Knowledge, attitudes, and practices (KAP) towards COVID-19 among university students in Pakistan: a cross-sectional study

Introduction

An outbreak of enigmatic pneumonia, characterized by fever, dry cough, fatigue, and gastrointestinal symptoms, was reported in China in December 2019 [1]. Later, following the local health authority’s announcement of an epidemiological warning on 1 January 2020, the market was closed [2]. Fever, cough mostly dry, fatigue, muscle aches, and difficulty breathing are the main clinical manifestations of this profoundly infectious disease, while the advanced stage of the disease is described as respiratory discomfort, septic shock, and coagulation problems [3], [4]. The World Health Organization (WHO) announced a global public health emergency on 30 January 2020 [5].

The Government of Pakistan and the Ministry of Health have taken unprecedented steps to restrict the spread of the virus in the country. These include a complete lockdown at the start of the pandemic, followed by a smart lockdown in major cities and educational institutions’ closure [6]. The Ministry of National Health Services Regulation and Coordination (MoNHSRC) report identified 295,636 confirmed cases by 30 August 2020. The total number of cases in Sindh provinces was 129,268 among all the Pakistan regions, with 2,398 reported deaths. Punjab has 96,741 confirmed cases and 2,196 deaths, and Khyber Pakhtunkhwa has 36,017 confirmed cases and 1,250 deaths, Balochistan has 12,842 confirmed cases and 141 reported deaths, Gilgit Baltistan has 2,863 confirmed cases and 67 deaths, Azad Jammu Kashmir has 2,294 confirmed cases and 61 deaths, while the Islamabad Capital Territory has 15,611 confirmed cases and 175 deaths [7].

The pandemic has put the education system in a difficult situation, especially for university students who were at their time free but with limited experiences. Their behaviours and attitudes were assumed to be affected by the outbreak. The outbreak of SARS in 2003 suggested that public knowledge and attitudes towards the pandemic were linked to panic emotions, which in turn had an impact on measures to control the pandemic. As a result, the assessment of knowledge and attitudes about COVID-19 insights, into preventive practices could be gained. During the pandemic, the government of Pakistan closed down educational institutions. Knowing about the ‘student’s’ knowledge (K), attitudes (A), and practices (P) against COVID-19 will help governments and policymakers to control the pandemic by targeting vulnerable populations. The study aimed to evaluate the student’s knowledge (K), attitudes (A), and practices (P) against COVID-19.

Materials and methods

An online cross-sectional survey was conducted between 15 June and 20 July 2020 at various universities in Pakistan. The data was collected using a random sampling method. The questionnaire was based on information provided on the WHO and the Government of Pakistan websites for COVID-19 [8], [9]. The questionnaire was not validated and was used to collect information from students about awareness of COVID-19. The online link to the questionnaire was shared with university students through social media (WhatsApp and Facebook messenger). The questionnaire included the informed consent of the participants prior to the completion of the questionnaire. The researcher inserted a brief introduction to the background, purpose, procedure, voluntary participation, confidentiality, participation notes and completion of the questionnaire. The first part of the questionnaire concerned the students’ demographic characteristics—the second part of the questionnaire (K1–K10) dealt with the knowledge and transmission of COVID-19. Every question was answered as yes/no and not sure. The score of 1 was given for each correct answer and 0 for each incorrect/not sure answer. A total score of ≥8 was considered good knowledge; a score of 7 was deemed to be fair, while a score of ≤6 was regarded as poor knowledge. The third part of the study consisted of two questions (A1–A2) about attitudes towards COVID-19 with a yes/no answer choice. The fourth part comprised six questions to the practices toward COVID-19, which were answered as yes/no. A mean score ≥5, indicated good practices against COVID-19, a score of 4 as fair practices, while three or less than 3 showed poor practices among the university students.

Statistical analysis

The data were analysed using the statistical package for social science (SPSS) version 25.0. A descriptive analysis was used to measure the study characteristics, the level of knowledge, attitudes, and practices. Standard deviation and mean were used to compare each variable based on demographic classification. In addition, the Mann Whitney test and ANOVA test with a 95% confidence level were carried out to examine the difference between variables.

Results

A total of 358 respondents responded to the survey. Five respondents were not willing to participate, and 353 of the respondents completed the survey. The demographic characteristics of the respondents were shown in Table 1. The study showed that the majority of the respondents (68%) had good knowledge of COVID-19. The mean knowledge score for COVID-19 was 8.78 ± 1.63 (range 1–10). The high knowledge score was in the 28–38 age group, with a mean score of 8.94 ± 1.81 SD. Ph.D. students have a high score of knowledge compared to master and bachelor students. Respondents in Azad Jammu Kashmir territory have higher knowledge score (9.36 ± 0.92) as compared to students in other regions. There was a significant difference in knowledge score across education and study province (p<0.05), as shown in Table 1.

while the percentage of respondents’ level of practice is shown in Table 3.

Assessing the respondents’ attitudes, 53.5% stated that they were satisfied with the facilities provided by the government of Pakistan. Responses to statements of attitudes can be seen in Figure 1

Figure 1:

Attitudes towards COVID-19 by the students

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The students’ mean practice score was 5.08 ± 1.312 SD (Range 1–6), which showed that the students do better practices against the pandemic. The students from Azad Jammu Kashmir do better practices 5.45 ± 1.21 as compared to students in other provinces of the study. We found a significant difference in practice scores between the study area (p<0.05), as shown in Table 1. The results of the student responses to COVID-19 practice statements were shown in Table 4, while the students’ level of practice is shown in Table 3.

Discussion

Since the outbreak of COVID-19, it has promptly become a menace to public health and has led to massive socioeconomic damages worldwide. Strenuous measurements have been enforced, including lockdowns, social distancing, closing educational institutions, banning public gatherings, and establishing quarantine centres in Pakistan to mitigate the outbreak effectively.

In this study, the students have good knowledge of COVID-19 as the mean knowledge score was 8.78 ± 1.63 (range 1–10). The overall correct student knowledge was 87.75%. This study is in range with previous research conducted in Vietnam and China, where participants’ correct knowledge score was high [10], [11]. We found a significant association in knowledge score between educational level and study area (p<0.05). The high study level was associated with high knowledge score of respondents. These results of this study are consistent with a study conducted in China [12]. Most of the respondents in this study (95.8%) were aware of the disease’s clinical signs and symptoms, and 89.5% were aware that there was no specific treatment as of the date of the survey. The results of this study are consistent with prior research conducted in Saudi Arabia [13].

The question from K6–K10 was about the mode of transmission where the overall score of respondents was 83%. The majority of respondents (94.3%) indicated that isolation and quarantine are common strategies that can help control the spread of diseases, while the correct score for human-to-human transmission by droplet and contaminated hand was 94.1%. These results are supported by previous studies in Malaysia and Ethiopia [14], [15]. The correct scores of the respondents for the virus cannot be transmitted through mosquitos were 72.2%. Our study result is in line with the study conducted in Nigeria [16]. The respondents’ attitude towards the government approach to the pandemic was satisfactory. The responses to attitudes are different from the study conducted in China and Saudi Arabia, where most of the respondents were optimistic about the ‘government’s’ approach to the pandemic [11], [13]. Students have shown better preventive practices to control the spread of the pandemic. The mean student preventive practice score was 5.08 ± 1.312 SD. The majority of respondents (90.9%) indicated that they often wash their hands with soap for 20 s, while 76.5% use sanitizers consistent with previous research [14]. The student’s practices of avoiding crowded places were also high, as 88.1 % reported avoiding crowded places, which is in line with the Malaysia study [14]. The majority of respondents (93.2%) indicated that they avoided contact with people who respiratory illness, symptoms, and covered their nose and mouth while sneezing which is in line with the study conducted in South Korea [17].

Conclusions

The study showed a comprehensive assessment of the student’s awareness of COVID-19 when all the institutions were closed. The results showed that most respondents have good knowledge of COVID-19 and follow precautionary practices to combat the rise of COVID-19. This study’s results may be useful for policymakers and healthcare authorities on further health interventions, awareness campaigns toward COVID-19, and health education programs. Health education programs aimed at mobilizing and improving information related to COVID-19 are required, particularly for vulnerable groups, to increase their preventive practices.