What are the challenges of promoting mask use and how can they be addressed?

While there is growing evidence supporting the fact that using face masks reduces the chance of transmitting and getting COVID-19, there are challenges in promoting widespread mask wearing behaviour. Below we list some of the most common challenges and how they can potentially be addressed:

  • Wearing masks correctly: In order for masks to be effective, they must be worn correctly. Refer to this resource to read more about how fabric face masks, surgical masks and N95 respirators should be worn safely. It is important for users to cover both their nose, mouth, and chin with the mask and make sure it fits snugly and comfortably against their faces. Common ways masks may be incorrectly worn include not covering the nose, or being worn upside down or inside out. Surgical masks and some fabric masks have nose pieces, and adjusting them can give the mask a better fit. To ensure masks are worn correctly, clear communication on mask guidance is essential. Photos or diagrams showing correct and incorrect mask use can be helpful in communicating how masks should be worn. Another common mistake is the sharing of face masks. Sharing face masks increases the risk of coming in contact with the respiratory droplets of someone who is infected and can defeat the purpose of wearing a face mask. To avoid mask sharing, ensure everyone has access to several face masks.

  • Access: At the start of the pandemic there was a global shortage of surgical masks, which was greatly concerning especially for health workers. Initially, wearing face masks was not recommended to ensure there would be enough personal protective equipment available for health workers, but eventually the guidance was changed and updated to recommend the use of fabric masks in public settings. The guidance to wear fabric masks may also make mask wearing behaviour possible for more people by making masks more accessible. Studies have been conducted to explore how masks made of different fabrics affect ease of breathing, filtration, and other mask properties so that masks can be sewn at home with locally available materials (Study 1, Study 2, Study 3). In a study in Bangladesh they found that the free distribution of masks led to a three-fold increase in mask use which was sustained over time. Here is an example of refugees making their own face masks and distributing them within their communities. The United Nations Development Programme and UNICEF are also distributing fabric face masks across South Sudan to limit the transmission of coronavirus.

Image: A series of illustrations by Green String Network, showing the correct and incorrect ways to wear a face mask.

  • Washing: In order for fabric masks to be effective, they need to be washed after each use or once they become dirty or damp. In Nigeria, face mask acceptance is high, but mask washing behaviour has yet to become widespread. For populations that wear fabric masks, it is useful for individuals to have at least three masks so they can be washed regularly. In settings where hygiene kits are being distributed, consider including masks with laundry detergent to encourage their hygienic use. Also consider distributing a washing line to allow people to hang up their masks to dry.

  • Disposal: It is also important to be clear about safe disposal of single-use masks like surgical masks or N95 respirators. To enable this behaviour, it may be helpful to make bins available specifically for the disposal of surgical masks so that they can be appropriately managed and disposed of as medical waste to limit any negative effects on the environment. The bins should be placed in areas where people are likely to change masks so as to remind individuals and support correct disposal behaviour. Fabric masks can be washed and reused but should also be disposed of if they become damaged or are no longer able to form a snug fit over the face.

  • Comfort: Another barrier to consistent mask wearing is that some people may experience difficulty breathing, or discomfort from ear straps. There are many products designed to make mask wear more comfortable, including mask extenders, mask cord adjusters, masks which tie behind the head instead of using earloops, headbands that attach to masks, and anti-fog sprays for glasses.

Images: Products that can make wearing a mask more comfortable include mask extenders, masks which tie behind the head instead of using earloops, mask cord adjusters, and headbands that can attach to masks.

  • The changing state of evidence and varying mask policies: As the pandemic has progressed, so too has the guidance on the use of face masks due to the changing state of evidence on COVID-19 transmission. At first, face masks were not recommended for general public use to ensure that health workers and those infected or exposed to COVID-19 would have enough resources and personal protective equipment (PPE) available. However, now that there is evidence that pre-symptomatic and asymptomatic individuals can transmit the virus via respiratory droplets, the official guidance from the WHO and CDC has changed to recommend mask use by the general public. Because there is still a concern of a PPE shortage among health workers, homemade or fabric face masks are encouraged by the public. Due to the changing evidence, guidance and infection rates, there have been varying mask policies put in place. Many populations in East Asian countries, such as China and Japan, quickly adopted the practice of wearing masks in the early phase of the pandemic, as it was already customary to wear masks during public health crises. Other countries implemented national mandates for masks and imposed fines for refusal to wear a mask to control the spread of COVID-19. In the US there has not been a nationwide mandate to wear masks, but some states have implemented their own mask mandates. There is some emerging evidence that the states with mask mandates in place have experienced fewer cases of COVID-19.

  • Rumours, misinformation and disinformation: Many countries are facing challenges due to rumours and misinformation surrounding COVID-19 and the use of face masks. Some common rumours include that masks deprive the body of oxygen and that they can cause carbon dioxide poisoning. This resource refutes myths related to wearing face masks with facts. To combat these rumours, online platforms (e.g. Facebook, Google, Twitter) have been actively prioritising information from trusted authorities, such as the Centers for Disease Control (CDC) and World Health Organization (WHO). Some platforms, such as YouTube, are also moderating and removing content that contradicts information from the scientific community. There are also online resources and fact-checking networks that debunk myths and disinformation and provide answers to common questions about COVID-19. The WHO and UN have partnered with other organizations to address the challenges of misinformation during the pandemic, which include reporting inaccurate information when seen online. This resource includes guidance on tracking and addressing rumours surrounding COVID-19.

  • Distrust of government or public health authorities: The way a government delivers information and support during the pandemic has an effect on the way its people respond and implement recommended prevention measures. A government’s previous track record of taking action or inaction on issues of national importance can also have an effect on people’s perceptions of the government’s response to the pandemic. There are multiple studies that show populations who trust in their government are more likely to practice recommended preventative behaviours during disease outbreaks (Study 1, Study 2, Study 3). However, distrust in government and public health institutions can undermine pandemic responses. For example, among some populations in Nigeria, the government was perceived to have a poor record of delivering services and information in a reliable manner, which in turn has affected how Nigerians have followed the government’s lockdown measures. Distrust in many governments has also increased since the start of the pandemic, in part because of initial slow responses, inconsistent messaging and poor leadership. People are slow to adopt face mask recommendations when they also see government leaders disregarding those same recommendations. In Cameroon, restrictions and public health measures have been put in place to limit the spread of coronavirus, but some people have been frustrated by changing regulations and believe the rules have not been appropriately followed by the members of the government. There is also a concern over the influence of politics on public health institutions that are supposed to prioritise the health of the public when making recommendations. To address these challenges, it is important to consider the perception of the agencies that are issuing coronavirus policies, including mask mandates. The public should have confidence that the recommendations and mandates are based on evidence, not politics, to ensure guidance is trusted and followed.

  • Concerns about personal freedoms: Another barrier which can prevent widespread mask use is that people believe it is their right to choose whether they wear a face mask. Some of those who oppose wearing masks refer to themselves as “anti-maskers” and have protested against the mask guidance. The subject of wearing masks and whether they violate an individual’s personal freedom has also become an increasingly political issue, especially in the United States. While it can be challenging to convince people to wear masks, it is helpful to emphasise that by wearing a mask, they are protecting those who are around them, especially vulnerable populations. Adding a personal element to the message that wearing a mask is important can be achieved by highlighting that members of their community are at risk of contracting coronavirus. This type of messaging relies on people acting out of empathy rather than personal interest. A study on motivation for mask use showed that people who wear masks because they are concerned for the safety of their community are viewed as competent and possessing strong character. Since some people refuse to wear masks because they feel that their freedom of choice is being taken away from them, it is worth considering how to give them back some of their ability to make personal choices, and that can be in the form of selecting from different options of appropriate face masks. In settings where people may not be motivated to wear masks for the benefit of others, it may be worth highlighting the evidence that face masks can protect their wearers from inhaling respiratory droplets of infected individuals. Both the social and personal motivations of your population should be assessed through formative research and then appropriately emphasised to have the greatest effect on mask-wearing behaviour.

  • Mask use with niqabs: A niqab is an article of clothing, worn by some Muslim women, that covers the entire face, except for the eyes. There is currently no global guidance on whether niqabs could effectively reduce the transmission of COVID-19. Based on what we know about how fabric masks work to prevent COVID-19 transmission, niqabs are likely to be less efficient at preventing transmission because they are composed of a single layer of fabric and they are loose-fitting. In the absence of global guidance we have seen national attempts to regulate or promote mask use in relation to niqabs. For example, in North West Syria the coordination mechanism did a survey and found that people were unsure about what women wearing the niqab should do. Consequently the coordination mechanism collectively decided that niqabs were unlikely to do the same job as a mask and therefore they are asking women to wear masks under or over their niqabs. There may be challenges with enforcing the use of niqabs with face masks. Wearing a mask outside a niqab may be very uncomfortable. If masks are worn under niqabs, it may be very difficult to monitor mask use. Ultimately decisions around this need to be taken following discussion between governments and implementing actors. For an issue like this the acceptability of the recommendations is key, so consulting women and their families is essential.

  • Promoting mask use among children: While children can still get and transmit COVID-19, the chances of them becoming severely ill is lower than adults. As such, the WHO advises that children who are older than 5 years of age wear face masks, or follow the specific guidance of your region. This evidence-based resource by UNICEF and the WHO gives detailed information on mask guidance for children. To ensure children wear masks correctly, it is important that masks are the correct size (e.g. smaller than adult masks) and covers their nose, mouth and chin without any gaps. In some settings, there may be guidelines in place requiring children to wear face masks in schools. This toolkit provides advice on how to make children more comfortable with wearing face masks, including making their masks more attractive and comfortable and incorporating play into practicing mask wearing behaviour. Encouraging children to wear masks may require family members and teachers to answer their questions about coronavirus, listen to their concerns and explain why wearing a mask is important. When children see other children and adults wearing masks, it can normalize the behaviour of wearing face masks. Wearing masks may also be more appealing for children if they see their favourite cartoon characters also wearing masks.

How can behaviour change principles be applied to mask wearing?

It may not be possible to change people’s behaviour just by telling them to wear a mask or telling them why wearing a mask is important. In such cases, it can be helpful to rely on behaviour change principles. Behaviour change principles can be applied alongside other measures to increase mask wearing behaviour, including mask legislation (e.g. requiring masks in public, and paying fines or facing penalties for noncompliance). The following general principles of behaviour change can strengthen promotion and communication about wearing face masks but should be adapted to suit the local context. Note that because wearing face masks in public is a relatively new behaviour, many of these ideas have not been evaluated, but they are based on behaviour change theories and community-level initiatives.

Target specific behaviours, audiences, and settings: Whenever communicating guidance for health behaviours, it is important to consider exactly what the target behaviour is, who should be practicing the behaviour, how the behaviour should be practiced, and when it should be practiced. It may be helpful to review this resource on population targeting when making these decisions. Recommendations should be as specific as possible to encourage appropriate adherence and wearing face masks. For example, the CDC provides very specific information on the key times a face mask should be worn, who should and should not wear face masks, and provides alternative suggestions (e.g. use of face shields, physical distancing) for circumstances when regular face mask use is not possible. Some individuals with health conditions may be exempt from wearing a mask and it can be useful to make sure that others in your community are aware of this. When designing programmes to promote face mask use, make sure to utilise behaviour change frameworks and formative research to better understand the behaviour within a particular context. It may also be helpful to target other mask-related behaviours, including handwashing, washing or disposing a face mask at the correct time, buying and wearing a clean mask, or remembering to have a face mask when leaving the house.

Communicate how masks can limit transmission: While some masks can offer the wearer some degree of protection against personal exposure to coronavirus, the primary function of using a face mask is to decrease the likelihood of an infected individual transmitting the virus to others (particularly if the person is asymptomatic). As such, it is important to emphasise that by wearing a face mask, you are acting out of a consideration for others. The act of wearing a mask can demonstrate that you have a concern for the health of people around you. This simulation provides a good visual explanation for how face masks can protect individuals and limit the transmission of coronavirus. These videos help to visualise how viruses transmit when we breathe, speak, cough or sneeze and shows the effect that masks can have in reducing this (Example 1, Example 2). It is also important to emphasize that masks are only effective if used correctly, this video can help explain this.

Source: Duke Health

Inspire people to act for the sake of others, not just themselves: In order for face masks to be effective in limiting the transmission of coronavirus, it is necessary that people wear them in public at the appropriate time. Similar to physical distancing, following public health recommendations and wearing a face mask protects others, especially those who are particularly vulnerable to COVID-19. By focusing on empathy and acting altruistically, it may be possible to change behaviours and increase the appropriate use of face masks. One study found that prosocial messaging, communication that highlighted how members of the community were at risk of getting sick and that individual efforts could keep others safe, was effective in getting people to practice COVID-19 preventive behaviours (i.e. washing hands, practicing physical distancing). The video below is from Pakistan and shows a famous artist and a chorus of others singing Pakistan’s national anthem for their independence day while wearing masks. It is an example of how to spread the message that people should be united in the effort to help protect the health of one another.

These public service announcements from the USA encourage people to #maskup to show others you care about them while also giving you an opportunity to express yourself by wearing a mask that has images, logos or phrases on them. A product of an ad contest in New York, this video emphasises that everyone needs to do their part and work together to protect themselves and everyone around them, and this can be done by wearing face masks.

Lastly the video below comes from Nepal. It emphasises that wearing masks, as well as other COVID-19 prevention behaviours are not easy to do, they require us to make short term social compromises to ensure that we can be together in the long term.

Build social norms around mask-wearing: Another strategy in increasing the uptake of appropriate mask use is to develop the social norms around the behaviour. Because wearing a mask in public is a very visible behaviour and benefits others, social influences and norms can play a role in practicing the behaviour. Even in areas where there may not be government mandates requiring masks to be worn in public, many businesses now require their employees and customers to wear face masks, which reinforces the expectation that masks should be worn to prevent the transmission of coronavirus. When strong social norms are in place, there may be pressure on others to behave in the same way to fit in. Formative research may be helpful in understanding how face coverings are perceived in your context, and those findings could be used to create norm-based messaging. Having important members of society, especially those in leadership positions, wear masks in public may also help establish norms around wearing masks. The media also plays an important role in creating social norms around mask-wearing because people can see others practicing the behaviour even if they are unable to see it in person due to physical isolation. This video does a nice job of showing that many people have different reasons for wearing a face mask and preventing the spread of coronavirus, which may be for a grandparent or their own health. The Pandemic Action Network also has a global #MaskingForAFriend campaign, for which they encourage people to share who they wear a mask for, and also use celebrities to normalise mask-wearing. A number of universities have created campaigns based on social norms to promote mask-wearing behaviours by showing that most of the students support and practice those behaviours themselves. In Northwest Syria, the NGO, Relief Experts Association, held a competition for people to make short videos about mask-wearing that targeted how the behaviour could fit with the local norm of doing right by others. This Social Norms Exploration Tool may be useful in better understanding norms in your setting and how to develop mask wearing programmes that are centered around these norms.

Image: A banner on display in Battery Park City, New York is part of a larger campaign to encourage the community to wear face masks

Image: Photos from the Pandemic Action Network’s #MaskingForAFriend campaign

Images: Examples of norm-based messaging to encourage mask-wearing behaviours.

The video above video was an entry in a video competition run by the Relief Experts Association in North West Syria and demonstrates how the decision to wear a mask can affect the people around you.

Encourage the behaviour through reminders: As more and more locations make rules about wearing face masks, reminders can prompt people to wear them appropriately in those spaces. Keeping a face mask with other items that are routinely taken when leaving the house (e.g. keys, wallet) can help remind individuals to take their mask with them. A study in Bangladesh found that having people who move around communities actively reminding people to wear masks can increase mask behaviour by about 30%.

Many businesses and indoor spaces have signs posted as cues both outside (to remind customers to put on a face mask before entering) and inside (to remind customers to keep their masks on so their nose and mouth are covered).

Images: Signs posted outside businesses to remind customers of face mask requirements

A multi-media campaign in Atlanta, Georgia called Big Fact, Small Acts, has been creating yard signs and adding masks to murals around the city to remind people to wear face masks when they are out in public. Murals painted by graffiti artists in Senegal show people practicing preventative behaviours, including wearing masks, and are useful in conveying health messaging in areas with lower literacy.

Image: A mural painted in Senegal tells people to “Wear a protective mask”

Twitter has been posting outdoor ads with user’s tweets which use humour as a way to encourage the public to wear face masks.

Source: Adweek

In Trabzon, Turkey, cameras have been installed at busy bus stops to show passengers video footage of themselves with their face covered by an image of a virus if they are not wearing a mask and to remind them to wear a mask. If the camera detects that they are wearing a mask, it displays a message thanking the individual.

It may be helpful to consider how to make disposable face masks available to people who do not have them but need them when out in public and how making them available can also act as a reminder to wear a face mask. For example, in some settings vending machines dispensing face masks are becoming popular and are often found in transit hubs (e.g. bus stations, train stations, metros).

Image: Mask vending machines allow people to purchase masks at a train station in Bangkok, Thailand.

Use trusted voices to model the behaviour: Leaders and influencers, especially at the community-level, can be key in encouraging the public to practice mask behaviours. They can also be helpful in establishing social norms around wearing masks. In Kerala, India, a campaign to bring public awareness to the importance of masks printed a magazine showing various prominent people from within the state all wearing face masks.

Image: The front page of a newspaper in Kerala, India, shows prominent people from the state wearing masks.

A media campaign called You Will See Me, targets communities of color that are disproportionately affected by COVID-19, and has messaging inspiring others to wear face masks. The Victorian government in Australia has created a series of humorous videos featuring well known athletes, comedians and actors emphasising the importance of engaging in preventative behaviours, such as wearing a face mask, to limit the spread of coronavirus. Religious leaders can also model mask wearing behaviours and have an influence on communities of faith.

Images: The Pope and an imam leading prayer while wearing face masks

Making wearing masks attractive and desirable: Fabric masks can be home-made and customised to reflect the identity of its wearer. One strategy in promoting mask wearing is to communicate how they can be worn as means of personal expression. Colorful masks, masks with animal print or faces, and adding their name on the mask can make wearing face masks more acceptable among children. Many retail stores are now stocking and marketing fabric masks as fashionable accessories for their customers. Some people have been matching their masks with their outfits or their head wraps. Face masks with designs on them for different holidays may also make wearing them more attractive and desirable. People can show their support for their favorite sports teams, schools, or brands by wearing fabric masks with logos, mascots and images. Fabric masks are also being used as a platform to bring awareness to social issues. For example, in Thailand, fabric face masks have been designed and sold to raise awareness and funds for cleft palate corrective surgery.

Images: These are some examples of how fabric masks can be made attractive and desirable for wearers: children’s masks with animal print, matching masks and outfits, matching masks with headwraps and using traditional fabrics, and masks with sports logos.

Editor Notes:

Written by: Anika Jain

Reviewed by: Peter Winch, Ben Tidwell, Penninah Mathenge, Jacqueline Knee

Last update: 15.01.2021

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