Evaluation of the Knowledge, Attitudes, and Resulting Behavior Changes in Response to COVID-19 Among Students at the College of Applied Medical Sciences (CAMS), Jazan University, Saudi Arabia

Introduction

The Coronavirus 2019 (COVID-19), a new unprecedented strain caused severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was initially reported in Wuhan, China (December 2019), spread rapidly around the world. Many patients started to develop pneumonia of unknown etiology.¹ COVID-19 effects the respiratory system, while the symptoms range from mild clinical manifestations to numerous fatal complications, including severe bilateral pneumonia, Acute Respiratory Distress Syndrome (ARDS), and septic shock, eventually resulting in multi-organ failure.^3,4 In March 2020, the WHO declared COVID-19 as a global pandemic.^5,6

The WHO stressed awareness as a preventive measure to protect against COVID-19 to slow down the spread of COVID-19. Moreover, recent research suggested that practicing preventive measures at an individual level is an effective tool in halting the spread of infection.^7,8 Social distancing, staying at home, wearing a mask, were strictly enforced by the governments in many countries for the prevention of the epidemic.⁹

Huge efforts and research were conducted on the clinical manifestations, pathophysiology, diagnosis, and treatment of COVID-19. However, few research explained the behavioral changes and psychological impact among the affected population.^10–13 Several studies have been conducted in Saudi Arabia to assess the knowledge, attitude, and practices among various strata of the Saudi population and in different regions of KSA, but only few studies dealt with the issue of behavioral changes.^14,15

In this context, we will establish evidence-based information to contribute at addressing this gap and establish a foundation for interventions. Additionally, this study intends to furnish baseline data by studying two major concepts: knowledge and attitudes that lead to specific behaviors (practices). Hence, the aim was to examine the impact of knowledge and attitudes on behavioral change, including the demographic characteristics of the study population. Subsequently, we employed two predictors of the predisposing constructs in the PRECEDE model¹⁶ as an investigative step to represent factors that illustrate the behaviors of Jazan University students in this study towards the COVID-19. In addition, the PROCEED model generates objectives and criteria for evaluation. However, we have not restricted ourselves to a specific theory or a conceptual framework. Nevertheless, the conceptual plan is a simplified multidisciplinary model that combines knowledge, attitudes, and behaviors to serve the purpose of the investigation.

The aim of our study was to assess the overall knowledge regarding COVID-19 precautions in a section of a young educated population and to understand the general, psychosocial, and behavioral changes in the young population with regard to the new way of life due to COVID-19.

Materials and Methods

Study Design, Population and Setting

Observational cross-sectional study was conducted among students at the College of Applied Medical Science, Jazan University. The main inclusion criteria were being regular students in the college and registered for the academic year 2019/2020, and age above 18 years. The College of Applied Medical Science has six programs: Medical Laboratory technology, Clinical Nutrition, Diagnostic Radiology, Physical Therapy, Respiratory therapy, and emergency medical services. Four programs had male and female students, except for respiratory therapy and emergency medical services programs, which only enrolled male students.

Sample Procedure

We used the equation of the cross-sectional survey, which is given by the following formula

The parameters of the formula including n: the initial sample size; π:is an anticipated population proportion. Z: is the standardized variable that corresponds to 95% confidence level; d: the desired marginal error. Since there is no estimate of the prevalence of knowledge/precautionary behavior among study participants at Jazan University, it is safer to set a prevalence of 50%. Based on the values π = 0.5, d, the desired marginal error = 0.04, and z = 1.96, the initial sample size will be 600 participants. The sample size was increased by 5% to account for non-response, providing a final sample size of 630 students. Stratified random sampling was used to select the study participants. The College was divided into six strata according to different specializations. Probability proportional-to-size sampling (PPS) was used to determine the number of participants in different strata. In the final stage, systematic randomization was used to select the study units.

Data Collection and Study Tool

Data were collected using a web-based questionnaire. A survey link was distributed to the selected students. This self-administered questionnaire comprised four sections, with the first section collecting sociodemographic information, while the second section assessed COVID-19 related knowledge (n = 10), with the response (yes and no). The third section involved attitudes questions a Likert scale type question (n = 10). The final section contains the practice questions (n = 10) with the responses (never, sometimes and always). The Internal consistency of the three main domains of the questionnaire were as follows; Knowledge (Cronbach’s alpha: 0.699), Attitude and Practice reliability (Cronbach’s alpha= 0.837 and.0927), respectively.

Data Analysis

Data analysis was conducted using Statistical Package for the Social Sciences (SPSS version 24). The analysis involved descriptive and inferential statistics. Simple tabulation, frequencies, and chi-squared tests were used to test the association between different variables. A Shapiro–Wilk test of normality showed that the Knowledge, Attitude and Practice scores were not normally distributed (p < 0.05), so we used the quartiles and interquartile range to summarize the data. Kruskal–Wallis and Mann–Whitney U-tests were used to compare the groups. The students’ knowledge, attitudes, and practices were quantified into scores. The total knowledge score was assessed by assigning a score of 10 to each correctly answered item. The same was applied for assessing students’ practices, as correct practices were given a score of 10. The total score for attitudes was calculated by assigning 10 points to positive attitudes. Linear regression models were used to evaluate the predictors of three outcome measures: knowledge, attitudes, and practice scores. A p value less than 0.05 will be used to indicate statistically significant results.

Ethical Considerations

Ethical clearance was obtained from the Jazan Research Ethics Committee (reference number: REC42/1/024). All study participants read, understood and signed the study consent. All information was kept confidential and not accessed except for scientific research purposes. Helsinki declaration and Saudi Bioethics were the Ethical guidelines for this study.

Results

The KAPs scores according to sociodemographic characteristics were calculated for the students of College of Applied Medical Sciences, Jazan University and Jazan, as shown in Table 1. The total number of respondents was 54% male and 46% female, with significant differences in their KAP score. The majority of participants were 21–23 years of age. The students were from academic levels 3 to 8 (18 to 24 years old), although most respondents were from level 4. Around (41.6%) of the respondents lived in semi-urban villages within the Jizan region, which consists of a group of small semi-urban villages. Most respondents were unmarried (90.7%), and most lived with their families (91.8%). Knowledge scores differed significantly according to sex and academic level (p < 0.05). Additionally, there were significant differences according to attitude scores and academic level (p < 0.05). No significant difference was found between practice scores according to different socio-demographic backgrounds (p > 0.05 for all).

Table 1 Distribution of KAP Scores According to Some Selected Socio-Demographic Characteristics (N=546)

Furthermore, the questionnaire involved information regarding the students’ knowledge regarding COVID-19 symptoms (Table 2). The general knowledge of COVID-19 showed that the proportion of students with correct answers ranged from 43.3 to 95%. There was no significant difference between males and females, except for views on the treatment of coronavirus from home remedies (p < 0.05). 85.8 Of the males were in favor of home remedies, whereas 65.9% of females were believed to be home remedies (Table 2).

Table 2 General Knowledge About COVID-19 Among Study Participants (N=546)

The respondents’ attitudes towards being infected with COVID-19 are also assessed in Table 3. Some answers to the questions, such as what they would do if they think that they had symptoms of the coronavirus, had significant differences between males and females in their following responses: See Table 3.

Table 3 Student’s Attitudes Towards Being Infected with COVID-19

Table 4 shows practice related to COVID-19 prevention among study participants. Large proportion always adhered to the good practice except for wearing gloves when going out of the home (42.3%) said never. With regards to not gathering with more than 5 people (45.4%) said sometimes. Table 4 demonstrates the percentage of people who never adhered to the practices related to COVID-19 prevention which showed majority of people did not prefer to wear gloves while going outside while only a very minority of people preferred to go outside without wearing a mask.

Table 4 Practices Related to COVID-19 Prevention Among Study Participants (N=546)

We assessed the extent of the issues faced by the respondents during the COVID-19 shutdown and social distancing (Table 5). There are significant differences between male and female participants in some issues, such as loss of income, loss of job, and inability to attend religious rituals or religious events. Unable to get enough food, medications, and supplies in the house, difficulty in accessing the healthcare system, domestic violence, crowding in the house, and anxiety and stress of family members.

Table 5 Student’s Experiences During COVID-19 Shutdown and Social Distancing

Table 6 shows Linear Regression Analysis of factors associated with knowledge, attitude, and practice scores among study participants. The result found that females were significant predictor of increased knowledge attitudes and practice scores (p < 0.05 for all). Those within age group of (21–23) years, and those over the age of 23 years are associated with higher knowledge, attitude, and practice scores (p < 0.05 for all). Also, students who reside in urban and semi-urban areas were also significant predictors associated with increased scores of knowledge attitudes and practice (p < 0.05 for all).

Table 6 Linear Regression Analysis of Factors Associated with Knowledge, Attitude, and Practice Scores Among Study Participants

Discussion

This cross-sectional survey sheds the lights into students’ KAP towards COVID-19 from various programs at the College of Applied Medical Sciences, Jazan University, KSA. The level of awareness of about COVID-19 and the willingness to carry out appropriate practices were discussed.

The results of this study documented somewhat higher willingness to carry out appropriate practices to prevent COVID-19, this pattern is similar to study conducted by Alhajjaj et al, 2020 in KSA, where majority of participants supported protective measures taken for COVID-19 prevention.¹⁷ Our KAP survey results go along with other KAP surveys in other countries, which showed that our group of people were knowledgeable about COVID-19 in the early stages of the outbreak.^18–21 For example, Abdel Wahed et al concluded that the grossly knowledge level of Health care workers (HCWs) was by and large high, especially among physicians. A more positive attitude was detected among allied health professionals than among physicians. Risk sensitivity was high among HCWs. The causes of increased risk insight need to be considered by the government and the Egyptian Ministry of Health.²² According to Limbu et al their healthcare workers have analogously better knowledge regarding COVID-19. Pertinent practice correlates with better knowledge, and a positive attitude towards COVID-19 infection is observed with growing age. Hence, training on protection and protective course of action for having a positive attitude among healthcare workers is necessary to fight against COVID-19.²³

The online survey respondents were both male (54%) and female (46%), young (18–23 years), and in rural, semi-urban, and urban settings. It is generally believed that men are more revealed to information technology and public information in the KSA. Erroneous information spreads as rumors among women’s groups, without being critically appraised or discussed. However, our study depicted a slightly higher score for knowledge and attitude in females than in males. The reason may be an equal level of education in the participants, as opposed to the surveys conducted with the general public, where females are relatively less educated.²⁴

There were a significant number of participants who preferred home remedies, particularly females, which is probably due to the acuteness and severity of the illness as well as the unavailability of a definitive scientific cure. The public should be made aware of the latest developments regarding the treatment of COVID-19 and should be taught about red flags when seeking medical help and to stop home remedies, which can be supported by the following reports. Rabbani et al concluded that evidence-based and context-specific likelihood communication and community engagement, and a social and etiquette change communication strategy against COVID-19 should be developed in Bangladesh, targeting different socioeconomic groups.²⁵ There was a remarkable effect of gender and academic level on the knowledge scores of the participants.¹⁷ The other part of questionnaire was composed of questions based on knowledge of the symptoms of COVID-19. Both male and female participants showed good knowledge of most symptoms.²⁶ The knowledge of some of the symptoms was significantly higher in females than male participants as shortness of breath, fatigue, persistent pain or pressure in the chest, headaches, and body aches. Similar results were found in other studies conducted in other regions of Saudi Arabia.²⁷

In this study, it was apparent that the students were concerned about self-safety regarding the seriousness of the coronavirus COVID-19. The majority mentioned that covid-19 was very serious for them (70.1%), followed by their families (65.5%) and community (65.3%). About 32.1% of participants mentioned that it is a serious disease in the Jazan region, 28.6% stated that it is serious for the community, and 28.3% stated that it is a serious disease for the world.

In terms of practices and behavioral changes, a majority of participants in the study were concerned about loss of income, loss of employment, inability to attend religious rituals or religious events, inability to get enough food, medications, and supplies in the house, difficulty in accessing the healthcare system, domestic violence, crowding in the house, and anxiety and stress of family members. Although the anxiety scores of each individual were not tested in the study, most participants were concerned about basic life amenities and the inability to provide them to their dear ones. There were anxieties related to social isolation, which led to increased stress levels among families. Further studies are needed to quantify stress levels among the population and their short- and long-term adverse effects.

Strengths and Limitations

This study has some limitations, first the population selected in the study was one college students, which does not represent the general population as a whole. Further studies are needed to represent other population groups in society. The other limitation of the study is the online survey, which has got its own disadvantages, including the inability to connect with students from remote areas, response bias, and survey fatigue. Despite these limitations, the current research adds new information to the existing literature regarding the knowledge of COVID-19 precautions and the understanding of the general behavioral changes in the young population with regard to COVID-19. These findings may be useful to policymakers and healthcare administrators in developing intervention programs.

Conclusions

In conclusion, our results showed that the participants had moderate knowledge, which was reflected in their behavior change with positive attitude, awareness, and precautionary measures. It was also found that females have a slightly higher score for knowledge and attitude than males which is in contrast to the general public. Most of the participants in the study were concerned about the major basic issues of concerning life during the pandemic. The study outcome suggests the need for interventions to bridge students’ knowledge and practice gaps.