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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.

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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.

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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.

mask wearing rural
Intentions to wear a mask became significantly less likely as the level of rurality increased. J. William Pro

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.

  • To all the liberal people who insist their perception of wearing masks is a God send. I am 71, don’t wear a mask unless mandated to as in stores, got Covid. It lasted 5 days with flu like symptoms. My family did not isolate me. We lived like we always do. They all tested negative. Now you can say I am not the norm, but there are many people just like me. Also, and I say this because of my age, we all die of something. Killing an economy, spikes in suicide, family abuse, depression, murder, and on and on are NOT an acceptable side effect of trying to save everyone from a virus that will be around forever. In case nobody told you, viruses NEVER go away. So take your fear mongering, and keep it in your sh$thole cities where it and you belong.

    • A pandemic is an epidemic that has gone to a global scale. While it is true that viruses never go away, some of them go through mutations and become “rock stars” of the virus world and go on super tours to every corner of the world, which is what’s happening now. So it’s not like every other virus, and it will continue to be quite contagious for some time. There are similarities to other members of the virus universe, though, in the way that some people are naturally more immune, or just less affected, than others (as you and your family seem to be, thankfully).

      That being said, it is important for everyone to be aware that not everyone is super-healthy, naturally resistant, or has big family support systems if they DO get sick. I’m so happy that some people have the option to turn their backs on mask-wearing, and can loudly proclaim their disdain of the system by calling it rigged, or fear-mongering, or liberal-whatever. It’s America, and I’m proud to be a veteran that volunteered to protect the rights of everyone who believes.. well, everything they believe. 🙂

      But I’m also a single mom with 4 kids, on (VA) disability, and it would not be a good thing for me to get sick. I have other conditions that would put me at risk for more than just 5 days of flu-like symptoms. Also, because I don’t have a large family family support system, I am forced to be on one of those people who live in a s***-hole city. I guess my point is, I find it sad when people who are in places like the little town I wish I still lived in, say things like this. For me, and others who have no choice in this big faceless society, this stuff is a really big deal, as I have no one to take care of my kids should I get this virus. I’m low-income, VA Housing voucher pays my rent, I have to use food stamps and put the kids on Medicaid, but I’ve got a small-town heart and living this way is horrible. I’d do anything to be working and being back home in the Oklahoma countryside. I don’t want to wear masks everywhere, but I do, and whenever I see people either not wearing them or having them down too low, I get worried and sad. All the people who live their lives like nothing is happening (and it’s not just the small towns that do so) are the reason this thing is getting worse, not better.

      I cherish the freedom to make these choices in this country I love so much. The virus also loves people who choose to ignore it. Just Me, it is wonderful to hear from someone who got the virus and recovered – stuff like that is what gives me hope for tomorrow. I can’t help thinking of the 230k+ voices we aren’t hearing, though. Those are the ones that don’t have the freedom to choose anymore, or to weigh in on the subject themselves.

      Forgive me if any of this had an angry or accusing tone. That’s not how I meant it. God bless you, sir, and may you and yours continue to stay safe.

    • Your decision to risk the lives of your family, based only on your convictions was a selfish and stupid act. You apparently got lucky and contracted only one of the milder strains. But, you could not have known. And, can you prove “there are many people” just like you? This sounds like just another one of your convictions. You are so mean-spirited. Have you no empathy? I thank God there are more reasonable and sensitive people where I live, or I might end up like one of the 240,000 who have died a horrible death, wracked with pain, suffocating, unable to see their loved ones. You spread a horrible message.

    • (I’ll try this again, dammit.)
      Just because you got lucky, and either caught a mild strain or have a fantastic immune system does not give you the right to expose others who may not be so lucky. You were selfish and stupid to expose your family, not knowing anything about how it would turn out… going on nothing but your outlandish convictions. Are you not aware that 240,000 people have died horrible deaths from COVID, wracked with pain, suffocating, and unable to see their loved ones? Do you remember the reports back in the early days about the virus tearing through senior living centers, killing as many as 50% of the occupants? What you did was illogical and your message is despicable and potentially dangerous. The upward spike in cases is currently in rural areas? Don’t you get the news, or does it only play in sh$thole cities, like mine?

  • Duh…how about the fact that I’m way more than “socially distanced” in my rural community most of the time. No one wears masks in rural Mexico….only on their way to town where there’s a law. But there is virtually no covid in San Miguel de Allende…even with it’s dark little houses in town…or maybe covid isn’t a very important threat.

  • Are we just leaving out how hard it is to find masks that actually fit?
    Most of them are too large for, and sometimes fall down under my nose. That looks like the case pictured above as well. Unless you can figure out a way to knot the earloops in the perfect spot, not so tight that your ear(s) get folded, and evenly on both sides so your mask isn’t crooked, then this is just what happens.

    • I work in the healthcare field, and yes, many masks don’t fit a smaller face. There’s an easy fix: tie a small knot in each earloop to tighten up the seal. Problem solved. Also, a surgical mask isn’t always necessary. For the general public, you can get away with making your own from various materials, and for those, you can make to fit your size. Or if you can’t get to a store, you can buy masks online, providing you live in an area with a stable internet connection. The options are out there. So there’s really no excuse for not wearing a mask other than if someone doesn’t want to.

  • Your presumption that rural=ignorant needed to be left completely out of this equation.
    What urban dwellers do not factor in is distance. People in farm communities may work alone on their own property for an entire day or even longer without being exposed to other people. They are not ignorant, they are extremely fortunate to be independent business owners who are largely self sufficient. There is very little reason to wear masks unless you need to be exposed to others.

  • It’s really unfortunate that governments are ignoring the preponderance of the evidence that masks do not prevent the spread of respiratory viruses. Masks my ay stop droplets but aerosols easily escape. If you are not aware of the major evidence against masks and the faulty experimental design of pro mask studies, I would be happy to share that with you. Furthermore, masks are causing overgrowth and imbalance in the oral microbiome, which causes inflammatory conditions, with negative systematic consequences. Evidence of this is acne around the mouth and poorer oral health noticed by dentists since mask mandates.

  • Rural? I live in New Jersey and everyone is wearing masks wrong. I teach respirator safety,and we have a fantastic governon ( even though he opened up everything WAY too early) I suspect that was pressure from outside sources. He had great intentions but he was not aware of people not listening to him ,because of let’s say certain news networks and a orange bigot telling them the contrary. For all the “let’s work together hoo-ha”. There was never a PSA instructing people how to wear masks properly. People need to know the how’s and why’s. We got plenty of why’s but not so much of How’s. There should be a five minute tutorial on how to wear each separate style of masks. You’d think it’s self explanatory but people don’t care about others anyway and they hate wearing masks that with them suspecting Covid 19 is a hoax. You get people not doing it and if they do it’s a half a$$ attempt

  • The person who wrote this article obviously does not have their finger on the pulse of the rural community. Next time the author should interview some actual people from rural communities instead of guessing at the reasons why they don’t wear masks. Really poor, but typical journalism for our times. For many if not most of us in my rural California community this has everything to do with an extreme dislike and distrust of government intrusion. Many move to rural communities because they are tired of being told how to live their lives. Also common sense and the ability to run simple percentages and realize that we would rather live a full life no matter how long it may or may not be, than live a life where we wander around in fear that we will be part of the small 5% who have gotten the virus and even smaller still percent (less than one half of one percent) who get the virus and die. We can see the bigger picture and see the emotional, physical, and financial damage being done by over zealous talking heads who think they know what is best for everyone. We can look past the small risks to see the bigger long term risks to our children and frankly all of us by extreme restrictive measures. My husband had the virus (tested positive twice) which basically ended up being cold or flu like symptoms for six days and the regular few weeks to get back into peak shape to perform his duties as a firefighter. We as a family did not separate ourselves from him. We lived as we normally would and none of the rest of us had any signs or symptoms. What I experienced personally is the only thing I can trust right now and I don’t appreciate the fear mongering that is being spread by social media and mainstream media. No one asked to tell our more typical story of COVID they only want to tell the tiny percent of sensational stories that get lots of clicks which means more money for them.

    • Great comment. And on top of that, most research shows masks dont prevent the spread of respiratory viruses, but this is ignored for some reason. Masks also cauaing bacterial issues in and around the mouth which can make people inflamed and sick. Good for you and your community to see past this nonsense.

    • All your points about why people don’t wear masks are completely well representative of non-mask wearers. You’ve made a calculated decision, etc. But can I just say… it’s not just about you. We don’t get to live in a bubble, the consequences of actions travel outside your sphere and hurt others. And to think, all we need to do to be considerate of others is to wear a simple mask and go about our day. But hey maybe I’m just sensitive to those people dying, silly, sensitive me. I mean people dying vs. wearing a mask, you’d think this would be simple.

  • Funny, I thought I was looking at the US 2020 election map. The resemblance is uncanny, or should I say telling. High rural and least mask-wearing states voted one way …. Low rural and high mask wearing states voted the other. The research in this article appears to prove a politically driven issue.
    Mask wearing contains spread, that is clear. But masks not worn properly (cover the nose, seal on the cheek) defeat the purpose. Some widespread public education seems certainly warranted.

  • The reason people aren’t wearing masks is not because no one has shoved it down their throats that it can help. It’s because it doesn’t help, it’s unnatural, humans need not just physical closeness but to see faces. The whole thing is ridiculous and makes no sense. People in rural areas are conservative more too. They don’t just buy into the excess fear touted by the left.
    This pandemic does not kill many people, and certainly very very few under 70. All this mitigation is destroying the world, not helping. Hurting our children, not protecting, and making life unlivable.
    What’s the point in saving every life possible, only to re see life and the country not worth living in so that all these people who survive, have nothing left to live for anyhow? Because that’s what’s going on.
    Yes, let’s save all the humans from covid, then send them into a world of loneliness, poverty, pain, never hugging or feeling closeness, afraid of everything, shall we? Just so a few hospitals who had 100 years to plan for this, don’t fill up?
    Give me a break. People know what the “ science” says. They don’t care and don’t want to exist this sad way.

    • Wow Mr. Scientist you got it all together. I hope when you get Covid ( oh and how I hope you do) you don’t spread it to others in your family who aren’t total fuc#@ng idiots. Don’t you have an echo chamber to go watch to support your cognitive dissonance?

    • Mask wearing is simply a fetish that not everyone wants to be a part of.
      Why do people (“experts”) just assume that they are a help without proper evidence? I would assume that the sun goes round the earth but I think I’m probably wrong!

    • Thank you Doctor Mengula. You seem to have a great knowledge on Covid,and the pure racism is like a cherry on top for your pursuit of being the internet’s bigot of the year . Congratulations

    • Actually in the nursing homes I work with the 90 year olds are the ones shrugging this off when they test positive, and mad as hell about isolation, the 60-70 year olds with multiple medical issues are the ones struggling and dying. Interestingly too, my feisty folks in the homes refuse to wear masks as well…and that is THEIR choice. They’ve earned that right.

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