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By Rose Hoban

In the days after this fall’s election, Gov. Roy Cooper said he hoped to “depoliticize” the wearing of masks and other public health measures designed to reduce transmission of the coronavirus.

“I think it’s going to be a natural occurrence, now that the election is over,” said Cooper at a press briefing  “We believe that since it won’t be part of campaigns any more that more people will look at this holistically and will try to come together to slow the spread of the virus.”

“We won’t have the distraction of this election, where… the politicizing of the pandemic, it was central in many things, many ways, and wearing a mask, whether you did it or not, seemed to be a political statement,” he said. “Now, we don’t have to worry about that.”

But people’s lack of adhering to public health advice continues to be a worry. A month after the election, COVID-19 is surging across North Carolina.

Now we are at more than 6,000 people being confirmed positive for this virulent pathogen in one day and the state passing a milestone with almost 2,200 people hospitalized with the disease, with the number of cases and deaths steadily increasing. Rural parts of the state, which overwhelmingly voted for Cooper’s opponent Dan Forest, are being particularly hard hit.

These numbers indicate that getting people to embrace public health measures to slow the spread of COVID-19 will likely take more than an election outcome. Months of President Donald Trump and other political leaders’ public rejection of mask-wearing and social distancing means these measures remain deeply politicized, even as cases and deaths soar.

Changing people’s minds requires concerted effort, say experts in the field of behavior change, but exactly what type of effort will turn the tide in North Carolina will take a combination of strategies. And what works in one place might not be as effective in another, according to the research.

One thing seems clear, turning the tide on COVID-19 will come down to what happens on a local level, often through one-on-one interactions.

The Kardashian effect

Statewide mask mandates have been shown in the research to drive down rates of infection, something that was shown in multiple states. A recent report from the Centers for Disease Control and Prevention showed that even county-by-county mandates had a measurable and significant effect in driving down case rates. But while having a statewide mask mandate in place, Cooper’s orders put the burden on local authorities to enact and enforce them.

In lots of places, that’s not happening.

“The Granite Falls police department, they said they’re not enforcing these rules,” said a frustrated Fred Fowler. He said he’d seen officers sitting in a local restaurant, “hee-hawing without a mask. They don’t pay that mandate for the mask any attention.”

Fowler said lack of enforcement shows throughout his small town on the border of Caldwell and Catawba counties. People don’t wear masks in stores or restaurants, he reported.

He said with his emphysema he doesn’t like going into the local stores anymore.

“It would help if the stores could just turn around to [customers without masks], and say ‘look, we’ll shop for you but you can’t come in unless you wear the mask,’” that “would put an end to it,” he said.

Fowler is onto something. There’s an entire body of literature around so-called influencers driving other people’s behavior, and it’s the reason advertisements use celebrities for product endorsements, whether it’s Kim Kardashian’s Instagram account or the advertisements plastered all over NASCAR vehicles and driver jumpsuits.

With that in mind, Mandy Cohen, secretary of the state Department of Health and Human Services, said people on her team have skipped the big names. They’ve been calling around to local leaders, particularly in the faith community, to get them on board with talking up compliance with masks and social distancing in their communities.

“We have a team of folks that picks up the phone and calls small churches, big churches, synagogues, mosques, all across the state continuum, to talk to folks when I’m on, let them know about resources,” Cohen said recently during an interview with NC Health News.

Local influencing is a strategy being employed in tiny western Graham County, said Sophia Paulos, the economic development coordinator there.

“First and foremost, [county commission chairman] Dale Wiggins continues to actively pull the politics out and just talk to the community about wearing masks and how serious the virus is and why it’s important,” she said. “That is becoming more and more effective as he is joined by other voices from different aspects of leadership in the community.”

Paulos also said that Wiggins has been joined in speaking out about mask-wearing by local doctors, the county health director and religious leaders.

Their cause was tragically helped somewhat by the death of a prominent community leader.

Dr. Mandy Cohen, Secretary of the North Carolina Department of Health and Human Services, listens to Governor Roy Cooper during a press briefing on the COVID-19 virus at the Emergency Operations Center on Monday, June 8, 2020 in Raleigh. Photo credit: NC Dept of Public Safety

The personal transcends the political

“She was an active supporter of the Republican Party, active, like, very serious GOP supporter, and had no known underlying conditions and she got COVID,” said Paulos about a local woman who died several weeks ago. “It was awful. This was like three weeks ago and was the first notable death outside of the nursing home.”

Sometimes it takes knowing someone who’s gotten sick from COVID or someone who’s died to get people’s attention. Paulos said the woman’s death was something of a wake-up call for many people in Robbinsville, the county seat, in no small part because the woman was only in her 50s and active in the community.

“The nursing home is like conceptually, it’s like, ‘Oh, well, they’re really susceptible. It’s really sad, they died, but they’re really old. It’s not gonna affect me’” Paulos said. “So here’s this woman who’s like, in the prime demographic of this county, a woman in her 50s.”

“It shocked everybody,” said Pastor Eric Reece, from the United Methodist Church in Robbinsville.

Reece has noticed an increased number of people wearing masks in the wake of her death.

The increased mask-wearing could be that Reece has spent months giving out masks when distributing groceries at the local food pantry and in time, more people have seen the effects of COVID.

“We would have a food distribution, and one handed out individual masks there,” he said. In subsequent months, people would ask for more of the masks, not just one. “They come in packs of five, we would just hand out the packs of five. And then and we would ask folks, you want some, you know, you want some, and they’d say, ‘we can use in 10 or 12 times that.’”

Sometimes it takes getting sick yourself, as in the case of former New Jersey Gov. Chris Christie, who likely contracted COVID at a White House gathering. After spending a week in an intensive care unit, Christie penned a Wall Street Journal op-ed entitled, “I Should Have Worn a Mask.”

Sometimes even that isn’t enough. Fowler has lost a couple of friends to the disease. His two daughters both contracted COVID, one, a 38-year-old, got it this summer and five months later has lingering problems. But Fowler’s brother who lives nearby? Unconvinced.

“I told him, ‘Look it got my kids, it could kill yours and your family’ and he said, ‘Well, if they die, they die,’” he said. “Dangdest thing I ever heard in my life, I’ll be honest.”

Why some might not care

There are entire academic disciplines dedicated to understanding what gets people to change their behavior. It’s one of the hardest tasks in health care, politics, buying habits, anything. In recent years, behavioral psychologists and practitioners of a discipline called behavioral economics have studied how people make their decisions by putting people into brain scanning machines and then asking them to complete tasks or to make choices. This way, they can see which parts of the brain “light up.”

Jeff Stein, who studies the decision-making processes underlying lifestyle-related diseases in the department of Nutrition Studies at Virginia Tech, said that it can be hard for some people to grasp the value of doing something now that will benefit you down the road, or may not have an obvious benefit at all, like not seeing family at the holidays.

“It’s probably not a surprise that behavioral consequences or outcomes, if they’re delayed, they’re worth less to us,” he said. “So we prefer immediate gratification obviously. Some people can tolerate delays to gratification, though and some others can’t. So I think that gets a lot of people in trouble.”

You can see it on the brain scans.

He said the scans for folks who don’t want to delay a reward show less activity in areas of the brain that are responsible for planning and other executive function. He noted maybe this could be happening now, nine months into the pandemic. At this point, it may be hard for people to consistently motivate themselves to keep social distancing, mask-wearing and washing their hands. “Because most of the sort of bad things that could happen from not adhering to these safety protocols are delayed.”

“You may have a difficult time considering the value of doing this stuff.”

Peer pressure

It seems that one of the most effective ways to get people on board with public health mitigation measures will be the same thing that worked in high school: peer pressure and leadership from people close to you who you respect.

Recently, the Centers for Disease Control and Prevention published a look at what happened in Kansas where the governor’s mask mandate was made optional for counties. The 24 counties that adopted the mask mandate and enforced it saw a six percent decrease in the number of cases, but the counties without the mandate saw a 100 percent increase.

Figures such as local religious leaders can be an important influence, said Dennis Taylor, a critical care nurse who is president of the North Carolina Nurses Association. He was concerned that there were people in his Winston-Salem church going without masks.

“I went to our board of deacons at the church. And I said, ‘you know you really need to get up from the pulpit and encourage folks to wear a mask, and you need to be doing the same thing as well, to show and to be that example,’” he said. He told them that in his job he sees people die from COVID daily. “I see the impact it has on their families, and it’s real, it’s here, and it’s not going away.”

The following week, he saw a change. For one thing, the church had gone back to using only every other pew. The other change was at the front of the sanctuary.

“They were all wearing a mask,” he said. “And I think that sends a message.”

Stein said the research shows this kind of subtle peer pressure has an effect.

“I think the more we see people in our own community and who are more like us wearing masks and engaging some in the social distancing and personal and public protective behavior, I think the more likely it is that we’re going to adopt it, that our own family or friends begin wearing masks,” he said. “And that makes us more likely to wear a mask… rather than some governmental figure saying you have to wear masks.”

Pastor Reece from Robbinsville said he’s just trying to lead by example, which in the end, may be the most effective.

“You know, talking to folks and stuff, and just saying, ’Hey, just trying to convince ‘em, hey, this is a good thing.’ And most folks have been, you know, willing to at least listen,” he said.

“There’s just, you know, a few diehard folks, and some of them are not so much religious, as just stubborn. And I was born and raised in western Carolina, and so I understand that stubborn streak that goes with it.”

Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...