Is low mask wearing in rural communities a sign of poor health messaging?

As the U.S. heads toward a third peak in the pandemic, rural counties are among the areas most severely affected by Covid-19. While their absolute numbers of cases are still relatively small compared with large cities, case rates and death rates are growing fastest in rural counties.

This is especially worrisome because characteristics associated with poor Covid-19 outcomes, like older age, poorer general health, and fewer health care providers per capita, are more common in rural communities. In addition, many rural counties have been slowest to adopt key preventive public health measures such as social distancing and mask-wearing.

The Centers for Disease Control and Prevention recommends the use of face masks to limit the spread of Covid-19, and state mask mandates are generally associated with a decrease in case rates. Yet many individuals in rural communities eschew wearing masks.

This may be partly due to public health messaging that hasn’t been tailored to rural communities. Retention of health messaging is lower in rural areas than it is in urban or suburban areas, suggesting that there is no such thing as a one-size-fits-all approach when it comes to disseminating crucial health information to the public.

It is a challenge to create effective prevention-related messaging when the people it targets believe their risk is relatively low. In rural areas, low perceived risk of Covid-19 could spawn more widespread skepticism toward, and nonadherence to, government mask mandates. Reluctance to follow mask guidelines earlier in the pandemic in rural areas continues in spite of the current evidence indicating uncontrolled community spread in many rural states.

The current and projected increases in Covid-19 cases in rural areas may have resulted from people not following recommended preventive measures during the summer months when Covid-19 cases in these areas had not yet made headlines.

To explore that idea, we examined data from the New York Times’ mask-wearing survey and the Index of Relative Rurality, a widely used indicator that measures counties on a continuous scale from 0 to 1, with 1 being most rural, based on several geographic and population characteristics, including total population.

We found that intentions to wear a mask became significantly less likely as the level of rurality increased, even after adjusting for daily Covid-19 incidence during the two weeks before the mask survey.

One possible interpretation of our results is that individuals may decide to wear masks — or forgo them — based in part on their perception of whether mask-wearing is an effective preventive tool. This has important implications as near-universal mask-wearing is generally thought to be required for optimal prevention of community transmission of Covid-19.

Individuals living in rural counties with only a few reported cases may have a lower sense of personal risk from the coronavirus. This is consistent with our findings that many rural counties were not experiencing significant Covid-19 outbreaks during the summer and many of these counties had lower proportions of residents reporting regular mask-wearing.

Human behavior is notoriously difficult to change and the habit of not wearing masks in rural counties established during the summer most likely persisted even as the number of cases in those counties has risen.

Public health messaging is not monolithic. It must be tailored to communities, recognizing cultural norms and engaging local community leaders in its dissemination. For example, distrust of medical providers and outsiders can be a norm embedded within the culture of some rural communities.

Mask-wearing in rural communities, like other preventive behaviors, does not occur in a social vacuum. It is critically important to understand local community norms and values to effectively disseminate life-saving public health messaging.

The need to engage rural communities in Covid-19 risk mitigation strategies is more urgent now than ever before, as hospitals in some rural counties are reaching their capacity to treat new Covid-19 patients. One way to do this is to emphasize the sense of belonging and the desire to be a good neighbor that are cornerstones of many small and rural communities.

Mask-wearing is an act of caring for others and as such is ultimately something that rural Americans can feel good about doing.

Nickolas D. Zaller is a professor of health behavior and health education, director of the Southern Public Health and Criminal Justice Research Center, and co-director of the Rural and Global Public Health Program, all at the University of Arkansas for Medical Sciences. George Pro is an assistant professor of health behavior and health education in the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences. The authors thank J. William Pro for creating the map.