Researchers investigate the social drivers of mask wearing during COVID-19.
When an independent report investigating the August 2019 death of Elijah McClain was released in February, it found that police had no legally justifiable reason to stop McClain that evening – let alone search him and restrain him with multiple carotid chokeholds. McClain, a 23-year-old Black man, died after Aurora, Colorado police officers restrained him and fire paramedics injected him with ketamine.
McClain was walking home from a convenience store when police officers stopped him. The officers were responding to a 911 call about a “sketchy” person wearing a ski mask and waving his arms. McClain’s family says he often wore a ski mask because he has anemia, a blood condition that made him get cold easily.
As a group of researchers from Jefferson’s Department of Family and Community Medicine noted, one of the decisions that factors into mask wearing can be attributed to racism and race relations throughout the country. Members of minority racial groups, particularly Black and Hispanic men, may be resistant to mandates requiring them to wear a mask in public, given racial stigmas and societal inequities that continue to criminalize them based on their appearances.
For many, leaving the house without a face mask since the onset of the COVID-19 pandemic has become somewhat taboo, as unlikely as forgetting your mobile phone, or sunglasses on a bright, sunny day.
We need to bring the message to the public in a way that will meet them where they are.
— Allison R. Casola
But as the Jefferson researchers, led by Allison R. Casola, PhD, explored in a recent article, the individual decision to wear a mask during COVID-19 is deeply rooted across one’s social-ecological network. The social-ecological model, a fundamental public health framework, categorically describes the implications of an individual’s societal environment, interpersonal relationships and community setting, and personal characteristics on health-behavior decision making.
“Countries like the United States endorse individualism, self-expression and personal identity,” Dr. Casola says. “That can make it hard to convince people to abide by mask recommendations as a means to protecting others, because my mask protects you from me and your mask protects me from you.”
To limit the spread of COVID-19, the Centers for Disease Control and Prevention issued recommendations that individuals wear face masks in public. Public health experts have spent the better part of a year emphasizing that masks are one of the most effective tools to help fight the pandemic, and many U.S. states long ago introduced some kind of mask requirement. But as the researchers note, inconsistencies among state mandates for mask wearing can lead to confusion among the public. Many might wonder why it is mandatory in one state, but not in another. “It sends conflicting messages to the public about what is really necessary and can contribute to internal uncertainty on what to do or who to believe,” Dr. Casola says.
She and her team also investigated how interpersonal influences such as community and social networks can influence one’s decision to wear a mask. In rural communities, for example, especially earlier in the pandemic, mask wearing wasn’t perceived as that important. “Early on, COVID-19 hadn’t had the same impact on more rural parts of the country as it had on urban communities,” Dr. Casola says. “At that time, it was possible that people in rural communities may not have known anyone with the virus and felt that mask wearing was simply an overreaction.”
Then there’s the simple question of access to masks. As Dr. Casola and her colleagues note in the study, with 11.8% of American households living under the poverty line, it may not be possible to purchase a mask in person or online. As she notes, masks are required for entry on public transportation, at grocery stores and pharmacies. This creates further barriers for essential workers trying to get to work, or people who need to get food, prescriptions and household necessities for their family.
The researchers also point out that early in the pandemic, COVID-19 was labeled as a virus that would disproportionately affect the elderly, resulting in low levels of perceived susceptibility, feelings of naïve invincibility and limited uptake in mask wearing among young and middle-aged adults.
“Some may feel that mask wearing identifies them as weak or scared of the virus, which can resonate as harmful gendered norms of not feeling strong or masculine,” Dr. Casola says.
The researchers also determined that declining to wear a mask for some could symbolize their right to exercise their personal liberties as a U.S. citizen – as the refusal to wear a mask in public may suggest one’s support of reopening the country, getting Americans back to work, and a general sense of misguided “patriotism.”
Even as more Americans are vaccinated, the importance of wearing a mask in public will be no less critical in defeating the coronavirus. “We need to stay vigilant, because not everyone can get the vaccine yet, or are simply unable to get the vaccine due to other health concerns,” Dr. Casola says. “Mask wearing will be around for a while, and we need to keep that message up.”
Moving forward, the researchers stress the importance of working together to develop factual, tailored health communication messaging related to mask wearing. To promote a singular message—wear a mask—among a diverse American population, future resources should consider the social-ecological attributes influencing the intended audience.
The key, according to the researchers, will be to listen to the communities being served and engage with key stakeholders and leaders to collect more information about the experiences of these individuals. “It’s a waste of time, effort and funds to develop messaging that does not or will not resonate,” Dr. Casola says. “We need to bring the message to the public in a way that will meet them where they are.”