Dr Ling Chan, Dr Sophie Febery, Prof Michael Baker, Dr Amanda Klasvig, Prof Nick Wilson

Whilst the New Zealand Government has recently recommended using face coverings or fabric masks as a strategy to contain COVID-19 pandemic virus transmission, the uptake of mask use in the public has been suboptimal. In this blog, we explore using “Mask Day” at school to promote positive public messages on masks, which may lead to increased public engagement of mask use within the wider community.

Aotearoa New Zealand is currently experiencing a second outbreak of COVID-19, necessitating Alert Level 3 restrictions in Auckland and Alert Level 2 within the rest of the country. Despite the welcome change in the Government’s recent promotion for mass masking [1], mask wearing in public is still not mandatory at this stage (though will become so on public transport, planes and taxis on 31 August). This voluntary approach has led to suboptimal public engagement with masking.

The current low level of mask uptake in New Zealand is perhaps unsurprising, due to the previous lack of support by the NZ Government and the World Health Organization. Our successful elimination of SARS-CoV-2 from the first stringent lockdown has led to complacency by the general public in maintaining infection control measures throughout Alert Level 1. The public’s risk perception of pandemic virus transmission is likely low, and as a consequence low levels of mask uptake are being observed, particularly in the South Island.

Asymptomatic transmission of SARS-CoV-2 has emerged as a major driver of virus circulation: a recent evaluation from Spain of 61,000 people found that around a third of those infected were asymptomatic [2]. This significant proportion of asymptomatic transmissions forms the basis for the ‘mass masking’ strategy to curb the spread of silent infection with the COVID-19 pandemic virus. There is strong evidence that face coverings are effective as ‘source control’ by limiting the spread of potentially infected droplets [3], which can travel further than the 1-2 m distancing guidelines indoors [4]. As policy-makers grapple with a second outbreak of infection in Aotearoa (the “Auckland cluster”), mass masking can assist with providing disease control while Alert Levels are lowered [5].

Images provided with permission by North East Valley Normal School

Currently, the lack of public engagement with masks can potentially lead to stigmatisation of those wanting to mask [6]. Insights from behavioural science suggests that people perceive an action as correct if they observe others performing it [7] [8], this is described as ‘social contagion’. One way to promote mass masking as an act of social contagion, in the absence of a mask mandate, may be via schools holding ‘Fun Mask Days’.

Observational survey at a school ‘Fun Mask Day’

The North East Valley Normal School in Dunedin held a ‘Fun Mask Monday’ on 17 August 2020, with the Principal’s aim being to socialise the idea of masking amongst the school children between ages of 5-11 years. The activity was not compulsory, but children were encouraged to wear a mask to school. An observational survey was conducted by the lead author (Dr Chan – who has a child attending this school) where the teachers were asked to count the number of children wearing masks during roll call and the number of children wearing masks at home time. A Google form was used for the teachers to input the data. A majority (10/12) of the classes in the school responded. Out of a total of 184 children (range 12-22 per class), 94 (51%) wore masks at roll call (range per class: 5-13). Just over a third (35%; 57/163) of children wore masks at home time (range per class: 1-11).

Children engaged with fun mask sewing activities during the day in some of the classes, whilst learning about the pandemic and how masks work to protect others in the community. The teachers reported the children “remain confident and supportive” of masks and “became accepting and relaxed whether others wore masks or not”. There was an atmosphere of excitement as pupils put on masks at the school gates. Some older pupils are continuing to sew masks for their “COVID preparation bags” and other classmates beyond the Mask Monday.

More children were noted by teachers to wear a mask to school the next day, due to improved confidence and a lack of stigma from masking.

Images provided with permission by North East Valley Normal School

Comment on this initiative

Our impression is that this “Mask Day” was a very successful event and notably, the event was entirely an initiative of the school. Collective action such as this can potentially foster a sense of social solidarity which can lessen the fear of the pandemic and help reduce infection rates [9].

The initiative showed an around 50% uptake of masking within the primary school on Mask Day. This level of engagement is higher than the observed masking levels in the general public in the South Island at the present time (eg, supermarkets, public transport). Children appear more adaptable to new norms than adults, as it was reported by teachers that children who had parents expressing concern over masks, still remained supportive and accepting of classmates who wished to mask.

Schools as powerful places to spread positive public health messages 

Mass masking is a new norm in many non-Asian high-income countries and behaviour change requires not only verbal recommendations, but also real interventions in the environment with possible added legislation [9]. As the pandemic continues with threats of repeated outbreaks in the future, particularly if border restrictions in NZ relax, children will be exposed to more masked adults which may induce fear. In many areas of the world where there are high levels of community transmission, children are also required to wear masks at school.

Where mask hygiene cannot be easily complied with amongst the younger school children, hand washing and social distancing remain key measures to reduce the risk of SARS-CoV-2 transmission in this group; as highlighted by the American Academy of Paediatrics [10]. Esposito et al reason that universal mask use seems necessary to continue with daily lives, and to obtain maximal compliance, preparing healthy children to use a mask is strongly needed [11]. Young children should not be compelled to wear masks; if they experience difficulty with mask wearing they could instead focus on good hand hygiene and distancing.

Within Aotearoa, our first strict lockdown brought us precious time to be proactive. Preparing the youngest members of our team of 5 million to mask up and educating them on mask hygiene will avoid anxiety and fear, should mandatory masking requirements extend beyond public transport in the future. As the WHO’s latest recommendation on the 21 August states that all children over the age of 12 should use face coverings within areas of community transmission [12]; initiatives such as School Mask Days may have a valuable contribution to make in normalising mask use.

Effective health communication is a key factor in fighting the COVID-19 pandemic [13] and schools are well placed to provide health promotion. This need has been demonstrated by this Dunedin primary school where there was a swift increase in mask use confidence by the children. This change may in turn lead to an improvement in mask use in the adults within the wider school community. Using schools to develop a positive mask ‘social contagion’ effect may be necessary to combat silent COVID-19 transmissions and so minimise the need for going back up the Alert Level system.

Acknowledgements: The lead author thanks the School Principal and participating teachers for their assistance with the survey.

References

1. COVID-19: Use of masks in the community. Ministry of Health, NZ. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-health-advice-general-public/covid-19-use-masks-community
2. Pollan M, Perez-Gomez B, Pastor-Barriuso R, et al. 2020. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet. 2020; 396(10250): 535–544.
3. Chu DK, Akl EA, Duda S, Solo K et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet 2020; 395: 1973-87. https://doi.org/10.1016/S0140-6736(20)31142-9
4. Bourouiba L. et al., “Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19.,” JAMA, 2020.
5. Kvalsvig A, Wilson N, Chan L, Febery S et al. Mass Masking: An alternative to a second lockdown in Aotearoa. N Z Med J 2020; 133(1517).
6. Coronavirus: Kiwis outside of Auckland mocked, laughed at for wearing face masks.  Stuff. Aug 15. 2020 https://www.stuff.co.nz/national/health/coronavirus/300083046/coronavirus-kiwis-outside-of-auckland-mocked-laughed-at-for-wearing-face-masks
7. Farrow K, Grolleau G, Ibanez L. Social norms and pro-environmental behavior: A review of the evidence. Ecological Economics 2017. (doi: 10.1016/j.ecolecon.2017.04.017).
8. Frank R. Under the Influence: Putting peer pressure to work. Princeton University Press, 2020 (ISBN: 9780691193083).
9. Lunn P., Belton C., Lavin C., McGowan F., Timmons S., Robertson D. ESRI; 2020. Using behavioural science to help fight the coronavirus.https://www.esri.ie/system/files/publications/WP656.pdf Working paper # 656.
10.  American Academy of Pediatrics. Masks and children during COVID-19. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/masks-and-children-during-covid-19/
11. Esposito S, Principi N. To mask or not to mask children to overcome COVID-19. Eur J Pediatr. 2020 May 9: 1-4. doi: 10.1007/s00431-020-03674-9 [Epub ahead of print]
12. Q&A: Children and masks related to COVID-19. WHO 21 August 2020. https://www.who.int/news-room/q-a-detail/q-a-children-and-masks-related-to-covid-19
13. Finset A, Bosworth H, Butow P, et al. Effective health communication – a key factor in fighting the COVID-19 pandemic. Patient Education and Counselling 103 (2020) 873-876 doi: 10.1016/j.pec.2020.03.027