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Prevalence and predictors of mask use on a large US university campus during the COVID-19 pandemic: A brief report

Published:December 06, 2021DOI:https://doi.org/10.1016/j.ajic.2021.11.028

      Highlights

      • Observational study assessed mask use on a US university campus.
      • Over 90% of observed persons were wearing masks.
      • Mask use was significantly associated with being indoors, female, campus location.

      Abstract

      This observational study was conducted to determine the prevalence and correlates of wearing masks at a large Midwestern US university during the COVID-19 pandemic. A total of 7,237 individuals were observed over 24 hours. Overall mask use prevalence was 90.6% (95% confidence interval: 89.9, 91.2); mask use was significantly associated with being indoors (vs outdoors), female (vs male), and at the athletic center (vs the student union).

      Key words

      Introduction

      During the COVID-19 pandemic, near-ubiquitous use of masks in community settings was recommended.
      • Fisher KA
      • Barile JP
      • Guerin RJ
      • et al.
      Factors associated with cloth face covering use among adults during the COVID-19 pandemic - United States, April and May 2020.
      However, personal protective equipment is considered to be one of the least effective hazard control measures due to their reliance on an individual's behavior.

      NIOSH. Hierarchy of Controls [Internet]. 2020. Available at: https://www.cdc.gov/niosh/topics/hierarchy/default.html. Accessed May, 17 2021.

      The extent to which individuals have worn masks in nonoccupational settings, particularly in institutions of higher education, is not yet fully described. Therefore, the goal of this research was to determine the prevalence and correlates of mask use on a large United States university campus.

      Methods

      In fall 2020, there were >40,000 students on campus taking in-person and/or online classes. University policy required wearing masks at all time while indoors (if not eating) and required wearing masks outdoors (if not social distancing). Removal of masks indoors for eating or drinking was permitted for <15 minutes if social distancing could be observed. All students, faculty, and staff completed a pledge stating that they would follow these policies; violators could face disciplinary action. Information regarding these policies were posted widely in print and electronic formats throughout the semester.
      Data were collected using direct observation on weekdays from 9:00 AM to 6:30 PM. Observers were 3 undergraduate students with prior research experience. They were trained using written materials and in-person meetings. A standardized data collection form was used to collected data outside (near the building entrance) or inside (in a common area) one of 3 locations on campus (student union/academic building/athletic center) over the course of one hour. Observers collected data on all persons in the area, including mask use (none/incorrectly worn/correctly worn), perceived gender (male/female/unknown), and perceived student status (student/nonstudent/unknown). If there was any uncertainty about gender or student status, observers were instructed to mark “unknown.” Correct usage was based on US Centers for Disease Control and Prevention guidelines.
      Data were analyzed using Stata 16.0 (College Station, TX, USA). Few individuals were wearing masks incorrectly (<10%), so this category was combined with correctly wearing masks for analyses. Logistic regression models were used to assess correlates of mask use. Adjusted regression models included gender (male/female/unknown), student status (student/nonstudent/unknown), location relative to the building (inside/outside), and building (student union/academic building/athletic center). Standard errors were adjusted for potential correlation based on collection period.

      Results

      Overall, 6555 out of the 7237 observed persons wore masks (90.6%; 95% confidence interval (CI): 89.9, 91.2) (Table 1) during 24 collection periods (24 hours). 2063 out of 2,140 persons were wearing masks indoors (96.4%; 95% CI: 95.5, 97.1); 4492 out of 5097 people wearing masks outdoors (88.1%; 95% CI: 87.2, 89.0). Observed mask use did not significantly change over time (Fig 1).
      Table 1Relationship of demographic and location characteristics with wearing masks on a large university campus, September-November 2020
      CategoryVariableN wearing masks/ N totalPercent wearing masks (95% CI)Adjusted odds ratio (95% CI)
      Standard errors are adjusted for clusters based on sampling event (N=24). Values are odds ratio (95% confidence interval).
      ,
      The adjusted model includes all variables shown the table.
      Indoors only, N = 2,140
      N = 2,126 for adjusted regression model.
      GenderFemale977/1,00896.9 (95.7, 97.8)referent
      Male1,081/1,12795.9 (94.6, 96.9)0.76 (0.36, 1.60)
      Undetermined5/5NCNC
      Student statusNonstudent183/19195.8 (91.8, 97.9)referent
      Student1,871/1,94096.4 (95.5, 97.2)1.15 (0.30, 4.36)
      Undetermined9/9NCNC
      BuildingStudent union324/33796.1 (93.5, 97.7)referent
      Academic building1,435/1,48296.8 (95.8, 97.6)1.18 (0.40, 3.50)
      Athletic center304/32194.7 (91.6, 96.7)0.70 (0.24, 2.01)
      Outdoors only, N = 5,097
      GenderFemale1,993/2,20590.4 (89.1, 91.5)referent
      Male2,485/2,87586.4 (85.1, 87.6)0.67 (0.56, 0.81)
      Undetermined14/1782.4 (57.3, 94.2)0.52 (0.22, 1.25)
      Student statusNonstudent394/47083.8 (80.2, 86.9)referent
      Student4070/4,59188.7 (87.7, 89.5)1.39 (0.99, 1.95)
      Undetermined28/3677.8 (61.5, 88.5)0.76 (0.56, 1.04)
      BuildingStudent union1,397/1,63285.6 (83.8, 87.2)referent
      Academic building2,295/2,59188.6 (87.3, 89.7)1.25 (0.78, 2.02)
      Athletic center800/87491.5 (89.5, 93.2)1.74 (1.36, 2.23)
      Overall, N = 7,237
      GenderFemale2,970/3,21392.4 (91.5, 93.3)referent
      Male3,566/4,00289.1 (88.1, 90.0)0.68 (0.57, 0.82)
      Undetermined19/2286.4 (65.2, 95.5)0.60 (0.25, 1.42)
      Student statusNonstudent577/66187.3 (84.5, 89.6)referent
      Student5,941/6,53191.0 (90.2, 91.6)1.36 (0.98, 1.89)
      Undetermined37/4582.2 (68.3, 90.9)0.80 (0.55, 1.16)
      BuildingStudent union1,721/1,96987.4 (85.9, 88.8)referent
      Academic building3,730/4,07391.6 (90.7, 92.4)1.26 (0.82, 1.95)
      Athletic center1,104/1,19592.4 (90.7, 93.8)1.54 (1.11, 2.14)
      LocationOutside4,492/5,09788.1 (87.2, 89.0)referent
      Inside2,063/2,14096.4 (95.5, 97.1)3.1 (2.14, 5.53)
      95% CI = 95% confidence interval; NC = not calculated.
      low asterisk Standard errors are adjusted for clusters based on sampling event (N=24). Values are odds ratio (95% confidence interval).
      The adjusted model includes all variables shown the table.
      N = 2,126 for adjusted regression model.
      Fig 1
      Fig 1Percent of individuals wearing masks at each observational period over time, either indoors (hollow circle) or outdoors (solid circle). Lines indicate trend over time indoor observations (dashed line) and outdoor observations (solid line).
      Overall, a higher proportion of women wore masks (vs men) and a more students wore masks compared to nonstudents (Table 1). Mask use prevalence was highest at the athletic center and lowest at the student union. Patterns were similar when stratified by location.
      In adjusted logistic regression models, individuals wearing masks were significantly more likely to be female (vs male), inside (vs outside), and at the athletic center (vs the student union) (Table 1). Results were similar in unadjusted models and when stratified by location, although indoor observations were not statistically significant.

      Discussion

      We report a very high mask use prevalence in this study; across all categories observed, mask use prevalence was >80%. This is higher than several studies of mask use in health care settings, some of which have reported prevalence lower than 50%.
      • Moore D
      • Gamage B
      • Bryce E
      • Copes R
      • Yassi A
      BC Interdisciplinary Respiratory protection study group
      Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines.
      ,
      • Nichol K
      • McGeer A
      • Bigelow P
      • O'Brien-Pallas L
      • Scott J
      • Holness DL
      Behind the mask: determinants of nurse's adherence to facial protective equipment.
      In contrast, research conducted during the COVID-19 pandemic reported somewhat higher mask use prevalence either on university campuses (85.5%)
      • Barrios LC
      • Riggs MA
      • Green RF
      • et al.
      Observed face mask use at six universities - United States.
      or community settings (65.7% to 89%).
      • Fisher KA
      • Barile JP
      • Guerin RJ
      • et al.
      Factors associated with cloth face covering use among adults during the COVID-19 pandemic - United States, April and May 2020.
      ,

      Ganczak M, Pasek O, Duda-Duma Ł, Świstara D, Korzeń M. Use of masks in public places in Poland during SARS-Cov-2 epidemic: a covert observational study. BMC Public Health. 2021 Feb 23;21:393.

      ,
      • Hutchins HJ
      • Wolff B
      • Leeb R
      • et al.
      COVID-19 mitigation behaviors by age group - United States, April-June 2020.
      This was not universal, as Deschanvres et al. still reported lower mask use prevalence in a community setting during the pandemic (56.4%).
      • Deschanvres C
      • Haudebourg T
      • Peiffer-Smadja N
      • et al.
      How do the general population behave with facemasks to prevent COVID-19 in the community? A multi-site observational study.
      Prior work suggests that requirements (vs guidelines), training, and/or a concern about specific risks may contribute to increased mask use prevalence
      • Moore D
      • Gamage B
      • Bryce E
      • Copes R
      • Yassi A
      BC Interdisciplinary Respiratory protection study group
      Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines.
      ,
      • Nichol K
      • McGeer A
      • Bigelow P
      • O'Brien-Pallas L
      • Scott J
      • Holness DL
      Behind the mask: determinants of nurse's adherence to facial protective equipment.
      ,
      • Deschanvres C
      • Haudebourg T
      • Peiffer-Smadja N
      • et al.
      How do the general population behave with facemasks to prevent COVID-19 in the community? A multi-site observational study.
      • Lai X
      • Wang X
      • Yang Q
      • et al.
      Will healthcare workers improve infection prevention and control behaviors as COVID-19 risk emerges and increases, in China?.
      • Haischer MH
      • Beilfuss R
      • Hart MR
      • et al.
      Who is wearing a mask? Gender-, age-, and location-related differences during the COVID-19 pandemic.
      ; these might contribute to our results. Similarly, higher use when masks are required versus recommended likely explains the higher mask use prevalence observed indoors versus outdoors in this, and other studies.
      • Barrios LC
      • Riggs MA
      • Green RF
      • et al.
      Observed face mask use at six universities - United States.
      ,

      Ganczak M, Pasek O, Duda-Duma Ł, Świstara D, Korzeń M. Use of masks in public places in Poland during SARS-Cov-2 epidemic: a covert observational study. BMC Public Health. 2021 Feb 23;21:393.

      ,
      • Deschanvres C
      • Haudebourg T
      • Peiffer-Smadja N
      • et al.
      How do the general population behave with facemasks to prevent COVID-19 in the community? A multi-site observational study.
      We observed a higher mask use prevalence among women versus among men. This trend is reported in many

      Ganczak M, Pasek O, Duda-Duma Ł, Świstara D, Korzeń M. Use of masks in public places in Poland during SARS-Cov-2 epidemic: a covert observational study. BMC Public Health. 2021 Feb 23;21:393.

      ,
      • Deschanvres C
      • Haudebourg T
      • Peiffer-Smadja N
      • et al.
      How do the general population behave with facemasks to prevent COVID-19 in the community? A multi-site observational study.
      ,
      • Haischer MH
      • Beilfuss R
      • Hart MR
      • et al.
      Who is wearing a mask? Gender-, age-, and location-related differences during the COVID-19 pandemic.
      but not all
      • Fisher KA
      • Barile JP
      • Guerin RJ
      • et al.
      Factors associated with cloth face covering use among adults during the COVID-19 pandemic - United States, April and May 2020.
      ,
      • Moore D
      • Gamage B
      • Bryce E
      • Copes R
      • Yassi A
      BC Interdisciplinary Respiratory protection study group
      Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines.
      prior studies. Although not statistically significant, our finding that the student mask use prevalence was higher than that of nonstudents is not consistent with to prior reports suggesting less mask use among young adults in community settings
      • Fisher KA
      • Barile JP
      • Guerin RJ
      • et al.
      Factors associated with cloth face covering use among adults during the COVID-19 pandemic - United States, April and May 2020.
      ,
      • Hutchins HJ
      • Wolff B
      • Leeb R
      • et al.
      COVID-19 mitigation behaviors by age group - United States, April-June 2020.
      ,
      • Deschanvres C
      • Haudebourg T
      • Peiffer-Smadja N
      • et al.
      How do the general population behave with facemasks to prevent COVID-19 in the community? A multi-site observational study.
      ,
      • Haischer MH
      • Beilfuss R
      • Hart MR
      • et al.
      Who is wearing a mask? Gender-, age-, and location-related differences during the COVID-19 pandemic.
      ; however, it is consistent with a high student mask use reported from other university campuses.
      • Barrios LC
      • Riggs MA
      • Green RF
      • et al.
      Observed face mask use at six universities - United States.
      Anecdotal reports from observers suggest the nonstudents were largely campus visitors or contractors, who could have had less training and a much lower chance of disciplinary action, which may have contributed to prevalence of mask use.
      The highest mask use prevalence was at the athletic center, followed by the academic building and the student union. The exact reason for this is unknown. Some possibilities are that individuals could be barred from using the athletic facility if found to be in violation of the mask use policy. The results also reflect the likely proportion of campus visitors to the various buildings or the likelihood of eating inside the buildings. Both visitors and eating would be highest in the student union and lowest in the athletic complex. Data collectors noted individuals who recently ate may not have replaced their mask immediately.
      A substantial limitation is that observers were also asked to use their own judgement to assess gender and student status. For this reason, observers were encouraged to indicate “unknown” if they were unable to make a determination, and this category was retained in analyses. Additionally, race/ethnicity data were not collected because direct observation could result in a high level of misclassification for this variable.
      This study also has several strengths. Data were collected on a large sample of individuals. Additionally, as a direct observational study, these results are not subject to reporting bias. Overall, this adds to scientific knowledge for face mask use in academic settings where mask use was required.

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