Using Masks for In-Person Service Delivery During COVID-19 Pandemic: What to Consider

Updated on August 26, 2021

As of July 27, 2021, the Centers for Disease Control and Prevention (CDC) recommends the use of masks for all teachers, staff, students, and visitors to K–12 schools regardless of whether they have been vaccinated to help mitigate the transmission of COVID-19. The CDC also has new guidance for fully vaccinated people, especially for those in high transmission areas. The CDC continues to recommend the use of masks by all individuals in health care settings. Local rules and regulations may require all individuals to use masks in certain situations. Businesses and workplaces, including private practices, can set their own policies. Use of masks is especially important when it isn’t possible to follow physical distancing standards.

School and Public Policy on Mask Use

ASHA recommends adhering to the most current CDC guidelines to inform policies for the use of masks across all school and public settings. Questions have arisen regarding a possible connection between mask use by those who interact with young children (e.g., teachers, caregivers, daycare providers) and delays in speech, language, and social development for children with typically developing speech, language, and hearing. The American Academy of Pediatrics (AAP) and ASHA collaborated on an article regarding this issue, Do Masks Delay Speech and Language Development? (see the reference section below for pertinent research). These are the conclusions by the AAP and ASHA:

While this is a natural concern, there is no evidence that use of face masks prevents or delays speech and language development.
Babies and young children study faces intently, so the concern about solid masks covering the face is understandable. However, there are no known studies that show that use of a face mask negatively impacts a child's speech and language development.
Babies and toddlers can get all the face time they need in the home with family members who aren't wearing face masks.
Regardless of mask use, some children will take longer to reach speech and language milestones—and some may need help meeting them.
When it comes to use of face masks, the bottom line is safety first! Masks reduce transmission of COVID-19 and can make in-person schooling possible.

Audiologists and speech-language pathologists (SLPs) can share current research findings with families, school boards, teachers, and others to make sure that policies regarding mask use in schools and for the public are informed by science, particularly data that demonstrate definitively that mask use reduces infection. The benefits of mask use should outweigh any concerns about possible impact on speech and language development. ASHA’s Code of Ethics Principle I, Rule M states: “Individuals who whold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.” Principle III, Rule E states “Individuals’ statements to the public shall adhere to prevailing professional norms and shall not contain misrepresentation when advertising, announcing, and promoting their professional services and products and when reporting research results.” ASHA places a priority, first and foremost, on health and safety.

See the information below for additional considerations for mask use while providing in person service delivery.

Types of Masks

The CDC identifies three types of face masks [PDF] that meet the standard of medical grade personal protective equipment (PPE):

Surgical mask
N95 respirator
Elastomeric half facepiece respirator

Although cloth face coverings to help slow the spread of COVID-19 are acceptable for general use by the public, the CDC specifically states that they are not categorized as medical PPE. The correct mask type varies based on the type of service you’re providing.

The CDC has also outlined specific guidance for putting on (donning) and taking off (doffing) PPE.

Service Delivery Considerations

Telepractice

When possible and appropriate, telepractice is strongly encouraged for audiology and speech language pathology services to mitigate COVID-19 transmission risk. You may use telepractice as the sole model of service delivery or complementary to in-person services. For example:

Although the SLP could do instrumental assessment of swallowing in person, they could provide the dysphagia intervention via telepractice.
Although the audiologist needs to do cochlear implant candidacy evaluation and initial activation in person, they could provide follow-up programming via telepractice.

In the school setting, service delivery options may include virtual-only interactions, hybrid (virtual and in-person) services, staggered/rotated scheduling, or fully in-person sessions. State, local school district, and CDC considerations for schools should be followed. School-based audiologists and SLPs should evaluate their own risk and that of the students they serve when making decisions about service delivery.

Across settings, providers may also use group telepractice sessions along with in-person, one-on-one services—following federal, state, district, facility, and state licensure regulations and guidance. For more information and resources on telepractice, visit ASHA’s COVID-19 telepractice page.

Choosing the Right Mask for the Service You’re Providing

Although all in-person services provided by audiologists and SLPs carry risk of COVID-19 transmission, not all procedures need the same type of precautions or PPE, according to the CDC.

When to Use an N95 or Higher-Level Respirator

N95 masks are recommended for aerosol-generating procedures (AGPs), which the CDC defines as medical procedures that are “more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing” and result in “uncontrolled respiratory secretions.” Higher-level respirators, like elastomeric half facepiece respirators, are also suitable, depending on your employer's guidelines.

AGPs should not be completed without the proper PPE, according to CDC guidelines. Providers should also wear N95 masks when providing services that require close physical proximity to the patient/client.

Examples of AGP Procedures in Speech-Language Pathology

Dysphagia care (instrumental and non-instrumental assessment and treatment)
Instrumental assessment of voice via endoscopy, with or without stroboscopy
Assessment and management of  laryngectomy, including voice restoration using voice prosthesis and stoma care
Assessment and treatment of  tracheostomies, with or without mechanical ventilation, including suctioning
Non-invasive ventilation such as high-flow nasal oxygen and nasal cannulae

For detailed information, see ASHA Guidance to SLPs Regarding Aerosol Generating Procedures.

Examples of Possible AGP and/or Close-Proximity Procedures in Audiology

Otoscopy
Cerumen management
Real-ear measurements
Earmold impressions
Dizziness and balance measurements
Evoked potential testing

When to Use a Surgical Mask

Surgical masks are acceptable PPE for other services provided by audiologists and SLPs that have lower transmission risks than AGPs. “FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated” the CDC states.

Making Sure PPE Is Available for the Client/Student and Provider

You (or your employer) will need to make sure you have adequate access to appropriate PPE (via a reliable pipeline) to meet ongoing practice needs and ensure your own safety as well as that of your clients/students. Needs may evolve, depending on the types of diagnoses you come across in your practice setting and the types of services you need to provide. Clinicians are also encouraged to ensure that alternate PPE is available for clients/students to use in case the client/student and/or caregiver does not have access to required PPE during the session.

Cloth Face Coverings

Cloth face coverings are not surgical masks, respirators, or other medical PPE. The CDC emphasizes that it’s critical to teach and reinforce the use of cloth face coverings—as well as engaging in frequent hand-washing and not touching the face—for children and the public. You should also provide information on proper use, removal, and washing of cloth face coverings.

It’s important to note that cloth face coverings should not be placed on

children younger than 2 years old,
anyone who has trouble breathing or is unconscious, or
anyone who is incapacitated or otherwise unable to remove the cloth face covering without assistance.

Determining Whether PPE Negatively Affects a Service

Although critical to infection control, masks may negatively affect audiology and speech- language pathology services.

As a clinician, use your clinical judgment (in compliance with requirements established by employer and/or federal, state, and local oversight bodies) to determine whether mask use is the most appropriate protocol for service delivery—or if you can or should make modifications.

If you’re modifying recommended best practices, make sure you’ve documented informed consent from the client/student or caregiver.

Here are some examples of how masks can negatively affect services:

Increased difficulty in understanding speech: Masks attenuate sound by 3–12 dB and also result in low-pass filtering of high-frequency sounds, making it more difficult to understand speech and some higher-pitched voices (Goldin et al., 2020). Listening to masked speech can be especially hard for people with hearing loss.
Reduced discrimination of speech signal among competing noise: For example, reduced discrimination may occur in the presence of traffic or noisy yard work like lawn mowing.
Reduced intelligibility of the wearer’s speech: Listeners may perceive speech as muffled or lower in volume.
Loss of visual cues: Masks remove the ability to speech read and see facial expressions, which augment communication.
Increased difficulty of verbal communication: Speaking and understanding language while wearing a mask can be hard for people with communication problems like aphasia, voice problems, and autism.
Reduced ability to provide appropriate cues to the client/student: Masks can reduce one’s ability to provide communication cues—for example, in the case of speech sound production.
Noncompliance of mask wearing: Masks can be uncomfortable for young and school-aged children, and for people who wear hearing aids or cochlear implants. Noncompliance with mask use can also be an issue for those with cognitive or sensory deficits.

Options for Modification

For non-AGPs provided to clients/students who do not have COVID-19, modifications to service delivery may include (but are not limited to) the following:

masks with clear panels
face shields when paired with masks
plexiglass or other clear barriers
physical distancing
use of voice amplifiers
use of family member/caregiver as model or extension of clinician’s hands
use of videos or images for demonstration

It’s important to note that there is no documented clinical evidence on how these modifications impact effectiveness of overall infection control processes used in clinical practice.

Taking Steps to Enhance Communication While Wearing Masks

Make sure you have the attention of your client/student before you start talking.
Face them directly, and make sure nothing is blocking your view.
Speak slowly and slightly louder, but don’t shout or exaggerate your speech.
Optimize hearing—confirm that those who use hearing aids or cochlear implants are wearing their devices or use a portable amplifier. Use your eyes, hands, and body language to add information to your speech.
Provide visual references (e.g., printouts, notes, images) to accompany communication.
Ask if they understood you—if they didn’t, rephrase it or write it down.
Ask them to repeat important information to see whether they understood what you said.
Reduce competing noise in the environment, if possible.
If you’re talking with someone new, ask the person what you can do to make communication easier for both of you.

Additional Resources

From ASHA

From Other Organizations

References

Goldin, A., Weinstein, B. E., & Shiman, N. (2020). How do medical masks degrade speech perception? Hearing Review, 27(5), 8–9.

Ruba, A. L., & Pollak, S. D. (2020). Children’s emotion inferences from masked faces: Implications for social interactions during COVID-19. PLoS One, 15(12), e0243708. doi:10.1371/journal.pone.0243708

Singh, L., Tan, A., & Quinn, P. C. (2021). Infants recognize words spoken through opaque masks but not through clear masks. Developmental Science, Epub ahead of print available from https://doi.org/10.1111/desc.13117. doi:10.1111/desc.13117

Smiljanic, R., Keerstock, S., Meemann, K., & Ransom, S. M. (2021). Face masks and speaking style affect audio-visual word recognition and memory of native and non-native speech. Journal of the Acoustical Society of America, 149(6), 4013. doi:10.1121/10.0005191