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.

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.

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?