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Background: Guidelines and recommendations from public health authorities related to face masks have been essential in containing the COVID-19 pandemic. We assessed the prevalence and correlates of mask usage during the pandemic. Methods: We examined a total of 13,723,810 responses to a daily cross-sectional representative online survey in 38 countries who completed from April 23, 2020 to October 31, 2020 and reported having been in public at least once during the last seven days. The outcome was individual face mask usage in public settings, and the predictors were country fixed effects, country-level mask policy stringency, calendar time, individual sociodemographic factors, and health prevention behaviors. Associations were modelled using survey-weighted multivariable logistic regression. Findings: Mask-wearing varied over time and across the 38 countries. While some countries consistently showed high prevalence throughout, in other countries mask usage increased gradually, and a few other countries remained at low prevalence. Controlling for time and country fixed effects, sociodemographic factors (older age, female gender, education, urbanicity) and stricter mask-related policies were significantly associated with higher mask usage in public settings, while social behaviors considered risky in the context of the pandemic (going out to large events, restaurants, shopping centers, and socializing outside of the household) were associated with lower mask use. Interpretation: The decision to wear a face mask in public settings is significantly associated with sociodemographic factors, risky social behaviors, and mask policies. This has important implications for health prevention policies and messaging, including the potential need for more targeted policy and messaging design., Comment: 39 pages, 2 mian figures, Appendix

The U.S. COVID-19 Trends and Impact Survey (CTIS) is a large, cross-sectional, Internet-based survey that has operated continuously since April 6, 2020. By inviting a random sample of Facebook active users each day, CTIS collects information about COVID-19 symptoms, risks, mitigating behaviors, mental health, testing, vaccination, and other key priorities. The large scale of the survey – over 20 million responses in its first year of operation – allows tracking of trends over short timescales and allows comparisons at fine demographic and geographic detail. The survey has been repeatedly revised to respond to emerging public health priorities. In this paper, we describe the survey methods and content and give examples of CTIS results that illuminate key patterns and trends and help answer high-priority policy questions relevant to the COVID-19 epidemic and response. These results demonstrate how large online surveys can provide continuous, real-time indicators of important outcomes that are not subject to public health reporting delays and backlogs. The CTIS offers high value as a supplement to official reporting data by supplying essential information about behaviors, attitudes toward policy and preventive measures, economic impacts, and other topics not reported in public health surveillance systems.Significance statementThe U.S. COVID-19 Trends and Impact Survey (CTIS) has operated continuously since April 6, 2020, collecting over 20 million responses. The largest public health survey ever conducted in the United States, CTIS was designed to facilitate detailed demographic and geographic analyses, track trends over time, and accommodate rapid response to emerging priorities. Using examples of CTIS results illuminating trends in symptoms, risks, mitigating behaviors, testing and vaccination in relation to evolving high-priority policy questions over 12 months of the pandemic, we illustrate the value of online surveys for tracking patterns and trends in COVID outcomes as an adjunct to official reporting, and showcase unique insights that would not be visible through traditional public health reporting.

Simultaneously tracking the global COVID-19 impact across multiple populations is challenging due to regional variation in resources and reporting. Leveraging self-reported survey outcomes via an existing international social media network has the potential to provide reliable and standardized data streams to support monitoring and decision-making world-wide, in real time, and with limited local resources. The University of Maryland Global COVID Trends and Impact Survey (UMD-CTIS), in partnership with Facebook, invites daily cross-sectional samples from the social media platform’s active users to participate in the survey since launch April 23, 2020. COVID-19 indicators through December 20, 2020, from N=31,142,582 responses representing N=114 countries, weighted for nonresponse and adjusted to basic demographics, were benchmarked with government data. COVID-19-related signals showed similar concordance with reported benchmark case and test positivity. Bonferroni significance and minimal Spearman correlation strength thresholds were met in the majority. Light Gradient Boost machine learning trained on national and pooled global data verified known symptom indicators, and predicted COVID-19 trends similar to other signals. Risk mitigation behavior trends are correlated with, but sometimes lag, risk perception trends. In regions with strained health infrastructure, but active social media users, we show it is possible to define suitable COVID-19 impact trajectories. This syndromic surveillance public health tool is the largest global health survey to date, and, with brief participant engagement, can provide meaningful, timely insights into the COVID-19 pandemic and response in regions under-represented in epidemiological analyses.Significance StatementThe University of Maryland Global COVID Trends and Impact Survey (UMD-CTIS), launched April 23, 2020, is the largest remote global health monitoring system. This study includes about 30 million UMD-CTIS responses over 34 weeks (through December 2020) from N=114 countries with survey-weights to adjust for nonresponse and demographics. Using limited self-reported data, sampled daily from an international cohort of Facebook users, we demonstrate validity and utility for COVID-19 impacts trends, even in regions with scant or delayed government data. We predict COVID-19 cases in the absence of testing, and characterize perceived COVID-19 risk versus risk-lowering measures. The UMD-CTIS has the potential to support existing monitoring systems for the COVID-19 pandemic, as well as other new, as-yet-undefined global health threats.