Original Research

US trends in mask wearing during the COVID-19 pandemic depend on rurality


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George Pro1
PhD, Assistant Professor *

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Krista Schumacher2
PhD, Coordinator of Rural Research and Grant Development

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Randolph Hubach3
PhD, Associate Professor

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Nickolas Zaller4
PhD, Professor

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Zachary Giano5
PhD, Postdoctoral Fellow

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Ricky Camplain6
PhD, Assistant Professor

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Carolyn Camplain7
JD, Senior Program Coordinator

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Shane Haberstroh8
EdD, Associate Professor

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Julie A Baldwin9
PhD, Regent’s Professor

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Denna Wheeler10
PhD, Clinical Associate Professor


1, 4 Department of Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, Arkansas, USA

2, 3, 5, 10 Center for Rural Health, Oklahoma State University, 1716 Phoenix Avenue, Tulsa, Oklahoma, USA

6, 9 Center for Health Equity Research, Northern Arizona University, 1395 South Knoles Drive, Flagstaff, Arizona, USA; and Department of Health Sciences, Northern Arizona University, 1100 South Beaver Street, Flagstaff, Arizona, USA

7 Center for Health Equity Research, Northern Arizona University, 1395 South Knoles Drive, Flagstaff, Arizona, USA

8 Department of Educational Psychology, Northern Arizona University, 801 South Knoles Drive, Flagstaff, Arizona, USA

ACCEPTED: 4 May 2021

early abstract:

Introduction: Facemasks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on multiple factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing.
Methods: We used national data from the New York Times’ COVID-19 cross-sectional mask survey to identify the percentage of a county’s residents who reported always/frequently wearing a mask (July 2–July 14, 2020). We used the NYT COVID-19 data repository to calculate county-level daily case rates for the two weeks preceding the mask survey (June 15–July 1, 2020), and defined county rurality using the Index of Relative Rurality (n=3,103 counties). We used multivariate linear regression to predict mask wearing across levels of rurality. Our model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a state-wide mask mandate.
Results: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001).
Conclusions: Upticks in COVID-19 cases and deaths in rural areas are expected to continue throughout the  spring and summer, and localized outbreaks will likely occur indefinitely. Our findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.