Image by Mike Licht licensed under Creative Commons.

Mask wearing is an essential way to prevent coronavirus transmission. But if we’re going to defeat COVID-19, a disease which has killed nearly 140,000 Americans, many of them people of color, we should focus on systematic approaches to reduce risk across the board, including universal mask wearing.

My last article pointed out that while mask wearing is extremely important, shaming individuals can worsen health inequities and distracts from pressure on policymakers to undertake or scale-up system-wide approaches.

Let’s look at what does work to change health behavior while reducing COVID-19 transmission, and why it matters for reducing disparities.

To change behavior, meet people where they are

The important goal of encouraging people to wear masks across the board is the purview of a field called health promotion.

As a former health promoter whose job it was to encourage people to take up habits like condom use and handwashing, I learned that if you don’t get the message, the messenger, and the medium right, you get tuned out; or worse, you contribute to a narrative of blaming individuals (often individuals from particular, less empowered groups) for what is a systemic problem.

Current health promotion approaches, the results of decades of research and experimentation, emphasize:

  • engaging the audience in their own decision-making process
  • shifting the way they see themselves, rather than pressuring them to behave in a specific way
  • participation
  • audience buy-in
  • building relationships and sustainability

Campaigns that make use of these techniques need resources and time to work. They cost more and might not feel as gratifying as telling people they can “eat a bag of nails”, but they have the clear advantages of being effective and less likely to cause damage.

There’s a lot of fancy science that comes down to this: when you make it easy and very clear what people should do to protect themselves and their loved ones, they’re more likely to do it.

Context is important: for example, it’s simply harder for some people than others to wear a face mask. (Is it realistic to expect unhoused people to wash their masks after every use, or to have an unlimited supply of disposables? Or are we just content to disregard them?).

An effective mask wearing campaign would play on what has worked in other settings and also what experts are saying about changing COVID-specific behavior. Masks should be free and available, everywhere people need to wear them. The signs below, for instance would make great health promotions if masks were provided for free to people.

COVID-19 hasn’t been around long enough for a robust evidence base to develop. But an earlier study found that “perceived susceptibility, cues to action, and perceived benefits”, were significant predictors of mask wearing during the SARS epidemic. Another study conducted during the avian influenza epidemic found that mask wearing and other preventive behaviors were associated with perception of risk, as well as having accurate knowledge about the fatality rate and local outbreaks.

Several local settings are applying those principles to COVID-19 with mask-wearing promotion campaigns that meet people where they are.

One setting in which social pressure could, however, be constructive is where it could lessen the burden of mask enforcement on frontline service workers. It’s an opportunity to put privilege to nonaggressive use for needs that aren’t one’s own.

Two gentlemen chatting with masks by Elvert Barnes licensed under Creative Commons.

We need whole-system approaches

“Don’t speed”: we used this analogy in the previous post to highlight that that social pressure is not as effective at getting drivers to drive with care for others’ lives as systemic approaches, which include laws, compliance efforts like education and indeed traffic citations, as well as road design.

Applying that framework to COVID-19 risk, let’s look at what would make a whole-system approach, many of which are already in place and could be scaled up, which the local, state and federal health agencies can take forward with enough resources and political will.

This recent article captures a lot of great ideas, mostly revolving around the idea that it’s imperative to achieve the right balance between safety and measures that we can withstand for as long as required. GGWash has also talked about the importance of public space measures that will allow cities in the Washington region to go the distance back in April. We could even go further back in the causal chain, and target the differences in resources allocated to Black lives and opportunities more broadly.

None of these approaches depend on convincing people that not wearing a mask makes them a bad person, a task which is tremendously difficult, ethically fraught, and yields imprecise results.

Streatery on 19th St near Dupont Circle by Joe Flood licensed under Creative Commons.

COVID-19 isn’t equal-opportunity

Black and Latinx populations are at higher risk of COVID-19 because of fundamental differences in how our society treats them and values their lives. Masks help a lot, but they’re the last line of defense when everything else in the prevention chain fails. The fact that that chain (plus healthcare when people do fall ill) fails among people of color at higher rates than white people is a feature of systemic racism.

There are broader costs too. The US has chronically underfunded our public health system, partly because there’s a dominant narrative that if someone gets sick, it’s their fault. But the field of public health has long recognized that health outcomes are far more strongly related to systemic and environmental factors than individual choices.

The percentage of people’s health (measured by illness, injury, and length of life) that’s determined by factors that can be changed. Centers for Disease Control and Prevention, used with permission.

The way forward

Shaming only makes sense in a policy-absent setting where we’re truly on our own, incapable of collective action. We can do better with policies, some of which involve mask wearing like a universal mask mandate coupled with free and accessible masks, and even specific and non-aggressive social norm-setting. But taking it on ourselves to police public space in an aggressive and non-specific manner is not supported by decades of research and practice. Addressing the systems that produce the outcomes is.

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Tagged: coronavirus, equity, public health

Caitlin Rogger is deputy executive director at Greater Greater Washington. Broadly interested in structural determinants of social, economic, and political outcomes in urban settings, she worked in public health prior to joining GGWash. She lives in Capitol Hill.