Qualitative study on the shifting sociocultural meanings of the facemask in Hong Kong since the severe acute respiratory syndrome (SARS) outbreak: implications for infection control in the post-SARS era

The outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003 marked a critical turning point for public health development in Hong Kong. The SARS outbreak caused 1755 infection cases, with 299 deaths in Hong Kong, yielding a fatality ratio of 17 % [1]. The outbreak has facilitated the development of public health at the institutional level, but it has also enabled the Hong Kong population to become aware of the importance of personal hygiene and infection prevention at the community level. Facemask use, which was a remarkable social and health behavior in Hong Kong during the SARS outbreak, was widely recognized by the Hong Kong population for the first time. Since then, the Hong Kong population has become familiar with the use of facemasks in public spaces.

For this study, a qualitative research design involving individual, in-depth semistructured interviews was adopted. A total of 40 participants were recruited from and interviewed at one private-practice primary health care clinic during the peak season of influenza A (H3N2) in January 2015 in Hong Kong through purposive sampling. A phenomenological approach was adopted for data analysis.

The SARS outbreak in 2003 marked a critical turning point in the development of infection control and public health in Hong Kong. One of the most remarkable outcomes in terms of infection control after the SARS outbreak was the awareness of facemask usage in Hong Kong, not only at the clinical level but also at the community level. Although Hong Kong citizens have become familiar with facemask use since the SARS outbreak, the sociocultural meanings of facemasks have been undergoing constant change, which resulted in the participants experiencing hesitation to use facemasks in the post-SARS era. The old meanings associated with facemasks that had developed during the SARS outbreak failed to be sustained in the post-SARS era. Changes in the sociocultural meanings of the facemask not only influenced the participants’ perceptions of facemask but also influenced their views of those who used facemasks, which ultimately affected their health behavior, reducing the likelihood of their facemask use in the post-SARS era. Moreover, the negative perceptions associated with facemasks also contributed to the changes in the sociocultural implications of facemasks in post-SARS Hong Kong. As indicated by the participants, the shifting meanings of facemasks could be explained by the violation of society’s norms and ideologies, by the violation of the traditional Chinese cultural beliefs on healing, and by the projection of the difficult relationship between mainland China and Hong Kong.

The experiences of the participants since the SARS outbreak are critical in the shaping of their perceptions of facemasks. All of the participants had firsthand experience with SARS in Hong Kong during the SARS outbreak, and they had differing experiences during the outbreak. Certain participants lost their family members during the outbreak because of SARS, some other participants had family members who were infected with SARS, and others were not directly affected by SARS but were frustrated by it. Although they had different experiences of the SARS outbreak, they had all used a facemask throughout the outbreak because of fear and sociocultural forces. When the post-SARS era approached, however, the different experiences of the participants influenced their perceptions of facemask use. The lack of a direct experience with an epidemic in the post-SARS era for many participants, in addition to the social changes, made them disregard the infection prevention value of facemasks, thereby contributing to the shifting sociocultural meanings of facemasks in the post-SARS era.

The extent of the participants’ experiences with the SARS outbreak also significantly influenced how they perceived facemask usage behavior in the post-SARS era. Those who encountered more direct and traumatic experience in the SARS outbreak and the older had a more positive attitude toward facemask use compared with younger participants, who perceived facemask use to be more negative in the post-SARS era. Because the younger participants were unaware of what had transpired during the SARS outbreak because of their young age (certain participants were in primary school during the outbreak), they did not have a clear understanding of why they were required to use a facemask during the outbreak. Many of them had used a facemask during the SARS outbreak, merely because of the control of social institutional forces such as their parents, teachers, and school. Consequently, without a strong experience, these younger participants did not have the cultural foundations to understand facemask usage behavior in the post-SARS era. By contrast, older participants typically had a more positive attitude toward facemask use in the post-SARS era, even though they did not use a facemask in the post-SARS era. The older participants usually displayed more intense feelings and relayed such experiences pertaining to the SARS outbreak, leading to a stronger understanding regarding the importance of using a facemask in the post-SARS era.

The only meaning of facemasks that remained static during and after the SARS outbreak in Hong Kong was their purpose of practical infection prevention. Although according to clinical guidelines facemasks should theoretically be used predominantly by patients with respiratory tract infections to prevent them from infecting others [16–18], the participants commonly perceived the opposite: Facemasks were perceived as a tool for preventing themselves from becoming infected during the SARS outbreak and in the post-SARS era. Such an embedded perceived purpose of facemasks thus explains the participants’ reluctance to use a facemask, despite their experiences with respiratory tract symptoms in the post-SARS era.

Symbolic meanings are often constructed for practical use. In addition to the practical purpose of infection prevention, facemasks also conveyed critical symbolic meanings to participants during the SARS outbreak. These symbolic meanings were largely constructed by a social authority—health care providers—resulting in the construction of a new social norm. The health care profession is a form of social institution [19]; the public’s trust in health care providers [19] often enables them to assume an authoritative role in most societies, making them a key social group with authority and social power over the creation of new social norms and the implementation of social control [20]. During the SARS outbreak, health care providers occupied an even more prestigious position, and they were portrayed as social heroes in the battle against SARS [21]. Thus, they held even more power in the construction of this new social norm. They used facemasks in media appearances [22], and they encouraged the public to use facemasks in the community during the SARS outbreak [23]. Therefore, other than stethoscopes and white coats, facemasks were an additional entity associated with health care providers during the SARS outbreak, causing facemasks to become another critical symbol representing health care providers at the time.

The symbolic association of facemasks with health care providers influenced the participants’ use of facemasks during the SARS outbreak at two levels. First, the use of facemasks among health care providers on different social occasions and in media appearances was crucial for the construction of this new social norm and for normalizing the use of facemasks, because of their social power. Health care professionals, as a social institution, allowed them to exercise social control with respect to facemask use in the community, which motivated the participants to use a facemask during the SARS outbreak. Second, the participants used facemasks as a form of symbolic support for health care providers. Because facemasks were perceived as a tool for infection prevention, using a facemask did not simply prevent the participants from becoming infected, but by so doing, it also implied a show of support for health care providers in an attempt to reduce their workload and the burden on the health care system. Using a facemask was akin to a symbolic declaration that they were committed to reducing the burden on the health care system by preventing themselves from becoming infected. Such symbolic support for health care providers through facemask use extended further to the social implication of displaying civic responsibility. These sociocultural processes hence contributed to the symbolic construction of the facemask during the SARS outbreak.

In addition to the health care providers, the mass media played a critical role in the construction of such symbolic implications by reinforcing the new social norm of using facemasks in public areas during the SARS outbreak. Chinese-language media devoted significantly more space to reporting news on SARS daily [24]. Photographs showing people using facemasks occupied the newspaper headlines every day [24]. People who failed to use a facemask in public areas were represented as abnormal in news reports. Those who were infected with SARS were condemned as spreading the virus in these reports. “Super virus spreaders” [25], for example, was the popular term used by the mass media for representing patients infected with SARS. Such a sensational reporting style with moral judgment and condemnation thus made the infection of SARS antisocial. Consequently, people were afraid of becoming infected with SARS, and this constructed, normalized, and reinforced the new social norm of using facemasks in public spaces. Those who failed to use a facemask were perceived as antisocial, and thus, were discriminated against. The construction of such a social norm portrayed facemasks and reinforced them as a sign of civic responsibility on another level: The purpose of using a facemask was represented as not only for the user’s benefit but also for the good of the community and as a show of support.

The perception of the predominant use of facemasks for infection prevention also made facemasks a critical tool for the participants to achieve a sense of control and security during the SARS outbreak. The high mortality rate and unknown transmission route of SARS made it a mysterious disease to most Hong Kong citizens during the outbreak [24]. In the social atmosphere that was filled with uncertainty, using a facemask was the only measure for the participants to protect themselves. Consequently, the use of a facemask for infection prevention was further reinforced, which deterred the participants from learning the other critical use of facemasks, that of preventing the transmission of infectious diseases to others. Hence, the participants had been unaware of using a facemask when they experienced respiratory symptoms, both during and after the SARS outbreak.

The perception of the use of facemasks for infection prevention was thus embedded in the participants’ minds during the SARS outbreak and continued into the post-SARS era. The embedded belief in the purpose of the facemask for infection prevention served as an underlying factor for cultivating a shift in the meanings associated with facemasks in post-SARS Hong Kong. Although using a facemask in public areas was constructed as a new social norm in Hong Kong during the SARS outbreak, and such behavior was constructed to be a symbol of support for health care providers and a display of civic responsibilities at the time, these social norms and meanings have been gradually diminishing in post-SARS Hong Kong. The absence of an epidemic outbreak that is similar to that of SARS as well as the physical discomfort when using a facemask were the immediate factors, but other sociocultural values as well as the changes of social and political environment also interlocked to contribute to the shift in the meanings of facemasks in the post-SARS era.

The sociocultural meanings of facemasks have shifted from positive to negative in post-SARS Hong Kong. Without the presence of a significant epidemic outbreak, the embedded stereotypes toward facemask among the participants thus reoccupied their perceptions. The embedded traditional Chinese cultural belief regarding infectious diseases and healing acted as a considerable obstacle in preventing almost all the participants from using a facemask in post-SARS Hong Kong, resulting in a failure to sustain facemask usage for preventing the spread of infectious diseases. Traditional Chinese medicine (TCM) is the most popular ethnic medical system in Hong Kong, existing alongside the mainstream biomedicine. Influenced by views in TCM, the popular belief of “virus and bacteria must be released from the body for recovery” was deeply ingrained in the participants’ minds. The use of a facemask, however, violates this TCM ideology, because a facemask prevents viruses and bacteria from escaping the body, which is perceived as hindering recovery from the participants’ perceptions. Consequently, the use of a facemask was not welcome by the participants, due to this violation of traditional Chinese cultural belief on healing. This contributed as an underlying factor to the shift in meaning of facemasks, resulting in the failure to sustain the values associated with facemasks that had developed during the SARS outbreak.

To reinforce such traditional cultural values on disease and healing belief, the participants thus recreated the new meanings of facemask that were consistent with these long existing cultural values in the post-SARS era. Using a facemask in the post-SARS era was no longer perceived as a sign of civic responsibility; instead, such health behaviors were stigmatized and constructed to be correlated with a person’s negative attributes. Using a facemask was also correlated with a person’s low social standing and was even correlated with antisocial people such as criminals and violent protesters. With these negative attributes attached to facemasks, the sociocultural meanings of facemasks have shifted from positive to negative, which further deterred the participants from using a facemask in the post-SARS era.

Although the participants still perceived infection prevention to be the main purpose of using a facemask in post-SARS Hong Kong, and although the participants commonly believed that facemasks were for use by healthy people to prevent themselves from becoming infected, the intention to prevent infection has been associated with negative attributes after the SARS outbreak. Those who used a facemask in public areas in the post-SARS era were stigmatized by the participants with different biases (e.g., strangeness, mental illness, and mysophobia). These stigmas violated the sociocultural ideals of Hong Kong. Patients with psychiatric diseases have been stigmatized in Hong Kong as, for instance, crazy, dangerous, and violent [26], and were thus perceived to pose a hidden risk to society [27]. Those with mysophobia were often stigmatized as mentally ill as well [28]. To avoid being stigmatized as mentally ill, the participants were deterred from using a facemask.

In addition, other negative attributes associated with facemasks in the post-SARS era also violated the dominant ideologies of Hong Kong. Because of the mass media, according to the participants’ perceptions, the use of a facemask was often associated with people who were antisocial (e.g., criminals and violent protesters). Indeed, antisocial deviants in Hong Kong often used facemasks intentionally in media coverage. Hence, the use of a facemask was widely perceived as a tool for avoidance of being recognized for engaging in actions that violated the law. Under the further reinforcement of the mass media, the participants thus constructed a negative association with the use of facemasks. The negative perception of those who used a facemask was reinforced further after the Umbrella Movement in late 2014, in which the protesters went on riot with facemasks. In a society with a heavy emphasis on law and order such as that of Hong Kong, the participants were deterred from pursuing this health behavior because they did not wish to be misperceived either as antisocial criminals or violent protesters. The mass media and the changing social and political environment in Hong Kong, thus, have contributed to the shifting social and cultural meanings of facemask in post-SARS era.

Moreover, facemask use was often associated with people who were low on the social hierarchy. To the participants, cleaners were another social group who often used facemasks. Because cleaners were perceived to hold a low social status in Hong Kong, this violated the capitalist ideology of Hong Kong, which strongly emphasizes wealth and a high social status. All of these negative attributes were constructed to be correlated with the use of a facemask in the post-SARS era, which prevented the participants from using a facemask. The sociocultural meanings of the facemask have thus been undergoing continuous change in Hong Kong. These changes influenced the participants’ perceptions of the facemask and hindered their adoption of facemask usage behavior.

Although facemasks are still perceived as a tool for infection prevention after the SARS outbreak, the participants also held contradictory views on the use of facemasks pertaining to their use as an obligation for patients with infectious diseases. However, patients using a facemask were often subjected to a stronger stigma according to the participants, because these patients were often viewed as suffering from serious infectious diseases that could endanger others’ health. Consequently, using a facemask in public was frequently an invitation for social seclusion. To avoid being isolated, the participants were thus deterred from using a facemask in post-SARS Hong Kong.

The fragile relationship and sociopolitical tensions between Hong Kong and mainland China, in addition to the widespread distrust among Hong Kong citizens of mainland China, also led to participant concerns regarding the safety of and confidence in facemasks, preventing them from using facemasks in post-SARS Hong Kong. This subtle display was made tangible and reinforced by the mass media through news reports. Because of the numerous media reports regarding the unscrupulous and unhygienic production process of products made in China, the participants held a high degree of distrust in mainland Chinese products. Because most facemasks were assumed to be produced in mainland China, the participants experienced doubt and lacked confidence in the quality and hygiene of the facemasks. At the same time, mass media had been kept reinforcing about “black-heart cotton” in their reports about mainland Chinese products, making the participants commonly perceived that the facemask could itself contain toxins, and labelled these facemasks as making of “black-heart cotton”. As shown by the participants, such sociopolitical tension as well as the cultural differences between Hong Kong and mainland China thus projected on and manifested in the participants’ doubt regarding the safety of facemasks, which aroused their sense of insecurity. The failure to sustain the sociocultural implications of facemasks in post-SARS Hong Kong can thus also be explained by the sociopolitical tension between Hong Kong and mainland China.

Traditional Chinese gender values could explain the participants' gender differences of their acceptance of using a facemask in the post-SARS era. Male participants were particularly more reluctant to use a facemask, because facemask usage behavior violated the sociocultural expectations of men in Chinese societies. To these participants, using a facemask was widely perceived as a sign of weakness, thereby violating the sociocultural expectations of men, who should be “strong” and “brave.” The violation of traditional Chinese cultural expectations regarding men thus served as a considerable obstacle for the male participants in using a facemask in post-SARS Hong Kong.

Facemask use should thus not be simply viewed as a public health behavior; instead, sociocultural reasons are intertwined to explain people’s usage or avoidance of facemasks. Because of the negative stereotypes associated with the use of facemasks in post-SARS Hong Kong, the sociocultural meanings of facemasks have undergone continuous change, from positive to negative. Because of the changes in social needs, the meanings of facemasks that had developed during the SARS outbreak could not be sustained in the post-SARS era. During the SARS outbreak, the social functions of the facemask were significant not only in terms of providing a practical approach to infection prevention, but also in providing symbolic uses for obtaining a sense of control and security, fulfilling the new social norm, and displaying civic responsibility and support for health care providers. To fulfill these social needs, the sociocultural meanings of facemasks were thus constructed to be positive. However, such social needs were lacking in the post-SARS era, leading to changes in the social functions and sociocultural meanings of facemasks. The changes to the social and political environment generated a negative image of facemask usage, preventing the participants from pursuing this health behavior. The experiences of the participants thus enabled a holistic understanding regarding the perceptions of facemask use. The shifting sociocultural meanings of facemask use in Hong Kong, however, can impose a potential risk to the public health of Hong Kong citizens in case of a future epidemic outbreak. Witnessing younger participants tending to hold more negative perceptions of facemask usage in the post-SARS era was alarming. These findings have critical implications for health authorities in designing a culturally responsive infection prevention and facemask usage policy in the future.