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

      BMJ Global Health
      BMJ Publishing Group
      health policy, public health, qualitative study, respiratory infections

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          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.


          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.


          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.


          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.

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          The behaviour change wheel: A new method for characterising and designing behaviour change interventions

          Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
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            Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis

            Summary Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and is spread person-to-person through close contact. We aimed to investigate the effects of physical distance, face masks, and eye protection on virus transmission in health-care and non-health-care (eg, community) settings. Methods We did a systematic review and meta-analysis to investigate the optimum distance for avoiding person-to-person virus transmission and to assess the use of face masks and eye protection to prevent transmission of viruses. We obtained data for SARS-CoV-2 and the betacoronaviruses that cause severe acute respiratory syndrome, and Middle East respiratory syndrome from 21 standard WHO-specific and COVID-19-specific sources. We searched these data sources from database inception to May 3, 2020, with no restriction by language, for comparative studies and for contextual factors of acceptability, feasibility, resource use, and equity. We screened records, extracted data, and assessed risk of bias in duplicate. We did frequentist and Bayesian meta-analyses and random-effects meta-regressions. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO, CRD42020177047. Findings Our search identified 172 observational studies across 16 countries and six continents, with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings (n=25 697 patients). Transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 m (n=10 736, pooled adjusted odds ratio [aOR] 0·18, 95% CI 0·09 to 0·38; risk difference [RD] −10·2%, 95% CI −11·5 to −7·5; moderate certainty); protection was increased as distance was lengthened (change in relative risk [RR] 2·02 per m; p interaction=0·041; moderate certainty). Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD −14·3%, −15·9 to −10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12–16-layer cotton masks; p interaction=0·090; posterior probability >95%, low certainty). Eye protection also was associated with less infection (n=3713; aOR 0·22, 95% CI 0·12 to 0·39, RD −10·6%, 95% CI −12·5 to −7·7; low certainty). Unadjusted studies and subgroup and sensitivity analyses showed similar findings. Interpretation The findings of this systematic review and meta-analysis support physical distancing of 1 m or more and provide quantitative estimates for models and contact tracing to inform policy. Optimum use of face masks, respirators, and eye protection in public and health-care settings should be informed by these findings and contextual factors. Robust randomised trials are needed to better inform the evidence for these interventions, but this systematic appraisal of currently best available evidence might inform interim guidance. Funding World Health Organization.
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              Boundary-Work and the Demarcation of Science from Non-Science: Strains and Interests in Professional Ideologies of Scientists


                Author and article information

                BMJ Glob Health
                BMJ Glob Health
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                6 January 2021
                : 6
                : 1
                : e004068
                [1]departmentInstitute for Global Health , University College London , London, UK
                Author notes
                [Correspondence to ] Dr Po Man Tsang; po.tsang.19@ 123456ucl.ac.uk
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                : 28 September 2020
                : 04 December 2020
                : 09 December 2020
                Original Research
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                health policy,public health,qualitative study,respiratory infections


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