To Get People to Wear Masks, Look to Seatbelts, Helmets and Condoms

In the pediatric clinic where I worked for many years in Boston, each room held a clear plastic bowl full of brightly colored condoms. They were there on display, vivid and eye-catching, and part of my job — every provider’s job — was to offer them cheerfully and matter-of-factly and above all non-judgmentally to adolescents at every visit.

Pediatricians relentlessly and repetitively talk about safety precautions. Put the baby in an appropriate car seat — every time. Wear seatbelts — every time. Wear a bike helmet — every time. Use a condom — every time (this is where people usually make a joke about not doing all these things at once — don’t try to use the condom while riding your bike or driving your car).

What have we learned from those habits that could also apply to wearing masks?

More and more studies show that masks keep everyone safer. They protect other people if you are infected but you don’t know it; this includes those who are asymptomatic and those who will go on to develop symptoms. And yes, masks also offer some degree of protection to the wearer, although that varies with the type of mask.

Dr. Benjamin Hoffman, the medical director of the Tom Sargent Safety Center at Doernbecher Children’s Hospital in Oregon, said that to help communities think about masks, “the point is to reinforce for those already doing the right thing, and help convince those who have not made up their minds.”

The campaigns to get people to use condoms, to wear bike helmets and to wear seatbelts all involved taking an extra step. All three involve some sacrifice of personal comfort and convenience, sacrifices which seem trivial to some and highly non-trivial to others.

And just as we need to wear seatbelts every time we’re in the car, even though we don’t expect to crash, we need to wear masks in public, even if we don’t believe we or the people we encounter have the coronavirus.

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Let’s start with condoms, since those are clearly the best analogy: You wear a condom to protect yourself, but also to protect your partner.

Michelle Ybarra, the president and research director of the Center for Innovative Public Health Research, said that over time, “we’ve done a pretty good job of convincing teenagers” that the “idea that you can serosort” — or determine whether a sexual partner has H.I.V. by how they look — doesn’t work. Asking sexual partners if they have sexually transmitted infections is also not a good strategy; people may be infected and not know it.

With the coronavirus, Dr. Ybarra said, “There are people, we don’t know how many, who are asymptomatic or very mildly symptomatic, they could be walking around being positive and not knowing it.”

A few weeks ago, Jill McDevitt, a sexologist in San Diego, posted on social media about how some of the information from condom research might apply to the mask discussion. “We can pull right from the condom data and make it work,” she said.

In particular, she focused on the need to acknowledge that wearing one doesn’t feel as good as not wearing one. “No one’s like, ‘Whoo-hoo, I get to wear a mask today!’” Dr. McDevitt said. Telling people it does feel the same, she said, “feels invalidating — people dig their heels in more.”

We should focus on helping people connect with friends and family without fighting. “Lead with empathy,” she said. Start by acknowledging, “This is hard for you.” Start by asking, “How do we make this as easy as possible?”

With condoms, that meant making them accessible, available, free — like the ones in our exam rooms. But it also meant helping people negotiate, Dr. McDevitt said: “It can be, say, something like, it sucks to wear a mask, I don’t like them either, this is not forever, but in the meantime it allows us to be safer when we’re together.”

Or maybe it’s offering, “Let me help you find one that’s more comfortable for you, they make ones that don’t fall off your nose or fog up glasses.”

Dr. Ybarra said, “We say, people don’t think condoms feel good, let’s talk about what can increase pleasure.” It helps to elicit the messages from the population you’re trying to educate, she said, to listen carefully and learn what the cultural barriers may be, and to hear from the people who are choosing to wear masks. And it helps to contextualize risk, she said, to offer data and to send the message, “We are all in this together, we are all at risk.”

Another guideline that carries over from sexual negotiation, Dr. McDevitt said, is the importance of consent: People are allowed to change their minds. “We’re allowed to walk away if someone doesn’t want to wear a mask, we’re allowed not to spend time with them.”

But it’s not only condoms that involve a sacrifice of personal comfort. As someone who grew up in the pre-bike-helmet era, I initially kind of resented the idea of having to wear one, since it would squish my curly hair and take away the childhood feeling of the wind in my face — but when I had kids of my own, I insisted on them and I wouldn’t get on a bike without one.

Dr. Hoffman said that the pillars of injury prevention are the three Es: enforcement, education and engineering, and the best possible campaigns incorporate all three.

Engineering can mean transforming the environment so that protection doesn’t depend on the human element — putting airbags in cars, for example, or putting guardrails on roads — and it can mean building in reminders when people don’t have their seatbelts fastened.

Enforcement can mean requiring that manufacturers build in those protections, but it can also mean requiring humans to take a step: Wear helmets to ride motorcycles or bikes, or to ski. With regard to masks, enforcement can mean rules about needing a mask to enter a building, a store, a clinic, a train or bus or plane.

Dr. Frederick Rivara, a professor of pediatrics at the University of Washington, and the training core co-director of the Harborview Injury Prevention and Research Center, said, “What we learned from the bike helmet story was the focus of the campaign was trying to get a critical enough mass of people using helmets that the people not wearing helmets looked like the odd man out.”

The idea was to get groups to do it together — schools and community groups buying helmets or holding activities related to helmet wearing. On the other hand, he said, with bike helmets, the emphasis was on self-protection, while with masks, people are being asked to protect others.

“What we need to do for masks is make it enough of a norm so people not wearing it stand out rather than the reverse,” Dr. Rivara said.

“Kids are going to do what their parents do, what their community does, what their peers do,” Dr. Hoffman said. It’s all about “normalizing the behavior, accepting the behavior, helping the child understand the significance and the utility — kids will do what they’re supposed to do, they’ll do the right thing if they’re role modeled.”

Normalization was the most important strategy to promote condom use during the H.I.V. epidemic, Dr. McDevitt said. But it took some time, and we have to apply those lessons quickly if we’re going to get the benefit with masks. “Wear your own mask, wear it properly,” she said. Use positive reinforcement: “Compliment people when they wear a mask.”

And if they don’t or won’t? “Asking questions can be really positive: I notice you’re not wearing a mask, do you need one? I’m curious about the not-wearing-a-mask? Versus: Put one on, what’s wrong with you?”

She noted that even with the normalization of condom use, there is not 100 percent compliance. “It’s a harm reduction model in which the goal is to get as many people as possible to have as many tools as possible to be as safe as possible, as often as possible.”

Dr. Perri Klass is the author of the forthcoming book “A Good Time to Be Born: How Science and Public Health Gave Children a Future,” on how our world has been transformed by the radical decline of infant and child mortality.