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‘I was in the Co-op and I heard a child ask his father if he could have a face mask like mine.  The father replied, ‘no, don’t be so soft, we’re not doing that!’

There has recently been a major ‘about turn’ by the UK Government in mandating that people wear a face covering such as a face mask, in shops, banks and other public spaces, as well as on public transport in England.  This has elicited strong reactions from and between those who oppose mask-wearing and those who are pro. In this blog, we take a look at some of the broader sociological factors that might influence public mask-wearing decisions, and which may contribute to making it such a divisive issue.  We suggest that these are important to consider in public health messaging aimed at containing the COVID-19 virus.

As the Covid-19 pandemic continues, it is apparent that the virus may be an ongoing threat for some time.  Initial focus on the rapid development of a vaccine appears to have given way to a range of public health measures to support societies with how to live with, and contain, the virus.  Protecting ourselves and others has become a key public health message globally, with maskwearing, handwashing and social distancing central to interventions and practices.  Despite initial uncertainty about mask-wearing, the benefits have become more evident, and a study by Eikenberry and colleagues reports that face-mask wearing by the general public “is potentially of high value in curtailing community transmission and the burden of the pandemic.  The community-wide benefits are likely to be greatest when face masks are used in conjunction with other non-pharmaceutical practices (such as social-distancing), and when adoption is nearly universal (nation-wide) and compliance is high”.

At least 120 countries have mandated the use of face coverings in a range of situations including public spaces, shops and on public transport. Indeed mask-wearing has arguably allowed some governments to relax lockdown restrictions and encourage people to go out for work and leisure in a bid to restore economic activity.  However, mask-wearing advice has proven controversial.  There have been disagreements between academics, the president of the United States, Donald Trump repeatedly refused to wear a mask in front of the media, despite legislation requiring him to do so. The president of Brazil, Jair Bolsonaro, also resisted wearing a face mask in public, only later to test positive for coronavirus.

Groups such as Masks4All, use the slogan ‘I protect you, you protect me’ to promote the notion that a ‘critical mass’ of mask-wearing in the community is needed for reciprocal protection of individuals. Cheng and colleagues argue that this shifts the focus from solely; “self-protection to altruism, actively involves every citizen, and is a symbol of social solidarity in the global response to the pandemic.”  However, with self-interest as a dominant driver of health behaviours, getting the public on board with such public health messages and interventions is a challenge, even in these times of unprecedented risk.

Looking at the sociological dynamics involved in face-mask wearing provides some insights into this challenge, and into individual decision-making that leads to (non-)conformance. It highlights structural inequalities, gender and cultural influences (amongst others), which need to be considered by public health professionals and others involved in developing coherent messages to help reduce transmission of the virus.

Health inequalities

The existence of health inequalities is well recognised, and disparities based on poverty, income inequality and social class are enduring and well documented.  In the UK, austerity politics have aimed at the welfare state, disproportionately affecting the working classes and reducing health-related assets among this group.  The resultant socio-economic conditions have exacerbated poverty and created favourable conditions for infectious diseases to thrive, while undermining access to health-care.  While Covid-19 is indiscriminate to class, with Prince Charles and Prime Minister Boris Johnson becoming infected, the social conditions that exacerbate the spread of Covid-19 certainly follow class or affluence lines.  For example, lower-paid workers (e.g. those in the ‘gig economy’), are less able work from home, more likely to use public transport, have inadequate access to sick pay, and have poorer housing conditions.   All these factors can facilitate the transmission of infection. Mortality rates for those living in more deprived areas are more than double those for people living in less deprived areas, therefore engaging these communities in transmission prevention practices is a matter of life and death.  However, health protection and promotion initiatives demonstrate class-based impacts, so that they are less effective among those who need them most.

Gender

How does gender impact mask-wearing? In some cultures where masks are already commonly worn (e.g. China) gender may not matter much.  Yet in others, like the UK and the US, where mask-wearing is less common, gender may play a significant role.  Evidence from other pandemics, including SARS and H1N1, shows that men are less likely to wear face coverings than women.  The anecdote at the start of this blog suggests that mask-wearing is ‘soft’ with feminine connotations.  Perceiving mask-wearing as feminine and ‘not masculine’ may come about because men are conditioned to seeing themselves as ‘tough’ and not in need of protection – which may suggest some misunderstanding of how face coverings work.  Gendered notions of care are, however, well versed with women shouldering the greatest caregiving burdens of child-rearing, or looking after sick or elderly relatives.  This can be extended to health protection in terms of an expectation that women will perform the labour of protecting men, so that men may be less inclined to engage as they do not see such protective labour as their responsibility.

Another reason may be that men are more likely to engage in risk-taking behaviour than women and do so in specific contexts.  Research in the USA has found that men intended to wear a mask covering less often than women because they believe they are less likely to be infected.  The authors also found that men reported negative emotions around wearing face coverings – men stated more than women that wearing a mask was not ‘cool’ but a sign of weakness, stigma and as shameful.

Cultural differences

Mask-wearing is also culturally conditioned, for example, in East Asian countries such as Japan, where it reflects perceived public health risks and responsibilisation of citizens for their own and others’ safety.  As a widespread hygiene practice among East Asian populations living in other countries, wearing a face mask may be exacerbating discrimination and xenophobia based on the Covid-19 pandemic’s probable origin in China.  Social reactions against ‘foreignness’ and ‘others’ have always accompanied ‘plagues’.  In the current pandemic, those most at risk from Covid-19 are those who are already stigmatised, including the homeless, migrants and refugees.  These associations may contribute to a reticence towards mask-wearing.

In conclusion therefore, taking a sociological look ‘behind’ the face mask enables an understanding of broader factors influencing individual mask-wearing decisions and behaviour, for which there may be far-reaching consequences.  Potential for community transmission is ever-present, and may lead to further lockdowns, along with subsequent strain on National Health Service and care systems, and on individuals.  Therefore actions to minimise infection, of which public mask-wearing is considered part, are pivotal.  Relations between those in wearing and non-wearing ‘camps’ are contentious, as evidenced at the start of this piece.  Understanding differences be they gendered, class-based or cultural, is important in developing appropriate interventions and effective health messaging.  Compelling public health messages about the need to wear masks to protect ourselves and others require competent leadership and trust in leaders, and this may be where attention needs to focus if we are to change public behaviours.  The question is, how to increase public mask-wearing without enforcement, and its possible ramifications?

About the Authors: Donna Bramwell is a sociologist and qualitative Health Services Researcher with the Health, Organisation, Policy and Economics group at the University of Manchester(@DonnaBramwell)Mhorag Goff is a Research Associate in the Centre for Primary Care at the University of Manchester with expertise in qualitative social science and a background in STS approaches to health data and health information systems (@mhoraggoff); Natalie Hammond is a sociologist and Senior Lecturer in Social Care at Manchester Metropolitan University (@thenataliejane).