People all over the world are wearing masks in public now as part of the strategy to slow the spread of the novel coronavirus and save lives. The high rates of asymptomatic and pre-symptomatic spread, plus evidence that the virus is passed mainly by inhalation rather than by touch support the use of masks by everyone when they are in a public place and cannot maintain 6 feet (2 meters) distance from others.

But many North Americans are refusing to wear masks even though there is plenty of evidence now that face coverings of any kind can make a difference. They are a minor inconvenience and are inexpensive… so why is there such resistance? Are people just too uncomfortable? Embarrassed? Don’t they believe the experts? I was curious so I did some research on why our uptake of masks has been so slow and reasons people refuse to wear them.

Why weren’t masks required sooner?

Initially, the reasons public health authorities gave for not advising the public to wear masks when outside their homes included:

1. The efficacy of non-medical masks is unmeasured and often questioned because cloth masks are not commercially produced and tested
   1. Some materials and designs are more effective than others. But evidence is emerging that any face covering will reduce viral load on exposure enough to slow the rate of spread.
   2. By analyzing the changes in the curve of disease cases when each new strategy was started in Italy and New York City between January 23^rd and May 9^th, researchers were able to illustrate the impact of each measure. The study showed that, while physical distancing made a difference, the change was greater when masks were mandated to be worn by everyone when in public.
   3. The reduction in new cases of COVID-19 when masks were mandated is clearly visible on graphs—with a “flattening of the curve” easily seen. This contrasts with the rest of the world where physical distancing, quarantine and isolation continued to be used alone. Here is one of the graphs… the circled dots show when masks were mandated to be worn in public in Italy and New York City:
   4. 
   5. Note that Wuhan, China (the dark red line) mandated masks early, along with other measures.
2. Masks might encourage people to touch their faces to adjust the mask
   1. My question is: do healthcare workers touch their faces more when wearing a mask or to they adapt to it quickly when told they must not do this? This, again, is not a conclusion from research and, in fact, I’ve read the opposite expert opinion elsewhere: that a mask stops a person from touching their face…it physically blocks you from doing so.
3. Non-healthcare people don’t know how to put on and remove a mask properly
   1. A significant cause of infections of healthcare workers is improper removal of contaminated protective clothing. But is this also an issue for people who wear a mask in public? Since the main purpose of masks in public is to prevent the wearer from expelling droplets, removal is less crucial. However, as with other measures, it’s a matter of educating the public.
4. Masks need to be saved for healthcare workers, as there are not enough available for everyone (at least in North America)
   1. There is no question that high-level masks should be reserved for those working directly with people who are infected. The N95 mask is designed to filter out 95% of particles from air the wearer is inhaling. However, simple, inexpensive, even homemade cloth masks may be all the is needed to prevent the production of droplets and aerosols when in public. 

And I found several explanations for why people might choose not to wear a mask, in spite of the science now emerging…

Culture

First, wearing a mask isn’t part of our culture here in North America (except among health care workers) and people often feel uncomfortable with change. Other parts of the world, like Asia, had already started using masks in public when previous viruses caused deaths there. They also use them to protect themselves from high levels of pollution in dense cities. Apparently, wearing a mask in Asian countries when you’re ill is so imbedded into the culture, it’s considered rude and inconsiderate to cough or sneeze into your hand or sleeve—you’re expected to wear a mask if you are sick, even with a cold. So, themask-wearing culture was already established there. However, masks were accepted quickly in Europe and Scandinavia when they were threatened by COVID-19, so that’s only a small part of the explanation.

Vanity

Our face is what we show the world—part of what makes us attractive to others and recognized by friends. Women wear makeup to enhance their looks. Men show their character through grooming, facial hair, and a healthy smile.

One article I read, even suggested some people feel wearing a mask makes them appear weak and overly worried about an invisible threat. Most healthy, strong people only get a mild case, so wearing a mask must suggest you are not healthy and strong… right? (read with sarcasm…)

But, because we now know that the virus spreads easily before symptoms appear and that a large percentage of those with the virus never develop symptoms, we all need to think about the people to whom we could unknowingly pass the virus. Would you feel guilty if you learned you caused someone else to suffer and possibly die? Young, healthy people wear masks to protect others more than themselves… and caring for others isn’t a weakness.

Communication

A large part of communication is visual. The expression on a face tells much of what a person is thinking. A smile brightens someone’s day. Some people worry about that loss of communication, and it’s important. But they say the eyes are the window to the soul…perhaps we can learn to read expressions in the eyes better, just like those who are blind become more sensitive to sounds. And, like the blind, we can learn to be more sensitive to the tone of voice that speaker is using.

But another option to improve visual communication and facial recognition, is the face shield. Although not considered as effective as a well-made mask, shields still make a difference in reducing dispersion of droplets so use will reduce the spread of the coronavirus by those who cannot wear a mask. Face shields also offer an option for children, who might have difficulty with a mask. Some have the shield attached to a sun hat to make it easy and comfortable to wear. Note that masks are not recommended for children under age 2.

Physical discomfort

Many people find wearing a mask just plain uncomfortable. It can be stuffy and hot, feeling your breath in your own face. The elastics can make your ears sore, the fabric and pressure required to form a seal can irritate the face…

The key here is to have a mask that fits properly. You want it snug but not so tight it pulls your ears forward. It should have enough room for your nose and be made of a material that is smooth enough not to irritate your face. It needs to fit closely enough that air doesn’t pass around the edges and be “breathable” enough that you can breathe easily through the fabric. And, especially in hot weather, you want it to be absorbent so it will stay cooler on your face. I hope manufacturers and researchers are working on this! Since it may be over a year until we have a vaccine for everyone, we need good quality reusable masks and information on the best materials to use if making them.

Confusion

Another problem in convincing people to wear masks in North America, is the confusion over whether we really need to wear one in public. Initially, authorities told us masks were not necessary and might even increase our risk but, with research, this has been shown to be incorrect. Recommendations gradually changed from “don’t wear a mask” to “they might help” then to “you should/must wear a mask when you cannot stay more than 2 meters (6 feet) away from others (depending on your area)”. The initial recommendations were based on a lack of information (because the virus is so new) and the worry that the public would buy all the available masks, leaving none for front line health care workers who needed them more. Homemade and reusable masks are solving this problem and production of disposable masks has greatly increased.

But there’s also a lot of misinformation surrounding masks, especially on social media. Myths such as “masks don’t work”, “they make you sick”, “they deprive you of oxygen” or “cloth masks are worse than none” continue to circulate in spite of the science that shows any mask is better than nothing because it traps exhaled droplets and aerosols that can potentially contain viruses. As health professionals, we need to continue to debunk these myths, and teach proper use and care of reusable masks.

Political

It’s hard to imagine, but the health-related issue of wearing a mask has become a political issue in some areas. Some people tolerate change better than others, and I suspect the wholesale changes we’ve endured with self-isolation, quarantines, and physical distancing are taking their toll on the mental health of many. Demanding that they also cover their face has just been too much for some, adding to the stress that’s already sky-rocketed over the past few months. Refusing to wear a mask when required is a way of rebelling, of demanding a return to a normalcy we can’t safely have right now. Life is hard for so many in 2020. It will be difficult to find a cure for all of what’s happening, but we have to keep moving ahead, one step at a time.

While we are proud of our rights and freedoms in North America, we need to ask: do we have the right to harm others? A positive test result is considered reliable but tests currently available are known to have significant false-negative rates that vary, and performance is not well verified in real-life settings. In many situations it is not possible to be 100% certain that no infectious individuals are present with this fast-spreading disease. Masks reduce the possibility that an asymptomatic person will spread the virus to others when in public and a well-made mask fitted properly likely gives some protection to the wearer. I like to use the analogy of drinking and driving… none of us has the right to drive when impaired, because doing this could easily harm others.

World Health Organization (WHO)

However, the World Health Organization (WHO) insists that “masks alone are not a replacement for physical distancing, hand hygiene, and other public health measures.” Their current statement suggests that cloth masks may provide a “modest reduction in transmission” by:

• “reducing the risk of asymptomatic carriers spreading the virus”
• “reminding the population that the pandemic is ongoing and everyone can play a role in stopping it”

As well, they suggest masks may stimulate the economy by “encouraging the public to create their own masks.” Masks have become an item in high demand.

They also suggest there are disadvantages to cloth masks worn by the public, including:

• Touching the mask too often (usually due to a poor fit)
• Potential to cause headaches, breathing difficulties or skin irritations and
• The possibility of creating a “false sense of security” as they are not 100% protective

However, please note that these disadvantages are not supported by objective research. I find it odd that a high level of proof is required to recommend a measure, but disadvantages not supported by objective studies are readily shared.

So, do I wear a mask?

Yes, I’m an “early adopter” … I started wearing a mask in mid-March when I had to return from a winter vacation a month earlier than planned. I was in Spain as the country was shutting down due to the virus and was lucky to get a flight home as quickly as I did. I tried to buy a mask to protect myself on the 3 flights and 4 airports I had to pass through, but there were none left for sale anywhere. I started making masks for myself, friends and family as soon as I arrived home, knowing what was coming. And I continue to look for research indicating the ideal materials and design.

I also accepted covering part of my face more readily than many would because of my past experiences. As a hospital pharmacist, I prepared sterile medicines and was required to wear a surgical mask (sometimes for hours at a time) to protect the products I was making. We all breathe out little droplets containing bacteria when we talk and exhale, and just a single droplet falling on the medicine meant it would no longer be sterile. Later, as a compounding pharmacist in the community, I worked with potent drugs in powder form. I upgraded to an N-95 mask to filter the air I was breathing in, so I wouldn’t inhale powders that escaped into the air. So, I was used to the concepts of protecting myself and others by wearing a mask.

Of course, some people cannot tolerate wearing a mask—for example, those with breathing problems like asthma or emphysema, those with mental health problems, or children under 2 years. But, as with vaccines, if enough of those who can wear a mask do it, those who cannot will be protected. Recent modelling suggests that, if 80% of people wore a cloth mask in public, the spread of the virus could be stopped. Over 90 countries now require masks to be worn in public places and many countries that adopted this policy early, along with other measures, are reported to have had less than 1000 deaths due to COVID-19.

But we need to realize that most of the public only needs to wear a mask for short periods of time—only when they are not sure they can stay at least 2 meters away from others. I keep one in my pocket or purse whenever I go out so I can slip it on when needed. Here in New Brunswick, Canada, we are told we must put one on when entering a public place, but we can remove it if we see that we will be able to keep our distance from others once there. It seems to be a good compromise. However, increasingly stores and restaurants are requiring all patrons to wear a mask when in their establishment (except when eating in a restaurant).

I have never had to wear my mask for more than an hour at a time. It is different for workers who have close contact with the public, though, and they should have several washable masks, so they can change to a fresh one every few hours. They would also benefit from breaks during the day in a place where it’s safe to remove the mask for a while. But, like health care workers, it’s something you just get used to because it’s necessary.

I believe that all of us who are in a position to influence public health need to make the time and effort to educate others. Even if it is not possible to change the mind of an outspoken person spreading misinformation, if we speak out, others who are undecided will at least hear or read a science-based counter argument. Especially when reliable sources are quoted, they may be swayed to believe the truth. And, importantly, we can lead by example.

For tips on how to counter misinformation, please read “Fighting the Infodemic” by Dr. Michelle Cohen (reference below).

References

The psychology behind why some people won’t wear masks—CNN https://www.cnn.com/2020/05/06/health/why-people-dont-wear-masks-wellness-trnd/index.html

A Doctor Explains Why 45% of All Americans Refuse to Wear a Protective Mask—Forbes https://www.forbes.com/sites/johnbbrandon/2020/05/06/a-doctor-explains-why-45-of-all-americans-refuse-to-wear-a-protective-mask/#2a188b29213d

Why are people refusing to wear masks amid coronavirus threat?—KSAT.com https://www.ksat.com/news/local/2020/05/27/why-are-people-refusing-to-wear-masks-amid-coronavirus-threat/

Refusing to Wear a Mask Is a Uniquely American Pathology—SLATE https://slate.com/news-and-politics/2020/05/masks-coronavirus-america.html

Over 100 health leaders to governors: Require masks to help contain the coronavirus—USA Today https://www.usatoday.com/story/opinion/2020/05/14/require-masks-stop-coronavirus-spread-over-100-health-leaders-column/5182076002/

Identifying airborne transmission as the dominant route for the spread of COVID-19 – PNAS https://www.pnas.org/content/early/2020/06/10/2009637117

A modelling framework to assess the likely effectiveness of facemasks in combination with ‘lock-down’ in managing the COVID-19 pandemic – Proceedings of the Royal Society A https://royalsocietypublishing.org/doi/10.1098/rspa.2020.0376

Fighting the Infodemic – Canadian Healthcare Network https://www.canadianhealthcarenetwork.ca/physicians/discussions/fighting-the-infodemic-59364

Jeannie Collins Beaudin is a recently retired Canadian community pharmacist with 40 years of experience, including specialization in compounding pharmacy, and hormone assessment and management. In addition to publishing her book, Can I Speak to the Hormone Lady? Managing Menopause and Hormone Imbalances in 2018, she has written articles and blogs for Pharmacy Practice + Business since 2006, peer reviewed educational programs for Canadian pharmacists since 1998 and publishes a weekly health blog found on her website.

Editor’s Note –The views expressed in the nurse influencer posts are those of the contributing authors. NPWH does not sanction the content of these posts.