Boundaries of solidarity: a meta-ethnography of mask use during past epidemics to inform SARS-CoV-2 suppression

BACKGROUND: Many countries aiming to suppress SARS-CoV-2 recommend the use of face masks by the general public. The social meanings attached to masks may influence their use, but remain underinvestigated. METHODS: We systematically searched eight databases for studies containing qualitative data on public mask use during past epidemics, and used meta-ethnography to explore their social meanings. We compared key concepts within and across studies, then jointly wrote a critical synthesis. RESULTS: We found nine studies from China (n=5), Japan (n=1), Mexico (n=1), South Africa (n=1) and the USA (n=1). All studies describing routine mask use during epidemics were from East Asia. Participants identified masks as symbols of solidarity, civic responsibility and an allegiance to science. This effect was amplified by heightened risk perception (eg, during SARS in 2003), and by seeing masks on political leaders and in outdoor public spaces. Masks also acted as containment devices to manage threats to identity at personal and collective levels. In China and Japan, public and corporate campaigns framed routine mask use as individual responsibility for disease prevention in return for state- or corporate-sponsored healthcare access. In most studies, mask use waned as risk perception fell. In contexts where masks were mostly worn by patients with specific diseases (eg, for patients with tuberculosis in South Africa), or when trust in government was low (eg, during H1N1 in Mexico), participants described masks as stigmatising, uncomfortable or oppressive. CONCLUSION: Face masks can take on positive social meanings linked to solidarity and altruism during epidemics. Unfortunately, these positive meanings can fail to take hold when risk perception falls, rules are seen as complex or unfair, and trust in government is low. At such times, ensuring continued use is likely to require additional efforts to promote locally appropriate positive social meanings, simplifying rules for use and ensuring fair enforcement.