ASSOCIATION BETWEEN LIVING WITH PEERS AND COVID-19 GUIDELINE ADHERENCE AMONG UW

UNDERGRADUATE STUDENTS DURING WINTER QUARTER 2021

Penguin: Callista Ordonez, Kaija Corry, Kaushik Komandur, Lauren Witty, Lucy Artman, and Talal Mustafa

BACKGROUND
In response to the COVID-19 pandemic, many government agencies in the US introduced public health
guidelines to reduce the spread of the virus. Though these policies were heavily emphasized, adherence was
inconsistent between various sectors of the population.1 As a whole, university students in the US have
reported moderately high rates of compliance to these public health guidelines.1 In a nationwide survey
conducted early in the pandemic, 70% of college students reported following physical distancing guidelines.2
Because adherence is not extensive, it is important to investigate the factors that facilitate nonadherence in
this population. A recent Danish study reported that university students ascribed nonadherence to the peer
pressures to engage in social activities.3 These results suggest that interactions with peers are important to
investigate when combatting guideline nonadherence (and viral spread) among college students.2,3

Our study focuses on exposure to peers within housing, as student residence halls have been previously
identified as a barrier to COVID-19 guideline adherence.4 In January 2021, Washington State (WA) imposed
Phase 2 of its COVID-19 reopening plan, limiting weekly social gatherings outside households to five persons
unmasked.5 Our research examines whether there was an association between living with peers and
nonadherence to this guideline among college students. To this end, we surveyed University of Washington
students about their activities during Winter Quarter 2021 (WQ), from January to March 2021.

Specific Aims and Hypotheses

Aim 1 (descriptive aim): To determine the proportion of UW undergraduate students living with peers during
WQ. Hypothesis: About 40% of UW students were living with peers during WQ.
Aim 2 (analytic aim): To assess the association between living with peers and adherence to WA COVID-19
gathering guidelines during WQ. Hypothesis: UW students living with peers are less likely to adhere to WA
COVID-19 gathering guidelines during WQ compared to UW students living in other settings.

METHODS

Study Design and Population

This was a cross-sectional study that was conducted to address our descriptive and analytic aims. The target
population was undergraduate students who lived in Washington during WQ. The source population was UW
undergraduates, as they were accessible to the research team. The inclusion criteria were: being over 18
years old, being a UW undergraduate, and living in Washington during WQ. The exclusion criterion was:
moving or changing who you lived with during WQ because this could alter the exposure and confounders by
introducing more variability in social situations. The study population was students who fit the above criteria
and were invited to complete the survey through a non-probability convenience sampling method. We hoped to
reach a sample size of 50 participants who completed our survey.

Data Collection Procedures

Our survey was self-administered by participants electronically through a Google Forms survey. Participants
could access the survey through the link they received while being recruited through Instagram, RSO
communication (GlobeMed, Campus Visit Program, National Society of Black Health Care Professionals), the
Greek community (Pi Beta Phi), formal class communication (BIOL 465), and work communication (Lander RA
staff). The form was available for an individual to complete a maximum of one time (verified by participant
email, which was kept anonymous to the team) between 11/8 until 11/21. It was estimated to take participants
about 10 minutes to complete. The Instagram handles used were @lucyartman, @lauren.witty,
@callistaordonez, and @kaijaa.corry.

The questions on the survey varied in format. Most questions were basic, non-identifying multiple choice
questions related to demographic and background information. There were several questions regarding
participants’ living situation with multiple suggested choices, as well as an “Other” write-in option. At the end of
the survey, participants were asked one or two open-ended questions -- dependent on their previous
responses on the frequency of gatherings they attended -- regarding college students’ attitudes towards
COVID-19 policies.

Data Analysis
To address our descriptive aim, we calculated the proportion of students who lived with peers during WQ.
Then, we found the prevalence of attending high gatherings (i.e. low adherence) among all the students living
with and without peers. “High” (or “frequent”) gatherings were defined as attending more than one gathering of
5+ unmasked people outside the respondent’s household per month. We calculated a crude prevalence ratio to
determine the association between living with peers and the rates of high gatherings. For confounders, we
calculated an adjusted prevalence ratio for both confounders (focusing again on the prevalence of high
gatherings) by stratifying by Greek membership and high risk for COVID-19 status. We compared the adjusted
prevalence ratio to our crude prevalence ratio to examine evidence of confounding. Finally, to analyze our
open-ended questions, we reviewed our responses and coded the quotations.

RESULTS
Population Characteristics
Our survey collected data from 102 respondents, with 81 eligible University of Washington undergraduate
students. 58% of the study population identified as White, with the next largest racial demographic being
18.5% Asian-identifying. Additionally, nearly 80% of participants identified as female. Detailed demographic
data is available in Table 1 in the Appendix.

Aim 1 Findings
Approximately 68% of all respondents indicated that they lived with peers during the Winter Quarter of 2021.
The prevalence of each living situation is indicated in Table 1.

Aim 2 Findings
Overall, 29.6% of participants attended more than one gathering of 5+ unmasked people per month (Table 2).
Comparing those who lived with peers to those who did not, the crude prevalence ratio of respondents
participating in a high number of gatherings of 5+ unmasked people was 3.31 (95% CI: 1.08-10.1) (Table 3).
This ratio suggests that people who lived with peers during WQ 2020 were 231% more likely to attend more
than one gathering of 5+ unmasked people per month compared to people who did not live with peers.

Confounding
In our study, we analyzed two potential confounders: being a member of Greek life, and being ‘high-risk’ for
COVID-19. We anticipated that those in Greek life would be more likely to live in settings with peers and attend
more social events. Additionally, we thought that high-risk individuals would be less likely to live with others and
attend gatherings to minimize their risk of developing COVID-19. Regarding Greek life membership, which
represented 30.9% of our study population, we found a Mantel-Haenszel adjusted prevalence ratio for
attending high gatherings of 2.32 (95% CI: 0.75-7.2). Addressing participants who were ‘high-risk,’ which
represented 6.17% of our study population, we found the adjusted prevalence ratio of 3.27 (95% CI: 1.08-9.93)
(Table 3). There was only a 1.21% difference between the crude and adjusted prevalence ratio for high risk
participants, suggesting that being high risk was not a significant confounder. The rates of Greek membership,
attending frequent gatherings, and high risk status for those living with and without peers are in Figure 1.
Since the Greek life membership adjusted prevalence ratio of 2.32 had a 35.2% difference from the overall
unadjusted prevalence ratio of 3.31, there is strong evidence of confounding for our Aim 2 analysis by Greek
life membership. Therefore, this adjusted prevalence ratio was utilized in our analysis. The prevalence of
attending frequent gatherings between those with and without Greek membership is shown in Figure 2.

Qualitative Results
Coding our qualitative results allowed us to create a list of reasons why university students did not adhere to
COVID-19 gathering guidelines during WQ. This list of different experiences and perspectives gave context to
their previous answers, and may also be used to inform future UW COVID-19 policies (Tables 9 & 10). The
results of the qualitative questions indicate that the majority of individuals who broke guidelines knew the risks
of their choices, and mostly did so as they were interacting with trusted individuals. These individuals often
cited “Social Interaction” and “Trust in Family/Friends” as the most common reasons for non-adherence (Table
9). In comparison, respondents thought that other college students would break guidelines due to perceived
minimal risk of COVID-19 infection, a general misunderstanding of COVID-19 transmission, and for selfish
social reasons (Table 10).
DISCUSSION

For Aim 1, we hypothesized that 40% of UW students lived with peers during WQ 2021. We inferred that
students wanted to remain at home for emotional comfort and financial assistance from family members. Our
hypothesis was not supported, as we found that 68% of students lived with peers. One study prior to the
pandemic from the University of Cincinnati found that students that live with peers have better social skills and
are more satisfied with their entry into college.6 Another study examined student responses to COVID-19, and
concluded that college students had diminished mental health due to isolation and the uprooting of social
opportunity in a pivotal time of transition towards independence.7 While these initial studies suggest that living
with peers can make the college experience more fulfilling, gaps remain in fully understanding students’
motivations and other factors that may influence living with peers during the pandemic.

For Aim 2, we hypothesized that students living with peers would have higher prevalence of low adherence to
COVID-19 gathering guidelines compared to those living without peers during WQ 2021. We reasoned that
students living with peers may be more likely to engage in group activities during isolation. The crude
prevalence ratio comparing the rates of low adherence between those living with versus without peers was
3.31 (95% CI: 1.08-10.1). When adjusting for Greek life membership, the prevalence ratio was 2.32 (95% CI:
0.75-7.2). Since the confidence interval includes 1, we cannot conclude that there was a difference in
adherence between these groups, and our hypothesis is not supported. Our analysis suggests that Greek life
is an important confounder. In one study conducted on community groups at a university in Arkansas,
researchers observed this at 91% of gatherings at the start of the 2020-21 academic year were related to
Greek life activities.8 Our study infers similar results, but more research should be conducted to directly
examine the association between Greek life membership and COVID-19 guideline adherence.

This study has limited external validity. The study population was restricted to UW students, which may not
accurately represent the target population of college students in WA state. Providing the survey to students at
other universities and colleges in Washington would have increased generalizability. Internal validity is also
limited because participants experienced recall bias as they were asked to recall adherence to guidelines
during a time period over 6 months ago. To minimize recall bias, our study could have focused on a more
recent time period. Another potential threat to this study’s internal validity is social desirability bias. Though the
survey was anonymous, participants may have underreported their tendency to break guidelines out of fear of
social judgment or repercussions. By using a non-probability convenience sampling method to share the
survey, the study introduced selection bias -- UW students in the research team’s social circles were
overrepresented. To target a more diverse sample of UW students and increase internal validity, the study
could have recruited participants by posting flyers across campus. Finally, our threshold for low adherence was
chosen based on personal experience, and not on previous data. Accessibility is a key strength of the study; by
using a Google form, our survey was distributed quickly, easy to complete, and assessed the exposure and
outcome simultaneously - loss to follow up was not of concern. Overall, the study procedures went according
to plan, and the survey received more than double the target number of responses. Further, to improve the
usefulness of the survey, there should have been a larger emphasis on increasing gender diversity (80% of the
study population was female).

Other studies exploring college student adherence to COVID-19 guidelines take descriptive approaches to
measuring compliance, whereas our study provides analytic information on adherence to COVID-19 guidelines
based on students’ living situations. Additionally, the qualitative questions in the study revealed students’
perceptions of both their personal and collective efforts to adhere to COVID-19 guidelines. Their answers show
that individuals tend to validate and excuse their own nonadherence, while perceiving others in the same
situation as selfish. This observation provides insight into the sociological implications of the pandemic and
may explain varied adherence to COVID-19 guidelines among college students. These findings, along with
future quantitative research, can help universities create health and housing policies that effectively reduce the
prevalence of COVID-19 among the student body. Our study explored participants' individual motives for
breaking COVID-19 guidelines, but upstream approaches to preventing viral spread need to be guided by
future work examining structural barriers (i.e. socioeconomic status) that may influence guideline adherence.
 APPENDIX

REFERENCES

1. Reinders Folmer C, Brownlee M, Fine A, et al. Social distancing in America: Understanding long-term
adherence to COVID-19 mitigation recommendations. PLoS ONE. 2020;16(9). doi:10.31234/osf.io/457em
2. The Impact of COVID-19 on College Student Well-Being.
https://healthymindsnetwork.org/wp-content/uploads/2020/07/Healthy_Minds_NCHA_COVID_Survey_Report_
FINAL.pdf. Published May 2020. Accessed November 4, 2021.
3. Varol T, Crutzen R, Schneider F, et al. Selection of determinants of students' adherence to COVID-19
guidelines and translation into a brief intervention. Acta Psychologica. 2021;219.
doi:10.1016/j.actpsy.2021.103400
4. Berg-Beckhoff G, Guldager J, Andersen P, Stock C, Jervelund S. What predicts adherence to
Governmental covid-19 measures among Danish students? International Journal of Environmental Research
and Public Health. https://pubmed.ncbi.nlm.nih.gov/33668540/. Published February 13, 2021. Accessed
November 4, 2021.
5. Wafai Y. Here's what you can and can't do under Inslee's COVID-19 'healthy washington' plan to
reopen the State. The Seattle Times.
https://www.seattletimes.com/life/heres-what-you-can-and-cant-do-under-inslees-covid-19-healthy-washington-
plan-to-reopen-the-state/. Published February 11, 2021. Accessed November 4, 2021.
6. Lundgren DC, Schwab MR. The Impact of College on Students: Residential Context, Relations with
Parents and Peers, and Self-Esteem. Youth & society. 1979;10(3):227-236. doi:10.1177/0044118X7901000301
7. Duong V, Pham P, Yang T, Wang Y, Luo J. The Ivory Tower Lost: How College Students Respond
Differently than the General Public to the COVID-19 Pandemic. Published online 2020. doi:
10.1109/ASONAM49781.2020.9381379.
8. Vang KE, Krow-Lucal ER, James AE, et al. Participation in Fraternity and Sorority Activities and the
Spread of COVID-19 Among Residential University Communities - Arkansas, August 21-September 5, 2020.
MMWR Morb Mortal Wkly Rep. 2021;70(1):20-23. Published 2021 Jan 8. doi:10.15585/mmwr.mm7001a5
 TABLES & FIGURES

Table 1. Demographics of University of Washington Undergraduates Respondents (18+)

Number Percentage
(N = 81)

Race & Ethnicity *

American Indian or Alaska Native 1 1.23%

Asian 26 32.10%

Black or African American 3 3.70%

Hispanic 5 6.17%

Native Hawaiian or Pacific Islander 3 3.70%

White 60 74.07%

Other: Middle Eastern 1 1.23%

Gender

Female 64 79.01%

Male 13 16.05%

Non-Binary 4 4.94%

Living Situation

Alone 4 4.94%

Family 22 27.16%

Peers 55 67.90%

* Respondents who indicated multiple categories were counted towards each one, resulting in a number
greater than our sample size

Table 2: Summary Statistics

Exposure: % of Respondents Living with Peers 67.9%

Outcome: % of Respondents with “High” Frequency 29.6%

of Social Gatherings

Confounder 1: % of Respondents with Greek Life 30.9%

Membership
Confounder 2: % of Respondents that Identify as 6.2%
“High Risk” for COVID-19

Table 3: Crude and Adjusted Prevalence Ratios

Prevalence of Crude PR (95% CI) Mantel-Haenszel Mantel-Haenszel

High Gatherings Adjusted PR (95% Adjusted PR (95%
CI) for Greek Life CI) for High Risk

Living with Peers 21/55 = 38.2% 3.31 (1.08 - 10.1) 2.32 (0.75 - 7.16) 3.27 (1.08 - 9.93)

Living without 3/26 = 11.5% Referent Referent Referent

Peers

Table 4: 2x2 Table of Exposure & Outcome: All Data Included

High Gatherings Low Gatherings Totals

Living with Peers 21 34 55

Living without Peers 3 23 26

Totals 24 57 81

Table 5: 2x2 Table of Exposure & Outcome, Adjusting for Confounders: Just Members in Greek Life

High Gatherings Low Gatherings Totals

Living with Peers 15 6 21

Living without Peers 1 3 4

Totals 16 9 25

Table 6: 2x2 Table of Exposure & Outcome Adjusting for Confounders: Everyone Not in Greek Life

High Gatherings Low Gatherings Totals

Living with Peers 6 28 34

Living without Peers 2 20 22

 Totals 8 48 56

Table 7: 2x2 Table of Exposure & Outcome Adjusting for Confounders: Just High Risk Individuals

High Gatherings Low Gatherings Totals

Living with Peers 1 2 3

Living without Peers 0 2 2

Totals 1 4 5

Table 8: 2x2 Table of Exposure & Outcome Adjusting for Confounders: Everyone Not High Risk

High Gatherings Low Gatherings Totals

Living with Peers 20 32 52

Living without Peers 3 21 24

Totals 23 53 76

Table 9: Qualitative Questions - Question 1

Question 1: Why did you choose to participate in gatherings of over 5 unmasked people and choose not to
adhere to the Washington State Guidelines?

Code Definition Number of Respondents

Household bubbles Respondents who indicated that they only 2
saw 1 or 2 other households repeatedly
and formed a quarantine “bubble”

Social Interaction Respondents indicated that they needed 8

to see family/friends for social interaction

COVID-19 Resources: Testing and
Vaccines
Respondents indicated that they felt safe 2
not following guidelines as they were
utilizing COVID safety precautions, like
social distancing during gatherings,
regular testing or getting vaccinated

Not High Risk Respondents indicated that they were not 3

at high risk for COVID-19 and therefore
did not feel like seeing people would be
unsafe
 Work Respondents indicated that they were 1
unable to follow guidelines due to work
obligations

Trust in Friends/Family Respondents indicated that they trusted 6

their friends/family to be safe, and
therefore felt comfortable seeing them

Table 10: Qualitative Questions - Question 2

Question 2: Why do you think college students in general may not adhere to social gathering guidelines of
limiting unmasked gatherings to under 5 people?

Code Definition Number of Respondents

Perceived Minimal Risk Respondents said that college students did not feel that 37
they were at high risk for COVID infection or bad COVID
outcomes, so they were okay with breaking guidelines

Self Interest Respondents who may understand a risk is being taken, 30

but are motivated out of their personal desires to
continue to break guidelines

Peer-Pressure Respondents indicated that college students feel 14

pressured into attending gatherings, and breaking
guidelines, by their peers

Isolation Respondents indicated that college students were likely 7

to feel isolated during this time, due to online school, and
needed social interaction

Mental Health Respondents indicated that college students may want to 4

socialize more as a way to mitigate the impacts of poor
mental health

Misunderstanding COVID Respondents indicated that college students may not 6

Information have understood guidelines, their purpose, and how
COVID spreads

Lack of Control Over Respondents indicated that college students may not be 2
Others able to control the actions of their peers and who their
roommates bring back to their shared households

Trust Respondents indicated that college students trust the 4

people that they are interacting with when breaking these
guidelines, and therefore feel safe in their choices
Figure 1. Prevalence of Outcome and Confounders Based on Those Living With and Without Peers

Figure 2. Proportion of Students Attending Frequent Gatherings Based on Greek Life Membership