A study in Bangladesh tripled the rate of mask-wearing. Is it possible to do the same in the U.S.Zoomen this image to toggle caption Ian Morton/NPR Ian Morton/NPRHow can you convince someone to wear a face mask?As cases of the delta variant increase among both unvaccinated persons and vaccinated individuals, this question is often back in people's minds.Even though there are mask regulations, social pressure, and rewards for kids who properly wear masks, the country is still divided about mask-wearing. At a White House press conference on Thursday, President Biden condemned antimasking behavior.Some countries are making some progress in getting people to stop hiding. Stanford, Yale and GreenVoice, a non-governmental organization in Bangladesh, have been conducting an ongoing study in 600 villages of Bangladesh. The goal is to identify the most effective methods for changing behavior, with the aim of sharing them around the world.These methods may be particularly helpful in reducing COVID-19 infection in low-income countries, where vaccine supply is limited. Although the methods may not be effective in all countries, they may have some useful lessons for countries such as the U.S. where masking has become politicized.The study was inspired by a concerning observationMushfiq Mbarak, Yale University's professor of economics, said that the experiment was inspired from a worrying observation he made during the pandemic. He noticed that no one was covering their faces while he was working in Bangladesh in May 2020.Click to enlarge the image toggle caption Munir Zaman/AFP via Getty Images Munir Zaman/AFP via Getty ImagesMobarak was alarmed that masks offer the best chance for Bangladeshis of stopping the spread coronavirus. It is near impossible to distance yourself from public places in Bangladesh, which is one of most densely populated nations in the world. A weak health-care system can mean that COVID patients may not receive the treatment they need immediately, according to Lawrence Gostin (professor of global health law at Georgetown University), who was not part of the research.They provided free masks and reminded you often.Mobarak began a quest for ways to get Bangladeshis to use masks.Mobarak and a team of researchers collaborated with the Bangladesh Medical Research Council and Ministry of Health and Family Welfare in order to develop and implement a program to evaluate various strategies for increasing mask-wearing.This would be done by testing the idea in real life with 341 830 people in 600 villages in Bangladesh, some in rural areas and others just outside major cities. From November 2020 to January 20,21, the experiment was carried out in waves.Researchers randomly selected 300 villages to receive mask interventions over eight weeks. The comparison group included 300 villages that received no intervention.The core practices were developed from the best of marketing, psychology and social literature.These strategies were essentially about free reminders and face coverings. Each household received three masks for free, and people could also pick up masks in mosques or at markets. The videos showed Bangladeshis such as Shakib Al Hasan, the cricket star of Bangladesh, and Prime Minister Shiekh Hasina discussing when and how to use the masks. At Friday prayers, local imams discussed the importance and use of masks. Program volunteers remind people to wear masks in public places like markets, several times a week.Researchers wanted to test behavioral nudges in addition to the core interventions.The researchers split the test group into three groups to evaluate incentive offers. If at least 75% of the village's adult residents are still hiding eight weeks after the experiment began, one set could receive $190 to buy an item for the entire community.Another option was text messages. Two-thirds of participants received text messages two times per week during the intervention period, with reminders to cover up.The researchers then tested the style. A third of the group was given a cloth mask with different colors and a printed Bangladeshi flag instead of a surgical mask.Researchers began the second phase after the first phase was completed. The researchers observed people going about their daily business in public places, such as markets and mosques. They counted the number of people wearing masks in each village for 10 weeks.This effort doubled the use of masksMobarak and his colleagues were shocked by the results. Core interventions, which included free masks and reminders frequently, more than tripled the mask use from 13% to 42% in treatment villages.People continued to wear masks even after the volunteers left the villages. "Even after we had finished everything for 10 weeks, mask-wearing continued. "That's what got our excited," Mobarak says.Laura Kwong (assistant professor in environmental health sciences, University of California, Berkeley), who was involved in the study, said that none of the additional nudges or incentives helped.She says that the text messages were not effective because people received too many texts. The money reward did not work as the goal of 75% village members wearing masks was too lofty.Kwong says even the failures are valuable lessons. "The advantage of this study was that we learned a lot more about what is unnecessary to make [masking] successful."However, individual color preferences in face coverings did make a difference. According to Mobarak, people who were given a blue surgical mask were 2.9% less likely to use it than those who were given a green one. In villages that had cloth masks, people were 5.8% more likely than those who received a red or violet mask to wear it.Mobarak says that the next phase will examine whether mask interventions resulted in lower COVID-19 rates in villages.This effort is being extended to other countriesThe researchers have now turned the best practices of their experiment into a model called “NORM,” short for:No-cost free masks distributed door-to-doorInformation about masksRecommendations for public and private reinforcement of mask-wearing behaviourLocal leaders can model and endorse.BRAC, an international development organization, and partners are currently expanding the NORM model to more than 100 million people in Bangladesh, India and Mexico. The program was launched in June.Gostin believes masking interventions can be a tremendous help in low-resource environments. He says that while masks will not stop a raging epidemic from erupting, they might help to flatten the curve and save the health system. "You are using masking to buy time until they get more vaccines."These methods may work in America.Can "NORM" convince more Americans to cover up?Jay Van Bavel associate professor of psychology at New York University who studies human behavior and the social sciences of psychology, says that "I don’t think it would have a similar dramatic effect in the U.S."Van Bavel says that face masks have become so politicized in America, as well as vaccines, that they have become a symbol for identity. He says that early surveys during the pandemic showed that Democrats were more likely to wear face masks than Republicans, and that behavior has remained. He adds that people continue to "refuse masks for ideological reasons".Van Bavel, who offers free masks at convenient locations, believes that some of the NORM models may not be as helpful as they seem. He says, "I have often stated that there should be a free box of masks in grocery stores because people forget them or don't have the money to replace them."Role models can be a positive influence on health behavior. Van Bavel refers to a August paper in the journal PNAS. "They discovered that Trump would have endorsed the vaccine if he had been vaccinated. That would have encouraged more Republicans to get vaccinated. He didn't advocate. He didn't do a public video."Van Bavel says that if all else fails, it is possible to regulate behavior. Van Bavel says that "universities" and companies now require everyone to have their vaccines in order to allow them to go to work or school. Although it may not be liked by everyone, protestors in Tennessee rallied against the school-masking mandate. However, "a lot of [employers] and teachers are at their wits' end."
