We examined support of mask use as a public health prevention measure used to control the spread of SARS-CoV-2 transmission among a large sample of Canadian secondary school students during the 2020/21 school year, the first complete school year following the beginning of the pandemic. The majority of secondary school students were supportive of wearing a mask in indoor public spaces and of schools requiring mask use while at school. Factors associated with support were comparable across outcomes in that support for mask use and school requirements were both higher in students that reported higher perceptions of COVID-19 severity and susceptibility for young people, concern about their own or their family’s health, having had discussions around ways to prevent infection, and knowing that individuals with COVID-19 do not always show signs and symptoms, and, in particular, that masks reduce the risk of SARS-CoV-2 transmission when individuals cough.
A higher proportion of adolescents reported being supportive of mask use in indoor public spaces relative to school requirements for student mask use; about 9% were unsupportive across both items, while more students reported being neutral or unsure regarding support for school requirements for mask use than wearing mask in public spaces. The difference may reflect the specification of mandated use in the school item, while the public spaces item simply refers to mask wearing. Alternatively, the familiarity and shared social identity in the school context as opposed to other indoor public spaces could play a role. Shared group membership is shown to attenuate health risk perceptions, and in turn, increase health risk behaviours, whereas individuals more readily distance themselves from strangers (Cruwys et al., 2020). It is also possible that concerns about social norms, appearance, comfort, and communication may be more salient in the school context than other public spaces, given the amount of time spent there and as a key context for peer socialization among young people.
Support for masks was higher in females than males, consistent with evidence in adults (Brankston et al., 2021). The predictors examined in the current study, including COVID-19 related health concerns, knowledge, and discussions, demonstrated similar associations with mask support across sex. Further research is needed to examine factors that may influence varying support for public health measures in population subgroups, including intersections of gender, SES, race, and geographic location, given disparities in access to information, and real and perceived capacity to exercise self determination.
In the first full school year following the onset of the pandemic, most students appear knowledgeable around risks related to COVID-19, transmission, and preventative measures; however, results support a continued need for improved public health messaging and education targeting adolescents. Over one-quarter of students had never had discussions around measures to prevent infection with family, friends, and/or health care professionals, at least 6 months into the COVID-19 pandemic, and these students were less likely to support mask use. Similarly, in previous analyses using COMPASS study data from Quebec adolescents during the first few months of the pandemic, compliance with COVID-19 preventative measures was positively associated with discussions about preventative measures and what to do in case of infection, as well as pandemic-related knowledge and perception of risk related to COVID-19 (Bacque Dion et al., 2021). Having these discussions during low stress times is advisable; in a longitudinal study of adolescents, more frequent parent-adolescent conversations early in the pandemic predicted increased adherence to preventative behaviours throughout the pandemic when adolescents reported low stress, but when adolescents were high in stress, they predicted decreased adherence via reduced empathetic concern (Peplak et al., 2021).
Improving knowledge about mask use efficacy appears particularly important for adolescent support for mask use and a valuable target for public health messaging. Adolescents that acknowledged that mask use can reduce droplet transmission when a person coughs were 7–8 times more likely to report mask support. Supporting adolescents’ health literacy through discussions with key individuals in their lives appears beneficial and may help combat the overabundance of false and correct information available online (Pan American Health Organization, 2020). As a dominant source of health information, particularly for younger persons (Ettel et al., 2012), public health agencies have begun to harness social media platforms to disseminate preventative messages (Basch et al., 2022). Peers are also likely to be worthwhile targets for messages targeting adolescents. In US youth, the desire to avoid contracting and spreading SARS-CoV-2 and peer influence were associated with mask use (DeJonckheere et al., 2021). Similarly, in an online survey of Canadian adolescents, social responsibility was associated with more adherence to public health measures while social concerns regarding maintaining social ties and social judgement were associated with less adherence (Craig et al., 2021).
Results resemble available evidence among adults. Surveys conducted early in the pandemic among Canadian adults found high levels of support for mandatory mask policies in public spaces (74%) (Angus Reid Institute, 2020). As restrictions were lifting, in March 2022, 73% of Canadians reported that they would support the continuation of mask requirements in public spaces (Angus Reid Institute, 2022). Adults with positive perceptions of mask use were more likely to report fears of contracting COVID-19; negative perceptions of mask use were associated with discomfort, concerns about appearance and negative attention from others, difficulty establishing the habit, and beliefs that masks are ineffective, possibly harmful, unnecessary (e.g., in the context other protective measures), and an infringement on independence (Betsch et al., 2021; Howard, 2020; Taylor & Asmundson, 2021). In adults, resistance to mask use has been explained as psychological reactance, described as a reaction to fear when there is a lack of self-efficacy to reduce the threat (Mallinas et al., 2021; Taylor & Asmundson, 2021). According to the EPPM, when individual’s threat (perceived severity and susceptibility) and efficacy (response efficacy and self-efficacy) appraisals are high, they will be motivated to engage in the adaptative behaviour, but when their threat appraisal is high and efficacy appraisal is low, individuals may enter defensive avoidance to control the fear. Suggestions to improve messaging, and avoid psychological reactance, have included supporting self-efficacy in engaging in preventative behaviours, gain-framed messaging around personal benefits, prosocial framing (i.e., emphasizing social responsibility in terms of how individual choice impacts others), and indirect or subtle “nudges” (Benhan et al., 2021). Further research is required to test these strategies among adolescents.
4.1. Limitations
The relatively lower online response rates during the pandemic and missing data may introduce bias as students not responding may differ in their perceptions of mask use and the COVID-19 pandemic. Random factors likely contributed to the lowered participation rate during the pandemic, such as whether schools and classrooms administered the survey during class time. Also, COMPASS is an ongoing general health survey, that added COVID-19 items; potential bias in participant COVID-19 perceptions may be less likely, as a non-COVID-19 specific study. Further, the COMPASS study does not use student names to help improve perceptions of anonymity and the passive consent protocols are shown to be important for collecting robust data by helping to improve response rates and the generalizability of results (Thompson-Haile et al., 2013). However, COMPASS was not designed to be representative. No data were available on potentially important influences on adolescents’ perspectives (e.g., social norms and peer influence) based on developmental stage and evidence from research on mask use policy compliance. Adolescents’ perceptions of support for mask use and policies among their peers and parent(s)/guardian(s) should be considered in future research. Lastly, the COVID-19 pandemic context has changed rapidly, and these data were collected during the 2020/2021 school year, before the omicron variant emerged and coinciding with the original and alpha variant waves in Canada.
4.2. Conclusions
The majority of adolescents in this large population-based sample of secondary school students reported support for mask use in indoor public spaces, as well as school mask requirements, during the 2020/2021 school year. Support for mask use was associated with perceptions of risk, health concerns, and knowledge and discussions regarding SARS-CoV-2 transmission and COVID-19 preventative measures. Improving perceptions of the efficacy of mask use for preventing SARS-CoV-2 transmission appears particularly important for adolescent mask support.