Encouraging the public to see face masks as a social practice, which they can use to express their cultural background or their personality, could encourage more people to use them regularly, say researchers writing in The BMJ today.

Helene-Mari van der Westhuizen and colleagues at the University of Oxford argue that protracted debates about face coverings as a medical intervention have delayed implementation of a valuable preventive tool—and they say face coverings need to be grounded in the social and cultural realities of affected communities.

Most countries now recommend or mandate the wearing of face coverings to some extent, to reduce the spread of COVID-19.

Debate about whether the public should wear them initially focused on the medical narrative of benefits and harms, such as whether they would be effective and whether recommending medical masks would reduce the supply for healthcare professionals.

This view of face masks as a medical intervention has persisted in public health messaging about the use of face coverings. This includes emphasising medial narratives about “donning and doffing,” (putting on a face covering in a certain way) “decontamination” (how to clean it ) and “risk” (not touching certain parts of it).

But recognising and embracing the sociocultural narrative of face coverings could encourage the public to select one that is meaningful to them and that they will therefore be more likely to wear, the authors argue.

“Wearing face coverings is being rapidly introduced as a public health intervention in countries with no cultural tradition of doing so,” they write. “For successful uptake, such interventions need to be grounded in the social and cultural practices and realities of affected communities, and campaigns should not only inform, but also work to shape new sociocultural norms.”

Framed socioculturally, face coverings are clothing or accessories, they explain, and wearing one is a social practice—a behaviour that has a particular meaning in a particular society.

For instance, face coverings have been associated with assuming a different identity (worn by a superhero), avoiding recognition and persecution (worn by a criminal), to exhibit modesty (expected of women in some cultures), having an infectious disease (worn by a patient), for protection (against pollution, dust, pollen) and for cultural ceremonies (worn for celebration).

The symbolic meaning of a face covering to a particular society will also be influenced by social expectations (eg, what we expect a shop assistant, bus driver, or nurse to be wearing), norms (what is viewed as morally correct and as right and proper behaviour), and laws and regulations (whether it is mandatory).

There are examples of face coverings adapting to cultural traditions. For example, in India, a loose end of a piece of clothing, from a saree is now more frequently used also to cover the face during the current pandemic.

In some Asian countries, face coverings have been widely used in public in previous respiratory virus epidemics and uptake during COVID-19 has been swift and near universal. This might also be linked to cultural meaning systems that emphasise the boundary between a clean and pure inner self and a potentially polluted outside (similar to the removal of shoes on entering the home).

The ability to personalise cloth face coverings also offers an opportunity to improve uptake through desirability as an accessory, they add.

The wide variation in materials and style raises questions about the efficacy and reliability of face coverings, and public health policy must consider the trade-off between efficacy and compliance, they stress. “A face covering that is 100% effective at preventing transmission but only worn by 10% of the population will have less impact than one that is 50% effective but worn by 95% of the population.”

Instead of continuing to debate technical specifications and efficacy, sociocultural framings should be explored to encourage their use, conclude the authors. “This can be done by emphasising underlying values such as solidarity and communal safety. Such measures are likely to enhance the uptake of face coverings and help curb the devastating impact of the pandemic.”