Normalizing masks and hard-earned lessons from the AIDS pandemic.

Though CDC guidelines recommend wearing cloth masks to reduce the spread of COVID-19, you can expect public adherence to vary as much as expert opinions and role modeling from political leaders varies. We need to be concerned about the latter because it keenly influences the former. Many have characterized this pandemic as unprecedented, but I’m certain that thousands of public health workers who fought the AIDS pandemic are experiencing déjà vu as we again watch the interplay between a rampant pandemic and the attendant economic collapse of nations. As someone who worked in AIDS prevention in Zimbabwe in the early 2000’s, at the epicenter of the pandemic during the height of the spread, I was complicit in the lag time it took public health authorities and political leaders to shift from a message about safe sex to one about safer sex. Multiple years of creative and constant campaigns about the need for abstinence were matched by multiple years of the wildfire spread of AIDS. But surely, we thought, we couldn’t recommend condom use alongside abstinence since condoms were not 100 percent effective! Or should we have?

(For this full editorial with citations about the skills based education needed to promote mask use, go to the open access article at The American Journal of Health Promotion.)

Given our 24/7 breaking news about this pandemic, many consider COVID-19 to be incomparable. Nevertheless, in 2000, the first year I worked in Zimbabwe, nearly 4,000 young lives were lost every week and 200,000, mostly young people and children, would die in that small country that year. A study I led showed that only 27 percent of men felt using a condom was a “mutual decision.” If attitudes about abstinence and condom use were to change, the culture of entitlement would need to change first. Eventually it was the unmitigated crisis, more than the veracity of condom use research, that led to new messaging: Abstinence is the only sure way to stop HIV, but if you are going to have sex, for sure, use a condom.

Review the few studies about the filtering effectiveness of cloth and surgical masks now being cited assiduously by both those recommending for and against DIY masks, and you will find they are basing their opposing positions on the very same studies. One study opposing the use of masks notes that results from a study by Davies and colleagues was not used because they did not measure “filter efficiency” or use “respirators as positive controls.” But remarkably, the first figure shown in the Davies study is about the filter efficiency of various materials and is featured prominently to make the case for the filtering value of masks in an expert commentary (i.e. surgical mask 96 percent, tea towel 83 percent, t-shirt 69 percent).

There are several hard-earned lessons about condom use that apply to mask education in the months ahead as quarantines are eased. First, we need “skills-based” education. Protection from well fitted, properly sanitized masks will increase proportional to the clarity and consistency of instruction. As the OSHA web site on respiratory protection shows, there are right and wrong ways to use masks. Gladly, DIY videos on making and wearing masks are proliferating.

People also need the belief that ‘I can do this’, and peers are better at building self-efficacy than parents or teachers. A trending YouTube video offers a great example of the power of peer education. An earnest young woman brightly says: “I protect you and you protect me” and you’re left feeling happy to do your part. Can we coalesce around wearing masks as a civic duty in a country synonymous with independence? The study of hygiene habits of health care professionals, aptly titled “It’s Not All About Me,” compared messages about protecting “you” versus your “patient” and found that they were more motivated by caring for others than caring for themselves. Changing just one word made all the difference.

The magnitude of this crisis demands clear messaging and culture change that amplifies the role of masks in neighborliness and the viability of our returning to work sooner than later. Social distancing is the only sure way to stop COVID-19, but if you are going to go out, for sure, wash your hands often and wear a mask.

Paul Terry, Ph.D., is Editor in Chief of the American Journal of Health Promotion and a Senior Fellow at the Health Enhancement Research Organization (HERO). He is the author of “Breaking Stone Silence: Giving Voice to AIDS Prevention in Africa.” Africa World Press.

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