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Stagnant since 1903, at an elevation of 2,744 m, a volcano erupts on Baekdu Mountain located on the Chinese-North Korean border. Armed with the threat of imminent eruptions, a team of uniquely trained professionals from South and North Korea unite. Together, they must join forces and attempt to prevent a catastrophic disaster threatening the Korean Peninsula
7 of 10
rating=850 Votes
Hae-jun Lee, Byung-seo Kim
release year=2019
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Started off at a slow pace but that's because the background needed to be in place. Mid way thru, it was edge of the seat and Lee Byung Hun was just stellar. Still as charismatic as ever, his character made the movie interesting. Plot was exciting and even my teen daughters enjoyed the movie. Appeal to all ages. Must watch. Ashfall aussies. Ashfall 2019. Ashfall movie download. Below my expectations. Suppose the disastrous erruption was kept far way behind the scnene. The core is strongly focus on the "rescue" mission in which i think the emphasis was bluntly executed. The pulling in of the westerner and the Chinese into the play just not adequately boost up the hype to gain excitement. I noticed most of the facial expression in the movie is very "plastic" except for my idol BHLee.
Edit Storyline Stagnant since 1903, at an elevation of 2, 744 m, a volcano erupts on Baekdu Mountain located on the Chinese-North Korean border. Armed with the threat of imminent eruptions, a team of uniquely trained professionals from South and North Korea unite. Together, they must join forces and attempt to prevent a catastrophic disaster threatening the Korean Peninsula. Written by Stanton Plot Summary | Add Synopsis Taglines: No option for failure Details Release Date: 19 December 2019 (South Korea) See more » Box Office Budget: $17, 700, 000 (estimated) Opening Weekend USA: $36, 201, 22 December 2019 Cumulative Worldwide Gross: $61, 255, 955 See more on IMDbPro » Company Credits Technical Specs See full technical specs ».
Ashfall volcano. Ashfall cgv. Ashfallow citadel door. Ashfall fossil beds state historical park. Ashfall meaning. Ashfall 4. Ashfall book 4. We use cookies to offer you a better experience, personalize content, tailor advertising, provide social media features, and better understand the use of our services. To learn more or modify/prevent the use of cookies, see our Cookie Policy and Privacy Policy. Communities living near active volcanoes may be exposed to respiratory hazards from volcanic ash. Understanding their perception of the risks and the actions they take to mitigate against those risks is important for developing effective communication strategies. To investigate this issue, the first comparative study of risk perceptions and use of respiratory protection was conducted on 2003 residents affected by active volcanoes from three countries: Japan (Sakurajima volcano), Indonesia (Merapi and Kelud volcanoes) and Mexico (Popocatépetl volcano). The study was designed to test the explanatory value of a theoretical framework which hypothesized that use of respiratory protection (i. e., facemask) would be motivated by two cognitive constructs from protection motivation theory: threat appraisal (i. e., perceptions of harm/ worry about ash inhalation) and coping appraisal (i. e., beliefs about mask efficacy). Using structural equation modelling (SEM), important differences in the predictive ability of the constructs were found between countries. For example, perceptions of harm/ worry were stronger predictors of mask use in Japan and Indonesia than they were in Mexico where beliefs about mask efficacy were more important. The SEM also identified differences in the demographic variants of mask use in each country and how they were mediated by the cognitive constructs. Findings such as these highlight the importance of contextualising our understanding of protection motivation and, thus, the value of developing targeted approaches to promote precautionary behaviour. Factors motiv ating the use of respiratory protection against volcanic ashfall: A comparative analysis of comm unities in Japan, Indonesia and Mexico Judith Covey a, *, Claire J. Horwell b, Laksmi Rachmawati c, Ryoichi Ogawa d, Ana Lillian Martin-del Pozzo e, Maria Aurora Armienta e, Fentin y Nugroho f, Lena Dominelli g Claire J. Horwell:; Laksmi Rachmaw ati:; Ry oichi Ogawa:; Ana Lillian Martin-del Pozzo:; Maria Aurora Armienta:; Fentiny Nugroho:; Lena Dominelli: a Department of Psychology, Durham Univ ersity, South Road, Durham DH1 3LE, UK b Institute of Hazard, Risk and Resilience, Department of Earth Sciences, Durham University, South Road, Durham DH1 3LE, UK c Research Center for P opulation, Indonesian Institute of Sciences (LIPI), 12710, Indonesia d Regional Management Research Centre, Graduate School of Humanities and Social Science, Kagoshima University, K orimoto, 1-21-24, Kagoshima 890-8580, Japan e Instituto de Geofisica, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacan, Me xico D. F., Mexico f Department of Social Welfare, F aculty of Social and Political Science, Univ ersity of Indonesia, Kampus Baru UI Depok, Jawat Barat 16424, Indonesia g Faculty of Social Sciences, Univ ersity of Stirling, Colin Bell Building, Stirling FK9 4LA, UK Abstract Communities living near active v olcanoes may be exposed to respiratory hazards from volcanic ash. Understanding their perception of the risks and the actions they take to mitigate against those risks is important for developing effecti ve communication strategies. T o in vestigate this issue, the first comparative study of risk perceptions and use of respiratory protection was conducted on 2003 residents affected by active v olcanoes from three countries: Japan (Sakurajima volcano), Indonesia (Merapi and Kelud volcanoes) and Mexico (Popocatépetl v olcano). The study was designed to test the explanatory value of a theoretical framew ork which hypothesized that use of respiratory protection (i. e., facemask) would be motivated by tw o cognitive constructs from protection motivation theory: threat appraisal (i. For example, perceptions of harm/ worry were stronger predictors of mask use This is an open access article under the CC BY license (). * Corresponding author. j. (J. Covey). Declarations of Interest None. Europe PMC Funders Group Author Manuscript Int J Disaster Risk Reduct. Author manuscript; av ailable in PMC 2019 September 04. Published in final edited form as: Int J Disaster Risk Reduct. 2019 April; 35:. doi:10. 1016/ Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts in Japan and Indonesia than they were in Mexico where beliefs about mask eff icacy were more important. The SEM also identified differences in the demographic variants of mask use in each country and how they were mediated by the cognitiv e constructs. Findings such as these highlight the importance of contextualising our understanding of protection motivation and, thus, the v alue of developing targeted approaches to promote precautionary beha viour. Keywords Threat appraisal; Coping appraisal; V olcanic ash; Respiratory protection; Risk perception; Protection motivation 1 Introduction 1. 1 Background Around 600 million people around the world live in areas potentially affected by v olcanic hazards [1]. During a volcanic crisis, populations may be evacuated to remo ve them from life-threatening hazards (e. g., pyroclastic flows), but they may still be e xposed to potentially hazardous airborne volcanic emissions. V olcanic ash is a pervasive hazard, with distribution potentially over thousands of square kilometres. Inhalation of the ash can exacerbate existing asthma and bronchitis symptoms as well as respiratory symptoms such as cough and breathlessness [2, 3]. The respiratory health hazard of the volcanic ash does, howev er, depend upon its physicochemical composition which can vary substantially among eruptions and even within a single eruption sequence [4–6]. Other studies hav e indicated that personal attributes such as gender, age, and cultural beliefs and e xisting respiratory health conditions may also affect health outcomes [7, 8]. Although there is limited clinical/epidemiological evidence on the pathogenic potential of chronic exposures to ash [3], the ash is often rich in crystalline silica [9, 10] which, for industrial exposures, is known to cause silicosis and is classed as a Group 1 carcinogen [11]. So, consideration of the respiratory hazard associated with chronic exposure is important and agencies generally take a precautionary approach: individuals are advised to protect themselves from ash inhalation, by staying indoors or wearing light-weight disposable respiratory protection such as a facemask (see www advice). That being said, very little is known about the precautions that communities affected by volcanic ash actually take. It is important to document whether people follo w even the most basic advice that might be offered, such as staying indoors, or what types of respiratory protection (if any) they rely upon and believe to be ef fective. Research, to-date, on this issue is limited to a small survey conducted in Y ogyakarta, Indonesia in the days following the eruption of Kelud volcano in February 2014 [12]. The interviewers recorded the types of masks people wore, where they had got the masks from, why people wore masks, who advised them to wear a mask, and whether people thought their respiratory protection was effectiv e. They found that 65% of the 125 respondents were observed wearing disposable surgical masks of the type distributed by gov ernment agencies and easily procurable from shops, and 16% were using some form of cloth over their mouth Covey et al. Page 2 Int J Disaster Risk Reduct. Author manuscript; available in PMC 2019 September 04. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts and nose which they had been advised to use when masks were unavailable. Their motivation for using respiratory protection (or not) was, ho wever, unclear given that a substantial proportion of the respondents were not convinced of the effecti veness of their chosen protection. Understanding how people choose actions and make decisions in the face of risk is critical [13], so that, if mask wearing is encouraged, agencies can tailor advice to ensure better uptake. This pilot paved the way for the research reported in this paper, which was conducted as part of the Health Interventions in V olcanic Eruptions (HIVE) project ( nsortium/). The aim of the HIVE project was to provide an evidence base on effecti ve respiratory protection against volcanic ash for community use. This evidence base includes not only identifying which types of respiratory protection are effective and wearable [the results of which are published in: 14–16] b ut, also, understanding the factors that influence people's motivation to protect themselv es and the actions they take when ash is in the air, including whether or not the y wear masks. In this study, we were particularly interested in ho w the motivations and actions taken dif fer among communities that are diverse not only in their experiences of dif ferent kinds of volcanic eruptions and ashfall but, also, in their socio-demographic and cultural make-up. Comparisons were made, therefore, among three communities from Japan, Mexico and Indonesia. These communities not only represent very different cultures but, as set out below, they have li ved with very different e xperiences of volcanic activity. The types of official intervention in response to v olcanic ashfall have also been variable. This study therefore provides a unique insight into how different communities percei ve and respond to the potential hazards of volcanic ash in the air. In the sections that follow, we describe the three volcanic communities selected for comparison and the theoretical framework designed for the collection and analysis of data. 1. 2 Three different volcanic communities 1. 2. 1 Japan (Sakurajima volcano)— Since 2009, Sakurajima V olcano on Kyushu Island, Japan, has been in a phase of enhanced activity with frequent eruptions (sometimes several per day) totalling between 450 and 1000 times per year ( www kagoshima/vol/data/). In 2011, there were 996 eruptions and, at its peak, 150 eruptions were recorded for a 1-month period. During times of volcanic activity, communities in the city of Kagoshima and surrounding rural districts of Kihoku, Ushine, Kaigata and Sakurajima Island, itself, have been exposed to frequent ashfall e vents. The city has well organised ash removal practices including re gular use of ash road sweepers and issuing people with yellow plastic bags to collect the ash from their properties. The ash also has economic benefits in terms of its use in pottery studios which incorporate volcanic ash into their creations (e. g., ). Although the Kagoshima City local government do recommend exposure reduction, including refraining from going out and wearing a mask when there is heavy ashfall (see enjo/hoyobo-yobou/kenko/kenko/sejin/), the advice is not well advertised and there are no public announcements when eruptions occur. Although the local gov ernment stores stockpiles of masks for use in a flu Covey et al. Page 3 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts pandemic, masks are not routinely distributed so, if residents or visitors want to use them, they need to obtain their own. 2 Mexico (Popocatépetl)— Millions of people, in the metropolises of Mexico City and Puebla, as well as smaller towns and villages, live in the shado w of Popocatépetl volcano, one of Mexico's most active v olcanoes. Since 1994 it has been producing powerful explosions at irregular intervals. Small amounts of ash are detected relati vely often (sometimes several times a week) and heavy ashfall on the surv ey area occurred less than a month before the survey was conducted [17–20]. Civil protection authorities typically issue advice to residents affected by the ashfall, to cover their noses and mouths with masks or damp handkerchiefs, close windows, and remain at home or stay indoors during ashfall. When there is increased activity with ashfall, the State governments are advised by the National Center for Disaster Prevention (CEN APRED) to distribute masks to the population. Masks are obtained mainly through State and Federal funds. Some are stockpiled and some are bought when activity increases. Howev er, volcanic risks do not seem to feature particularly highly in the list of hazards that are worrisome to people who live near the volcano [21], which raises questions about whether this advice is taken and the masks are used. 3 Indonesia (Merapi and Kelud V olcanoes)— Over the past decade, communities living in Y ogyakarta and Sleman district in Ja va, Indonesia have been e xposed to volcanic ash following major eruptions of Merapi in 2010 and, more recently, Kelud in 2014. In the aftermath of the 2014 eruption, the sudden deposition of several centimeters of ash on the city of Y ogyakarta, which is situated 200 km west of Kelud v olcano, was surprising and had not been anticipated. In 2010, the eruption of Merapi (which is just 30 km north of Y ogyakarta city) was the largest in a century, and killed at least 300 people. These were, therefore, very different ashfall experiences compared to those of the communities around Sakurajima and Popocatépetl for whom airborne ash is relatively commonplace. This difference may be reflected not only in the response of government agencies and NGOs to the ashfall but also the community reaction. When ashfall is unexpected, it might evoke substantial anxiety in the population, e ven if the ash is only airborne for a matter of days and the hazard is short-lived. Concerns might also have been heightened by the disaster management approach taken by government agencies to the eruptions. As documented in Horwell et al. [12], more than a million disposable surgical facemasks were quickly distributed by government agencies and hospitals to the general public in Y ogyakarta, and residents were also advised to use some form of cloth over their mouth and nose. 3 Theoretical model T o understand people's motivations in these communities, and the factors which af fect their use of respiratory protection, the collection and analysis of the data were informed by the theoretical model shown in Fig. This model was designed to explain variance in the use of protective actions using a range of socio-demographic variables (i. e., geographical location, age, gender, education lev el, self-reported medical history of respiratory problems) and selected cognitive constructs informed by Protection Motiv ation Theory (PMT) [22, 23]. Covey et al. Page 4 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts PMT has been widely adopted as a framework to explain and predict protectiv e health behaviours [24], with recent research successfully applying the theory to understand behaviours in response to natural hazards such as fires [25, 26], floods [27–30], earthquakes [31], and tsunamis [32]. Little is known, howe ver, about mitigation beha viour in response to volcanic ashfall. PMT proposes that protective responses arise from cognitiv e appraisals of the harm or damage associated with the threatening event (threat appraisal) along with the belief that the occurrence of the threatening event can be effecti vely avoided (coping appraisal). T aking inspiration from this theory and recognising the importance of affect as well as cognition in guiding perceived risk [33], we propose that residents who protect themselves from inhaling volcanic ash (protective action) would percei ve inhaling ash to be more harmful to their health (perceived harm) and be more worried about the ef fects of the ash on their health (perceived worry) than residents who do not protect themselves. In addition, the y would be more likely to use respiratory protection if they perceive it to be ef fective at protecting them from the harmful effects of the ash (perceived response ef ficacy PMT also identifies beliefs about self-efficacy as determinants of protecti ve action. A person needs to believe the y can successfully enact the recommended behaviour and if someone thinks, for example, that wearing a mask will be difficult, they will not wear one. In our model, this type of self- efficacy belief is captured within the costs and barriers construct where we also consider a broad range of resource-related attributes of the type conceptualised within Lindell and Perry's [34] Protective Action Decision Model (P ADM) as potential barriers against the use of respiratory protection (e. g., cost, inconvenience, lack of a vailability, discomfort, social unacceptability/ norms). The structural nature of our model also allowed us to ask questions about whether the effects of socio-demographic variables on protective actions can be e xplained indirectly through their effects on either threat or coping appraisals. For example, if we f ind that older people are more likely than younger people to use a facemask for respiratory protection, we could establish, through structural modelling, whether this difference can be explained by corresponding differences in threat appraisal (i. e., older people perceive that ash is more harmful to their health/ are more worried about the effect of the ash) or coping appraisal (i. e., older people perceive that masks are more effecti ve at protecting them from inhaling ash). Moreover, a multi-le vel approach was taken to the structural modelling to compare the explanatory value of the constructs between each volcanic community. This allowed us to identify both the similarities and differences in the factors which influence people's motivations to take precautionary action and, where we f ind the results are consistent, we can be more confident about generalising our findings to other communities affected by ashfall around the world. 2 Method 2. 1 Sample and sampling procedure A survey was conducted between May and September 2016 on residents from communities exposed to volcanic ashfall from three different countries – Japan (Sakurajima v olcano) (N = 749), Mexico (Popocatépetl volcano) (N = 654), and Indonesia (Merapi and Kelud Covey et al. Page 5 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts volcanoes) (N = 600). Respondents aged 13 and over were recruited both from the major urban areas that have been affected by ashfall from these v olcanoes (i. e., Kagoshima city in Japan, Puebla city in Mexico, and Y ogyakarta city in Indonesia) and from rural communities (i. e., Sakurajima Island and surrounding districts of Kihoku, Ushine and Kaigara in Japan; the small town of Santiago Xalitzintla in Mexico; and villages in the Sleman District in Indonesia). This allowed us not only to make comparisons among different countries b ut also between the residents of urban and rural communities within those countries. The use of a random sampling method from the populations of interest was not deemed practical. In Japan, for example, since the 1990s and 2000s, there have been well- documented problems of declining response rates to social survey research due to concerns in Japanese society about the criminal use of their personal information [35]. So, even if the planned sample is drawn randomly from the population, a low response rate could produce a biased sample. In Indonesia, randomly sampling was also difficult because, at the research sites, permissions for interviews first had to be obtained from community leaders (e. g., village heads). In Mexico, the situation was similar where different groups are represented by their community leaders who recommend participation or not. A non-probability quota sampling method was used instead, and was designed to produce a sample with a mix of residents that was broadly comparable to the demographics of the populations of each country and region, as determined from local census data [36–40]. Descriptive statistics for the samples are shown in T able 1, along with the a vailable census data. The census data clearly show how the demographics dif fer among the three countries, particularly in terms of age and education level. The target population in Japan includes a much higher percentage of older people (39. 0% over 60) than the populations of Mexico and Indonesia (19. 0% and 13. 5% over 60). The Japanese and Indonesian populations are also more highly educated than the Mexican population with 65. 7% and 51. 5% of residents graduating high school compared to 28. 1%. Although not shown here, there are also differences in the characteristics of the populations between the urban and rural regions within each country. F or example, in all three countries, the populations of the urban areas included a higher percentage of people who had graduated high school, with a particularly large difference in Mexico (Japan: urban 69. 7% rural 61. 7%; Mexico: urban 49. 8% rural 6. 6%; Indonesia: urban 55. 0% rural 48. 0%). Also the rural populations in Japan and Mexico in particular included a higher percentage of over 60 s (Japan: rural 47% urban 31%; Mexico: rural 24% urban 14%; Indonesia: rural 15% urban 12%). 1 As shown in T able 1, these demographic differences in the populations of the dif ferent countries and regions were reflected in the samples that were recruited. The sample quotas obtained were not, however, an exact match to the population statistics, due to practical difficulties recruiting respondents from certain groups. For e xample, the Japanese sample did not contain quite enough respondents in the youngest age-group and the most highly educated respondents were slightly over-represented in the Japanese and Mexican samples. The commonly used correction technique of weighting adjustment was therefore applied to 1 A breakdown of the census data and demographic characteristics of the samples in the rural and urban locations within each country is available on request from the first author. Page 6 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts the data to obtain estimates of the population means or frequencies, although it made little difference to our results. 2 The recency of the ashfall experiences of the survey respondents are also sho wn in T able 1. Ashfall was a more recent event in Me xico (56. 1% of respondents stated that they had experienced ashfall a week or month ago) compared to Japan (57. 4% few months ago) and Indonesia (93. 7% more than a year ago). Although we had expected the Indonesian sample to have the most distant experience of ashfall (the K elud eruption in 2014 was the last time volcanic ash fell on Y ogyakarta Province), when we designed the study we were e xpecting that the Japanese sample would have experienced the most recent ashfall. As noted previously, Sakurajima is known for its frequent activity and, in the summer months, the urban area chosen for the survey (Y oshino district of Kagoshima city) has, in recent years, experienced frequent ashfall, quite often on a daily basis. Howe ver, during the period the survey was conducted, there were only two explosions which produced ashf all at the Kagoshima observation point ( www). That does not mean to say that there would have been no airborne ash affecting residents, because ash lying on the streets or on roofs and buildings can be remobilised by traffic and winds. T able 1 also provides information about the self-reported incidence of respiratory health problems in each sample. Respiratory health problems were reported by about one in four of the Japanese sample (23. 6%) and about one in seven of the Mexican (14. 5%) and Indonesian (16. 2%) samples. Allergic rhinitis was, by far, the most frequently reported symptom by the Japanese (19. 0%), which is consistent with the high incidence of hay fever caused by sensitisation to Japanese cedar pollen [41]. Allergic rhinitis did not affect as many Mexicans (7. 2%) or Indonesians (3. 8%), but Indonesians reported a slightly higher incidence of asthma than the other countries (7. 2% vs. 6. 4% and 3. 4%). None of the other respiratory conditions affected more than 3. 1% of respondents. 2 Survey method The survey was administered by trained researchers in a face-to-face intervie w lasting around 20–30 min. An English language version was first produced by the HIVE project team and revised at a workshop also inv olving members of the project advisory board, held in November 2015. Translations into Indonesian, Japanese, and Spanish were check ed using back translation (i. e., the survey was translated back into English by an independent translator). The survey was then piloted in the local communities and then revised, twice. The translations of all revisions were checked again using back translation. The revisions made following piloting included changing the wording of some questions to improve understanding and reducing the number of questions to keep the survey to a more manageable length. 2 Adjustment weights were assigned to each survey respondent based on their age, gender, and education le vel. By dividing the population percentage by the corresponding response percentage, respondents in under-represented groups therefore get a weight greater than 1 and those in over-represented groups get a weight less than 1. These weighted values can then be used in the computation of means and percentages and compared alongside the unweighted values. It should be noted, however, that the weighted values produced very similar responses to the unweighted values and did not change the conclusions deriv ed from our results. Therefore, unweighted values are reported in the paper but weighted values are av ailable on request from the first author. Page 7 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts The survey items relev ant to the analyses reported in this paper are outlined below. 3 Protective actions— Respondents were asked which actions they had taken in the past to protect themselves from breathing in the volcanic ash. A list was provided: wet or remo ve ash outdoors, clean the house, limit time outdoors, keep windows and doors closed, wear a hat, use an umbrella/ parasol, hold a hand over mouth/nose, hold a handkerchief or cloth over mouth/nose, tie a scarf or bandana over mouth/nose, wear a sha wl or veil over face, wear a facemask (any type), other, take no action. F or mask use, they were asked additional questions in which they rated the frequency of usage of fiv e different types of masks (surgical mask, fashion mask, scooter mask, hard cup mask, highefficienc y mask 4) when ash is in the air, on a scale from nev er, sometimes, often, and always. Perceived harm, worry and mask efficacy— The three single-items sho wn below were used to measure each of these constructs. Harm— Respondents were asked if they thought that breathing in volcanic ash might harm their health on a scale from 0 (no harm) to 3 (very harmful). Worry— Respondents were asked whether they were w orried about breathing in volcanic ash on a scale from 0 (not at all worried) to 3 (very worried). Mask efficacy— Respondents were asked how effecti ve they thought each of the different types of masks would be in protecting them from breathing in the volcanic ash on a scale from 0 (not at all effective) to 3 (v ery effective). Although there can be psychometric advantages to using multipleitems when it is important to capture the broader range of meanings associated with a complex, multifaceted psychological construct, singleitems have comparable or equal predictive v alidity when used to assess uni-dimensional constructs, such as ours, that are easy to define, have high face- validity, and are unambiguous in their interpretation [42, 43]. Single-item measures are also less repetitive and time-consuming for respondents, which was an important consideration for our study. Respondents had limited time to complete the surv ey and, in our pilot work, we found that using multiple items to measure similar constructs led to less engagement in the interview. During the pilot phase, respondents complained that their time was being wasted by repeating questions that they felt they had already answered. For example, we found that some respondents were resistant to being asked two measures of perceived harm – one to measure how much harm they thought breathing the ash would hav e on their health (perceived sev erity) and one to measure how likely they thought it was that the y would be harmed by breathing in the ash (perceived probability). Feedback from the pilot suggested 3 The survey included some additional questions that are not relevant to this paper b ut will be reported elsewhere. For example, there were questions in which respondents were asked about the health symptoms they think occur or are made worse by volcanic ash, if they used a mask where they got it from, where they had received information from about the health ef fects of volcanic ash, and (if they had children aged 12 or under) how they protected them from the ashfall. 4 Mask types were identified based on the pilot study in Indonesia (Horwell et al., [12]), local knowledge from the HIVE project team of masks distributed in their communities, and confirmation through piloting in this study that these were recognised forms of protection. Pictures were shown of each type of mask (available on request) and a type of N95 mask was used to represent what we called the ‘high-efficiency mask’. Page 8 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts that the distinction between the two questions was not clear-cut to the respondents. In particular, they considered probability of harm when answering the percei ved severity question (i. e., the degree to which the ash is harmful to their health depends upon how likely it is to affect them). Their perception of the amount of harm caused by the ash could not easily be divorced from its probability of occurrence. Therefore, to av oid what some respondents regarded as a repetitive surv ey, a single measure of perceived harm, which did not differentiate between perceived se verity and perceived probability, was emplo yed. The piloting also highlighted the importance of keeping the rating scales quite short with response options that were clearly distinguishable. In piloting we had originally designed 5- point scales with ‘extremely X’ as the fifth point. Howe ver, feedback from the intervie wers indicated that some respondents found it difficult to discriminate between the response options. Substantial time was being spent on these questions and interviewers were running out of time to complete the survey. W e therefore removed the top item and reduced the ordinal scales to 4-points. Costs and barriers (mask use)— Respondents who said they did not use a facemask to protect themselves from breathing in the volcanic ash were asked to giv e any reasons for not wearing a mask. The following reasons were provided for them to choose from – wearing a mask is difficult, breathing ash doesn’t bother me, breathing ash doesn’t worry me, don’t think I need to wear a mask, don’t think masks are effective, ne ver considered wearing a mask, don’t have a mask, masks are expensi ve, don’t know where to get a mask from, inconvenient to carry mask around, wearing a mask is uncomfortable, wearing a mask would make me too hot, wearing a mask would affect my breathing, wearing a mask would create humidity/ moisture, wearing a mask is embarrassing, it's unfashionable to wear a mask, no- one else/few people wear a mask, masks not easily available, other reasons. 3 Data analysis The statistical software IBM SPSS with AMOS 22 was used to analyse the data. For descriptive information regarding the actions taken during ashf all, ratings of mask use frequency, perceived harm, perceiv ed worry, and reasons for not wearing a mask, percentages or mean values were computed from the ordinal rating scales. Percentages or mean ratings were computed both for the sample as a whole (pooled) and within each country (Japan, Mexico, Indonesia). Hierarchical logistic regressions were used to examine predictors of these actions and ratings with country dummies entered at step 1 and socio- demographic covariates (age, gender, education level, and respiratory illness) entered at step 2. Coefficients are reported as odds-ratios. Since the dependent variables were dichotomous (actions taken, reasons for not wearing a mask) or ordinal (ratings of mask use frequency, mask efficacy, perceiv ed harm, perceived worry) man y of the key assumptions of linear regression and general linear models regarding linearity, normality, and homoscedascity do not apply. The main assumptions for conducting binomial or logistic re gression set out by SPSS were, however, met (;). Page 9 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts The dependent variables were measured on either a dichotomous or ordinal scale; the independent variables are ordinal (age, education level) or cate gorical (country, gender, respiratory illness); and there is no multicollinearity between the independent variables (V ariance Inflation Factors (VIFs) were no greater than 1. 18); there is a linear relationship between any continuous independent variable or ordinal variable treated as continuous (age, education level) and the dependent variable (this was check ed using the Box-Tidwell procedure and in the reporting of the results we highlight a couple of cases where the linearity assumption did not hold); observations are independent and the dependent variables have mutually exclusi ve and exhaustive cate gories. However, the assumption of proportional odds was not met for any of the ordinal regressions. The tests of parallel lines were significant which suggest that the coefficients are dif ferent across response categories. Although we can determine which of our independent variables have a signif icant effect on our dependent variables, we cannot assume that they had identical effects at each cumulati ve split of the dependent variable. In our results we therefore highlight cases where the significance of the coefficients is not consistent at each cumulati ve split. Structural modelling was also used to estimate the coefficients for our theoretical model. The coefficients (non-standardized b values) were estimated using Mark ov chain Monte Carlo (MCMC) maximum likelihood (ML) estimation. Although the statistical assumptions for ML estimation would require that the endogenous (dependent) variables are continuous with a normal distribution, MCMC is an increasingly recognised approach to handling nonstandard conditions of the data, including situations like ours where the data are non- normal and have ordinal rather than interval or ratio properties [44]. 3 Results 3. 1 Protective actions The actions taken by the residents of each country to protect themselves from inhaling ash during heavy ashfall are shown in T able 2. A veraged across all three countries, o ver 80% of residents kept their windows and doors closed (96. 1%), cleaned the house (90. 3%), limited their time outdoors (84. 6%), and wetted/ cleaned the ash outdoors (80. 3%). The other types of actions were not so universally adopted although over half took actions lik e wearing facemasks (75. 0%), hats (67. 5%), or covering their mouth and nose with handkerchiefs (56. 3%) or hands (54. Umbrellas/ parasols (46. 4%), scarfs/ bandanas (35. 4%), or shawls/ veils (24. 8%) were only used by a minority across the whole sample although there were some notable regional differences. T o test for differences between the odds of the actions being adopted in each country, binomial logistic hierarchical regressions were conducted with country dummies entered at step 1 and socio-demographic covariates (age, gender, education level, and respiratory illness) entered at step 2. If the odds-ratio for the country dummy is significant at step 1 and step 2 then the difference between the countries cannot be fully accounted for by differences in the demographic covariates. No single country was significantly more or less likely to adopt all types of actions. There were, however, differences in the relati ve popularity of actions used in each country. The Covey et al. Page 10 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Japanese were most likely to hold a handkerchief or hand over their mouth/ nose, or use an umbrella/parasol, and least likely to wear a scarf/ bandana over their mouth/ nose. The Indonesians were most likely to clean the house, limit their time outdoors, wet/ clean ash outdoors, and wear a facemask but least likely to hold a handkerchief or hand ov er their mouth/nose. The Mexicans were more likely than the Japanese to clean their houses and wear a scarf/bandana over their mouth/ nose but less likely than both of the other countries to wear a hat. It was also notable that, in all but two country contrasts, the inclusion of the demographic covariates at step 2 did not change the significance of the odds-ratios. The dif ferences in the actions adopted among the countries were, therefore, not accounted for by differences in the demographic profiles of the samples. This implies that other factors, such as culture or accessibility issues, are probably more important in shaping which actions are most popular. The exceptions were the differences in limiting time outdoors and facemask use between the Japanese and Mexicans. These country contrasts were significant at step 1 but not at step 2. So, although limiting time outdoors and using masks was more common in the Japanese sample than the Mexican sample, these differences were probably accounted for by differences noted earlier between the samples in education levels (the Japanese sample included more highly educated respondents than the Mexican sample) and/or the incidence of respiratory illness (the incidence of respiratory illness was higher in the Japanese sample) which, as shown in T able 2, were significant cov ariates in step 2 of the model. The covariates identified as signif icant at step 2 also highlight some interesting differences in the actions taken by different demographic groups irrespectiv e of which country they came from. Older people were more likely to wet/ clean ash outdoors and wear a hat whereas younger people were more likely to hold a handkerchief or hand or tie a scarf/ bandana over their mouth/ nose. Females were more likely to keep windows/doors closed, clean the house, limit time outdoors, wear a facemask, hold a handkerchief over their mouth/ nose, use an umbrella/parasol, or wear a shawl/veil over their face. Males, on the other hand, were more likely to wear a hat. More highly educated people were more likely to clean the house, limit time outdoors, wet/clean ash outdoors, wear a facemask, hold a handkerchief over their mouth/nose, or use an umbrella/parasol. Less well educated people were more likely to wear a hat, tie a scarf/bandana over the mouth/nose or wear a shawl/ veil o ver their face. Finally, people with a respiratory illness were more likely to wear a facemask or shawl/ veil over their face. 3. 2 Frequency of mask use As shown in T able 3, respondents’ ratings of their frequency of usage of different types of masks identified that surgical masks were, by far, the most commonly used type of mask in all three countries. However, they were not used all of the time during ashfall by e veryone. In Japan and Mexico, less than half of the people who said they had used a surgical mask said they used it all of the time. Consistent use was more common in Indonesia, with over half of the people who said they had used a surgical mask wearing one all of the time. T o test for differences between the countries in mask use frequency, ordinal logistic hierarchical regressions were conducted with country dummies entered at step 1 and Covey et al. Page 11 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts demographic covariates entered at step 2. For this analysis, mask use frequency w as coded 0 (never), 0. 5 (sometimes or often), and 1 (always). If the coef ficient for the country dummy is significant at step 1 and step 2, then the difference between the countries cannot be fully accounted for by differences in the demographic covariates included in the model. As shown in T able 4, the country contrasts that were significant indicate that ratings of mask use frequency were higher in the Indonesian sample (M = 0. 80) compared to the Mexican (M = 0. 45) and Japanese sample (M = 0. 44). Although females, more highly educated people, and people with respiratory illness wore masks more often, these effects did not account for these differences (the country contrasts were still significant at step 2). Howe ver, it is worth noting that, although the analysis reported previously showed that the Mexicans were less likely to use facemasks than the Japanese, this contrast shows that the frequency of mask use was not significantly different. If the Mexicans w ore a mask, they were more likely than the Japanese to use it ‘always’ (27. 1% vs. 20. 3%) rather than ‘sometimes/ often’ (34. 9% vs. 47. This illustrates how our measure of mask use frequency provides a more sensitive measure of the extent of people's mitigation beha viour than the simple yes/ no question which asks whether or not they used a mask which does not tell us whether people are using masks consistently or not. T able 4 also shows descriptive statistics for the ratings of mask ef ficacy, perceiv ed harm and perceived worry. The results show that the Indonesians (who used masks most frequently) gave the highest ratings of mask eff icacy, perceived harm and percei ved worry. The Mexicans also rated these constructs significantly higher than the Japanese. This pattern of results is therefore not entirely consistent with our theoretical model which predicted that people who used masks more often would perceive masks to be more effecti ve protection (perceived mask eff icacy) and would perceive inhaling the ash to be more harmful to their health and be more worried about the effects of the ash on their health (perceiv ed harm/ worry). Although the Indonesians’ higher ratings of efficacy, harm and worry matched their higher frequency of mask use, the Mexicans’ higher ratings of these cognitive constructs did not. A more formal test of our theoretical model was conducted by estimating structural equation models for each country in IBM SPSS AMOS 22. The models estimated the total effects and direct effects of the geographical and demographic variables on mask use and the indirect effects through perceptions of mask efficac y and harm/ worry. Harm/ worry was represented by a latent variable measured by two highly correlated indicator variables, Harm and W orry (Mexico rs = 0. 536***, Japan rs = 0. 714***, Indonesia rs = 0. 550***), each of which each of which have measurement error terms (e1 and e2). Coefficients (unstandardized b values) for each structural ef fect shown in Fig. 2 were estimated using Markov chain Monte Carlo (MCMC) maximum likelihood estimation. T o test whether the structural models were equivalent or not between the countries, multiple group analysis was conducted in AMOS 22. T able 5 shows the estimated coefficients for the total ef fects, indirect effects and direct effects with significant cov ariances and paths illustrated in Fig. Some important similarities and differences in the estimated coefficients are apparent. Page 12 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts In terms of similarities, in all three countries it is notable from Fig. 3 that there was significant covariance between location and educational le vel (positive coef ficients: Japan b = 0. 069, Indonesia b = 0. 064, Mexico b = 0. 345) and age and education level (negati ve coefficients: Japan b = −0. 194, Indonesia b = −0. 061; Mexico b = −0. 267). These ef fects show that older people were less well educated than younger people and people living in the urban locations were more highly educated than people living in the rural locations. The effects were particularly strong in the Mexican sample which is in line with the census data where less than 10% of people in the rural location are educated to high school level compared to nearly 50% in the urban location. When interpreting the total effects of these variables we therefore need to be mindful of the possibility of multicollinearity whereby the estimated coefficient for any one v ariable (i. e., education) will depend on which other variables are included in the model (i. e., location and age). That being said, the V ariance Inflation Factors (VIFs) for location, education and age, even in the Mexican data, are all below the conservativ e cutoff value of 2. 50 (VIFs Me xico ≤ 1. 96, Indonesia ≤ 1. 04, Japan ≤ 1. 18). In terms of differences, although the coefficients for the total ef fects of mask efficac y were positive and significant in all three countries (i. e., residents who rated masks as more effective wore masks more frequently), multiple group analysis sho wed that the coefficient was significantly larger in Mexico compared to Japan ( χ 2 (1) = 27. 8, p <. 001) and Indonesia ( χ 2 (1) 10. 4, p =. 001). Also, the coefficients for the total effects of harm/ w orry were significant and positive in Japan and Indonesia (residents who rated the ash as more harmful, and were more worried about the ash, wore masks more frequently) but not significant in Mexico. Multiple group analysis also showed that the coef ficient was significantly larger in Japan compared to Indonesia ( χ 2 (1) = 13. 2, p <. The relativ e strengths of these coefficients also has implications for the ability of the harm/ worry and mask efficacy constructs to e xplain the total effects of the demographic and geographical variants of mask use. Fig. 3 also illustrates the differences in the total and indirect effects found for each country by showing only paths with significant coeff icients (indirect effects are shown by a path from the variant to mask use via either mask efficac y or harm/ worry). The direction of the indirect effects can only be confirmed, howe ver, by the data pro vided in T able 5. In some instances outlined below, where the sign of the coefficient for the indirect ef fect is opposite to the sign of the coefficient for the total effect, there is e vidence of inconsistent mediation [47]. 1 Location (Urban vs. Rural)— In Mexico, the total effect of location was positiv e and partially mediated by mask efficacy. This suggests that residents from the urban location of Puebla city used masks more frequently than residents from the rural location of Santiago Xalitzintla partly because they had a stronger belief in the efficac y of masks. The positive total effect of location that w as found in Indonesia (i. e., residents from the urban location of Y ogyakarta city used masks more frequently than residents from the rural location of Sleman district) could not however be e xplained in this way. Although the indirect effect via mask efficac y was significant, it is notable from T able 5 that the sign of Covey et al. Page 13 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts the coefficient for the indirect effects w as the opposite sign (–0. 024) to the coefficient for the total effect (0. 047). This, therefore, reflects inconsistent mediation [47] and suggests that, although the overall effect of li ving in the urban Indonesian location, rather than rural location, was to increase mask use, this particular mediational path had the opposite effect. People living in the urban location had weaker beliefs about mask eff icacy than people in the rural location which reduced their frequency of mask use. T o produce the total effect, other factors unrelated to beliefs about mask efficacy must, therefore, ha ve been increasing mask use in the urban sample. Although the total effect of location in the Japanese sample was not significant, a signif icant and negative indirect ef fect via mask efficacy w as found. So, like the urban Indonesian sample, people living in the Y oshino district of Kagoshima city had weaker beliefs about mask efficacy than those li ving in the rural areas around Sakurajima Island which reduced their frequency of mask use. T o end up with a nonsignificant total effect of location, other factors not included in our analysis must have increased mask use in the urban sample to cancel out the negative, indirect ef fect via mask efficacy. 2 Age— The positive total effect of age that was found in Japan was partially mediated by perceived harm/ worry which suggests that one of the reasons why older people in Japan were more likely to use masks than younger people was because they perceived the ash to be more harmful and were more worried about the effects of the ash. According to the results of this study, neither harm/w orry or mask efficacy mediated the negative total ef fect of age in the Mexican sample. Factors not included in our model must have reduced the frequency of mask use in older people relati ve to younger people. The total effect of age was not significant in the Indonesian sample and no significant indirect effects were found. 3 Gender— Neither harm/ worry or mask efficacy mediated the ne gative total ef fect of gender in the Japanese sample. Males were less likely to use masks than females and this difference was not explained by dif ferences in their perceptions of mask efficacy or perceived harm/ worry. Results shown here indicate that the total effect of gender was not signif icant in either Mexico or Indonesia and no significant indirect effects were found. 4 Education level— The positive total ef fect of education level that was found in the Japanese sample was partially mediated by mask efficacy. This suggests that one of the reasons why more highly educated people in Japan were more likely to use masks was because they perceived masks to be more ef fective. Although the model showed that the total effect of education le vel was not significant in the Mexican sample, an indirect effect via mask eff icacy was significant and positi ve. Although this might suggest that other factors, not included in our analysis, reduced mask use in the more highly educated sample to cancel out the positive indirect effect via mask ef ficacy, it is perhaps more likely that the non-significant total effect was attrib utable to the inclusion of Covey et al. Page 14 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts other predictors in the model that were significantly related to education level (i. This interpretation is supported by the finding that the removal of either age or location from the model resulted in a significant total effect of education. This suggests that the better educated people in the sample were using masks more frequently because they perceived masks to be more effecti ve, but that this relationship might be partly attributable to the fact that they were younger or more likely to be living in the urban areas. The total effect of education was not significant in the Indonesian sample and no significant indirect effects were found. 5 Respiratory illness— The positive total effect of respiratory illness in the Japanese sample was partially mediated by perceptions of harm/ worry. People with respiratory illness were more likely to use masks more frequently because they perceived the ash to be more harmful and were more worried about the effects of the ash. The positive total effect of respiratory illness in the Indonesian sample could not ho wever be explained in this way. No significant indirect effects were found. The total effects of respiratory illness were not significant in Mexico and no signif icant indirect effects were found. 3 Reasons for not wearing masks The structural models show that beliefs about mask efficac y and/ or perceptions of harm/ worry make significant contributions to determining the frequency of mask use and to explaining some sources of variance in mask use. Howe ver, their predicti ve ability is not entirely consistent across all three countries. Perceptions of harm/ worry played a stronger role in the Japanese sample whereas beliefs about mask efficacy played a stronger role in the Mexican sample. T o some degree, therefore, different factors moti vate mask use in the different countries. This difference can also be illustrated by dif ferences in the types of reasons given by residents who said they had not worn a mask, as sho wn in T able 6. In the Japanese sample 243 respondents had not worn a mask during ashfall and the most common reasons were that they had never considered wearing a mask (46. 1%) or that the mask would affect their breathing (41. 2%). Around a third of the sample who did not wear a mask considered masks as inconvenient to carry around (33. 7%) and around a quarter were not bothered by breathing in the ash (24. 7%) and/or thought masks were uncomfortable (24. 7%). Notably, self-ef ficacy and cost or accessibility issues were not frequently giv en reasons. Only 4. 2% of respondents gave the reason that wearing a mask was dif ficult and only 1. 2% of respondents gave the reason that masks were too expensi ve, 0. 8% that they were not easily available and no one said that they did not kno w where to get a mask from. Being unfashionable (3. 7%) or embarrassing to wear (4. 1%) were also rarely given reasons. In the Mexican sample 249 people had not worn masks and not having a mask was the most common reason (57. Comfort was also an important factor (42. 6%) and, to a lesser degree, factors such as the perceptions that no one else was wearing a mask (34. 9%). Around a quarter to a third of those who did not wear a mask had just not considered Covey et al. Page 15 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts wearing one (31. 3%), didn’t think they needed to wear one (28. 3%), were not bothered by the ash (27. 7%), or didn’t know where to get one (24. 1%). Although a slightly higher percentage of the non-mask wearers in Mexico identified self-eff icacy and cost as issues compared to Japan, the numbers finding masks difficult to wear (6. 0%) or e xpensive were still in a minority (12. Only 4 of the Indonesians said they had not worn a mask so analysis of the reasons for not wearing a mask in this sample is somewhat limited. But reasons identified by at least two of the four included issues with humidity/ moisture (50%), never considered wearing a mask (50%), or didn’t think they needed to wear a mask (50%). Within the Japanese and Mexican samples, we also explored whether the reasons for not using masks differed according to socio-demographic covariates (location, age, gender, education level, and respiratory illness) using binomial logistic regressions. These analyses were only conducted on reasons given by at least 10% of the sample and for most of the reasons there were no significant covariates. In the Japanese sample the following reasons for not wearing a mask were more likely to be given by: people living in rural locations (‘W earing a mask w ould make me too hot’ OR=2. 04, p = 0. 040); males or more highly educated people (‘W earing a mask is uncomfortable’ OR = 2. 72, p = 0. 015, OR = 1. 74, p = 0. 038); and people with respiratory illness (‘Breathing ash doesn’t bother me’ OR = 2. 68, p = 0. 023). In the Mexican sample the following reasons for not wearing a mask were more likely to be given by: people living in rural locations (‘Don’t think I need to wear a mask’ OR=2. 75, p = 0. 018; ‘Don’t know where to get a mask from’ OR=2. 69, p =. 032; ‘Masks not easily available’ OR=4. 86, p = 0. 025; ‘None else/few people wear masks’ OR = 3. 05, p = 0. 006); younger people (‘Breathing ash doesn’t bother me’, OR = 1. 54, p = 0. 034; ‘W earing a mask would make me too hot’ OR = 1. 72; p = 0. 021); and males or people with respiratory illness (‘Don’t think masks are effective’ OR=2. 97, p = 0. 018, OR = 3. 56, p = 0. 022). 4 Discussion The aim of this study was to document the types of respiratory protection from volcanic ash used by communities living near volcanoes in three countries – i. e., Japan (Sakurajima), Mexico (Popocatépetl) and Indonesia (Merapi, Kelud). W e also in vestigated how the use of respiratory protection varied according to a range of geographical and demographic characteristics and tested whether there are differences in the factors which influence people's motivations to take precautionary action. The survey demonstrated that the large majority of respondents from all three communities used basic methods to protect themselves from inhaling ash, such as keeping windows and doors closed, limiting time outdoors, cleaning the house, and wetting the ash outdoors. This is encouraging as it seems that people are following national and international guidelines on ash protection (e. g., those issued by CENAPRED ( www), the W orld Health Organization ( www) or the International V olcanic Health Hazard Network ( www g/ash-pamphlets)). Page 16 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Some actions were, however, more popular in certain countries – i. e., umbrellas/ parasols in Japan, wearing scarf or bandana over mouth/ nose in Mexico, and use of facemasks in Indonesia. These differences were not fully accounted for by differences in the demographic profiles of the communities which suggests they might reflect more general cultural or contextual differences. For example, umbrellas ha ve long been a feature of daily life in Japan. It is commonplace for Japanese people to carry umbrellas as protection from either the sun or the rain (see, e. So, using an umbrella as protection against ashfall when there is an eruption is a convenient extension to its other uses. The increased facemask use in Indonesia might also have reflected differences in the conte xt in which the community experienced the ashfall. [12], the ashfall in Y ogyakarta in the aftermath of the Kelud eruption in 2014 w as unexpected and prompted a quick response from local government and NGOs which included distributing facemasks and issuing advice (through a large volunteer network) to residents to use facial protection. This contrasts with the ashfall experiences of the communities living near Popocatépetl and Sakurajima, where eruptions are relatively frequent and ashfall is not an unusual occurrence. The unexpected nature of the Kelud ashfall in Y ogyakarta Province, and the government response, at least partially explains the increased facemask use (nearly 62% of residents said they had used a facemask all of the time) but this might also hav e contributed to raising concerns about the possibility that the ash might be harmful and beliefs about the effectiveness of masks (perceptions of harm/ w orry and beliefs about mask efficacy were significantly higher in the Indonesian sample than the other two samples). Being advised to use facial protection and being provided with a mask not only sends a strong message that there must be something to worry about but also implies that the masks being distributed (which were basic surgical masks) provide some useful level of protection. The roles of perceived harm/ worry and beliefs about mask ef ficacy in determining facemask use were central cognitive constructs in the theoretical model we proposed to explain variance in protective actions. The model's premises that people who used masks most frequently would be more concerned and worried about the harmful effects of the ash and believe masks to be more effecti ve were supported. Howe ver, the multi-group modelling showed that the predictive ability of each construct w as not entirely consistent across the communities. Although the Japanese sample were, on average, less concerned and worried about the harmful effects of the ash than either the Mexican or Indonesian samples (possibly due to the lack of intervention and information from governmental agencies), perceptions of harm/ worry were a stronger predictor of variations in mask use frequency within the Japanese sample. The Japanese residents who were most concerned and worried about the ash used masks more frequently. Percei ved harm/ worry was also a significant (if some what weaker) predictor of variations in mask use frequency within the Indonesian sample but, within the Covey et al. Page 17 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Mexican sample, it was not significant. The degree to which the Mexican residents were concerned and worried about the ash did not influence their mask use and the more worried residents did not use masks more frequently than the less worried residents. Perhaps the costs and barriers to mask use are more influential than their concerns about the ash, particularly for those Mexicans living in the rural areas who are also less con vinced, than those living in the urban areas, about whether masks offer ef fective protection. Beliefs about mask efficacy predicted v ariations in mask use frequency in all three communities and the effect was strongest in Mexico. Residents recruited from the urban areas of Puebla city, who were generally more highly educated, used masks more frequently and believed masks were more effecti ve than residents recruited from the rural community of Santiago Xalitzintla. Stronger beliefs about mask efficacy also mediated dif ferences in mask use frequency between the urban and rural residents in Japan and Indonesia. Howev er, in both of these locations, it was the residents from the rural rather than urban locations who perceived masks as more effecti ve. Although these findings highlight the explanatory value of the cogniti ve constructs as mediators of variants in mask use, a number of effects were left unaccounted for. For example, beliefs about mask efficac y could only partly account for differences in mask use between the rural and urban communities and we need to consider what additional unmeasured factors might be increasing mask use in the urban residents or reducing mask use in rural residents. People who live in cities may simply have better access to masks and the use of masks for a range of reasons, such as avoiding urban air pollution or for protection against communicable health threats, may have become normalised. W e hav e some evidence of this from our analysis of the reasons for not wearing masks where, in the Mexican sample, residents from the rural location were more likely to give reasons which suggested that masks were not easily available or that they percei ved very few people to be wearing masks. The more widespread use of masks in urban settings is also evident in Japan and Indonesia. Mask use is a common sight in Japanese city dwellers and has become embedded in the culture as routine practice to protect themselves and others against a range of health threats [48]. It has also become quite common for people to wear facemasks in Indonesia, especially when riding on mopeds, to protect from vehicle emissions and road dust (see e. g., ws/2014/09/18/commuters-complain-worsening-air). The effects of gender in the Japanese sample were also unaccounted for. Females used masks more frequently than males but gender had no effect either on perceptions of harm/ worry or beliefs about mask efficacy. Additional factors therefore need to be considered to explain these effects: women's decisions to wear masks (or men's decisions not to wear masks) could depend on several factors that hav e nothing to do with protection motivation from ash, such as custom, affordability, availability, comfort, and aesthetics. W e hav e some evidence from this study that men might be less inclined to wear masks because they find them more uncomfortable (the Japanese males in our study were more likely than females to give ‘wearing a mask is uncomfortable’ as a reason for not wearing one). The reasons why women might be more inclined to wear masks is more speculative, howe ver. Perhaps women Covey et al. Page 18 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts are more likely to use masks for social reasons such as combatting shyness, hiding their emotions, protecting their modesty or because they view masks as a fashion item [49, 50]. However plausible these suggestions might be, gi ven the increasing recognition of the impact of gender on health outcomes [e. g., 51], further study is warranted to understand why mask use differs between males and females. Whilst we can conclude that mask use for ash protection is relatively common across our three geographical locations, in Japan and Mexico, approximately one third of study participants never wear one for this purpose. The primary reasons giv en were different, however. In Japan, almost half of those respondents had simply nev er considered wearing a mask (for this purpose). People were also bothered by the inconvenience of carrying a mask and 41% were concerned it would affect breathing. In Mexico, the primary reason (57%) was that people did not have a mask, which might relate to the fact that 38% said they didn’t think they needed to wear one and 35% said nobody else/ few people wore a mask, indicating an influence of peer learning and pressure. However, 43% stated that they found masks to be uncomfortable. It was notable, however, that fewer respondents in Japan or Mexico said that they wouldn’t wear a mask due to being too hot (24% and 19%) or due to creation of humidity/ moisture (11% and 14%) despite daytime temperatures averaging above 25 °C over the summer months. This suggests that the warm climate in these surv ey regions was not a major barrier to mask use, a conclusion supported by the high uptake of mask wearing in Indonesia (96%) where the climate is very humid and hot throughout the year. Gi ven that the most common mask used is a surgical mask, which tends to fit loosely, this result is not surprising. If agencies start to distribute more effectiv e and well-fitting, industrycertified masks, climate may become more of a barrier to their uptake. 5 Conclusions and implications This study has contributed to our understanding of the reasons why people take actions to protect themselves from inhaling volcanic ash. From a theoretical perspective, it w as particularly notable that the predictive ability of the perceiv ed harm/ worry and mask efficacy cogniti ve constructs varied among the three communities. The relativ e contributions that each construct makes at explaining mask use frequency is not equiv alent and highlights the importance of not assuming that theoretical constructs identified as important predictors in one sample will necessarily be important predictors in other samples. This unique insight could only be gained from the methods employed here, where exactly the same methods were used to collect and analyse the data from all three communities. That being said, our theoretical model was, by design, quite simple, which limits the breadth of our understanding of the factors which motivate people to protect themselves. Although the two central psychological constructs were derived from the threat appraisal (harm/ worry) and coping appraisal (mask efficacy) constructs of PMT, the single-items used to measure these constructs did not enable us to separate out, for example, the predictive abilities of perceptions of severity of harm from perceptions of probability of harm. But this limitation should not detract from the importance of our findings and the implications that they could have for policy and interv ention. Page 19 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts By understanding the reasons why people take actions to protect themselves from ashfall, we have identified some approaches that might be used if agencies wanted to encourage people in these communities to use masks more consistently. F or example, in all three communities, people were more likely to wear masks if they believed them to be more ef fective, so if agencies can convince people that the masks offered will protect them (assuming that effective protection is of fered), they may be able to increase people's motiv ation to use masks more often, if climatic factors do not demotivate them. W e might e xpect that this approach would be most effectiv e in the Mexican communities where beliefs about mask efficacy were the strongest predictor. Moreover, less well-educated Mexicans, who liv e in the rural area, are probably most worth targeting with this type of approach because they have weaker beliefs about mask eff icacy than more highly educated Mexicans who liv e in the urban area. In Japan and Indonesia, on the other hand, it might be more beneficial to focus on raising people's knowledge about the potentially harmful effects of volcanic ash, perhaps through providing information or education. However, there could be ethical issues inv olved in interventions which target beliefs about mask efficacy or perceptions of harm/ worry. These interventions assume, of course, that it is correct for people to believe that breathing the ash is harmful to their health and something they should be concerned about and that a given mask is a highly ef fective form of protection. Both of these assumptions are questionable. Although ash inhalation might exacerbate respiratory problems in susceptible people [2], and limiting chronic exposure is probably advisable [52], there is a lack of evidence that it will have serious health consequences for most people [3], although the toxicity of ash appears to vary even within the same eruption sequence [5]. An intervention approach which specifically aims to raise concerns and worry people about the harmful effects of ash might, therefore, be unadvisable. An approach which addresses beliefs about mask efficacy will be more ethically sound. People need to know what level of protection is of fered by different types of masks or respiratory protection so that they can make an informed choice about what to wear [53]. Results from another workstream within the HIVE project provide the first data on the effectiveness of dif ferent forms of respiratory protection worn when volcanic ash is in the air [14, 15]. What these studies show is that the most effecti ve respiratory protection for adults is to wear a well-fitting, industry-certified mask such as an N95 mask (referred to in this study survey as a high efficienc y mask). Other types of masks, like the standard surgical mask, will provide less protection; although they may effecti vely filter ash [14], they often do not fit well to the face [15]. Updated advice on the IVHHN website emphasises the importance of a good fit and provides illustration of how to ensure a good f it ( ash-protection and facemask-leaflet). Acknowledgements The authors would like to thank the following individuals and members of the advisory board for assisting with various aspects of the design and conduct of the survey: T akeshi Baba, Peter Baxter, Mark Booth, Mik e Clayton, Djoni Ferdiwajaya, Rita Fonseca, Robert Gougelet, Makoto Hagino, Claudia Merli, Satoru Nishimura, Ernesto Schwartz-Marin, Ciro Ugarte and colleagues from the School of Public Health at Teik yo University, Japan (especially Mari Nishino and Y oshiharu Fukuda). Thanks to all of the participants who took part in the survey, and research assistants who helped conduct the questionnaires. Page 20 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Funding source The research was funded through the Health Interventions in V olcanic Eruptions project (HIVE) by ELRHA under the Research for Health in Humanitarian Crises (R2HC) programme (Grant Number 14048). 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Ethical considerations of recommending or distrib uting facemasks for community protection from ambient air pollution eventsProceedings of the IHRR/Dealing with Disasters Conference. Durham, UK: 2017. Page 23 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Fig. Proposed model to explain variance in protectiv e actions. Page 24 Int J Disaster Risk Reduct. Structural Equation Model estimated in AMOS 22 (all coefficients). Observed (measured) variables are shown in rectangles and unobserved (latent/unmeasured) v ariables in circles or ellipses. In this model the latent variable (Harm/ worry) is measured by two indicator variables, Harm and W orry, each of which have measurement error terms (e1 and e2). Residual error terms (or disturbances) are also associated with each dependent (endogenous) variable in the structural model (e3-e5). Some of the paths shown in the diagram are labelled with the number “1”. This means that those paths’ coefficients hav e fixed values set to 1. 00. These fixed values are necessary to set the scale of measurement for the latent factors and residuals. Covariances between the exogenous v ariables are shown with double ended arrows. Page 25 Int J Disaster Risk Reduct. Structural Equation Models for each country. Signif icant covariances between the exogenous variables and path coefficients are denoted in red (positi ve coeff icient) or blue (negative coefficient). Significant total ef fects are denoted by a red (positive coef ficient) or blue (negative coef ficient) border surrounding the variable. For e xample, in the Mexican sample, the border surrounding ‘location’ is red, which indicates that the total effect of location on mask use is positive (i. e., people living in the urban location used masks more frequently than people living in the rural location). In contrast, the border surrounding ‘age’ is blue, which indicates that the total effect of age on mask use is negativ e (i. e., older people used masks less frequently than younger people). Page 26 Int J Disaster Risk Reduct. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Covey et al. Page 27 Tab le 1 Demographic characteristics of respondents. Japan (N = 749) Mexico (N = 654) Indonesia (N = 600) N (%) Census N (%) Census N (%) Census Urban 431 (57. 5%) 320 (48. 9%) 300 (50. 0%) Rural 318 (42. 5%) 334 (51. 1%) 300 (50. 0%) Age group 13-39 years 218 (29. 1%) 36. 0% 357 (54. 6%) 57. 5% 305 (50. 8%) 54. 0% 40-59 years 223 (29. 8%) 25. 0% 160 (24. 5%) 23. 5% 179 (29. 8%) 32. 5% 60+ years 308 (41. 1%) 39. 0% 137 (20. 9%) 19. 0% 116 (19. 3%) 13. 5% Gender Male 325 (43. 4%) 46. 5% 307 (46. 9%) 47. 5% 294 (49. 0%) 49. 0% Female 424 (56. 6%) 53. 5% 347 (53. 1%) 52. 5% 306 (51. 0%) 51. 0% Education (highest level) No formal education 12 (1. 6%) 34. 3% a 127 (19. 4%) 71. 9% a 30 (5. 0%) 48. 5% a Primary/Junior high 84 (11. 2%) 274 (41. 9%) 261 (43. 5%) High school 310 (41. 4%) 65. 7% b 83 (12. 7%) 28. 1% b 217 (36. 2%) 51. 5% b College / graduate 300 (40. 1%) 170 (26. 0%) 92 (15. 3%) Missing 45 (5. 7%) – – Occupational status Full-time paid work 210 (28. 0%) 146 (22. 3%) 182 (30. 3%) Part-time paid work 141 (18. 8%) 42 (6. 4%) 29 (4. 8%) Self-employed 56 (7. 5%) 198 (30. 3%) 96 (16. 0%) Looking after family 14 (1. 9%) 94 (1. 1%) 101 (16. 8%) In training/education 32 (4. 3%) 72 (14. 4%) 141 (23. 5%) Retired 33 (4. 4%) 32 (4. 9%) 29 (4. 8%) Not working 206 (27. 5%) 58 (8. 9%) 21 (3. 5%) Other 18 (2. 4%) 0 (0%) 1 (0. 15%) Missing 34 (4. 5%) 5 (0. 8%) - Respiratory health problem One or more 177 (23. 6%) 95 (14. 5%) 97 (16. 2%) Asthma 48 (6. 4%) 22 (3. 4%) 43 (7. 2%) Bronchitis 23 (3. 1%) 20 (3. 1%) 6 (1. 0%) COPD 3 (0. 4%) 5 (0. 8%) 1 (0. 15%) Lung cancer 1 (0. 15%) 2 (0. 3%) 0 (0%) Cystic fibrosis 0 (0%) 1 (0. 15%) 0 (0%) Tuberculosis 0 (0%) 1 (0. 15%) 1 (0. 15%) Allergic rhinitis 142 (19. 0%) 47 (7. 2%) 23 (3. 8%) Other c 4 (0. 5%) 19 (2. 9%) 32 (5. 3%) When they last noticed ash in the air Last 24 hours 23 (3. 1%) 35 (5. 4%) 0 (0%) Int J Disaster Risk Reduct. Author manuscript; available in PMC 2019 September 04. Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts Covey et al. Page 28 Japan (N = 749) Mexico (N = 654) Indonesia (N = 600) N (%) Census N (%) Census N (%) Census Few days ago 51 (6. 8%) 211 (32. 3%) 1 (0. 15%) About a week ago 34 (4. 5%) 103 (15. 7%) 1 (0. 15%) About a month ago 103 (13. 8%) 264 (40. 4%) 1 (1. 3%) Few months ago 430 (57. 4%) 36 (5. 5%) 8 (1. 3%) About a year ago 53 (7. 1%) 2 (0. 5%) 27 (4. 5%) More than year ago 55 (7. 3%) 3 (0. 5%) 562 (93. 7%) Notes: a This census% refers to the combined percentages for No formal education and Primary/ Junior high b This census% refers to the combined percentages for High school and College/ graduate c Other types of respiratory health problems included dust allergy, shortness of breath, sinusitis, nose irritation, pneumonia, colds, flu, sore throat and persistent cough. Page 29 Tab le 2 Actions taken during heavy ashfall. Country contrasts 1 Covariates (Odds-ratios) Pooled Japan Mexico Indonesia Age Gender (1 = male) Education level Respiratory illness (1 = yes) Windows/ doors closed 96. 1% 96. 9% ac 93. 3% b 98. 2% c 0. 81 0. 39 *** 1. 29 1. 59 Clean house 90. 3% 84. 8% a 90. 8% b 96. 5% c 1. 20 0. 51 *** 1. 30 ** 0. 91 Limit time outdoors 84. 6% 85. 2% a 2 77. 2% b 2 91. 8% c 0. 89 0. 49 *** 1. 57 *** 1. 27 Wet/ clean ash outdoors 80. 3% 75. 2% a 73. 7% ab 94. 0% c 1. 48 *** 0. 82 1. 19 *, 3 1. 06 Wear facemask 75. 0% 67. 6% a 2 61. 8% b 2 98. 8% c 1. 00 0. 74 ** 1. 50 *** 1. 91 *** Wear a hat 67. 5% 75. 3% a 50. 6% b 76. 2% ac 1. 42 *** 1. 42 ** 0. 69 *** 0. 91 Handkerchief over mouth/nose 56. 3% 72. 5% a 51. 8% b 41. 0% c 0. 77 *** 0. 73 ** 1. 19 ** 1. 10 Hand over mouth/nose 54. 3% 71. 6% a 49. 8% b 37. 67 *** 0. 83 1. 03 1. 22 Use an umbrella/ parasol 46. 4% 65. 0% a 15. 7% b 56. 5% c 0. 31 *** 0. 99 Scarf/ bandana over mouth/nose 35. 4% 25. 2% a 39. 8% b 43. 3% b 0. 69 ***, 4 0. 89 * 1. 25 Shawl/veil over face 24. 8% 23. 6% a 18. 2% b 33. 3% c 0. 98 0. 34 *** 0. 87 * 1. 36 * Other 5 5. 7% 0. 8% 5. 4% 12. 2% – – – – Notes: * p <. 05. ** p <. 01. *** p <. 001. 1 For countries with a different superscript letter the difference is significant (p <. 05). F or countries with the same superscript letter the difference is not significant (p <. 2 The difference between these countries was not significant at step 2 when the covariates were included in the model. 3 Although this covariate is significant, the assumption of linearity between the independent variable (education le vel) and dependent variable (wet/ clean ash outdoors) does not hold. Analysis of educational level as a categorical rather than ordinal variable sho wed that those educated to high school or graduate level were significantly more likely to undertake this action than those with no formal education (ORs 2. 28 ** 1. 91 **), but that there was no difference between those with high school and graduate qualifications (OR 1. 20). 4 Although this covariate is significant, the assumption of linearity between the independent variable (age) and dependent v ariable (wear a scarf/ bandana over the mouth/nose) does not hold. Analysis of age as a categorical variable showed that those aged 40–59 or 60+ years were less lik ely to undertake this action than those aged 13–39 years (ORs 0. 57 *** 0. 50 ***), but that there was no difference between those aged 40–59 and 60+ (OR 1. 14). 5 Other types of actions taken to avoid breathing in the ash included shutting car windows, not going out, wearing a cap (as opposed to a hat), or putting a cloth in the mouth, or sweatshirt over the face. Page 30 Tab le 3 Frequency of use of different types of facemask. Japan Mexico Indonesia Always Sometimes/ often Never Always Sometimes/ often Never Always Sometimes/ often Never Surgical mask 19. 4% 44. 8% 35. 8% 25. 4% 34. 1% 40. 5% 58. 8% 39. 3% 1. 8% Fashion mask 1. 1% 4. 3% 94. 2% 2. 9% 96. 9% 2. 5% 13. 2% Scooter mask 0. 5% 98. 3% 0. 5% 0. 8% 98. 8% 6. 7% 12. 5% 80. 8% Hard cup mask 0. 7% 4. 9% 94. 4% 3. 4% 5. 5% 91. 1% 0. 5% 6. 5% 93. 0% High-efficiency mask 0. 7% 3. 9% 95. 6% 1. 8% 97. 2% 3. 3% 95. 5% Int J Disaster Risk Reduct. Page 31 Tab le 4 Country contrasts in mask use frequency, beliefs about mask eff icacy and perceptions of harm and worry. Country contrast 1 Covariates (Odds-ratios) Japan Mexico Indonesia Age Gender (1 = male) Education level Respiratory Illness (1 = yes) Mask use frequency 2 Never (0) 32. 4% 38. 1% 1. 2% Sometimes/ often (0. 5) 47. 3% 34. 9% 37. 2% Always (1) 20. 3% 27. 1% 61. 7% – – – – Mean (SD) 0. 44 a (0. 36) 0. 45 a (0. 40) 0. 80 b (0. 26) 1. 02 0. 68 *** 1. 48 *** 1. 58 ** Mask efficacy 2 Not at all effective (0) 3. 7% 7. 2% 0. 5% A little effective (1) 32. 7% 16. 4% 1. 5% Quite effective (2) 44. 5% 27. 8% 19. 0% V ery effective (3) 17. 2% 45. 9% 79. 0% – – – – Mean (SD) 1. 77 a (0. 78) 2. 16 b (0. 96) 2. 74 c (0. 49) 1. 11 1. 06 1. 24 *** 1. 04 Perceived harm No harm (0) 10. 2% A little harmful (1) 50. 3% 13. 6% 3. 3% Quite harmful (2) 21. 1% 30. 1% 23. 0% V ery harmful (3) 13. 6% 48. 8% 72. 5% Can’t say 4. 10% 1. 40% 0 – – – – Mean (SD) 1. 39 a (0. 87) 2. 23 b (0. 60) 2. 67 c (0. 91) 0. 91 1. 21 ***, 3 1. 34 *, 4 Perceived worry Not at all (0) 11. 1% 13. 3% 2. 58% A little worried (1) 53. 0% 23. 5% 4. 5% Quite worried (2) 19. 4% 31. 8% 28. 2% V ery worried (3) 13. 5% 30. 7% 65. 5% Can’t say 3. 6% 0. 15% – – – – Mean (SD) 1. 32 a (0. 86) 1. 66) 2. 58 c (1. 02) 1. 04 0. 86 1. 12 *, 5 1. 49 **, 6 Notes: * p <. 05) at step 1 and step 2. 2 The mask use frequency and efficacy ratings shown in this table refer to the ratings respondents g ave to the type of mask that they said they used most often. 3 This coefficient was not significant when the dependent variable w as dichotomised 0 = 0, 1, 2 1 = 3. Page 32 4 This coefficient was only significant when the dependent v ariable was dichotomised 0 = 0, 1 1 = 2, 3. 5 This coefficient was only significant when the dependent v ariable was dichotomised 0 = 0, 1 = 1, 2, 3. 6 This coefficient was only significant when the dependent v ariable was dichotomised 0 = 0, 1, 1 = 2, 3. Page 33 Tab le 5 Estimated total, indirect and direct effects from the structural equation models (b coeff icients). Japan Mexico Indonesia Total effect Indirect effect (harm/ worry) Indirect effect (mask efficacy) Direct effect Total effect Indirect effect (harm/ worry) Indirect effect (mask efficacy) Direct effect Total effect Indirect effect (harm/ worry) Indirect effect (mask efficacy) Direct effect Harm/worry 1 0. 157 ** − − − 0. 026 − − − 0. 039 * − − − Mask efficacy 0. 056 ** − − − 0. 172 ** − − − 0. 089 ** − − − Location (1 = urban) − 0. 030 − 0. 006 − 0. 009 ** − 0. 015 0. 164 * 0. 006 0. 038 * 0. 121 * 0. 047 * − 0. 005 − 0. 024 ** 0. 075 * Age 0. 056 ** 0. 0005 0. 032 * − 0. 061 ** − 0. 010 − 0. 065 ** − 0. 013 − 0. 003 − 0. 008 − 0. 011 Gender (1 = male) − 0. 131 ** − 0. 003 0. 004 0. 022 − 0. 023 − 0. 039 0. 001 − 0. 038 Education level 0. 010 0. 007 ** 0. 039 ** 0. 036 4 0. 001 0. 022 ** 0. 013 0. 026 0. 002 − 0. 0006 0. 024 Respiratory illness (1 = yes) 0. 144 ** 0. 038 ** 0. 005 0. 102 ** 0. 019 0. 016 0. 071 * 0. 069 * Model fit 2 (full model) RMSEA = 0. 098, p(RMSEA > 0. 05) = 0. 248 RMSEA = 0. 026, p(RMSEA > 0. 873 RMSEA = 0. 042, p(RMSEA > 0. 618 Model fit 2 (reduced model 3) RMSEA = 0. 039, p(RMSEA > 0. 807 RMSEA = 0. 024, p(RMSEA > 0. 973 RMSEA = 0. 034, p(RMSEA > 0. 890 Note: * 95% chance that credible interval does not contain zero. ** 99% chance that credible interval does not contain zero. 1 Unobserved (latent, unmeasured) variable constructed from the observed (measured) variables ‘harm’ and ‘worry’. 2 MacCallum, Browne and Sugawara [45] have used 0. 01, 0. 05, and 0. 08 to indicate e xcellent, good, and mediocre fit, respectively. Others suggest 0. 06 as the cutoff for poor-fitting models [46]. 3 The reduced model retained only paths that were significant. 4 If location or age were removed from the model, the total effect of education level on mask use w as significant (b ≥ 0. 060). Page 34 Tab le 6 Reasons given by respondents who said they had not worn a facemask to pr otect themselves from breathing in volcanic ash. Japan (N = 243) Mexico (N = 249) Indonesia (N = 4) Breathing ash doesn’t bother me 24. 7% 27. 7% 25. 0% Breathing ash doesn’t worry me 18. 5% 15. 0% Don’t think I need to wear a mask 18. 5% 38. 3% 50. 0% Don’t think masks are effective 5. 3% 11. 6% 25. 0% Never considering wearing a mask 46. 1% 31. 0% Don’t have a mask 20. 5% 57. 3% 0 Masks are expensive 1. 2% 12. 4% 0 Don’t know where to get a mask from 0 24. 1% 0 Masks not easily available 0. 8% 15. 3% 0 Wearing a mask is dif ficult 4. 1% 6. 0% 0 Inconvenient to carry a mask around 33. 7% 15. 3% 0 Wearing a mask is uncomfortable 24. 7% 42. 6% 0 Wearing a mask would mak e me too hot 23. 5% 18. 9% 0 Wearing a mask would af fect my breathing 41. 2% 16. 9% 0 Wearing a mask creates humidity/ moisture 10. 7% 13. 7% 50. 0% Wearing a mask is embarrassing 4. 7% 0 Wearing and mask is unfashionable 3. 8% 0 Noone else/few people wear a mask 10. 7% 34. 9% 25. 0% Other a 4. 1% 7. 6% 50. 0% Note: Respondents could select more than one reason. a Other reasons for not wearing a mask included the fact that they had not been provided with a mask, they use other things (like a handkerchief), glasses get fogged up wearing a mask, don’t like wearing a mask, don’t go out much, or stay in until the ashfall ends. Author manuscript; available in PMC 2019 September 04.... Here we present the data collected from selected communities around Sakurajima. Equivalent surveys were also conducted in communities in Indonesia and Mexico, which are affected less frequently by volcanic ashfall, and selected findings from all three locations have already been reported in Covey et al. (2019). (2019) paper adopted a cross-cultural comparative approach to specifically examine the use of respiratory protection across the three communities. The paper tested the hypothesis, derived from theories such as Protection Motivation Theory (Rogers & Prentice-Dunn, 1997), that the decision to use a facemask for respiratory protection was motivated by threat appraisal (e. g., perceptions of the harm caused by ash inhalation and worry about the effects of the ash) and coping appraisal (e. g., beliefs about mask efficacy)....... The survey also investigated a broader range of issues over and above understanding the motivations for mask use (published in Covey et al. 2019) and, in this paper, we report additional findings from the Japanese sample. The Japanese sample was unique from the Mexican and Indonesian samples in the sense that the community around Sakurajima volcano had been frequently exposed to volcanic ash, on an almost daily basis, for many years....... The framework for our analysis is shown in Figure 4; we used path analysis to explore the extent to which the influence of geographical and sociodemographic factors on ratings of the importance of protection were mediated by people's experience of symptoms and perceptions of harm. By examining the determinants of people's general motivation to protect themselves from inhaling the ash this analysis builds upon the data reported in Covey et al. (2019) which focussed on a specific behavioural response (i. e., using a mask). Further issues specific to mask use in the Sakurajima residents are also addressed in this paper.... Whilst, globally, volcanic eruptions are unusual and cause anxiety in affected communities, people living near Sakurajima volcano, Japan are exposed to frequent ashfall with little-to-no official intervention. As part of a wider project, this study assessed how this apparently normalised experience affects residents’ perceptions of health impacts, and whether it is important to protect themselves from ash inhalation. A survey of 749 residents found little evidence of normalisation. Respondents identified a range of symptoms (including eye irritation, low mood, sore throat, cough) perceived to be associated with ash exposure, with 67% experiencing at least one symptom. Only 6% of respondents thought it was not important to protect themselves, and path analysis showed that protection was particularly important to older people and those with existing respiratory disease, who were more likely to rate ash as harmful or associate symptoms with exposures. Therefore, some of the most vulnerable sectors of this community are adversely impacted by ash. However, despite the local government recommending protective measures, most respondents said they had not received advice, but would like to. They took actions that they thought were effective (keeping windows/doors closed) or were easily available (wearing surgical masks). Other research has shown that industry-certified (e. g., N95) masks are more effective than surgical masks. Here, respondents recognised this, but high-efficiency masks were rarely used, probably due to unavailability. The results demonstrate a need to provide ash-affected communities with targeted, evidence-based information on options for effective protection, coupled with ensuring that communities have access to suggested interventions.... A small study of facemask use in Indonesia during a volcanic eruption found that, of 125 participants, 77% wore various forms of facemasks as a protective mechanism against ash on their own initiative [9]. People make decisions based on a range of factors, including evidence, but also their intuition or common sense, and their social, cultural, religious and economic circumstances and values [51, 52]. Individual autonomy can be respected through providing information to enable individuals, families, or communities to decide whether they can or will adopt a precautionary approach, what risks they are willing to tolerate, what preventive mechanisms to use [53] and how any potential benefits could be maximised.... Disasters involving severe air pollution episodes create a pressing public health issue. During such emergencies, there may be pressure on agencies to provide solutions to protect affected communities. One possible intervention to reduce exposure during such crises is facemasks. Ethical values need to be considered as part of any decision-making process to assess whether to provide advice on, recommend and/or distribute any public health intervention. In this paper, we use principles from public health ethics to analyse the critical ethical issues that relate to agencies providing advice on, recommending and/or distributing facemasks in air pollution disasters, given a lack of evidence of both the specific risk of some polluting events or the effectiveness of facemasks in community settings. The need for reflection on the ethical issues raised by the possible recommendation/use of facemasks to mitigate potential health issues arising from air pollution disasters is critical as communities progressively seek personal interventions to manage perceived and actual risks. This paper develops an ethical decision-making framework to assist agency deliberations. We argue that clarity around decision-making by agencies, after using this framework, may help increase trust about the intervention and solidarity within and between populations affected by these disasters and the agencies who support public health or provide assistance during disasters. Inhalation of ash can be of great concern for affected communities, during and after volcanic eruptions. Governmental and humanitarian agencies recommend and distribute a variety of respiratory protection (RP), commonly surgical masks but, also, industry-certified N95-style masks. However, there is currently no evidence on how wearable they are within affected populations or how protective wearers perceive them being against volcanic ash (which will influence the likelihood of uptake of recommended interventions). Volunteers living near Mt. Sinabung, Sumatra, Indonesia, participated in a field wearability study, which included a high-efficiency mask certified to industry standards (N95-equiv. ); a standard, pleated surgical mask (Surgical); a Basic flat-fold mask (Flat-fold), and the surgical mask plus a scarf tied over the top (Surgical Plus) to improve fit. These types of RP had all performed well during earlier laboratory filtration efficiency tests. The N95-equiv. mask had performed significantly better than the other RP in the subsequent total inward leakage volunteer trials, whilst the Flat-fold and Surgical masks performed poorly, letting in a third of PM2. 5 particles (data published elsewhere). Thirty volunteers wore each mask for a 15-min walk before being asked to rate the comfort, breathability and perceived protection and fit of each. After wearing all of the masks, volunteers compared and identified their preferred type of protection. The feedback received from the volunteers suggested that the Surgical Plus and N95-equiv. masks were rated as being significantly hotter and more humid than other masks. The Flat-fold was rated to have better breathability than the other masks. mask was ranked as providing the best level of effectiveness of the four masks tested. Ultimately, when asked which type of mask they would choose to wear during ashfall, 33% selected the Flat-fold mask due to its comfort and simplicity, with the Surgical Plus being the least likely to be chosen of the four tested. The study findings are of benefit to agencies who need to make informed decisions on the procurement and distribution of RP for use by those affected in future eruptions and the provision of advice to communities on their usage. During volcanic eruptions and their aftermath, communities may be concerned about the impacts of inhaling volcanic ash. Access to effective respiratory protection (RP) is therefore important for many people in volcanic areas all over the world. However, evidence to support the use of effective RP during such crises is currently lacking. The aim of this study was to build the first evidence base on the effectiveness of common materials used to protect communities from ash inhalation in volcanic crises. We obtained 17 forms of RP, covering various types of cloth through to disposable masks (typically used in occupational settings), which communities are known to wear during volcanic crises. The RP materials were characterised and subjected to filtration efficiency (FE) tests, which were performed with three challenge dusts: ashes from Sakurajima (Japan) and Soufrière Hills (Montserrat) volcanoes and aluminium oxide (Aloxite), chosen as a low-toxicity surrogate dust of similar particle size distribution. FE tests were conducted at two concentrations (1. 5 mg/m³ and 2. 5 mg/m³) and two flow rates (equivalent to 40 and 80 l/min through 15. 9 cm² sections of each RP type). Each material was held in a sample holder and PM2. 5 dust concentrations were measured both outside the mask material and inside the sample holder to determine FE. A limited number of tests were undertaken to assess the effect on FE of wetting a bandana and a surgical mask, as well as folding a bandana to provide multiple filter layers. Overall, four RP materials performed very well against volcanic ash, with median FEs in excess of 98% (N95-equiv., N99-equiv., PM2. 5 surgical (Japan), and Basic flat-fold (Indonesia)). The two standard surgical masks tested had median FEs of 89-91%. All other materials had median FEs ranging from 23-76% with no cloth materials achieving >44%. Folding a bandana resulted in better FE (40%; 3x folded) than single-layered material (29%). Wetting the bandana and surgical mask material did not improve FE overall. This first evidence base on the FE of common materials used to protect communities in volcanic crises from ash inhalation has been extended in a companion study (Steinle et al., submitted) on the total inward leakage of the best-performing masks when worn by human volunteers. This will provide a complete assessment of the effectiveness of these RP types. Governmental and humanitarian agencies recommend and distribute a variety of respiratory protection (RP), most commonly surgical masks. However, there is currently no evidence on how effective such masks are in protecting wearers from volcanic ash. In Part I of this study (Mueller et al., 2018), we assessed the filtration efficiency (FE) of 17 materials from different forms of RP against volcanic ash and a surrogate, low-toxicity dust, Aloxite. Based on those results, we now present the findings from a volunteer simulation study to test the effect of facial fit through assessment of Total Inward Leakage (TIL). Four different disposable RP types that demonstrated very high median FE (≥96% for Aloxite; ≥89% for volcanic ash) were tested without provision of training on fit. These were an industry-certified mask (N95-equiv. ); a surgical mask from Japan designed to filter PM2. 5; a flat-fold basic mask from Indonesia; and a standard surgical mask from Mexico, which was also tested with an added medical bandage on top, as an additional intervention to improve fit. Ten volunteers (6 female, 4 male) were recruited. Each RP type was worn by volunteers under two different conditions simulating cleaning-up activities during/after volcanic ashfall. Each activity lasted 10 min and two repeats were completed for each RP type per activity. Dust (as PM2. 5) concentration inside and outside the mask was measured with two TSI SidePak aerosol monitors (Models AM510 and AM520, TSI, Minnesota, USA) to calculate TIL. A questionnaire was administered after each test to collect perceptions of fit, comfort, protection and breathability. The best-performing RP type, across both activities, was the industry-certified N95-equiv. mask with 9% mean TIL. The standard surgical mask and the basic flat-fold mask both performed worst (35% TIL). With the additional bandage intervention, the surgical mask mean TIL improved to 24%. The PM2. 5 surgical mask performed similarly, with 22% TIL. mask was perceived to provide the best protection, but was also perceived as being uncomfortable and more difficult to breathe through. This study provides a first objective evidence base for the effectiveness of a selection of RP types typically worn around the world during volcanic crises. The findings will help agencies to make informed decisions on the procurement and distribution of RP in future eruptions. Tsunami vertical evacuation (TVE) buildings have the potential to save many lives. Yet whether TVE buildings actually save lives depends critically on whether people trust and evacuate to them, a question that has not previously been researched. We examine the case of the city of Banda Aceh, Indonesia, where a M8. 6 earthquake on 11-April-2012 caused a spontaneous mass evacuation but no tsunami. Our survey of residents living near TVE buildings (n=202) shows that they clearly prefer horizontal evacuation: in the 2012 earthquake, only 26% evacuated to a TVE building, while 74% evacuated horizontally; if a similar earthquake happened in the future, only 32% intend to evacuate to a TVE building, while 68% intend to evacuate horizontally. To investigate the reasons for this, we extend protection motivation theory to examine people's choices among protective actions under social influence. Those who prefer to evacuate horizontally do not trust the safety of the TVE building and think they can reach a safe inland destination in time, while those who prefer to evacuate to a TVE building think they cannot reach a safe inland destination in time. Encouragement from friends and family influences people's evacuation destinations but official information and training do not. These findings suggest that more attention to the social context is crucial for the effectiveness of TVE buildings. Our extension of protection motivation theory to include choices among protective actions under social influence can be broadly useful in research on self-protective behavior in natural hazards, public health, and other contexts. The 2014 explosive eruption of Kelud volcano, Indonesia ejected fine-grained volcanic ash in a plume which travelled south westwards across the island of Java. In Yogyakarta, without warning, around 5 cm of ash was deposited within a few hours. This paper investigates the community and organizational response to the respiratory hazard of the ash fall, in the city of Yogyakarta. Crystalline silica (mostly cristobalite) was produced by vapor-phase crystallization and devitrification in the andesite lava dome of the Soufriere Hills volcano, Montserrat. The sub–10-micrometer fraction of ash generated by pyroclastic flows formed by lava dome collapse contains 10 to 24 weight percent crystalline silica, an enrichment of 2 to 5 relative to the magma caused by selective crushing of the groundmass. The sub–10-micrometer fraction of ash generated by explosive eruptions has much lower contents (3 to 6 percent) of crystalline silica. High levels of cristobalite in respirable ash raise concerns about adverse health effects of long-term human exposure to ash from lava dome eruptions. The management and outcomes of the volcanic crisis on Montserrat, which began with the onset of activity at the Soufrière Hills Volcano (SHV) on 18 July 1995, might have been very different without the scientific precedents set by the Mount St Helens eruption, USA, on 18 May 1980, and the research advances that followed. This narrative is intended to show the steps taken by health scientists in response to the unfolding developments at the volcano to characterize the hazard presented by the volcanic ash and to devise mitigation measures to prevent the development of irreversible lung disease in the island population. Initial assessments of the health risk for silicosis were deterministic and based on industry exposure limits derived from published epidemiological and clinical studies of workers exposed to dusts containing free crystalline silica. However, by 2003, new research findings on the ash enabled the risk to be updated with a probabilistic approach incorporating the expertise of scientists from a wide range of disciplines including toxicology, volcanology and statistical modelling. The main outcome has been to provide reassurance to the islanders and policy makers that the chances of developing silicosis on Montserrat are very small given the preventive measures that were adopted during 1995–2010 and the change in style of the eruption. Disastrous wildfires have occurred often in south-eastern Australia. Following multi-fatality wildfires in Victoria on 7 February 2009 the national approach to community wildfire safety, ‘Prepare, stay and defend or leave early’, came under intense critical scrutiny. The approach was revised subsequently so as to emphasise leaving as the safest option in the event of a wildfire warning. This study reports findings from a survey of 584 residents of at-risk locations. The majority (47%) reported that they intended to leave if warned of a bushfire threat. However, a substantial minority (24%) reported that they intended to stay and defend their home. A further 29% reported that they intended to wait and see what developed before making a final decision. Those intending to leave differed from those intending to stay and defend in several ways. Those intending to leave were characterised generally by being more concerned about the danger posed by bushfires, they viewed themselves as more vulnerable to bushfire threat and they were worried about their house being destroyed in their absence. Those intending to stay and defend were motivated, mostly, to protect their valued property and they believed that their efforts would be successful. They did not perceive themselves to be risk takers. Those intending to leave generally reported rather low levels of preparations for leaving safely. An appreciable percentage of those intending to stay and defend reported levels of preparations for safe defence which were probably inadequate for safe and effective defence.
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