On the psychology and politics of wearing masks – The BMJ – The BMJ

Throughout the covid pandemic, there has been a constant concern that the public would be the weak point in the responseeither unwilling or psychologically unable to abide by the measures necessary to control the spread of infection.

Sometimes, this concern has been expressed in specific (and racist) cultural terms. The freedom-loving British public, according to the government and others, would not wear the measures accepted by more conformist Asian societies. [1] In particular, we would not wear masks as (say) the Chinese are accustomed to do.

There is an irony in this claim, and also a profound misunderstanding of cultural practices as rooted in some timeless essence. For there is nothing traditional about Chinese mask wearing. Indeed, the imposition of masks was a deliberate political intervention by the Chinese Communist Party after 1949 as a symbolic break with tradition and a sign of modernity. [2] Equally, in the UK, the supposedly ingrained cultural aversion to masks very quickly evaporated once mask-wearing measures were introduced.

In June 2020, YouGov published an article which highlighted the British populations unique reluctance to wear face masks: only 21% of UK respondents indicated that they were covering their faces in public. In July 2020, masks became obligatory in shops and supermarkets in England. In August 2020, the ONS Coronavirus and the social impacts on Britain survey reported that 96% of adults were wearing masks.

At other times, concerns about public fragility have been expressed as a disdain for human psychology in general, our supposed inability to act rationally, especially in a crisis, and to put up with restrictions for any length of time. Most notoriously the notion of behavioural fatigue was used to delay lockdown in March 2020.

Once again, there is an irony to this claim which was hotly disputed by psychologists and other behavioural scientists as having no scientific status and which was soon debunked by the remarkable levels of resilience during the eventual lockdowneven in the face of considerable adversity. [3,4]

However, fatigue is one of those zombie ideas which has the ability to come back and bother us, no matter how many times it is killed off. Even as levels of adherence (and particularly of mask-wearing) stay stubbornly high, I have been asked by the media at least weekly throughout the pandemic whether people are about to grow tired and abandon all caution in the face of the pandemic. The question was posed with particular intensity in the autumn of 2020 after SAGE mooted a circuit-breaker. It was posed in early 2021 when soaring cases led to a new lockdown. In each instance the response was the same (including in these pages): no, fatigue is not the issue; people are still adhering to measures, they are ahead of the Government in wanting robust measures, and if they are behaving in ways that spread the virus it is less because of psychological motivations than structural constraintsbeing required to go into work, lacking the resources to self-isolate. [5]

And now, once more, groundhog day is upon us. Just as the governments winter plan moots the possibility of reimposing masks in certain spaces should the pandemic run still further out of control (as if 30,000 cases, nearly 1,000 hospitalisations a day and nearly 1,000 hospitalisations a week is not already enough to take action), The Guardian reports recent official figures with a screaming headline: More than 4m stopped wearing masks in Britain, ONS data shows. [6,7] Surely, even if it has taken much longer than expected, this is compelling evidence that people have finally run out of resilience and that there is no point in reinstituting covid measures since the population will simply ignore them?

What the data actually show, however, is that the percentage of people saying that they are wearing a mask in public at least some of the time has fallen from 98% to 89% between May and September. While that is indeed a significant drop, perhaps the more significant aspect of the data is that 9 in 10 people are still wearing masks even though the requirement to wear masks was largely removed in July. This is matched by more recent ONS data showing that 80% of UK respondents would support mask wearing becoming a requirement if hospitalisations rise. [8] It is also matched by unpublished data showing that, in early September, some 75% of respondents felt it was important to keep covid measures in place and 85% who felt it was important to wear face coveringsboth an increase on the July/August figures. This reflects a more general tendency for public attitudes to track levels of infection.

All in all, then, the bottom line is that it is still wrong to use the growing, but still small minority who are refusing masks to obscure the large minority who are not, or to assume that public fatigue is a reason to abandon protective policies. It is not only wrong, but dangerous since, as I have previously argued and as ever more research shows, peoples assumptions about others mask-wearing (and adherence more generally) influences their own behaviour. Indeed, even if individuals believe in the importance of masks, they wont wear them if they think others are not. [9]

However, having stressed this bottom line, it does remain true that mask wearing is slipping and that it is important to address the factors which impact levels of adherence. One is simple accessibility. People fail to wear masks either because they cant afford them or because they forget them. One study in Oslo found that distribution of free masks outside shops cut non-usage by nearly two-thirds from 8.3% to 2.9%. [10]

Another factor is perceived need. While adherence to mask-wearing often declines with time, it has less to do with fatigue than with a sense of declining risk, for if there is no risk, why wear a mask? [11,12] Hence messaging about the importance of masks as an efficacious means of stopping infections is critical. When government indicates that infection doesnt really matter (being unconcerned at the possibility of cases spiralling after the removal of restrictions on July 19th) it undermines the rationale for actions that limit infection. [13] But messaging is not only about what you say, it is equally about what you do. To tell others to wear masks in crowded spaces, but not to wear masks yourselves is a powerful signal that masks are not important. [14]

Perhaps most critically of all, policy and messaging are not separate things. Policy is messaging. It indicates the importance of a behaviour. That is why exhortations to wear masks in the summer of 2020 had little effect until legislation was introduced (leading, as we have seen, to compliance rocketing from some 20% to some 90%). But likewise, the removal of mask requirements sent a message in the opposite direction. If we want to enhance mask-wearing we need an alignment of government comms, government actions and government policy.

Of course, messaging is of little use if one doesnt trust the messenger, which is why the (re-) establishment of trust is so critical to all interventionsand not only trust in Government authorities, but also in scientific and in medical authorities. [15,16] While we dont have the space to address this in any detail, building trust is, perhaps, the most important behavioural dimension of the pandemic responseand a paternalistic belief in the psychological incapacities of the public is hardly a good starting point for building such trust. [17]

All these various factors apply to all covid measures: we need the means to adhere, we need the information to explain its importance, we need to trust the source of information. But there is one final factor which is particularly relevant to wearing face-masks, because unlike many other behaviours which are private (getting tested, getting vaccinated, washing hands), masks are a highly salient public sign that defines the identity of the wearer (or non-wearer). [18] They have intense symbolic value and hence the meanings attributed to mask wearing become of critical importance to whether masks are worn. We choose to wear masks (or not) because of what we want to say about ourselves and also what others will assume about us.

What is more, these meanings have become highly politicised in some places. In an era of resurgent populism, the right have used masks as a core symbol of elite oppression. Masks become muzzles. [19] The requirement to wear masks becomes an act of silencing. The success of this narrative is reflected in the way that use of masks associates negatively with Trump voting in the US and with Brexit voting in the UK. [20,21]

There is nothing inevitable about such associations. As we have already seen, masks can convey very different meanings, such as modernity and scientific rationalism. At other times and in other places they have come to signify solidarity and care for others. [22] The point is that levels of mask wearing are not dependent on ingrained cultural differences, but on situated processes of meaning making. These can operate at different levels. At a societal level, the role of Government is critical. In this regard the way that the lifting of mask regulations on 19 July was described as Freedom Day was highly unfortunate, compounded by the emphasis on personal responsibility rather than our social responsibility to act in ways that protect others and make them feel safe. Indeed, it was precisely such a sense of communal concern which underlay high levels of adherence in the first lockdown and which continue to be critical in terms of mask-wearing. [23-26]

The process of sense-making is equally critical at the level of groups and local communities. How can one draw on specific values and beliefs in order to determine the meaning of wearing masks for members of these collectivities? How is mask-wearing made normative or anti-normative? This is of crucial importance since such norms are critical to adherence in general and mask-wearing in particular. [27,28]

It is clear, then, that covid adherencelike all behavioursis complex, a function of many different factors. Nonetheless, there is one simple overall conclusion to be drawn. In contrast to the discredited claims that were rife at the start of the pandemic, there is nothing inherent in human psychology which limits adherence (whether to mask-wearing or anything else) and thereby constrains politicians freedom of manoeuvre. Rather, the availability of resources, the understandings and meanings which shape action arise out of a political process. What politicians do in terms of making masks available, showing that masks are necessary and framing the meaning of mask-wearing in large part determines whether masks are worn or not.

In short, if the health secretary decides to exclude mask mandates it is not a matter of bowing to psychological reality, but of making a political choice.

Stephen Reicher, School of Psychology and Neuroscience, University of St. Andrews

Yasemin Ulusahin, School of Psychology and Neuroscience, University of St. Andrews

Competing interests: SR participates in the UKs Scientific Advisory Group for Emergencies and its subgroups, and is a member of Independent SAGE. SR participates in the advisory group to the Scottish chief medical officer.

References:

1. This is a repeated theme in the evidence of Dominic Cummings to the Health and Care/Science and Technology Committees of the House of Commons on May 26t 2021: https://committees.parliament.uk/oralevidence/2249/html/2. https://99percentinvisible.org/episode/masking-for-a-friend/3. https://behavioralscientist.org/why-a-group-of-behavioural-scientists-penned-an-open-letter-to-the-uk-government-questioning-its-coronavirus-response-covid-19-social-distancing/4. https://www.kcl.ac.uk/policy-institute/assets/Coronavirus-in-the-UK-cluster-analysis.pdf5. https://www.kcl.ac.uk/policy-institute/assets/Coronavirus-in-the-UK-cluster-analysis.pdf6. https://www.gov.uk/government/publications/covid-19-response-autumn-and-winter-plan-2021/covid-19-response-autumn-and-winter-plan-20217. https://www.theguardian.com/world/2021/sep/15/more-than-4m-stopped-wearing-face-masks-this-summer-ons-data-shows8. https://yougov.co.uk/topics/health/survey-results/daily/2021/09/15/75ec5/19. https://academic.oup.com/abm/article/55/1/82/6029785?login=true10. https://www.mdpi.com/1660-4601/18/17/8971/htm11. https://www.tandfonline.com/doi/full/10.1080/15456870.2021.1951733?casa_token=SvgkoJVSObcAAAAA%3A7B-iDO-Pm_aiGFVDT_50BlaC3kDPsCfD2RJY77AZTXNvXhm3U5KVHFUDVbR9NFPzZy8dI6tvGtBmFw12. https://www.jmir.org/2020/11/e2137213. https://www.theguardian.com/world/2021/jul/06/covid-cases-rise-above-100000-a-day-sajid-javid-concedes-england14. https://www.theguardian.com/politics/2021/sep/14/one-rule-for-them-boris-johnson-criticised-maskless-cabinet-meeting15. https://www.sciencedirect.com/science/article/abs/pii/S0191886921001446?casa_token=nFcuLQnKCtQAAAAA:PTueHouiLeiLRk9oMQ9w2h_u9WXS3Z8eLSy328FXV-KyQ806vCWKz_76Ows0b_iRbPStJerz9C416. https://nymag.com/intelligencer/2020/06/american-public-health-experts-coronavirus-masks.html17. https://www.rcpe.ac.uk/college/journal/fragile-rationalist-collective-resilience-what-human-psychology-has-taught-us-about18. https://journals.sagepub.com/doi/full/10.1177/1354067X2095754919. https://thetab.com/uk/birmingham/2020/08/17/your-mask-is-a-muzzle-anti-mask-protestors-march-through-the-bull-ring-4508420. https://link.springer.com/article/10.1057%2Fs41302-020-00186-021. https://www.dailymail.co.uk/news/article-9760261/The-Brexit-mask-divide-Leave-voters-likely-ditch-face-coverings-laws-axed.html22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789204/23. https://www.reuters.com/business/retail-consumer/uk-looks-set-ease-restrictions-july-19-sun-cites-pm-saying-2021-06-28/24. https://www.theguardian.com/commentisfree/2021/jul/06/boris-johnson-policy-pandemic-restrictions25. https://blogs.lse.ac.uk/politicsandpolicy/lockdown-social-norms/26. https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/pt/covidwho-128291327. https://psyarxiv.com/9whp4/28. https://onlinelibrary.wiley.com/doi/full/10.1111/spc3.12596

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