (16%, n = 19), inclusion of a filter pocket (32%, n = 37), and indication that the mask was reversible (7%, n = 9). The comparisons among these categories helped to identify the most common configurations from the lists. Collectively, the most common mask would be the shaped style (57%) with stretch ear loops (67%), comprised of 2 layers (56%) of woven (36%) cotton (78%) with an all-over print (57%).
Observation of wear trials of the commercial face masks
The eight selected face masks were examined for design and construction techniques by the research team, and for use in wear trials by the child participants. The researchers’ university Institutional Review Board exempted the protocol for observing the eight purchased masks as worn by child participants, and the following observations of mask-related issues were made by members of the research team (see Fig. 5). Mask A was constructed of stretch fabric with a center front seam and stretch binding stitched around the perimeter of the mask, which creates a gathered shape that cups around the nose and mouth. However, this mask presented issues with the size of the non-adjustable ear loop being too small, which can cause the mask to pull tightly to the face and create tension and uncomfortable strain behind the ear. Masks B and C were non-stretch pleated masks found to be difficult to speak through due to tightness against the face, the label on the mask rubbed against the wearers’ skin, and the ear elastics were too small, causing discomfort. Mask D was a single-layered stretch shaped mask with built-in ear loop cutouts and a center front seam. This mask was reported positively by two of the child participants (age 5) regarding fit and placement, and negatively by the third (age 6), who was found to have issues with mask slippage out of place. Observations by the researchers include gaps around the edges of the mask and fogging of glasses, indicating issues with fit. Mask E, a gaiter style, was identified by all three participants as the most difficult to wear and use, and resulted in extra fabric bunched around the neck, which was an additional discomfort factor. Mask E was made of a tight and long knit fabric tube, which caused difficulty in donning due to the need to firmly pull the mask first down over their heads and then up to cover their small noses and mouths, which was challenging due to the limited dexterity of this age group. Mask F was a shaped style with a dart for the nose and separate piece of fabric for the chin, joined with a seam designed to cup around the face. Ear elastics were adjustable, which permitted for a more custom fit to the wearer. Mask G was designed as a flat, 2-dimensional panel that when worn is wrapped around a 3-dimensional form (the human face) with no shaping involved such as darts or gathers. This technique leaves large gaps at the edges of the mask, allowing for more air to pass around to the nose and mouth, and the elastics create tension on the ears causing discomfort. Mask H was constructed of a single layer of stretch fabric, gathered around the edges with a stretch binding in a technique similar to Mask A. However, due in part to differences in sizing and shaping, Mask H was found to be very tight across the face and pulled on the ears.