During the current pandemic, face masks have become part of everyday life. In many places their use is now a given. However, face mask mandates came to Switzerland fairly late in comparison with other countries. In April 2020, and again in October of the same year, Dr. Bettina Zimmermann, a bioethicist from Basel, asked people in German-speaking Switzerland how they perceived face masks and when they wore them.
Dr. Zimmermann, to what extent are face masks accepted by the Swiss population to prevent the spread of Covid-19?
To answer this question we would need quantitative data. In other words: "What percentage of people think they are a good thing, and what percentage do not?" However, ours is a qualitative study: we surveyed a total of 31 people in German-speaking Switzerland. This is not enough to allow statistical analysis - but that was not our aim. Nevertheless, we were careful to recruit as representative a cross-section of the population as possible, for instance in terms of age, lifestyle, education and income.
What can you conclude based on your survey on perceptions of face masks?
We wanted to know how people were experiencing the coronavirus pandemic, and to evaluate the reasons for their actions and details of their experiences. To that end we carried out interviews in April and October 2020, asking participants for their views relating to Covid-19. We kept the questions fairly open, and let people tell us how they felt about masks, for example.
In both surveys a few people said that masks frightened them and made them feel alienated. There seems to be a cultural connotation: many respondents associated masks with Asia, and didn’t want them to see them become ubiquitous over here.
People said that they accepted masks as a necessary evil, but hoped they would disappear once the pandemic was over. In April, masks were not very widespread as a measure to prevent infection, and were not mentioned very often. In October, however, they came up a lot more.
At the start of the pandemic the Swiss Federal Office of Public Health - the "BAG" - also said masks didn’t give very much protection...
Many people referred to what the authorities had said. They didn’t think masks were much use, so they didn’t wear them. Others were confused that masks had been so strongly rejected by the authorities. Some said they ridiculed people who wore them; one even saw mask-wearers as hysterical. Because a mask is such a visible thing, people noticed them a lot - in the spring, they were mostly negative towards them.
Were there other critical points?
People saw communication from the authorities concerning masks as contradictory. They were unsure whether masks did any good or not, and so started to weigh up the pros and cons for themselves. They felt that masks got in the way of communication, and reminded them that the pandemic wasn’t over yet. Others, however, saw them in a positive light, because they gave them a certain sense of security and allowed them to go places they wouldn’t have otherwise.
In October 2020 you surveyed the same people as in April. To what extent had their attitudes to masks altered?
It was a complete turnaround. In October, participants were much more open to wearing masks, and many did wear them where recommended. This is not particularly surprising, because evidence on the benefits of masks and communication from the authorities had fundamentally changed. Also, case numbers were rising. Now it was more the case that people got funny looks if they didn’t wear a mask - on the train, for example. After all, they had been compulsory on public transport since July. Unfortunately we didn’t have anyone in our cohort who said they were anti-mask. That would have given us an interesting perspective.
During the course of the survey, in mid-October, masks became compulsory in indoor spaces. What reactions were there?
Some people who we interviewed after that measure was introduced told us that it was a relief. Firstly because it meant more people were wearing masks, so individuals were less exposed, and secondly because they no longer had to decide for themselves when to wear one. It was also noticeable that people were worried in the face of the rising case numbers. Surveys from that time showed that agreement with face mask mandates was quite widespread among the population.
It did also come out that many participants appreciated the personal responsibility and autonomy that they had before masks were made compulsory. The authorities had expressly appealed to those values, after all. When masks became mandatory, you could definitely sense that some people felt rather forced into it.
Although it was not so much that they didn’t want to wear them. It was more that some wanted to be able to decide for themselves when and where they wore them. So we had a variety of reactions and views on face mask mandates.
You have mentioned that people felt exposed when they were the only ones to wear a mask. Do psychological factors like these influence people’s behavior?
Yes. This is one of the findings that we think are relevant. Before masks became mandatory, there were situations where they were recommended, such as when a lot of people were sharing a small space. Some participants told us they felt strange wearing a mask when nobody else around them wore one, despite the recommendation. They felt exposed and feared that others would think they were infectious. So they often didn’t wear one even when they felt they should. They acted in response to social pressure against their own intuition.
Would you then say that the introduction of face mask mandates made sense from a social viewpoint and continues to do so now?
Going by our data, yes, we can say that. If you want to push more people to wear masks, the best way to do it is to make it compulsory. On the other hand, I remember someone saying that relying on personal responsibility made him doubly motivated to wear a mask at times when it made sense to him. But not everyone has the knowledge or the capacity to make that decision on their own. It takes energy to always be thinking: "Should I wear a mask or not?" Peer pressure also influences people’s own decisions, even if not everyone is affected to the same extent. A sign saying "Face masks must be worn here" is clear, and so it can be a relief.
Does it follow that people who support masks consider other measures reasonable also?
I find it difficult to see a connection in the sense of a correlation. Which restrictions a person is willing to accept is a very individual matter. It depends on their personal risk assessment for both themselves and others. This is just as true for masks as for other measures.
What are the core findings of your surveys?
An important take-home message for us was that, particularly in culturally Western, liberal countries, you have to really consider what you might call the risk-benefit assessment of a face mask mandate versus the autonomy that people are accorded. From our point of view, this is not a pendulum that plainly swings in one direction or the other, but a question that constantly has to be reevaluated depending on the situation. From my point of view, that’s what Switzerland has been doing so far.
This study is part of the "Solidarity in times of a pandemic" (SolPan) research commons. This was established in March 2020, right at the start of the pandemic. Nine European countries were involved at the beginning; now five remain, one of which is the German-speaking part of Switzerland. The project is led by the Technical University of Munich.
Dr. Bettina Zimmermann is a researcher at the Institute for Biomedical Ethics at the University of Basel as well as at the Institute of History and Ethics in Medicine at the Technical University of Munich. She initially got involved with the data collection on a pro bono basis. From this year she has been supported with research funds from the University of Basel. The study was also supported by the German Federal Ministry of Education and Research (BMBF) and published in the journal BMC Public Health.
For the study, Zimmermann and her co-authors from the Technical University of Munich spoke with 31 individuals from German-speaking Switzerland in April 2020, and in October 2020 they interviewed 25 of them again. In October 2021 the same people gave their views once more - 23 from the previous year and four new participants. These interviews are being transcribed and evaluated at present. The initial results are expected in summer 2022.
Bettina Maria Zimmermann, Johanna Eichinger, Franziska Schönweitz, Alena Buyx Face mask uptake in the absence of mandates during the COVID-19 pandemic: a qualitative interview study with Swiss residents.
BMC Public Health (2021), doi.org/10.1186/s12889-021-12215-4