Introduction
COVID-19 is an emerging respiratory disease caused by the novel type of Coronavirus. This respiratory illness has received international attention and it is categorized as a high-threat disease in the US by the Center for Disease Control and Prevention (CDC). Reference Peeri, Shrestha and Rahman1 The first case of COVID-19 was diagnosed in Wuhan city, China in late December 2019. The World Health Organization (WHO) announced the disease as a pandemic in February, 2020. Around 62 countries reported 85176 confirmed cases with more than of 3000 death cases. Reference Nishiura, Jung and Linton2 In the Kingdom of Saudi Arabia, the first case was conformed in March, 2020.
The exact method of transmission of the novel Coronavirus is not clear yet. However, there has been a hypothesis that it spreads through direct contact, air droplet, or animal transmission. Also, the virus has 14 days of incubation before the clinical symptoms of illness becomes apparent. Reference Wujtewicz, Dylczyk-Sommer and Aszkiełowicz3,Reference Enberg4 The symptoms are fever, cough, myalgia, shortness of breath, dyspnea, hypoxemia and respiratory distress. Reference Li, Guan and Wu5 Adults and children are reported to experience less severity of symptoms compared to people who are immunocompromised. Reference Taghrir, Borazjani and Shiraly6 A treatment modality for affected individuals is quarantine and isolation in order to protect people who surround them, especially as there is no drug effective against the virus and the treatment is supportive. There is no approved antiviral drug or vaccine although great efforts have been shown from several pharmaceutical companies to discover such a vaccine.
Universities are likely to become explosive, infected, and epidemic epicenters due to their large number of young students, high levels of close social contact and permeable restrictions. Reference Van, McLaws and Crimmins7 It is very important to assess the knowledge and attitudes of university students to the COVID-19 virus, Reference Liang and Acharya8 because this can give an idea about what information they have and their attitude towards this crisis. Reference Peng, Wang and Zhang9 Attitude as defined by Abdelrahman, Reference Abdelrahman10 is something that “represents the positive or negative readiness towards certain things; a person, place, an event. Following the WHO declaration about a global pandemic, the government of Saudi Arabia has monitored the condition of the country’s health closely, particularly after the first national case diagnosis confirmation on March 2, 2020. The Kingdom of Saudi Arabia implemented preventive measures to control the spread of COVID-19; these measures included a national curfew to restrict human movement for most of the day and lockdown of schools, universities, national, and international flights, as well as suspended visits for Umrah, and visiting the Prophet’s Mosque. The assessment of KAP plays an integral role in identifying behavioral changes, acceptance, and identifying the required type of interventions to achieve the change. In addition, the novelty of the Coronavirus, along with its uncertainties make it critical for assessing medical students’ knowledge, attitudes and practice (KAP) towards COVID-19. The purpose of the study was to assess the knowledge, attitude and practice of undergraduate nursing students towards COVID-19.
Methods
Design and setting
The study employed describes a cross-sectional survey. All undergraduate nursing students, as well as the nursing interns, who were enrolled in King Abdulaziz University (KAU) in Jeddah and satisfied the inclusion criteria were included in the study, as follows:
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(1) The participants must be enrolled in the undergraduate nursing program in KAU.
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(2) Able to read and write English language.
Sample size and sampling technique
Based on Cohen’s sample power calculation on the minimum required sample size for observational study, Reference Statistical Power Analysis11 with the desired probability of (0.05), and small effect size of (0.05), and the statistical power level of (0.8), the required sample size is 255.
Data collection procedure
The study used several strategies to enhance the response rate of nursing students. The survey was administered online by Survey Monkey forms, Google forms, Facebook, Twitter, and WhatsApp. The research team sent several reminders to encourage all students to complete the survey. The data collection took place between April and July, 2020.
Outcome measures
The outcome measures of the study included 2 parts, the first part was related to the socio-demographic data of the study participants such as age, gender, education level, and marital status. The second part of the scale was a COVID-19 knowledge questionnaire which was developed by Hassan. Reference Hassan12 It had 5 dimensions which included 7 questions about the nature of the disease, 5 questions concerned the mode of transmission, 13 questions related to action(s) taken to handle suspected or confirmed cases, 4 questions related to precautionary measures by health care providers, and 4 questions related to the treatment of the disease. Each question was answered on a true/false basis with an additional ‘I don’t know’ option. The potential knowledge score ranged from 0 to 33; higher scores indicated better knowledge towards COVID-19. The internal consistency of knowledge items was 0.83. Attitudes towards COVID-19 were measured by 11 questions rated on 5 Likert scales: “Strongly agree to Strongly disagree.” Scores ranged from 11 to 55, with high scores indicating positive attitudes. The Cronbach alpha OD attitude subscale was 0.8 Also, the participants’ practice towards COVID-19 was assessed by 5 questions rated on a 5-point Likert scale: “Strongly agree to Strongly disagree.” Overall score ranged from 5 to 25, with high scores indicating better practices. The internal consistency of practice items was 0.83.
Data analysis
Data were analyzed using the Statistical Program (SPSS) version 24 (IBM Inc., Armonk, NY, USA). The research student coded data appropriately and entered it into the software. Data satisfied statistical assumptions such as normality, linearity, and homogeneity of variance. Descriptive statistics was used to report frequency and percentage, as well as mean alongside standard deviation. Moreover, inferential tests such as independent sample t-test and 1-way analysis of variance were used to compare the differences in study outcomes in relation to sociodemographic data. Pearson correlation test was used to examine the relationship between study outcomes and study participants’ characteristics. P < 0.05 was considered as statistically significant.
Results
A total of 255 undergraduate nursing students completed the survey questionnaire. Of these, a third of the study participants were between 18 - 21 years old and 100% of study participants were females; 33.72% of students were in their second year in nursing college compared to 21.56% who were in their fourth year. Moreover, almost 2-thirds of study participants resided with their family in the same home in rural areas (70%). Socio-demographic characteristics are shown in Table 1.
Table 1 Sociodemographic characteristics of participants
A total of 32 questions were used to measure knowledge on the COVID-19 virus. The first dimension has 7 questions, the average of study participants’ knowledge regarding the nature of disease showed that they had moderate level of knowledge regarding the nature of diseases. In the present study, the second dimension was measured by 5 questions and the average revealed that they had limited knowledge about the transmission of disease (average 2.14 ± 1.01). Furthermore, dimension 3 was measured by 13 questions in the used scale: the average reflected that study participants had moderate level of knowledge about appropriate intervention to deal with suspected or confirmed cases with COVID-19 (average 8.65 ± 2.27). Additionally, study participants had adequate knowledge about the precaution measures to control COVID-19 spread in the community. However, the results of the survey indicated that study participants expressed moderate level of knowledge towards treatment of COVID-19 cases. Overall, average knowledge scores of participants were 20.54. This reflects limited level of knowledge about the pandemic disease, as described in Table 2.
Table 2 Overall knowledge scores and its dimensions of study participants
The number and percentage of true, false and ‘I don’t know’ answers of study participants regarding the knowledge dimensions are shown in Table 3. As it can be seen, a higher percentage of correct answers were noted under the nature of the disease and precautionary measures by health care providers. Additionally, the study participants’ responses revealed that they had moderate level of knowledge regarding the actions in dealing with suspected, probable and confirmed cases. However, the lowest percentages were observed in transmission and treatment of disease. Notably, the study was conducted before vaccines became widely used or the virus’ variants spread.
Table 3 Study participants responses on knowledge scale about Coronavirus
The results of study participants regarding attitudes towards COVID-19 revealed that they had negative attitudes. For instance, only 27% of study participants agreed to work in a place with patients confirmed with COVID-19, in addition, the majority of students (67.2%) expressed that they were hesitant to care for such patients. Around 50% of participants believed disease transmission could be controlled by using protective measures, and more than 52.8% of study participants were in agreement of COVID-19 being a highly transmissible disease. Moreover, 50% of participants also agreed that COVID-19 would be successfully controlled by locking down crowded places such as schools. However, the remaining 50% of participants were unsure whether the virus could be controlled by lockdown measures. Only 9.7% of participants believed that health education was an effective measure to prevent the occurrence of COVID -19 and 47% were convinced that COVID-19 was a dangerous disease (see Table 4).
Table 4 Participant’s attitude about Coronavirus infection
There was a total of 4 questions to assess practice among the participants Also, most of them expressed unfavorable practices when they were asked about the efforts of different authorities for disease prevention and control; wherein 33.4% agreed that responsible authorities take the necessary measures for disease control, 55.9% agreed that Coronavirus has a deleterious impact on the economic status of the affected country. Among participants, 55.2% believed that COVID-19 is a preventable disease. Meanwhile, 45% of participants performed practices like wearing a mask is a correct way to control disease transmission while majority of the participants were certain that a reported case discovered to the health authority was a successful method of restricting disease spread (Table 5).
Table 5 Participant’s practice about Coronavirus infection
Discussion
To the best of our knowledge, there are no previous studies examining KAP among undergraduate nursing university students toward COVID-19. However, there are limited studies examining general community perception towards the pandemic.
It has been reported that the KAP for an infectious disease relies on several factors such as the prevalence and incidence of cases as well as mortality rate of affected people. Ever since the announcement of COVID-19 as a pandemic by the WHO, the knowledge, attitude, and practices toward COVID-19 has been growing day by day. Reference Huang, Wang and Li13,14 The fact that COVID-19 is a highly contagious disease makes the control of its spread a challenge, therefore, the effective strategy to control the spread of infectious diseases is by adopting strict sanitation measures as well as proper measures of handwashing. The Ministry of Health in Saudi Arabia implemented strict safety measures, for instance, wearing facemasks and gloves, and frequent handwashing.
The results of the study indicated that nursing students had moderate level of knowledge towards COVID-19 (average 20.54 ± 4.67). Looking at the table results reflected that some knowledge items towards COVID-19 were received by a high percentage compared to other items which were received by a low percentage. This suggests a higher number of participants had more knowledge and the other part (lower part) had less knowledge about the phenomenon. The finding of a higher rate of COVID-19 knowledge found among study participants can be related to the nature of their discipline (Nursing) even though the study was conducted at an earlier stage of the pandemic crisis. Also, the largest proportion of study sample was at an advanced education level, those students were more likely to actively learn information about the virus from a variety of authentic sources.
Regarding the nature of disease dimension, students appeared to have sufficient knowledge about the disease as most of them provided correct answers to questions related to symptoms, diagnostic criteria, and techniques as well as virus incubation period. In this study, the findings regarding the knowledge about COVID-19 among the students reflect a good relationship between their deep understanding and the information available about COVID-19 in literature and the media. Reference Huang, Wang and Li13,Reference Dhama, Sharun and Tiwari15 For example, most of the study participants defined frequent clinical manifestation of the disease (i.e., fever, dry cough, and dyspnea) and lack of effective approved treatment against COVID-19. This could be attributed to the seriousness of the COVID-19 disease, the number of new cases, as well as the mortality rate announced daily by the World Health Organization. This result is consistent with those reported elsewhere that students had adequate knowledge towards symptoms and preventive measures. Reference Hussain, Garima and Singh16,Reference Zhong, Luo and Li17 This could be explained by the fact that the Ministry of Health in Saudi Arabia conducted an official talk daily where the Health Minister and MoH used specified education channels to inform the public about the COVID-19 virus. Moreover, several reports are made available from the World Health organization and Center for Disease Control and Prevention.
With regard to the mode of transmission, the study participants demonstrated poor knowledge towards the recent transmission of the Coronavirus, this was evident from the average (2.14 ± 1.01). The percentage of correct answers was low when compared to that of non-correct answers, this could be explained by the novelty of the virus and several inconsistent information about the method of transmission by close contact (65%), air droplet (20%), or through haemo-dialysis (18%). Comparison of the findings with those of other studies confirms that students showed limited knowledge about COVID-19 mode of transmission. Reference Hassan12,Reference Al-Hanawi, Angawi and Alshareef18 It could be attributed to the spread of myths and misinformation driven by fear, blame and stigma. This may be a reflection of need to have more emphasis on the modes of transmission in the future educational campaign.
In terms of actions in dealing with suspected, probable and confirmed cases, the results of survey showed that participants reported the importance of social distance, and the importance of using surgical masks in prevention of disease spread. Similarly, the result of Al-Hanawi and Angawi Reference Al-Hanawi, Angawi and Alshareef18 showed that students of KAU showed a good knowledge towards the importance of frequent handwashing, mask and social distance in controlling the COVID-19 spread. The current study confirmed the fact that students of health colleges are more knowledgeable compared to other specialties and this result is in accordance with the documentation. Reference Amatya, Gorkhali and Mahotra19 In relation to public knowledge, general population stresses the importance of mask in prevention of disease spread. Reference Azlan, Hamzah and Sern20,Reference Lau, Hung and Go21 Several studies conducted in other Asian countries have indicated high levels of COVID-19 knowledge among the general population and healthcare workers. Reference Zhong, Luo and Li17,Reference Huynh, Nguyen and Tran22 Differences in measurement and scoring systems do not make it possible for accurate comparisons of knowledge levels across these studies.
Also, study participants had moderate knowledge about the appropriate treatment approach for COVID-19. The participants indicated oxygen, antibiotics, antivirals, or vaccination as management actions. This could be attributed to the fact that there are no approved drugs or vaccines against COVID-19. 14 This also accords with our earlier observations, which showed that participants expressed a wide range of views towards COVID-19 management by drugs, traditional treatment or vaccination. Reference Dhama, Sharun and Tiwari15,Reference Hussain, Garima and Singh16,Reference Al-Hanawi, Angawi and Alshareef18
In terms of student attitude toward Coronavirus, the study showed that participants had optimistic attitudes towards the pandemic. Around 27% of study participants stated they were hesitant to provide care for patient diagnosed with COVID-19. Furthermore, 54% of students reported that even if they use face masks, the risk of COVID-19 was still high. The results showed that the most of students applied precautionary measures in order to control COVID-19 spread. These measures included avoiding crowded places or wearing medical masks. These were consistent with strict measures as were implemented by the government. Approximately 75% agreed that gathering places should be locked down to successfully control COVID-19 spread. This finding is consistent with a recent study conducted in China, where the majority of participants were convinced that the disease is curable and that their country will combat the disease. Reference Zhong, Luo and Li17 However, these results contrast with other findings that suggest people tend to express negative emotions, such as anxiety and panic during a pandemic that could affect their attitude. In terms of practice, study participants showed good practice towards COVID-19. This is evident from their agreed responses. This result is supported by earlier studies which indicated that participants who had good knowledge of COVID-19 transferred it into practice.
It is worth noting that there was a significant difference in the mean of knowledge, attitudes, and practice scores according to the characteristics of study participants. For instance, students who were 22 years or older showed more knowledge, optimistic attitudes, and positive practice. In addition, educational level demonstrated significant difference in all dimensions of knowledge, attitudes and practice. This could be related to the fact that advanced students received more specialized nursing courses alongside epidemiology courses. This positive result was also echoed in students who lived in rural areas. This might be related to availability of information, strictness in application of governmental preventive measures. These results corroborate the findings of a great deal of the previous work in Alzoubi, Alnawaiseh, Reference Alzoubi, Alnawaiseh and Al-Mnayyis23 and Hassan, Reference Hassan12 who stated that age and education level influenced participants knowledge, attitudes and practices towards COVID-19.
Despite its exploratory nature, this study offers some insight into assessing undergraduate nursing students’ attitudes KAP towards COVID-19. However, the study had threats such as study participants being recruited from 1 government university which limits the generalizability of the study findings; moreover, almost all of the study participants were female.
Conclusion
Our findings suggest that undergraduate nursing students had good knowledge, positive attitudes, and good practices toward COVID-19. The results of the study should help stakeholders pay more emphasis to infectious disease and the nursing role in controlling its spread.
Ethical standards
The study sought ethical approval from the Scientific Research Committee at Fakeeh College for Medical Sciences (Ref: 1F-25). In addition, the data were collected online therefore the authors included a paragraph explaining the study purpose and participants’ commitment. Authors emphasized that their participation was voluntary, the questionnaire was anonymous, and the participants were assured of the confidentiality of their responses.
