awareness of covid 19 among students research paper

Fear of COVID-19 Among College Students: A Systematic Review and Meta-Analysis

Affiliations.

• 1 School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China.
• 2 Department of Public Health, Second Affiliated Hospital of Shandong First Medical University, Tai'an, China.
• 3 School of Pharmaceutical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China.
• PMID: 35299699
• PMCID: PMC8921101
• DOI: 10.3389/fpubh.2022.846894

Background: Mental health issue among college students is routinely a major public health concern, and coronavirus disease 2019 (COVID-19) pandemic may have exacerbated the students' mental health issues which include psychological distress, panic disorder, insomnia, and posttraumatic stress symptoms. However, few studies reached a consensus on the impact of COVID-19 fear on mental health among college students. Therefore, we aimed to conduct a systematic review and meta-analysis that quantitatively synthesized the fear among college students during the COVID-19 pandemic.

Methods: PubMed, EMBASE, CINAHL, and PsycINFO electronic databases were systematically searched to identify cross-sectional study reporting the state of COVID-19 fear examined by the Fear of COVID-19 Scale (FCV-19S) published up until November 20, 2021. Methodological quality was complied with the evaluation criteria of the Agency for Healthcare Research and Quality. The random effects model was employed to estimate the pooled mean of FCV-19S score. Subgroup analysis and meta-regression analysis were also conducted. Publication bias was assessed by Begg's test and funnel plot.

Results: A total of 16 studies with a sample size of 11,872 were included. A pooled mean of FCV-19S score was 17.60 [95% confidence interval (CI): 16.41-18.78]. The mean of COVID-19 fear in women (17.11, 95% CI: 16.59-17.64) was higher than that in men (15.21, 95% CI: 14.33-16.08). The highest and lowest pooled means of FCV-19S score were observed in the studies conducted in multiple countries that include Israel, Russian, and Belarus (21.55, 95% CI: 20.77-22.33) and in Europe (16.52, 95% CI: 15.26-17.77), respectively. No significant publication bias was detected by Begg's test.

Conclusions: College students experienced a moderate level of fear caused by COVID-19 pandemic. It is necessary to design and implement prevention programs that target the mental health of college students.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021287017, identifier: CRD42021287017.

Keywords: COVID-19; college students; fear; mental health; meta-analysis.

Copyright © 2022 Wang, Zhang, Ding, Wang and Deng.

Publication types

• Meta-Analysis
• Research Support, Non-U.S. Gov't
• Systematic Review
• COVID-19* / epidemiology
• Cross-Sectional Studies
• Students / psychology
• United States

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Open Access

Peer-reviewed

Research Article

Knowledge, attitudes, practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Medical Research and Medicinal Plants Studies (IMPM), Centre of Medical Research, B.P.6163 Yaoundé, Cameroon

Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Roles Formal analysis, Investigation, Methodology

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – original draft

Roles Investigation, Methodology, Project administration

Roles Conceptualization, Investigation, Methodology, Project administration

Affiliations Institute of Medical Research and Medicinal Plants Studies (IMPM), Centre of Medical Research, B.P.6163 Yaoundé, Cameroon, Centre Hospitalo-Universitaire, Yaoundé, Cameroon

Roles Supervision, Validation

• Adela Ngwewondo, 
• Lucia Nkengazong, 
• Lum Abienwi Ambe, 
• Jean Thierry Ebogo, 
• Fabrice Medou Mba, 
• Hamadama Oumarou Goni, 
• Nyemb Nyunaï, 
• Marie Chantal Ngonde, 
• Jean-Louis Essame Oyono

• Published: September 4, 2020
• https://doi.org/10.1371/journal.pntd.0008700
• Peer Review
• Reader Comments

Severe Acute Respiratory Syndrome Coronavirus 2 (COVID 19) has plagued the world with about 7,8 million confirmed cases and over 430,000 deaths as of June 13 th, 2020. The knowledge, attitude, and practices (KAP) people hold towards this new disease could play a major role in the way they accept measures put in place to curb its spread and their willingness to seek and adhere to care. We sought to understand if: a) demographic variables of Cameroonian residents could influence KAP and symptomatology, and b) KAP could influence the risk of having COVID19.A cross-sectional KAP/symptomatology online survey was conducted between April 20 to May 20. All analyses were performed using SPSS version 23. Of all respondents (1006), 53.1% were female, 26.6% were students, 26.9% interacted face to face and 62.8% were residents in Yaoundé with a median age of 33. The overall high score was 84.19% for knowledge, 69% for attitude, and 60.8% for practice towards COVID 19. Age > 20 years was associated with a high knowledge of COVID 19. Women had lower practice scores compared to men (OR = 0.72; 95%CI 0.56–0.92). 41 respondents had ≥3 symptoms and only 9 (22.95%) of them had called 1510 (emergency number). There was no significant difference between KAP and symptomatology. The presence of ≥ 3 symptoms in 4% of respondents (with 56% of them having co-morbidities) supports the current trend in the number of confirmed cases (8681) in Cameroon. The continuous increase in the number of cases and the overall good KAP warrants further investigation to assess the effectiveness of the measures put in place to curb the spread of the disease. Sensitization is paramount to preclude negative health-seeking behaviors and encourage positive preventive and therapeutic practices, for fear of an increase in mortality.

Author summary

SARS-COV-2 is transmitted from person-to-person through inhalation of aerosols from an infected individual. Old age and patients with pre-existing illnesses (like hypertension, cardiac disease, cancer, or diabetes) have been identified as potential risk factors for severe disease and mortality. More information about its distribution, transmission, pathophysiology, treatment, and prevention are needed. World Health Organization (WHO) recommends the prevention of transmission by using face masks, washing hands, and social distancing. We investigated the way people accept measures to curb the spread of disease and their willingness to seek and adhere to care when presenting symptoms. The knowledge of COVID 19 mode of transmission was satisfactory among the Cameroonian population. Most respondents had high practice scores towards preventive measures and positive health-seeking behaviors, although a few stigmatized the hospital milieu and resorted to auto-medications/ traditional concoctions. However, the continuous increase in the number of cases and the overall high KAP scores warrants further investigation to assess the effectiveness of the measures put in place. Also, the presence of COVID 19 symptoms in the population adds more evidence to active disease transmission in the community. This calls for widespread testing in the community because <22% of people with COVID 19 symptoms seek help.

Citation: Ngwewondo A, Nkengazong L, Ambe LA, Ebogo JT, Mba FM, Goni HO, et al. (2020) Knowledge, attitudes, practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon. PLoS Negl Trop Dis 14(9): e0008700. https://doi.org/10.1371/journal.pntd.0008700

Editor: Andrés Felipe Henao-Martínez, University Colorado Denver, UNITED STATES

Received: June 14, 2020; Accepted: August 11, 2020; Published: September 4, 2020

Copyright: © 2020 Ngwewondo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

According to the World Health Organization (WHO), viral diseases continue to emerge and represent a serious issue to public health. In the last twenty years, several viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) from 2002 to 2003, and H1N1 influenza in 2009, have been recorded. Most recently, the Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia in 2012 and now the new Coronavirus disease 2019 (COVID-19) has plagued the world. COVID-19 is an emerging respiratory disease caused by the highly contagious novel coronavirus (SARS-CoV 2) and was first detected in December 2019 in Wuhan, China [ 1 – 3 ]. This new virus has quickly spread globally afflicting 215 countries. As of June 13 th, 2020, over 7.8 million cases and 430,000 deaths have been reported globally [ 4 ].

In Cameroon, the first case confirmed on the 6 th of March 2020 was a French national who arrived Yaoundé. To control and avoid the rapid spread of the ongoing COVID-19 outbreak in the country, several measures were adopted by the government. These measures include the limitation of the number of passengers of public transportation; the closing of all schools; quarantine and care for infected people or suspected cases; closure of borders and suspension of flights; suspension of issuance of entry visas to Cameroon; gatherings of more than 50 people prohibited; bars, restaurants, and public places closed from 6 pm; consumer flow regulations set up in markets and supermarkets; urban and inter-urban travel only undertaken in cases of extreme necessity; overloading in public transport vehicles prohibited; implementation of virtual meetings; avoiding close contact such as shaking hands or hugging and covering the mouth when sneezing.

The number of those infected is still on the rise and after the government uplifted some of the COVID-19 restrictive measures on bars, taxis, restaurants. Several other cases were confirmed later amounting to 8681 cases, 4836 recovered and 212 deaths [ 4 ]. The infection rate and the resources needed to battle this disease can be expected to increase exponentially.

Currently, there is no approved treatment for COVID-19 and no clinical trial data supporting any prophylactic treatment. In the absence of this approved treatment, available treatments are directed at relieving symptoms and the panic of no approved treatment can lead to embracing other non-standard options. Agents previously used to treat SARS and MERS are potential candidates to treat COVID-19 [ 5 ] as well as various agents with apparent in vitro activity against severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). These include chloroquine and hydroxychloroquine, also used in the prevention and treatment of malaria and/or chronic inflammatory diseases. Remdesivir, an antiviral drug is being touted as a possible coronavirus treatment [ 6 ].

Responses to epidemics in Africa have been challenged by limited infrastructure and fragile healthcare systems. This includes the lack of adequate surveillance to assess the scope of the outbreak, and inadequate systems for the prevention, diagnosis, and management of a disease. Cases of COVID 19 as with other diseases are broadly classified as suspected, probable, and confirmed [ 7 ]. Assessing the symptoms of COVID 19 (suspected cases) is a preliminary step in the diagnosis and management of this disease.

Person to person transmission (community spread) is currently ongoing in the country, making it necessary to control the disease to avoid its rapid spread throughout the country. To guarantee successful disease control, people’s adherence to preventive and control measures are essential. This adherence is highly dependent on the population’s knowledge, attitudes, and practices (KAP) towards COVID-19 following the KAP theory. A previous study indicates that the knowledge level and attitudes towards infectious diseases are associated with the level of panic among the population, which can further complicate attempts to prevent the spread of the disease, thus prompting alternative treatment sources [ 8 ].

Due to shortages in diagnostic kits in our setting during our study, a questionnaire to gauge the symptomatic trend was issued to Cameroonians to strategically define an approach to address the outbreak. In this study, according to guidelines for clinical and community management of COVID-19 by the Cameroon National Health Development Plan, our objective was to evaluate the factors influencing the knowledge, attitudes, and practices of Cameroonian respondents on COVID 19 and also evaluate the associations between the demographics, KAP and symptoms of COVID 19.

Methodology

Ethical consideration.

The Ethical Committee of the Institute of Medical Research and Medicinal Plants Studies, Yaoundé, approved the study protocol and procedures before the formal survey.

Study design

This cross-sectional survey was conducted from April 20 to May 20, two weeks after the partial confinement was implemented in the country. Because it was not feasible to do a community-based national sampling survey during this period, data was collected online. Relying on the authors’ networks with local people living in all the 10 regions of Cameroon ( S1 Table ), a one-page recruitment sheet was posted to groups and individuals via “WhatsApp”, email, websites accounts. This page ( S1 Appendix ) contained a brief introduction to the background, objective, procedures, voluntary nature of participation, declarations of anonymity and confidentiality, and notes for filling in the questionnaire, as well as the link of the online copy questionnaire. The associations between the demographics and KAP, symptoms and KAP, comorbidities, symptoms of COVID 19 with age, and gender were assessed.

The independent variables were symptomatology, demographic characteristics (gender, age, profession, working environment, city of residence).

The dependent variables were knowledge, attitudes, practice, and symptoms of/towards COVID 19. Questions on knowledge were about the mode of transmission, attitude towards health-seeking behaviors and practices like avoiding crowded areas, wearing masks, washing hands and using sanitizers, taking vitamin C, citrus fruits, traditional concoctions, and drugs (chloroquine, ibuprofen, paracetamol). Symptomatology was assessed by someone presenting with fever, headache, dry cough/catarrh, throat irritation, diarrhea, difficulty breathing, and muscle pain. The symptomatology section was accompanied by associated comorbidities and diseases with similar symptoms.

Study population and eligibility criteria

Cameroonian residents, aged 18 years or more, employed or unemployed who understood the content of the recruitment page- and who agreed to participate in the study completed the questionnaire.

The questionnaire consisted of four parts: demographics, knowledge, attitudes, practices, and symptomatology. A COVID-19 KAP and symptomatology questionnaire was developed. The questionnaire had 32 questions: 7 items on knowledge, 4 items on attitudes, 9 items on practices, 5 items on symptomatology (for suspected cases), 5 on demographics, and 2 others (source of information). Questions were answered on a Yes/No basis with an additional “I don't know” option. Some open-ended questions were asked.

Statistical analysis

A score of 1 was attributed to a correct answer and 0 to a wrong answer for knowledge, attitude, and practice. The Knowledge range was 3–7, 1–4 for attitude, and 2–9 for practice. The overall scores of each individual were used to obtain mean scores for KAP. Blooms' cut-off was used. Frequencies of correct knowledge answers and various attitudes and practices were described. Multiple logistic regression analysis using all of the demographic variables as independent variables and knowledge/ practice score as the outcome variable was conducted to identify factors associated with knowledge and practice. Similarly, binary logistic regression analyses were used to identify factors associated with practices. Factors were selected with a backward stepwise method. Unstandardized regression coefficients (β) and odds ratios (ORs) at 95% confidence intervals (CIs) were used to quantify the associations between variables and KAP. Associations between demographic variables of gender and age were compared to comorbidities and symptoms (≥3). Also, associations between demographics and KAP were studied. Data analyses were conducted with SPSS version 23.0. The statistical significance level was set at p < 0.05 (two-sided).

Socio-demographic characteristics

A total of 1006 participants completed the survey. The average age of those who participated was 33±11.2. The demographic characteristics of all the participants are presented in Table 1 . Of all respondents, 53.1% were female and 26.6% were students in the university or high school. About the working environment, 26.9% of the participants interacted face to face with others (i.e customer services cashiers, hairdressers, traders, etc), 25.5% spent most of their time in the office, and 20.4% at home. Overall, 62.8% were residents of the capital city Yaoundé.

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https://doi.org/10.1371/journal.pntd.0008700.t001

Source/ period of information on COVID 19

For the source/period of information, 41.9% of the respondents knew when the disease began (December 2019) and 14.4% only knew in March 2020 when the first case was reported in Cameroon. Greater than half of the respondents (54.5%) got the information on COVID 19 for the first time via the television during the first and last 15 days of the study, the respondents got the information primarily through television followed by Whatsapp and websites ( Table 2 ).

https://doi.org/10.1371/journal.pntd.0008700.t002

Knowledge related to COVID 19

For the mode of transmission, 94.3% knew that the disease could be transmitted by droplets when an infected person coughs, sneezes or speaks, 75.6% said through kissing infected person, 74.7% through a handshake, 88.3% through touching a contaminated surface and then touching your eyes, nose or mouth ( Table 3 ). The results show that 84.19% (n = 847) respondents had high knowledge score of 4–7 on the transmission of the disease ( Table 4 ).

https://doi.org/10.1371/journal.pntd.0008700.t003

https://doi.org/10.1371/journal.pntd.0008700.t004

Attitudes towards COVID 19 pandemic

Attitude towards COVID 19 health-seeking behaviors was assessed. Of all respondents, 73.1% think they can be contaminated by health care workers, 28.6% refuse to go to the hospital even if they are suffering from another disease other than COVID 19. Out of the 28.6% of those who do not want to go to the hospital, 21.3% are afraid of being contaminated in the hospital with nosocomial infections like COVID19, 3.5% think the health personnel can misdiagnose their illness given that many other diseases have similar symptoms ( Table 3 ).

Regarding people's willingness to do a COVID 19 test, 72.0% were willing to do a voluntary test among which 47% of them preferred the house over the hospital for their medical care if tested positive. People’s preference for house medical care is because they are afraid of being contaminated in the hospital (38.6%), their families can take good care of them and they feel comfortable at home (58.1%) ( Table 3 ). Overall, 69% of respondents had a high attitude score of 2–4 for health-seeking behavior ( Table 4 ).

Practices towards COVID 19 pandemic

All the respondents use masks (100%), 94.5% wash hands and use sanitizers, 83.8% practice social distancing, or don’t go to crowded places, while 20% are confined at home. Looking at what people take as preventive measures, 74.6% eat citrus fruits and take vitamin C tablets. We also observed that 35.9% resort to traditional concoctions, auto medications like chloroquine (4.4%), (5.6%) paracetamol, and Ibuprofen ( Table 3 ).

Also, 60.8% of respondents were taking precautions (good practice) like avoiding crowded areas, wearing masks, washing hands, and using sanitizers, taking vitamin C and citrus fruits. Statistical significant differences in knowledge of disease transmission were observed with gender, working environment, and city of residence ( Table 5 ).

https://doi.org/10.1371/journal.pntd.0008700.t005

Age > 20 years was associated to high knowledge and attitude scores on COVID 19 ( Table 6 ). Women had lower practice scores compared to men (OR = 0.72; 95% CI 0.56–0.92) and Douala respondents had had high practice scores (OR = 1.16; 95%CI 1.13–2.45) when compared to those from Yaoundé ( Table 6 ).

https://doi.org/10.1371/journal.pntd.0008700.t006

Symptomatology and associated co-morbidities of COVID 19

Out of all the respondents, 71.7% reported no symptoms of the disease, while 5.0% reported fever, 8.3% dry cough/catarrh, 6.5% throat irritation, 13.1% headache, 0.9% diarrhea, 2.5% difficulty breathing, 6.0% muscle pain and 2.2% don’t smell odor or taste. Of all the respondents, 4.7% suffered from hypertension, 6.9% from a common cold, and 24.6% from malaria ( Table 7 ). Significant statistical differences were observed with respondents having hypertension > 30 years when compared to those <30 years ( Table 7 ). Forty-one respondents (4.1%) had more than 3 symptoms with only 9 (21.95%) who called 1510 while 32 (78.05%) did not call 1510 .

https://doi.org/10.1371/journal.pntd.0008700.t007

The association between the KAP and the symptomatology was assessed to see the influence of KAP on the risk of having the disease. Interestingly, there were no significant differences between those having symptoms and those without symptoms. Also, no significant difference was observed with those having <3 symptoms to those having >3 symptoms ( Table 8 ).

https://doi.org/10.1371/journal.pntd.0008700.t008

Overall 23 respondents having ≥4 symptoms had underlying comorbidities and 10 of them had other diseases with symptoms similar to COVID 19 ( Fig 1 ). Also, 168 (18.1%) out of 262 of those with symptoms did not have them recurrently.

Associations between the number of respondents with A) comorbidities, B) diseases with some common symptoms to COVID 19 and <4 symptoms or ≥ 4 symptoms of COVID 19.

https://doi.org/10.1371/journal.pntd.0008700.g001

COVID 19 is spreading rapidly across the whole world and increasing exponentially in Cameroon [ 4 ]. This is one of the first studies that identify symptoms (suspected cases) of COVID 19 which is a thoughtful thing to do in a population experiencing a sudden outbreak. This method used to recruit participants is cost-effective and feasible given that the data was collected during a period of confinement and it can be employed as a rapid screening method in subsequent pandemic situations. In this study, predominantly women in an overall 84.19% had adequate knowledge about the mode of transmission of COVID 19. Akwa et al. [ 9 ] reported in his study that > 80% of respondents knew the disease is transmitted by a handshake, person to person, and contact with infectious droplets only. Our findings show that there is an increase in the knowledge perception of disease transmission since respondents now know it is transmitted by touching contaminated surfaces and then touching eyes, nose, or mouth. We found that 69% of respondents had a high attitude score towards hospital seeking behavior while 60.8% took the necessary precautions like avoiding crowded areas, wore masks, washing hands regularly as stipulated by the WHO and CDC guidelines [ 10 ]. The practice score was not as high as expected because 39.2% of people resorted to traditional concoctions and auto medications. These potentially risky behaviors were related to the female gender maybe because within Cameroon traditional context women are caregivers to the family. So communication initiatives, educational forums are needed to educate women on these risky practices.

The strict adherence to preventive practices could primarily be attributed to the very strict prevention and control measures implemented by local governments to put on masks and washing hands at every public place. The big question remains as to whether the masks are appropriately used given the current increase in the number of cases in Cameroon. The efficiency of social distancing may be compromised given that 26.9% of respondents interacted face to face (like in customer service points, banks, markets, etc), and the government later uplifted restrictive measures on bars and other leisure places.

The factors: gender, age, and city of residence which correlated positively with knowledge, practice for COVID 19 will be useful for public health policy-makers and health workers to recognize the target population for COVID-19 prevention and sensitization. The level of awareness on COVID-19 among Cameroonian residents was expected because 44.1% of the respondents knew that the disease outbreak was in December 2019 and 54.5% of the respondents got the information through the television before the first imported case in the country was recorded in March 2020. Sample characteristics such as; University students (BSc, Master, and Ph.D.) and private-sector workers, actively acquired knowledge of this infectious disease from various television channels, websites, and WhatsApp because of the alarming and global situation of the epidemic. So good sources of communication among Cameroonian residents in pandemic situations like this are the television, social media followed by mouth to mouth communication by those who don’t have access to these technologies. Cases of COVID 19 as with other diseases are broadly classified as suspected, probable, and confirmed cases [ 7 ]. Also, clinical symptoms vary from mild to moderate other than severe in old people with comorbidities [ 11 ]. Assessing the symptoms of COVID 19 (suspected cases) is a preliminary step in the diagnosis and management of this disease. This study showed that 41/1006 respondents had ≥ 3 symptoms (Fever, dry cough/catarrh, throat irritation, headache) linked to COVID 19. This estimate is hypothetical as some COVID 19 symptoms are equally clinical signs of other diseases like malaria and respiratory tract infections (bronchitis) [ 12 ]. Respondents experiencing ≥ 3 symptoms must seek medical help since the differential diagnosis of malaria or respiratory infections and COVID 19 is slim. Also, there are no significant differences in KAP between those having symptoms and those without symptoms. This warrants further investigation to assess the effectiveness of the measures put in place to curb the spread of the disease given the continuous increase in the number of cases and the overall high KAP score.

Also, hypertension was more prevalent in respondents > 30 years old with P-value <0.001. Arif et al [ 13 ] showed that hypertension is linked to old age with an overall prevalence of hypertension of 41.9% (95% CI: 37.2–46.6) in a total of 418 residents in Ethiopia ≥ 50 years old. Overall 23 respondents having ≥4 symptoms had underlying comorbidities and 10 of them had other diseases with symptoms similar to COVID 19 in our study. This could be potentially dangerous for these patients given that, previous studies on coronavirus death rates have also been shockingly higher in pre-existing comorbidity such as cardiovascular disease, Diabetes, Hypertension, Chronic respiratory disease, Cancer [ 14 , 15 ]. Of all the respondents,168 (18.1%) out of 262 of those with symptoms did not frequently or habitually experience such symptoms. Among the 168 respondents, those presenting with ≥ 3 symptoms were considered as suspected cases.

The presence of ≥ 3 symptoms in 4% (56% of them with co-morbidities) of the population surveyed supports the current trend in the number of confirmed cases (8681) in Cameroon. Thus widespread testing in the community is relevant because <22% of people with COVID 19 symptoms seek help. Given that 32(78.05%) of respondents who had more than 3 symptoms and did not call 1510 , won’t be able to manage their conditions appropriately without the counsel of medical personnel they will further contribute to the spread of the disease. The hesitance to call was attributed to fear of getting contaminated, stigmatization if they are COVID 19 positive and misdiagnosis. Having symptoms and also comorbidities is high risk and not seeking help at the hospital and resorting to traditional concoctions with no standard dosage and auto-medications is much riskier. This calls for more sensitization and discrete ways of managing cases.

Recommendations

COVID 19 outbreak has put the whole world under panic and in our context stigma. People’s attitudes and practices could stem from panic and stigma or the knowledge provided to them. One way to avoid this could be to create a confidential online system to share COVID 19 experiences and consult online which is one of the objectives of our study. A better approach would have been to use more sophisticated software technics like qualtrics (which we didn’t have in our settings) to geolocalize suspected cases and circumscribe a particular neighborhood for rapid and prompt intervention. Also, telecommunication industries could engage in sending daily consultation messages to the population on COVID 19 symptoms which could serve as baseline data for health personnel. The effectiveness of the prevention measures of COVID 19 still needs to be well established (total confinement being the best option) reason being that there is an increase in the number of cases regardless of a high KAP score observed in our study. Our study opens more doors for scholars who could use the same research design to collect data in similar situations; and learning from what is happening in Cameroon could be useful for comparative studies on COVID 19 experiences of other African countries. Women should be the primary target audience for behavior change initiatives by program managers on the management and understanding of COVID 19 disease. This behavior change initiative is of paramount importance to preclude negative attitudes of not going to the hospital (or calling 1510) when sick and encourage positive preventive and therapeutic practices, for fear of a rapid rise in mortality rate due to auto medications and traditional concoctions.

Limitations of the study

Due to limited access to the internet and online information resources, populations in remote areas were not interviewed since the disease is most prevalent in the cities.KAP studies for people at the grass-root level in Cameroon are needed to assess their preparedness towards the COVID-19 pandemic. The second limitation is the limited sample representativeness used to assess suspected cases, comorbidities, and the unstandardized assessment of attitudes towards health-seeking behavior, which should be developed via focus group discussion and in-depth interview accompanied by confirmatory tests. Thirdly, a KAP is a quantitative tool and that to focus on behavior change qualitative work would be necessary. Finally a poststratification analysis was not feasible in our study reason being that the latest census in Cameroon was carried out in 2005.

Supporting information

S1 appendix. survey questionnaire..

https://doi.org/10.1371/journal.pntd.0008700.s001

S1 Table. City of residence of respondents.

https://doi.org/10.1371/journal.pntd.0008700.s002

Acknowledgments

The authors express their profound gratitude to all Cameroonian respondents for their immense collaboration and all those who made the online transmission of the questionnaire possible.

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ORIGINAL RESEARCH article

Awareness and preparedness of covid-19 outbreak among healthcare workers and other residents of south-west saudi arabia: a cross-sectional survey.

• 1 Department of Clinical Pharmacy, Pharmacy Practice Research Unit (PPRU), College of Pharmacy, Jazan University, Jazan, Saudi Arabia
• 2 Department of Pharmacology, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
• 3 Department of Pharmaceutical Chemistry, College of Pharmacy, Jazan University, Jazan, Saudi Arabia

Background: Coronavirus disease-2019 (COVID-19) was declared a “pandemic” by the World Health Organization (WHO) in early March 2020. Globally, extraordinary measures are being adopted to combat the formidable spread of the ongoing outbreak. Under such conditions, people's adherence to preventive measures is greatly affected by their awareness of the disease.

Aim: This study was aimed to assess the level of awareness and preparedness to fight against COVID-19 among the healthcare workers (HCWs) and other residents of the South-West Saudi Arabia.

Methods: A community-based, cross-sectional survey was conducted using a self-developed structured questionnaire that was randomly distributed online among HCWs and other residents (age ≥ 12 years) of South-West Saudi Arabia for feedback. The collected data were analyzed using Stata 15 statistical software.

Results: Among 1,000 participants, 36.7% were HCWs, 53.9% were female, and 44.1% were aged ≥ 30 years. Majority of respondents showed awareness of COVID-19 (98.7%) as a deadly, contagious, and life-threatening disease (99.6%) that is transmitted through human-to-human contact (97.7%). They were familiar with the associated symptoms and common causes of COVID-19. Health organizations were chosen as the most reliable source of information by majority of the participants (89.6%). Hand hygiene (92.7%) and social distancing (92.3%) were the most common preventive measures taken by respondents that were followed by avoiding traveling (86.9%) to an infected area or country and wearing face masks (86.5%). Significant proportions of HCWs ( P < 0.05) and more educated participants ( P < 0.05) showed considerable knowledge of the disease, and all respondents displayed good preparedness for the prevention and control of COVID-19. Age, gender, and area were non-significant predictors of COVID-19 awareness.

Conclusion: As the global threat of COVID-19 continues to emerge, it is critical to improve the awareness and preparedness of the targeted community members, especially the less educated ones. Educational interventions are urgently needed to reach the targeted residents beyond borders and further measures are warranted. The outcome of this study highlighted a growing need for the adoption of innovative local strategies to improve awareness in general population related to COVID-19 and its preventative practices in order to meet its elimination goals.

Introduction

An ongoing outbreak of infection by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), termed as COVID-19, aroused the attention of the entire world. The first infected case of coronavirus was reported on December 31, 2019, in Wuhan, China; within few weeks, infections spread across China and to other countries around the world ( 1 ). On January 30, 2020, the World Health Organization (WHO) declared the novel coronavirus outbreak a public health emergency of international concern, which was the 6th declaration of its kind in WHO history ( 2 , 3 ). Surprisingly, during the first week of March 2020, devastating numbers of new cases were reported globally, and the WHO declared the COVID-19 outbreak a “pandemic” on March 11 ( 4 , 5 ). The outbreak has now spread to more than 200 countries, areas, or territories beyond China ( 6 ). SARS-CoV-2 is a novel strain of the coronavirus family that has not been previously identified in humans ( 7 ). The disease spreads through person-to-person contact, and the posed potential public health threat is very high. Estimates indicated that COVID-19 could cost the world more than $10 trillion, although considerable uncertainty exists concerning the reach of the virus and the efficacy of the policy response ( 8 ).

The scientists still have limited information about COVID-19, and as a result, the complete clinical picture of COVID-19 is not fully understood yet. Based on currently available information, COVID-19 is a highly contagious disease and its primary clinical symptoms include fever, dry cough, difficulty in breathing, fatigue, myalgia and dyspnea ( 9 – 11 ). This coronavirus spreads primarily through respiratory droplets of >5–10 μm in diameter, discharge from the mouth or nose, when an infected person coughs or sneezes ( 12 , 13 ). Reported illnesses range from very mild (including asymptomatic) to severe including illness resulting to death. However, the information so far suggested the symptoms as mild in almost 80% of the patients with lower death rates. People with co-morbidities, including diabetes and hypertension, who are treated with the drugs such as thiazolidinediones, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin-II receptor blockers (ARBs) have an increased expression of angiotensin-converting enzyme-2 (ACE-2). Since, SARS-CoV-2 binds to their target cells through ACE-2, it was suggested that patients with cardiac disease, hypertension, and diabetes are at the higher risk of developing severe to fatal COVID-19 ( 14 , 15 ). Moreover, elderly people (≥65 years), those and people with chronic lung disease or moderate to severe asthma, who are immunocompromised (due to cancer treatment, bone marrow or organ transplant, AIDS, and prolonged use of corticosteroids or other medications), and those people with severe obesity and chronic liver or kidney disease are at higher risk of developing the COVID-19 severe illness ( 16 – 18 ).

Although, no specific vaccine or treatment is approved for COVID-19, yet several treatment regimens prescribed under different conditions are reported to control the severity and mortality rates up to some extent with few adverse effects, though further evidence is needed ( 19 ). Recently, results of ongoing trials aiming at drug repurposing for the disease have been reported, and several drugs have shown encouraging activity as far as reducing the viral load or the duration of therapy is concerned. Remdesivir is one such antiviral drug, and it has reduced the duration of therapy to 11 days in comparison to 15 days in the case of patients receiving standard care only. Therefore, the USFDA has granted the emergency use authorization (EUA) to Remdesivir for the treatment of suspected or confirmed COVID-19 cases ( 20 , 21 ); however, further investigations are required to collect the sufficient data ( 22 ). Favipiravir (Avigan) is another drug that has exhibited promising activity in significantly reducing the viral load in comparison to standard care in several trials ( 23 ). Apart from antiviral drugs, convalescent plasma for COVID-19 (as passive antibody therapy) has also been tested, proving to be of possible benefit in severely ill COVID-19 patients. However, it requires more clinical trials to be established for the optimal conditions of COVID-19 and as antibody therapy in this disease ( 24 – 26 ). Mono, and Sarilumab which are immunosuppressants and are humanized antibodies against the interleukin-6 receptor, were also tested on severely ill patients of COVID-19. They effectively improved the clinical symptoms and suppressed the worsening of acute COVID-19 patients and reduced the mortality rate ( 27 , 28 ). Very recently, a corticosteroid, Dexamethasone, has been reported to be a life-saving drug that reduced the incidences of deaths by one-third among patients critically ill with COVID-19 ( 29 ) requiring oxygen support.

So far, more than 9 million confirmed cases of COVID- 19 infections have been identified globally with more than 0.46 million confirmed deaths (as on June 21, 2020). Saudi Arabia has also been seriously affected by the COVID-19 pandemic and reported its first confirmed case on March 3, 2020. The numbers are continuously increasing and reached 157,612 on June 21, 2020, with 1,267 confirmed deaths all over the kingdom ( 30 , 31 ) having reproduction number from 2.87 to 4.9 ( 32 ). Before the emergence of COVID-19, Middle East Respiratory Syndrome-coronavirus (MERS-CoV) was the major concern in 2012 ( 33 ), though it was successfully controlled in Saudi Arabia. In response to the growing public health threat posed by COVID-19, the Saudi government adopted some unprecedented measures related to awareness and prevention in order to control COVID-19 transmission in the country. These measures included the closure of schools, universities, public transportation, and all public places as well as the isolation and care for infected and suspected cases ( 34 ). On March 9, 2020, government authorities announced the lockdown of the whole country and released advice for Saudi nationals and residents present inside or outside of country to stay at home and maintain social distancing. Moreover, the Saudi government decided to suspend congregational prayers across all mosques in the kingdom, including the two holy mosques in Makkah and Madinah ( 35 ).

The fight against COVID-19 continues globally, and to guarantee success, people's adherence to preventive measures is essential. It is mostly affected by their awareness and preparedness toward COVID-19. Knowledge and attitudes toward infectious diseases are often associated with the level of panic among the population, which could further complicate the measures taken to prevent the spread of the disease. As “natural hazards are inevitable; the disaster is not,” ( 36 ) to facilitate the management of the COVID-19 outbreak in Saudi Arabia, there is an urgent need to understand the public's awareness and preparedness for COVID-19 during this challenging time. The present study assessed the awareness and preparedness toward COVID-19 among South Western Saudi residents during the early rapid rise of the COVID-19 outbreak. It included HCWs (doctors, nurses, and community pharmacists) and other members of the community, including the employed, unemployed, as well as students.

Subjects and Methods

Setting and population.

A cross-sectional survey was conducted between March 18 and March 25—the week immediately after the announcement of lockdown in Saudi Arabia. For this study, two highly populated regions (Jazan and Aseer) of South-West Saudi Arabia and adjacent rural villages were selected. All Saudi citizens and residents, males and females of age 12 years or more (including HCWs and other community peoples), who were willing to participate in the study irrespective of COVID-19 infection status were included in the study. People who did not meet the above inclusion criteria were not eligible and were thus excluded from the study.

Sample Size

The required sample size for this study was calculated using a Denial equation ( 37 ) where the significance level (alpha) was set to 0.05 and power (1-β) was set to 0.80. It resulted in a required final sample size of 384 individuals. Therefore, to minimize the errors, the sample size taken for this study was 1,000.

Outcome Measures

The present study examined the level of awareness and preparedness toward prevention of COVID-19 using area, gender, age, education level, and occupation as explanatory variables among the residents (HCWs and other community peoples) of South-West Saudi Arabia.

Since this is a novel coronavirus with no such study having been conducted before, a standardized (structured, pre-coded, and validated) questionnaire was developed for this study by our co-authors, and it is based on frequently asked questions (FAQ) found on Centers for Disease Control (CDC) and WHO official websites ( 38 , 39 ). The questions were multiple choice and sought to gain insight into the respondent's awareness and preparedness toward COVID-19. A pilot survey of 10 individuals was undertaken first to ensure that the questions elicited appropriate response and there were no problems with the entry of answers into the database. Since, it was not feasible to conduct a community-based national sampling survey during this critical period; we decided to collect the data online through a Google survey. The self-reported questionnaire is divided into three sections. The first part is designed to obtain background information, including demographic characteristics (nationality, age, gender, level of educational, and occupation). The second part of the survey consists of questions that address awareness concerning COVID-19 (reliable source of information, symptoms, mode of transmission, incubation period, complications, high-risk population, treatment, and preventive measures). The third part of the survey consists of questions that address the preparedness to fight against COVID-19. The questionnaire is designed in English, being subsequently translated into Arabic for the convenience and ease of understanding of the participants, and it was pre-tested to ensure that it maintained its original meaning.

Data Collection and Analysis

Data were collected using a random sampling method and analyzed using the statistical software Stata 15. For categorical variables, data were presented as frequencies and percentages. A chi-squared (χ 2 ) test was used to examine the association between each item in awareness and explanatory variable in the bivariate analysis. Multivariable logistic regression was computed using each item in awareness and preparedness as an outcome separately to examine the relationships in the adjusted analysis. Differences were considered to be statistically significant at P ≤ 0.05.

Ethical Approval

The study protocol and procedures of informed consent were granted ethical approval by the “Institutional Research Review and Ethics Committee (IRREC), College of Pharmacy, Jazan University” before the formal survey was conducted. Since this study was conducted during the lockdown period, a Google survey was prepared with an online informed consent form on the first page. Participants are informed about the contents of the questionnaire, and they have to answer a yes/no question to confirm their willingness to participate voluntarily. In case of minors (participants below 16 years of age), they are asked to show the form to their parents/guardians before selecting their answer. The patients/participants or their legal guardians have to provide their written informed consent to participate in this study. After an affirmative response of the question, the participant is directed to complete the self-report questionnaire. All responses are anonymous.

Demographic Characteristics

Respondents' demographic descriptions are summarized in Table 1 . A total of 1,000 participants completed the survey questionnaire, the split being 46.1% male and 53.9% female. The majority of participants are from Jazan region (74.8%) compared to 25.2% from Aseer province. More than half (55.9%) of the participants are of <30 years of age, and 44.1% are aged ≥ 30 years. Around 79.5% respondents are university graduates holding a bachelor's degree or higher, whereas 20.5% of participants possess educational qualifications of secondary school or lower (non-graduates). HCWs make up 36.7% of participants, and 63.3% of participants are classified as other.

Table 1 . Socio-demographic characteristics of participants.

Knowledge of COVID-19 Disease and Personal Protection Measures

Table 2 displays respondents' knowledge about COVID-19, reliable sources of information, modes of transmission, symptoms of infection and complications, its perceived threat, and high-risk population. Respondents were allowed to choose more than one option from the choices given according to their understanding and conscience. The results indicated that majority of respondents had heard of and were aware of COVID-19 disease. Most of the participants (97.7%) correctly identified human-to-human transmission (contaminated person with virus) as the primary mode of transmission. Furthermore, fever, cough, and difficulty in breathing were stated as the most common COVID-19 symptoms by 89.8, 83.9, and 90.9% of respondents, respectively. The frequently reported complications of COVID-19 were pneumonia (79.4%), kidney failure (22.8%), and death (54.9%) by the respondents.

Table 2 . Awareness about COVID-19, its symptoms, transmission, and complications.

Participants' knowledge of personal protection against COVID-19 is summarized in Table 3 . The majority of respondents (76.4%) believe that there is no treatment available for COVID-19 to date, 47.1% report supportive care, and 45.8% state personal safety as the only treatment option. The most common personal protection practices adopted by participants are washing hands (92.7%), social distancing (92.3%), using a face mask (86.5%), and avoiding travel to infected areas or countries (86.9%). However, importantly, 63.8% participants believe in avoiding raw and under-cooked animal products, 16.2% choose to avoid purchasing products made in China, and 1.7% have knowledge of proper prevention methods. Approximately, half of the respondents (42.4%) report that they seek more information on COVID-19.

Table 3 . Awareness about personal protection and preparedness against COVID-19.

Preparedness to Fight Against COVID-19

Results of participants' preparedness against COVID-19 are summarized in Table 3 . Over one-third of participants are well-prepared and adopt various methods for the current situation. The majority of participants stat that they avoid crowded places, mass gatherings, or traveling to suspected areas (95.1%), and 82.7% wear face masks when going outside and have increased the use of hand sanitizers and home cleaning materials. Many of them (76.8%) now spend 20 seconds washing their hands using soap multiple times a day. However, it could be assumed from the survey that a considerable percentage of the participants do not find the protective measures necessary, visit crowded places, and do not wear face masks when leaving home.

On the other hand, HCWs also reported their preparedness on different areas to fight against COVID-19 ( Figure 1 ). All 367 (100%) HCWs who participated in this study say that they checked adequate supplies of goggles, masks, and gowns on hand for emergencies, 99.7% say they prepared links or are in contact with External Resource Centers for COVID-19 such as the CDC or WHO, 98% evaluated the patient care equipment, including portable ventilators (preparation and patient handling checklists), and 83.4% checked and prepared alternative suppliers list of certain personal protective equipment etc. Surprisingly, 18.3% of the respondents are unaware of any preparation, and 4.5% do not find it necessary.

Figure 1 . HCWs preparedness to fight against COVID 19. P1, Check adequate supplies of goggles, masks, and gowns on hand for emergencies. P2, Links to or contact External Resource Centers for COVID-19 (Coronavirus) (CDC, WHO etc.). P3, Check patient care equipment, including portable ventilators. P4, Recommendations for infection control to help biomedical and clinical engineers. P5, Check alternative suppliers of certain personal protective equipment. P6, Prepared the list to supply chain professionals. P7, Do not need any preparation. P8, I don't know.

Bivariate Analysis

The comparison between educational groups and occupational groups (HCWs vs. other residents) demonstrated significant differences in the level of knowledge and preventive measures for COVID-19 disease ( Tables 4 , 5 ). The survey shows educated participants (bachelors or more) and HCWs were more aware about COVID-19 symptoms ( P ≤ 0.001), incubation period ( P ≤ 0.001), complications ( P ≤ 0.001), high-risk populations ( P ≤ 0.01), and available treatment ( P ≤ 0.05) compared to less-educated (≤high school) ones and other residents (non HCWs). Jazan area participants heard about ( P ≤ 0.002), and showed more awareness regarding COVID-19 symptoms (fever: P ≤ 0.001), and available treatment (supportive care: P ≤ 0.001) as compared to the Aseer region. There were no significant differences found in knowledge level between gender (male vs. female) and age groups.

Table 4 . Awareness of COVID-19 stratified by occupation groups among the study participants ( n = 1,000).

Table 5 . Awareness of COVID-19 stratified by educational groups among the study participants ( n = 1,000).

Significant differences were observed in awareness about protective measures between educational groups and occupational groups ( Tables 4 , 5 ). The survey shows that the educated participants (Bachelors or more) and HCWs consider the use of face masks, frequent washing of hands, social distancing, and avoid traveling to an infected area or country as preventive measures, more so than their counter group ( P < 0.05). However, gender, age, and area comparisons on these measures were non-significant. Moreover, the survey exhibited no significant differences regarding preparedness to fight against COVID-19 level between areas, age, gender, and educational and occupational groups.

Multivariable Logistic Regressions

It was found that HCWs were more likely to be aware of COVID-19 symptoms (fever: OR = 2.15, P = 0.008; cough: OR = 1.66, P = 0.018 etc.), complications (pneumonia: OR = 2.37, P = 0.001; kidney failure: OR = 1.54, P = 0.013 etc.), populations at high risk, available treatment, and preventive measures compared to the other community members who were non-HCWs. On the other hand, less-educated participants (≤secondary schooling) were more likely to have knowledge about COVID-19 symptoms (fever: OR = 4.24, P = 0.014; breathing difficulty: OR = 2.94, P = 0.043 etc.), high-risk population (OR = 3.29, P = 0.001), complications, and preventive measures (social distancing: OR = 2.08, P = 0.008; avoid traveling to infected area or country: OR = 2.01, P = 0.002 etc.) compared to the higher-educated participants, as shown in Tables 6 , 7 . Tables displayed outcomes with statistically significant association only with explanatory variable. Area (Jazan vs. Aseer), gender (male vs. female), and age group (age <30 years vs. ≥30 years) were not associated significantly with COVID-19 knowledge. Surprisingly, no difference was reported for preparedness to fight against COVID-19 among participants.

Table 6 . Multivariable logistic regression on factors significantly associated with awareness toward COVID-19.

Table 7 . Multivariable logistic regression analysis on factors significantly associated with preventive measures toward COVID-19.

As the outbreak of COVID-19 is expanding exponentially, spreading beyond borders and spreading across continents, it has been classified as a “pandemic.” It created havoc and dismay among all nations. This new viral infection is successful in inducing restlessness, confusion, and fear among the people. The uniqueness of this infection is that it shows little or no symptoms in the beginning, and many do not even know they are infected. It does not induce any severe change or indication in the infected person so that he can seek medical attention at an early stage. By the time infected persons realize that they are infected, they might have spread the disease to a large number of people without their knowledge and any ulterior motives. Therefore, the first and foremost strategy to win the battle over COVID-19 shall be stopping the spread of disease effectively among the people. Hence, the main focus of this research was to assess the awareness of people, particularly among HCWs as well as other residents, about the disease, how they prepared themselves to fight against it, and whether they are participating in the eradication of the infection or not. We are aware that COVID-19 had taken the nation by surprise when they were least prepared to face the pandemic. To the best of our knowledge, this is the first study of its kind, conducted in Saudi Arabia that is assessing the awareness and preparedness toward COVID-19 among HCWs and other residents.

Our survey of HCWs and other residents of the study region was well-received. People of different educational backgrounds and employments participated in the survey. The majority of them are graduates, followed by people who had education up to high school. Similarly, among different employment backgrounds, HCWs make up more than one-third of the sample size. In the first place, HCWs and graduates should be aware of the disease profile, so that they can quickly spread the message among their family members, their neighbors, and all those who are within their contact. Analysis of the study results showed that both HCWs and the graduates possess adequate knowledge about the infection. It was a significant finding of our study that they can not only protect themselves against the disease but also help others to stay away from the infection by creating awareness for it. As the results suggested, health organizations (89.6%) and healthcare professionals (57.9%) are able to communicate effectively to the participants in convincing and making them understand the patterns and phases of the infection. This study also revealed that some people showed little trust in social media and other sources of communications such as television, newspaper, posters, etc. They were not convinced or accepting of the facts disseminated to them initially. It is probably for this reason that few people showed reluctance in following the guidelines given through these channels and kept ignoring them. This lack of acceptance might have accelerated the spread of this disease among the public.

Our study revealed that HCWs and people with a higher educational background (graduation or more) were more aware of the symptoms and the complications of COVID-19. It is spread via human-to-human transmission through droplet, feco-oral, and direct contact and has an incubation period of 2–14 days ( 13 ). The majority of the participants (97.7%) mentioned human-to-human contact as the primary cause of COVID-19 transmission. They were aware that the infection is related to the respiratory system, and there could be some difficulties in breathing with high temperatures accompanied by dry cough. Furthermore, it might lead to pneumonia, organ failure, and death. Indeed, COVID-19 induces these symptoms after the log period ( 40 ), although in some cases. Also, HCWs keenly follow the situation in the regions and the countries regarding the number of cases of infected and fresh cases reported daily. It perhaps helps them in getting prepared physically to manage the situation by acquiring the important things that are required in combating the disease, and it might also help them to get prepared mentally. They were aware of the social distancing, hand hygiene, using face masks, and avoiding traveling. These are the desired activities, which are expected to be practiced strictly in order to stop the spread of the disease ( 41 – 44 ). Our study revealed that HCWs and educated residents were following it meticulously. It was also known to them that no specific and effective treatment is available for COVID-19 to date, and whatever therapy is available at the designated centers is non-specific and treats only symptoms. They are sufficient enough to relieve the symptoms of the infection, to overcome difficulties in breathing, and to boost the immunity of the individuals. A similar level of awareness was reported in recent studies in China ( 10 ) and the UAE ( 45 ). This may be attributed to continuous practice of raising awareness about COVID-19 in communities about health issues by healthcare organizations and Saudi health extension workers, which has been effectively implemented in recent days ( 46 ).

Previously, MERS-CoV was a major global concern after it was first identified in 2012 in Saudi Arabia ( 33 ). Many awareness studies reported different levels of knowledge about MERS disease among Saudi HCWs and residents after the MERS outbreak ( 47 – 49 ). Present findings showed that the awareness regarding COVID-19 disease was higher compared to MERS. This can be ascribed to the global reach of COVID-19, as it is more serious than MERS owing to its high rate of transmission, alarming number of cases, and the continued global death count.

As far as preparedness to fight against COVID-19 is concerned, our study showed that all the participants were aware of avoiding mass gathering, avoiding traveling to suspected areas, the use of face masks and hand sanitizers, and maintaining proper food hygiene. During the lockdown period, the majority of the people who participated in our study stockpiled sufficient food items, and the frequency of going out to buy groceries and other food items can thus be avoided. According to them, a large number of people at supermarkets do not practice appropriate social distancing, and chances of contracting the infection might increase. This is genuinely desirable and precautionary in a situation like COVID-19, as coming closer to or violating social distancing is risky. Perhaps this preparedness is a reflection of steps taken by government authorities, as Saudi Arabia can control the spread of COVID-19 in South-West region. When the whole world is struggling to control COVID-19 spreading, Saudi Arabia has reported 1,155 positive cases (as of June 21, 2020) in Jazan and Aseer region (313 and 842, respectively) among 157,612 positive cases the entire country ( 50 ).

Also, our study confirmed that nearly half of the participants were ready to visit the hospital immediately if needed. The WHO recommends that identification of the infected individual is the first and essential step required in combating COVID-19. It also advises nations to allow citizens to get tested and put them in quarantine if they are infected. It is a significant step, as nearly 50% of the people are aware of the importance of testing in suspected cases but the remaining 50% of the participants are not. Doubts or fears about quarantine can make the public hide behind closed doors. This behavior of theirs could be dangerous, as it not only puts them in a difficult situation, but is risks their entire family and neighbors. Surprisingly, nearly 42.4% of the participants have asked for more information about COVID-19 so that they can take sufficient precautions and prepare themselves to avoid contracting the disease. These are the participants who had fewer opportunities to access healthcare services. They indeed need more information on COVID-19 to stay away from the deadly disease. This is the substantial finding of our study: nearly half of the participants did not have detailed information or a desire to gain more knowledge about the disease. The focus of the administrators should be on this category of people—the common man—so that they too can prepare themselves to fight the disease. Overall, the reported preparedness could be because the healthcare authorities have already initiated awareness and preparedness activities beyond their own borders. Every country around the world is being encouraged to draft a preparedness plan as per the WHO's global guidelines: “The ‘COVID-19' Strategic Preparedness and Response Plan” (SPRP). The SPRP outlines the public health measures that are needed to be taken to support countries to prepare for and respond to COVID-19 ( 51 , 52 ).

It was observed that the educational background plays a significant role in understanding the infection quickly. This survey showed that HCWs and people with higher education have a better understanding of the disease than their counterparts. Even though all the groups showed almost identical knowledge about the primary information of the disease, in some areas, such as disease complications, high-risk populations, personal protection measures, and treatment availability, a clear distinction exists. For example, only 68.78% of the less educated showed awareness of the high risk of contracting the infection of older people.

The WHO have initiated several online training sessions and materials on COVID-19 in various languages to strengthen preventive strategies, including raising awareness and training HCWs in preparedness activities ( 53 ). In several instances, misunderstandings among HCWs have delayed controlling efforts to provide necessary treatment ( 44 ), which led to the rapid spread of infection in hospitals ( 33 , 49 ) and putting patients' lives at risk. The present study also analyzed the preparedness of HCWs to fight against COVID-19 and found all participated HCWs were well prepared and ready for the current outbreak.

All participating HCWs report that they have adequate supplies of personal protective equipment's (PPEs), such as goggles, masks, and gowns, to manage emergencies, 99.72% of HCWs depend on an external resource center like CDC and WHO for the required emergency materials, and 98% HCWs say that they have already checked their hospitals equipped with patient care equipment, including portable ventilators. Surprisingly, few respondents (18.26%) say they were unaware of any preparation, and very few (4.36%) say that there is no need for any preparation. In general, our study indicated that the HCWs have well equipped themselves to fight against COVID-19. Although, hospitals and HCWs are fully geared up to face the pandemic situation, the best national option available is to spread awareness in order to stop the spread of disease. We have no other way but to educate our fellow citizens to not indulge in any activities that could lead them being a part of the problem. Instead, they should be encouraged to be the part of the solution.

The WHO has published guidance for public health and social measures at the workplace within the context of COVID-19. This included the standards for all workplaces and specific criteria for workplaces and jobs at medium risk and high risk. The guidance suggested to adapt the essential preventive measures for all workplaces, including practicing hand hygiene, respiratory hygiene, physical distancing (avoid direct physical contact by hugging, touching, or shaking hands), reducing and otherwise managing work-related travel, regular environmental cleaning and disinfection, risk communication, training and education, and management of people with COVID-19 or their contacts. In addition, specific measures for workplaces and jobs at medium risk included frequent cleaning and disinfection of objects and surfaces that are touched regularly (fomites). In such places where physical distancing of 1 meter cannot be maintained for a particular activity, all mitigating actions possible should be taken to reduce the risk of transmission between workers, clients or customers, contractors, and visitors, and these include staggered activities, minimizing face-to-face and skin-to-skin contact, ensuring workers work side-by-side or facing away from each other rather than face-to-face, and assigning staff to the same shift teams to limit social interaction. Along with that, such workplaces must be well-ventilated with a natural air of artificial ventilation without re-circulation of air for high-risk work activities and jobs. The WHO have advised that we find possibilities to suspend operations or adhere to the hygiene measures before and after contact with or suspicion of COVID-19. In such cases, workers must comply with the use of medical masks, disposable gowns, gloves, and eye protection for workers and use of protective equipment when in contact with COVID-19 patients, their respiratory secretions, body fluids, and highly contaminated waste. HCWs must be trained in infection prevention and control practices and use of PPEs to handle such situations ( 54 , 55 ).

The knowledge and awareness of the disease are important parameters for the adoption of protective measures that minimize the exposure risk of the illness. Our findings suggest that residents who are less educated and who are non-healthcare professionals possess less knowledge of COVID-19 disease and preventive measures than their counterparts. Therefore, health promotion and awareness programs are warranted to address these particular sections of the population. Thus, COVID-19 awareness programs and other educating strategies should be developed and implemented more effectively to eradicate this disease and increase the breadth of knowledge of rurally and minimally educated populations. These findings are useful for public health policymakers and health workers to recognize target populations for COVID-19 prevention and health education.

The strength of the study lies in its large sample size, recruited during a crucial period—the early stage of the COVID-19 outbreak in Saudi Arabia. Nevertheless, this was an online self-reported survey conducted during lockdown due to pandemic, and this affected our outreach to the general population. Our sample was obviously over-representative of well-educated people, including healthcare workers, and those who have access to computers and the internet. Hence it may not truly represent the entire population of the study region. Therefore, the generalization of the findings may suffer from reporting bias.

The present study sheds light on the current level of awareness regarding COVID 19, including knowledge, preventative practices, and preparedness in the South-West region of Saudi Arabia, which is still struggling to achieve its target of total COVID-19 eradication. The results of this survey indicated that the majority of respondents were aware of the knowledge, preventive measures and well prepared to fight against COVID-19. It was evident that the community's overall COVID-19 awareness and their preparedness among educated and HCWs populations were fairly satisfactory. However, there were few misconceptions regarding the mode of COVID-19 transmission among the participants, which need to be addressed. Knowledge and preparedness do translate into improved practices toward COVID-19 prevention and the same was reflected in this study. In order to achieve complete control over COVID-19, it would also be worthwhile to invest in various COVID-19 prevention efforts, including health education and innovative strategies based on local evidences to raise the community's awareness and to improve its preventative practices.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author Contributions

RT and PT: conceptualization, methodology, writing of the original draft, investigation, project administration, and final editing. SSA and AA: supervision, co-project administration, data collection, feedback, and making substantive changes. AM: software, validation, and formal analysis. SA: visualization and investigation. WA and DB: data collection and calculations, writing, reviewing, editing of the manuscript, and formal analysis. FA: preparation of Google form and Arabic translation. All authors participated in the distribution of the survey.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We wish to acknowledge Deanship of Scientific Research, Jazan University, Jazan, Saudi Arabia, for their continuous support throughout the study.

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Keywords: COVID-19, coronavirus, outbreak, awareness, preparedness, healthcare, residents, questionnaire

Citation: Tripathi R, Alqahtani SS, Albarraq AA, Meraya AM, Tripathi P, Banji D, Alshahrani S, Ahsan W and Alnakhli FM (2020) Awareness and Preparedness of COVID-19 Outbreak Among Healthcare Workers and Other Residents of South-West Saudi Arabia: A Cross-Sectional Survey. Front. Public Health 8:482. doi: 10.3389/fpubh.2020.00482

Received: 15 May 2020; Accepted: 28 July 2020; Published: 18 August 2020.

Reviewed by:

Copyright © 2020 Tripathi, Alqahtani, Albarraq, Meraya, Tripathi, Banji, Alshahrani, Ahsan and Alnakhli. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Pankaj Tripathi, pankaj10pcol@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• Published: 16 June 2020

COVID-19 impact on research, lessons learned from COVID-19 research, implications for pediatric research

• Debra L. Weiner 1 , 2 ,
• Vivek Balasubramaniam 3 ,
• Shetal I. Shah 4 &
• Joyce R. Javier 5 , 6

on behalf of the Pediatric Policy Council

Pediatric Research volume  88 ,  pages 148–150 ( 2020 ) Cite this article

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The COVID-19 pandemic has resulted in unprecedented research worldwide. The impact on research in progress at the time of the pandemic, the importance and challenges of real-time pandemic research, and the importance of a pediatrician-scientist workforce are all highlighted by this epic pandemic. As we navigate through and beyond this pandemic, which will have a long-lasting impact on our world, including research and the biomedical research enterprise, it is important to recognize and address opportunities and strategies for, and challenges of research and strengthening the pediatrician-scientist workforce.

The first cases of what is now recognized as SARS-CoV-2 infection, termed COVID-19, were reported in Wuhan, China in December 2019 as cases of fatal pneumonia. By February 26, 2020, COVID-19 had been reported on all continents except Antarctica. As of May 4, 2020, 3.53 million cases and 248,169 deaths have been reported from 210 countries. 1

Impact of COVID-19 on ongoing research

The impact on research in progress prior to COVID-19 was rapid, dramatic, and no doubt will be long term. The pandemic curtailed most academic, industry, and government basic science and clinical research, or redirected research to COVID-19. Most clinical trials, except those testing life-saving therapies, have been paused, and most continuing trials are now closed to new enrollment. Ongoing clinical trials have been modified to enable home administration of treatment and virtual monitoring to minimize participant risk of COVID-19 infection, and to avoid diverting healthcare resources from pandemic response. In addition to short- and long-term patient impact, these research disruptions threaten the careers of physician-scientists, many of whom have had to shift efforts from research to patient care. To protect research in progress, as well as physician-scientist careers and the research workforce, ongoing support is critical. NIH ( https://grants.nih.gov/policy/natural-disasters/corona-virus.htm ), PCORI ( https://www.pcori.org/funding-opportunities/applicant-and-awardee-faqs-related-covid-19 ), and other funders acted swiftly to provide guidance on proposal submission and award management, and implement allowances that enable grant personnel to be paid and time lines to be relaxed. Research institutions have also implemented strategies to mitigate the long-term impact of research disruptions. Support throughout and beyond the pandemic to retain currently well-trained research personnel and research support teams, and to accommodate loss of research assets, including laboratory supplies and study participants, will be required to complete disrupted research and ultimately enable new research.

In the long term, it is likely that the pandemic will force reallocation of research dollars at the expense of research areas funded prior to the pandemic. It will be more important than ever for the pediatric research community to engage in discussion and decisions regarding prioritization of funding goals for dedicated pediatric research and meaningful inclusion of children in studies. The recently released 2020 National Institute of Child Health and Development (NICHD) strategic plan that engaged stakeholders, including scientists and patients, to shape the goals of the Institute, will require modification to best chart a path toward restoring normalcy within pediatric science.

COVID-19 research

This global pandemic once again highlights the importance of research, stable research infrastructure, and funding for public health emergency (PHE)/disaster preparedness, response, and resiliency. The stakes in this worldwide pandemic have never been higher as lives are lost, economies falter, and life has radically changed. Ultimate COVID-19 mitigation and crisis resolution is dependent on high-quality research aligned with top priority societal goals that yields trustworthy data and actionable information. While the highest priority goals are treatment and prevention, biomedical research also provides data critical to manage and restore economic and social welfare.

Scientific and technological knowledge and resources have never been greater and have been leveraged globally to perform COVID-19 research at warp speed. The number of studies related to COVID-19 increases daily, the scope and magnitude of engagement is stunning, and the extent of global collaboration unprecedented. On January 5, 2020, just weeks after the first cases of illness were reported, the genetic sequence, which identified the pathogen as a novel coronavirus, SARS-CoV-2, was released, providing information essential for identifying and developing treatments, vaccines, and diagnostics. As of May 3, 2020 1133 COVID-19 studies, including 148 related to hydroxychloroquine, 13 to remdesivir, 50 to vaccines, and 100 to diagnostic testing, were registered on ClinicalTrials.gov, and 980 different studies on the World Health Organization’s International Clinical Trials Registry Platform (WHO ICTRP), made possible, at least in part, by use of data libraries to inform development of antivirals, immunomodulators, antibody-based biologics, and vaccines. On April 7, 2020, the FDA launched the Coronavirus Treatment Acceleration Program (CTAP) ( https://www.fda.gov/drugs/coronavirus-covid-19-drugs/coronavirus-treatment-acceleration-program-ctap ). On April 17, 2020, NIH announced a partnership with industry to expedite vaccine development ( https://www.nih.gov/news-events/news-releases/nih-launch-public-private-partnership-speed-covid-19-vaccine-treatment-options ). As of May 1, 2020, remdesivir (Gilead), granted FDA emergency use authorization, is the only approved therapeutic for COVID-19. 2

The pandemic has intensified research challenges. In a rush for data already thousands of manuscripts, news reports, and blogs have been published, but to date, there is limited scientifically robust data. Some studies do not meet published clinical trial standards, which now include FDA’s COVID-19-specific standards, 3 , 4 , 5 and/or are published without peer review. Misinformation from studies diverts resources from development and testing of more promising therapeutic candidates and has endangered lives. Ibuprofen, initially reported as unsafe for patients with COVID-19, resulted in a shortage of acetaminophen, endangering individuals for whom ibuprofen is contraindicated. Hydroxychloroquine initially reported as potentially effective for treatment of COVID-19 resulted in shortages for patients with autoimmune diseases. Remdesivir, in rigorous trials, showed decrease in duration of COVID-19, with greater effect given early. 6 Given the limited availability and safety data, the use outside clinical trials is currently approved only for severe disease. Vaccines typically take 10–15 years to develop. As of May 3, 2020, of nearly 100 vaccines in development, 8 are in trial. Several vaccines are projected to have emergency approval within 12–18 months, possibly as early as the end of the year, 7 still an eternity for this pandemic, yet too soon for long-term effectiveness and safety data. Antibody testing, necessary for diagnosis, therapeutics, and vaccine testing, has presented some of the greatest research challenges, including validation, timing, availability and prioritization of testing, interpretation of test results, and appropriate patient and societal actions based on results. 8 Relaxing physical distancing without data regarding test validity, duration, and strength of immunity to different strains of COVID-19 could have catastrophic results. Understanding population differences and disparities, which have been further exposed during this pandemic, is critical for response and long-term pandemic recovery. The “Equitable Data Collection and Disclosure on COVID-19 Act” calls for the CDC (Centers for Disease Control and Prevention) and other HHS (United States Department of Health & Human Services) agencies to publicly release racial and demographic information ( https://bass.house.gov/sites/bass.house.gov/files/Equitable%20Data%20Collection%20and%20Dislosure%20on%20COVID19%20Act_FINAL.pdf )

Trusted sources of up-to-date, easily accessible information must be identified (e.g., WHO https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov , CDC https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html , and for children AAP (American Academy of Pediatrics) https://www.aappublications.org/cc/covid-19 ) and should comment on quality of data and provide strategies and crisis standards to guide clinical practice.

Long-term, lessons learned from research during this pandemic could benefit the research enterprise worldwide beyond the pandemic and during other PHE/disasters with strategies for balancing multiple novel approaches and high-quality, time-efficient, cost-effective research. This challenge, at least in part, can be met by appropriate study design, collaboration, patient registries, automated data collection, artificial intelligence, data sharing, and ongoing consideration of appropriate regulatory approval processes. In addition, research to develop and evaluate innovative strategies and technologies to improve access to care, management of health and disease, and quality, safety, and cost effectiveness of care could revolutionize healthcare and healthcare systems. During PHE/disasters, crisis standards for research should be considered along with ongoing and just-in-time PHE/disaster training for researchers willing to share information that could be leveraged at time of crisis. A dedicated funded core workforce of PHE/disaster researchers and funded infrastructure should be considered, potentially as a consortium of networks, that includes physician-scientists, basic scientists, social scientists, mental health providers, global health experts, epidemiologists, public health experts, engineers, information technology experts, economists and educators to strategize, consult, review, monitor, interpret studies, guide appropriate clinical use of data, and inform decisions regarding effective use of resources for PHE/disaster research.

Differences between adult and pediatric COVID-19, the need for pediatric research

As reported by the CDC, from February 12 to April 2, 2020, of 149,760 cases of confirmed COVID-19 in the United States, 2572 (1.7%) were children aged <18 years, similar to published rates in China. 9 Severe illness has been rare. Of 749 children for whom hospitalization data is available, 147 (20%) required hospitalization (5.7% of total children), and 15 of 147 required ICU care (2.0%, 0.58% of total). Of the 95 children aged <1 year, 59 (62%) were hospitalized, and 5 (5.3%) required ICU admission. Among children there were three deaths. Despite children being relatively spared by COVID-19, spread of disease by children, and consequences for their health and pediatric healthcare are potentially profound with immediate and long-term impact on all of society.

We have long been aware of the importance and value of pediatric research on children, and society. COVID-19 is no exception and highlights the imperative need for a pediatrician-scientist workforce. Understanding differences in epidemiology, susceptibility, manifestations, and treatment of COVID-19 in children can provide insights into this pathogen, pathogen–host interactions, pathophysiology, and host response for the entire population. Pediatric clinical registries of COVID-infected, COVID-exposed children can provide data and specimens for immediate and long-term research. Of the 1133 COVID-19 studies on ClinicalTrials.gov, 202 include children aged ≤17 years. Sixty-one of the 681 interventional trials include children. With less diagnostic testing and less pediatric research, we not only endanger children, but also adults by not identifying infected children and limiting spread by children.

Pediatric considerations and challenges related to treatment and vaccine research for COVID-19 include appropriate dosing, pediatric formulation, and pediatric specific short- and long-term effectiveness and safety. Typically, initial clinical trials exclude children until safety has been established in adults. But with time of the essence, deferring pediatric research risks the health of children, particularly those with special needs. Considerations specific to pregnant women, fetuses, and neonates must also be addressed. Childhood mental health in this demographic, already struggling with a mental health pandemic prior to COVID-19, is now further challenged by social disruption, food and housing insecurity, loss of loved ones, isolation from friends and family, and exposure to an infodemic of pandemic-related information. Interestingly, at present mental health visits along with all visits to pediatric emergency departments across the United States are dramatically decreased. Understanding factors that mitigate and worsen psychiatric symptoms should be a focus of research, and ideally will result in strategies for prevention and management in the long term, including beyond this pandemic. Social well-being of children must also be studied. Experts note that the pandemic is a perfect storm for child maltreatment given that vulnerable families are now socially isolated, facing unemployment, and stressed, and that children are not under the watch of mandated reporters in schools, daycare, and primary care. 10 Many states have observed a decrease in child abuse reports and an increase in severity of emergency department abuse cases. In the short term and long term, it will be important to study the impact of access to care, missed care, and disrupted education during COVID-19 on physical and cognitive development.

Training and supporting pediatrician-scientists, such as through NIH physician-scientist research training and career development programs ( https://researchtraining.nih.gov/infographics/physician-scientist ) at all stages of career, as well as fostering research for fellows, residents, and medical students willing to dedicate their research career to, or at least understand implications of their research for, PHE/disasters is important for having an ongoing, as well as a just-in-time surge pediatric-focused PHE/disaster workforce. In addition to including pediatric experts in collaborations and consortiums with broader population focus, consideration should be given to pediatric-focused multi-institutional, academic, industry, and/or government consortiums with infrastructure and ongoing funding for virtual training programs, research teams, and multidisciplinary oversight.

The impact of the COVID-19 pandemic on research and research in response to the pandemic once again highlights the importance of research, challenges of research particularly during PHE/disasters, and opportunities and resources for making research more efficient and cost effective. New paradigms and models for research will hopefully emerge from this pandemic. The importance of building sustained PHE/disaster research infrastructure and a research workforce that includes training and funding for pediatrician-scientists and integrates the pediatrician research workforce into high-quality research across demographics, supports the pediatrician-scientist workforce and pipeline, and benefits society.

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Department of Pediatrics, Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA

Debra L. Weiner

Harvard Medical School, Boston, MA, USA

Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

Vivek Balasubramaniam

Department of Pediatrics and Division of Neonatology, Maria Fareri Children’s Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, USA

Shetal I. Shah

Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA

Joyce R. Javier

Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

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All authors made substantial contributions to conception and design, data acquisition and interpretation, drafting the manuscript, and providing critical revisions. All authors approve this final version of the manuscript.

Pediatric Policy Council

Scott C. Denne, MD, Chair, Pediatric Policy Council; Mona Patel, MD, Representative to the PPC from the Academic Pediatric Association; Jean L. Raphael, MD, MPH, Representative to the PPC from the Academic Pediatric Association; Jonathan Davis, MD, Representative to the PPC from the American Pediatric Society; DeWayne Pursley, MD, MPH, Representative to the PPC from the American Pediatric Society; Tina Cheng, MD, MPH, Representative to the PPC from the Association of Medical School Pediatric Department Chairs; Michael Artman, MD, Representative to the PPC from the Association of Medical School Pediatric Department Chairs; Shetal Shah, MD, Representative to the PPC from the Society for Pediatric Research; Joyce Javier, MD, MPH, MS, Representative to the PPC from the Society for Pediatric Research.

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Correspondence to Debra L. Weiner .

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Weiner, D.L., Balasubramaniam, V., Shah, S.I. et al. COVID-19 impact on research, lessons learned from COVID-19 research, implications for pediatric research. Pediatr Res 88 , 148–150 (2020). https://doi.org/10.1038/s41390-020-1006-3

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• Published: 18 April 2021

Improving knowledge, attitudes and practice to prevent COVID-19 transmission in healthcare workers and the public in Thailand

• Rapeephan R. Maude 1 , 2 ,
• Monnaphat Jongdeepaisal 2 ,
• Sumawadee Skuntaniyom 1 ,
• Thanomvong Muntajit 1 ,
• Stuart D. Blacksell 2 , 3 ,
• Worarat Khuenpetch 2 ,
• Wirichada Pan-Ngum 2 , 3 ,
• Keetakarn Taleangkaphan 2 ,
• Kumtorn Malathum 1 &
• Richard James Maude 2 , 3 , 4 , 5  

BMC Public Health volume  21 , Article number:  749 ( 2021 ) Cite this article

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Key infection prevention and control measures to limit transmission of COVID-19 include social distancing, hand hygiene, use of facemasks and personal protective equipment. However, these have limited or no impact if not applied correctly through lack of knowledge, inappropriate attitude or incorrect practice. In order to maximise the impact of infection prevention and control measures on COVID-19 spread, we undertook a study to assess and improve knowledge, attitudes and practice among 119 healthcare workers and 100 general public in Thailand. The study setting was two inpatient hospitals providing COVID-19 testing and treatment. Detailed information on knowledge, attitudes and practice among the general public and healthcare workers regarding COVID-19 transmission and its prevention were obtained from a combination of questionnaires and observations.

Knowledge of the main transmission routes, commonest symptoms and recommended prevention methods was mostly very high (> 80%) in both groups. There was lower awareness of aerosols, food and drink and pets as sources of transmission; of the correct duration for handwashing; recommended distance for social/physical distancing; and about recommended types of face coverings. Information sources most used and most trusted were the workplace, work colleagues, health workers and television. The results were used to produce a set of targeted educational videos which addressed many of these gaps with subsequent improvements on retesting in a number of areas. This included improvements in handwashing practice with an increase in the number of areas correctly washed in 65.5% of the public, and 57.9% of healthcare workers. The videos were then further optimized with feedback from participants followed by another round of retesting.

Conclusions

Detailed information on gaps in knowledge, attitudes and practice among the general public and healthcare workers regarding COVID-19 transmission and its prevention were obtained from a combination of questionnaires and observations. This was used to produce targeted educational videos which addressed these gaps with subsequent improvements on retesting. The resulting videos were then disseminated as a resource to aid in efforts to fight COVID-19 in Thailand and worldwide.

Peer Review reports

Introduction

COVID-19 is an emerging infectious disease caused by the SARS-CoV-2 virus, first discovered in the city of Wuhan, Hubei, China in December 2019 [ 1 ]. It spread to Thailand which reported the first case outside of China in January 2020 and then rapidly infected people around the world. On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic and it has since infected over 90 million people and caused 2 million deaths.

During the first wave of COVID-19 in Thailand, the government introduced a range of stringent measures to control spread including venue closures, travel restrictions, point of entry screening, quarantine, contract tracing and widespread infection prevention and control measures. These actions were very effective with Thailand suffering relatively few cases up until mid-December 2020 when a larger second wave occurred [ 2 ].

Key infection prevention and control measures for COVID-19 include social distancing, hand hygiene, use of facemasks [ 3 ] and personal protective equipment [ 4 ]. However, they have limited or no impact if not applied correctly through lack of knowledge, inappropriate attitudes or incorrect practice.

There have been a wide variety of studies to evaluate knowledge, attitudes and practice (KAP) for COVID-19 among healthcare workers and the general public [ 5 , 6 , 7 , 8 , 9 ]. The responses to such surveys vary widely between locations and subpopulations and a range of different scoring methods have been used. Studies have mostly focused on identifying which demographic and other variables are associated with different levels of KAP. Many have enrolled a single group of health professionals, sociodemographic/ethnic/occupational group, people with a specific chronic illness or from a single geographic location. This limits the generalizability of the findings. The few larger KAP studies covering multiple countries have included a broad range of questions. A study in 23 countries in mid-2020 found a good level of knowledge in 17.5% of participants, with this varying by country from 4.5 to 32.5% [ 7 ].

There have been few assessments of KAP focusing on the key infection prevention and control measures listed above. They have generally found levels of knowledge among healthcare workers and the public to be high and a lower proportion had good practice. For example, a study among healthcare workers in Bangladesh found 99.5% had good knowledge about PPE but only 51.7% had good practice with inadequate supply and lack of training cited by many as reasons for suboptimal practice [ 5 ]. In Nigeria, 83.7% of healthcare workers had good knowledge and 77.6% good practice towards COVID-19 prevention with good knowledge being associated with good practice [ 9 ]. Among the public, a study on COVID-19 prevention measures in Viet Nam found 92.2% to have a high knowledge level, 68.6% a positive attitude and 75.8% practiced all 6 measures to prevent virus spread with higher knowledge being associated with increased likelihood of practicing prevention measures [ 8 ]. In the public in Cameroon, 84.2% scored highly for knowledge, 69% for attitude and 60.8% for practice [ 10 ]. Evidence for educational interventions designed to improve KAP for personal protection against COVID-19 is lacking.

In order to maximise the impact of infection prevention and control measures on COVID-19 spread we undertook an intervention study to assess and improve knowledge, attitudes and practice among healthcare workers (HCW) and the general public in Thailand through educational videos.

Members of the public (‘public’) and HCW were enrolled in July to August 2020 in Ramathibodi Hospital (a 1400 bed medical school hospital), and Somdech Phra Deparatana Medical Center (a 350 bed medical centre with a range of specilalist services), both in Bangkok, Thailand. Both study sites provide care for suspected and confirmed COVID-19. Enrolment criteria for public were any adult patient or patient attendant visiting the hospital for an outpatient visit for any reason. HCW were any hospital staff coming into contact with possible or confirmed cases of COVID-19. Both groups were deemed at potential risk of contracting COVID-19 in a healthcare setting. All participants provided written, informed consent prior to participation.

All participants completed a baseline questionnaire between 15th July and 30th August 2020 to assess their knowledge and attitudes about COVID-19, in particular about handwashing and use of facemasks. The questionnaire was based on the World Health Organization (WHO) COVID Behaviour Survey downloaded on 15th May 2020 and translated into Thai language. This has since been updated by the WHO and is published online [ 11 ]. Attitudes were scored on a scale of 1 (least) to 7 (most). They were also observed by experienced infection control nurses whilst using masks and washing their hands using liquid soap and water. Mask usage was assessed by observing participants putting on a surgical mask. Participants were then visited later during the same working day to observe mask removal, and determine whether and how they kept the mask for later reuse. Hand washing was assessed by covering the hands with a fluorescent dye-containing powder and then washing the hands with soap and water followed by examination under an ultraviolet light [ 6 , 12 ]. To quantify hand washing effectiveness, a diagram of each hand split into 17 pre-defined areas was completed for each participant to mark any areas not covered by dye. The number of areas incompletely covered out of 34 was then counted. This method was adapted from one published previously [ 13 ].

Video development

Using information from an interim analysis of the baseline data, a set of educational videos was produced in Thai language. This was supplemented by information from a different study conducting in-depth interviews of HCW which will be published separately. These were split into three topics to fill gaps in knowledge identified in the data: hand washing, correct use of facemasks and correct use of personal protective equipment (PPE). The videos were produced in an official audio/visual studio at Ramathibodi hospital.

First follow-up

The same participants as at baseline viewed the videos and provided immediate feedback and suggestions on how to improve them, including technical considerations such as sound and graphics, clarifications and suggestions for additional or redundant content. They also completed the same questionnaire and observation of handwashing as at baseline to identify any changes in knowledge, attitudes or practice. The reassessment was conducted from 1 to 3 days after viewing the videos from 23rd to 30th November 2020. At that time there had been almost no local transmission of COVID for around 6 months.

Second follow-up

A final version of the videos was produced incorporating further interim analysis and the feedback, following which they were disseminated to HCW and the general public through social media, websites and display screens. A third questionnaire was administered to the same participants 1–3 days after viewing these final videos from 1st to 5th December 2020. The third questionnaire was administered to identify any changes in KAP over time, including those from viewing the final set of changes to the videos. This was done so the impact of the final disseminated version of the videos could be studied.

Data collection, statistical analysis and ethical approval

Data were collected on paper case record forms and entered into a secure online database. Statistical analysis was done using Microsoft Excel 2019 (Redmond, WA, USA) and GraphPad Prism version 9 (San Diego, CA, USA). Medians for items rated on a Likert scale of 1 to 7 were compared using the Wilcoxon matched pairs signed rank test. Before and after binary questionnaire results were compared using the Binomial test. The significance level was 5%. Sample size was estimated as a minimum of 100 required to be enrolled in each group (public and HCW) to have sufficient power for a binary question to detect an increase in correct responses of 8 (10%) in each group allowing for an increase of incorrect responses of 1 (1.3%) and assuming a 20% loss to follow-up.

Ethical approval was obtained from Ramathibodi Hospital Ethical Committee. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

One hundred public and 119 HCW were enrolled in the study (Table  1 ). Median age of public was 39 years with 74.0% female and median age of HCW was 37 years with 86.6% female. Occupations are shown in Table  2 with administrative and professional being the most common for public, while nurses and laboratory workers for HCW. None of either group had had confirmed COVID-19 infection, although 2.5% of HCW said they had had suspected COVID-19 infection that was not confirmed. Median household size was 3.5 for public and 3 for HCW, with 60.0% of public and 40.3% of HCW saying they lived with groups at increased risk from COVID-19. No-one reported living with or near to someone with confirmed COVID-19, although 1% of public and 6.7% of HCW reported living in the proximity of suspected COVID-19 cases.

Eighty seven public (87%) and 100 (84%) HCW completed a questionnaire after viewing the first set of videos and 88 (88%) public and 104 (87.4%) HCW after the final set of videos. At the second follow-up visit, following feedback from participants at the first follow-up, and because of the short time interval between follow-ups, questions on attitude were not included in the questionnaire to minimize respondent fatigue. Statistical results for comparison between baseline and follow-up are presented in Table S1 .

Responses to the questions about general knowledge of COVID-19 are shown in Fig.  1 . Overall level of knowledge was very high and similar among public and HCW with almost 100% knowing about droplet transmission and over 80% being aware of fever, cough, anosmia and sore throat as known symptoms. Among potential routes of transmission, awareness of pets was lowest followed by food and drink and aerosols. Awareness of surfaces as a possible source of COVID-19 increased after viewing the videos. Awareness of some symptoms was initially lower among the public but for diarrhoea and headache improved in both groups after viewing the videos. Awareness of muscle pain and nasal congestion improved among the public. Most people were not aware of any treatment or vaccines against COVID.

Knowledge about COVID-19 transmission sources ( a ), symptoms ( b ) and existence of treatment or vaccination for COVID-19 ( c ) before (1) and after (2) the first videos and after the final videos (3). HCW = healthcare worker, PBC = public. P values are shown for significant differences

Nearly 100% of public and HCW were aware of not touching eyes/nose/mouth, covering the nose and mouth when coughing or sneezing, wearing masks, self-isolation, physical/social distancing, handwashing, disinfecting mobile phones and surfaces as measures to prevent COVID-19 transmission (Fig.  2 a). Around half cited caution when opening letters and below 40% cited various other measures. Of different types of face coverings, awareness was highest of efficacy for N95 or equivalent respirators and medical/surgical masks (Fig. 2 b). More than 80% knew to change their mask daily and this increased after viewing the videos in both groups. A smaller proportion knew to wash their hands for 20 s, although lower for HCW, but this also improved substantially after the videos. The majority of both groups correctly identified washing hands with soap and water or cleansing with alcohol gel as effective, the latter increasing after videos. More than 50% correctly identified 1-2 m as the correct social distancing recommendation and this also increased after the videos.

Knowledge about which COVID-19 prevention measures ( a ) and which types of mask, hand hygiene and social/physical distancing ( b ) are effective to prevent transmission of COVID-19. Results are shown for before (1) and after (2) the first videos and after the final videos (3). HCW = healthcare worker, PBC = public. P values are shown for significant differences

Sources of information

Figure  3 shows where people said they obtained knowledge about preventing COVID-19. For both HCW and the public, the most commonly stated sources (> 80%) were their employer or workplace, conversations with friends and family, television, conversations with work colleagues, consultation with healthcare workers and Facebook. Twenty one percent of public and 23.5% of HCW said they had seen unclear or conflicting information. Examples included from the public concerned availability of PPE, to what degree face shields are protective and how many days people should remain in quarantine. HCW cited use of medical vs cloth masks, the amount of infection, what social distance is safe and about the need for detention of different groups of people entering the country. Facebook, Line message, television, Twitter, newspapers and conversations were among the list of sources of this unclear/conflicting information.

Sources of information about COVID-19 prevention stated by the public and healthcare workers (HCW) before (1) and after (2) the first set of videos. P values are shown for proportions before and after videos

The most trusted sources of information among the public were healthcare workers, their employer, work colleagues and WHO and government websites and television (Fig.  4 ). Among HCW, the most trusted sources were healthcare workers, their employer, work colleagues, the WHO website, television and scientific journals.

Trust in different sources of information about COVID-19 prevention assessed on a 7-point Likert scale before (1) and after (2) the first set of videos for the public and healthcare workers (HCW). Medians and interquartile ranges are shown

The main sources of information did not change after viewing the first set of videos. The proportions of HCW and public saying they had seen unclear or conflicting information also did not change ( p  = 0.12 and 1.00, respectively). Among HCW, there were increases in the proportions using YouTube (52.9 to 77.0%), Twitter (32.8 to 54.0%), scientific journals (32.8 to 55.0%), WhatsApp (7.6 to 31.0%) and healthcare workers (82.4 to 94.0%) as sources of information and decreases in the proportions using government press releases and other websites. Among the public, the proportion using government (46.0 to 59.8%) and other websites (11.0 to 17.2%) increased. There were no major changes in the level of trust in different sources of information after viewing the first set of videos (Fig. 4 ).

Attitudes were scored on a scale of 1 (least) to 7 (most) (Fig.  5 ). 95.0% of HCW and 92.0% of public scored their knowledge of preventing spread of COVID-19 as 5, 6 or 7. 96.6% of HCW and 86.0% of PBC scored themselves 5, 6 or 7 for knowing how to protect themselves from COVID-19 infection. 95.8% of HCW and 93% of public scored themselves 5, 6 or 7 for following recommendations in their country to prevent spread. Rating their ease of avoiding becoming infected with COVID-19, 41.2% of HCW and 43.0% of public scored this 5, 6 or 7 and for likelihood of becoming infected 41.2% for HCW and 18.0% of public scored 5 to 7. Severity if they were infected with COVID-19 was rated at 5, 6 or 7 by 56.3% of HCW and 54% of public.

Attitudes on a Likert scale of 1 (least) to 7 (most) before (1) and after (2) viewing the first set of videos. HCW = healthcare worker, PBC = public. P values are shown for comparison of before and after video viewing

Following viewing of the videos, there was a significant increase in scores among HCW of the likelihood of them contracting COVID-19 with those rating themselves 6 or 7 out of 7 increasing from 15.1 to 32.0% ( p  = 0.033). There was a decrease in scores for anticipated severity of COVID-19 among the public those scoring themselves 6 or 7 decreasing from 40.0 to 26.4% ( p  = 0.030). There were no other differences in attitudes between baseline and follow-up.

Amongst the public, 27.0%, and amongst HCW, 15.1%, said they had not washed their hands when it was necessary because of not having the right materials or facilities available. For masks, 14.0% of public and 4.2% of HCW said they had not worn a mask at some time when necessary as they did not have one with them.

Figure  6 shows the stated practices of people to prevent COVID-19 transmission, as compared to their knowledge in Fig.  3 . Overall the patterns of proportions of people with particular practices were similar to those for knowledge, however for many of the most widely used measures, the proportions were lower for practice, particularly among HCW. In particular, use of N95 respirators by HCW was noticeably lower than awareness with 58% saying they used them but 91.6% saying they are effective ( p  < 0.0001) at baseline.

Stated practices for COVID-19 prevention measures ( a ) and which types of mask, hand hygiene and social/physical distancing ( b ) are used by participants to prevent transmission of COVID-19. Results are shown for before (1) and after (2) the first videos and after the final videos (3). HCW = healthcare worker, PBC = public. P values are shown for significant differences

When observed for correct wearing of a surgical mask, 100% of both public and HCW did so correctly with the mask covering both nose and mouth and the metal strip molded around the nose. When observed for correct handwashing practice, 35.2% of public and 40.0% of HCW correctly cleaned all areas of both hands (Fig.  7 ). The areas most poorly covered were the backs of the fingers of both hands with 45.4% of public and 55.0% of HCW washing these areas correctly (Fig.  8 ).

Proportion of healthcare workers (HCW) and public (PBC) who correctly washed their hands by count of areas out of 34, before (1) and after (2) watching the first set of videos

Proportion of healthcare workers ( a ) and public ( b ) who correctly washed each area of the hands before (1) and after (2) watching the first set of videos

The proportions of public and HCW who did not wash their hands or wear a mask when necessary because of unavailability did not change after watching the videos.

On observation of mask wearing practice after watching the videos, 100% of both public and HCW continued to wear medical masks correctly.

On observation of handwashing practice there was an increase in the number of areas correctly washed in 65.5% of public with median (IQR) increase 4 (2–6), p  = 0.0050, and 57.9% of HCW with median increase 2 (1–4), p  = 0.0034 (Fig. 7 ). The proportion of people correctly washing each area of the hands also increased (Fig. 8 ) for public ( p  < 0.0001) and for HCW ( p  = 0.0002).

Feedback on videos

Overall, participant feedback was very positive with mostly minor changes to the videos being suggested. Examples included people asking to add how to keep masks during the day, whether and how often to reuse masks, more details about handwashing steps and how to put on and take off PPE correctly to prevent self contamination.

Dissemination

The final videos were disseminated via YouTube ( https://www.youtube.com/channel/UCkwebkw5bnEVaq4Ra0qmtaw ), Facebook, Line and organizational websites, as well as displayed in residential and commercial premises. Work is ongoing to produce versions with subtitles in different languages.

This study used questionnaires and direct observation of practice on HCW as well as the general public to assess the knowledge, attitudes and practice regarding preventing COVID-19 transmission and its prevention during the pandemic in Thailand. It identified knowledge gaps, inappropriate attitudes and suboptimal practices to target for improvement in health education programmes. In this study, they were addressed by developing and disseminating a set of educational videos focused on handwashing and mask wearing. Following participant feedback, these videos were optimized and a requested additional video on personal protective equipment for healthcare workers was added. The videos were then disseminated for viewing by the general public and healthcare professionals.

There have been many studies to evaluate knowledge, attitudes and practice (KAP) for COVID-19 [ 5 , 6 , 7 , 8 , 9 ]. Most of these were voluntary online surveys without a follow-up assessment or an intervention. The results of the surveys vary greatly between settings and use different methods of measurement thus making them difficult to compare and combine. Most previous KAP studies for COVID-19 have been done in either the general public or healthcare workers. This study included both groups which allowed direct comparison between them. It also recruited participants by approaching them individually, thus reducing bias that may be encountered in passive voluntary recruitment in online studies [ 14 ].

The study was able to demonstrate improvements in KAP after watching the videos. Although there was no control arm, many of the items which improved were specifically covered in the videos so it is likely that at least some of the improvement was because of watching them. This was borne out by participant’s comments. The development of the videos was deliberately done collaboratively with participants to maximise impact. Developing the video content based on identified gaps from the questionnaires, observations of practice and in-depth interviews ensured its relevance to the audience. Optimisation of the content based on user feedback helped to improve the clarity and understandability. Repeating the questionnaires and observations after viewing different iterations allowed assessment of impact by identifying specific improvements in KAP.

This approach had the advantage that all participants were able to provide anonymous feedback thus maximizing the range of viewpoints obtained. However, it only provided space for brief comments without opportunity for more detailed exploration of issues. An alternative could be to use one or more focus groups [ 15 ]. This has the potential for more in-depth discussion and candid responses among a small group of participants. However, the quality is highly dependent on the moderator, participants are generally self-selected and the process can be hijacked by outspoken individuals [ 16 ].

There have been previous intervention studies to improve KAP for other diseases similar to COVID-19. For SARS, telephone health education was able to improve knowledge of transmission routes and reduce anxiety among older adults in Hong Kong [ 17 ]. For MERS CoV in Saudi Arabi, knowledge and attitudes improved, but not practice among healthcare workers after a relatively intense educational intervention of presentations, brainstorming, interactive discussion and a short video [ 18 ]. Although effective, these methods have challenges of high resource requirements and limited scalability. This study used publicly available videos which can be rapidly and widely disseminated for maximum impact during a pandemic. The use of YouTube as the dissemination platform ensured it could be accessed through multiple types of devices at a time convenient for the audience, including mobile phones, tables, computers and smart TVs. It also made it possible for people to freely share it with others and for organisations to easily display the videos in their premises, thus widening the audience.

The method used in this study for developing the educational videos follows the principles of human centred design (HCD), namely empathy with the target communities, rapid prototyping, gathering of feedback and response iteration [ 19 ]. The process of multiple cycles of feedback from the target audience and rapid iteration in response the that feedback has been successfully applied elsewhere. This helps the audience identify with the content and ensures it meets their needs and wants [ 19 ]. After viewing the first version of the video on handwashing, some healthcare workers fed back that there should be more emphasis on washing all parts of the hands. This was from their own learnt experience having been formally trained in this. We were then able to expand this section of the video to cover this to the satisfaction of users in later feedback. HCD also includes a tolerance for failure during the design process [ 19 ]. An example from this study is that in the first video on mask wearing, the video development team did not account for the shortage of masks experienced by some participants and recommended they be disposed of after each use, as per the guidelines at the time. The participant feedback highlighted this and this led to the inclusion in the later videos of a section on how to keep a mask between uses.

The survey responses found a range of knowledge gaps, only some of which improved after watching the videos. There was low awareness of pets, food/drink and aerosols as sources of COVID-19 transmission. Although sparse, the evidence for these accumulated over the study period. Awareness was lowest for pets for which there was also the least evidence with only isolated case reports of infection in cats and dogs, as well as some wild animals: minks, tigers and lions [ 20 , 21 , 22 ]. The awareness of surfaces as sources of transmission increased with viewing the videos. There was a high level of awareness of the maximum incubation period of 14 days, perhaps because this had been well covered in both Thai and international media. There was also increasing awareness of the range of symptoms especially diarrhea, headache, muscle and body pain of which awareness was initially low. Awareness of fever, cough,  and anosmia was very high throughout. These three symptoms had also been highlihigh throughout. Theseghted in the popular media and government advice. Low proportions of both groups were aware of COVID-19 drug treatments or vaccinations and this did not increase during the study period. At the time of the study, there was ongoing research into both but no clear evidence of efficacy and there was little discussion of these in the national media in Thailand. Low awareness among HCW may be because they were not exposed to the ongoing research, there being no doctors included in the study. This was explored in more detail in a separate study conducting in-depth interviews among HCW.

Almost all participants correctly identified the major recommended measures to prevent COVID-19 transmission consistent with national and international guidelines. A minority identified homeopathy, herbal medicine, eating garlic/ginger/lemon and antibiotic use as effective. These measures have no evidence of clinical efficacy and are not recommended against COVID-19. For homeopathy, herbal medicine and garlic/ginger/lemon, there was an increase in the proportion believing them to be effective during the course of the study. These topics were not covered in the videos but in hindsight it may have been helpful to do so. Flu vaccine was identified as protective by an increasing proportion of both groups. Although not directly protective against COVID-19, it has been recommended to protect against coinfection with flu during the COVID-19 pandemic [ 23 , 24 ]. Caution about opening letters was identified by around half of participants; although there is no evidence for this, there was some coverage of this with fake news in the national media.

Most people correctly identified facemasks should be changed daily and this increased after watching the videos, which specifically mentioned this. Most people thought N95 respirators and medical masks were protective but less than half thought other types of masks are effective. Few people thought a cloth over the face was protective. The evidence for the relative efficacy of different types of masks against COVID-19 is weak but N95 respirators and medical masks are known to prevent transmission of other respiratory viruses and bacteria [ 25 , 26 ], N95 respirators are recommended for aerosolizing procedures and medical masks for general use. The recommendations for cloth or other types of masks are generally for where medical masks are not available [ 27 , 28 , 29 ].

Only a minority of both groups were aware of the recommended handwashing duration of 20 s [ 30 ]. There was a large increase in these proportions after watching the videos where this topic was specifically addressed. There was also an increase in the proportions of both groups who correctly identified the recommended distance for social/physical distancing, which was also in the videos [ 31 ].

The majority of people listed their employer, work colleagues and television as sources of information about COVID, more than official sources such as the government or WHO. Healthcare workers and employers were the most trusted sources. A range of social media was cited as sources but trust in these varied between different platforms with Facebook and Line being the most used and most trusted. Because of this, we chose to use both these platforms to promote our YouTube videos at the end of the project. Use of scientific journals, Twitter, YouTube and WhatsApp by healthcare workers and government websites by the general public decreased over time, perhaps because of information saturation or fatigue. The level of trust in sources generally did not change after watching the videos, although this was not included as a video topic.

Both groups rated themselves highly for level of knowledge about COVID-19 protection and spread with no change after watching the videos. However, there were many examples of improvement in knowledge from the questionnaires and observations so it is curious that people were not aware of this improvement.

There was a clear improvement of handwashing technique after watching the videos in both groups. This was covered in detail in the handwashing video and feedback was good on this particular component. Previous studies have shown video to be an effective medium for improving handwashing [ 32 ].

This study had a number of limitations. The sample size was relatively small, thus potentially limiting the representativeness. The study had to be completed quickly as the videos were needed for education and training. As data collection was done by busy healthcare staff alongside their day jobs, and during a pandemic with requirements for protective measures, the design deliberately prioritised collecting detailed responses from a fewer people over less information from larger numbers. This both minimized the number of patient-staff encounters and provided detailed and specific information on items of KAP that could be improved. Staff were encouraged to choose participants at random with broad entry criteria and there was a good range of occupations and age groups, although an excess of females. Between 12 and 16% did not return to complete a follow-up questionnaire after viewing the videos. This is despite the best efforts of the study staff with people taking leave from work, moving jobs or house and/or being unwilling or unable to return to the hospital. No doctors were included among the healthcare workers. A previous study in Bangladesh found doctors to have similar knowledge but a more positive attitude and poorer practice regarding PPE than other healthcare workers [ 5 ]. In Nigeria, doctors had better knowledge than other healthcare workers which was associated with better preventive practice [ 9 ]. Other than through participant feedback, it was not possible to clearly separate changes in KAP due to viewing the videos from those that occur for other reasons e.g. exposure to other information sources.

The study was conducted in two inpatient facilities which provide diagnostic and treatment services for COVID-19 in Bangkok. The populations attending these facilities may differ from other healthcare facilities in Thailand and from the general public outside of hospital. Being attached to a medical school and providing regular training for healthcare staff and the general public, it is likely that KAP among these groups would be better than in other locations. A much larger study would be needed to investigate this. An online questionnaire study in Bangladesh [ 33 ] found more accurate knowledge and positive attitudes with increasing age, education level, family income, and urban area residence. Among healthcare workers in a tertiary hospital in Nepal [ 34 ] appropriate practice correlated with better knowledge and a positive attitude towards COVID-19 infection was seen with increasing age.

Both the title and aims of this study included improving KAP through educational videos. From the improvements seen in this study, this appears to have been achieved. However, the first two assessments of KAP were done 3–4 months apart so it is likely that participants also learnt from other sources of information during this period. That some of the scores improved in the third assessment which was only a few days after the second suggests at least some impact from the videos. Additional evidence for people having learnt from the videos was the feedback obtained during the viewing.

The study also had strengths. The information collected from each participant was detailed and gave a nuanced understanding of areas needing improvement. The questionnaire was based on a detailed template from WHO adapted for the local context. The addition of observed practices by infection control expert nurses added another layer of evidence as well as visualising fluorescent powder on the hands of participants with standardized recording in 17 different areas. The comments and responses to the questionnaires and the observed practice on handwashing and mask wearing were used dynamically to improve the second set of videos to address the gaps in knowledge, attitude and practice.

The videos produced were quickly disseminated in Thailand by a variety of routes including the most popular social media channels. This coincided with the beginning of the second wave of transmission in the country. Being in Thai language, the videos have the major advantage of being easily accessed and understood by most of the population. With minor modifications of text, and replacement of subtitles and/or voiceovers they can also be easily adapted to other languages for use in other countries in the region and across the globe.

Detailed information on gaps in knowledge, attitudes and practice among the general public and healthcare workers regarding COVID-19 transmission and its prevention in Thailand were obtained from a combination of questionnaires and observations. This was used to produce targeted educational videos which addressed these gaps with subsequent improvements on retesting. The resulting videos were then disseminated as a resource to aid in efforts to fight COVID-19 in Thailand and worldwide.

Availability of data and materials

The data that support the findings of this study will be available upon reasonable request to MORU’s Data Access Committee [ [email protected] ].

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Acknowledgements

The authors thank the enrolled staff and members of the public for participating in this study.

The research was funded by a grant from the Thailand Center of Excellence for Life Sciences (TCELS) [Grant Number TC36/63]. This research was funded in whole, or in part, by the Wellcome Trust [Grant number 220211]. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

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RJM, RRM, MJ, SDB and WK conceptualized the study. RRM, MJ, SS, TM and KT collected the data. RJM and RRM wrote the main manuscript text and analysed the data. RJM prepared the figures. RJM, RRM, MJ, SDB, WK, WPN and KM reviewed the videos and the manuscript. The author(s) read and approved the final manuscript.

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Additional file 1 table s1.

. Results of the statistical tests for comparisons between baseline (1) and follow up (2 and 3). P values shown.

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Maude, R.R., Jongdeepaisal, M., Skuntaniyom, S. et al. Improving knowledge, attitudes and practice to prevent COVID-19 transmission in healthcare workers and the public in Thailand. BMC Public Health 21 , 749 (2021). https://doi.org/10.1186/s12889-021-10768-y

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Chinese university students’ intention to study abroad in times of Covid-19: the important role of student background characteristics

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• Tianyu Yang 1 ,
• Wei Bao 2 ,
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• Carla Haelermans 1 , 3  

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The COVID-19 pandemic has affected higher education students in many ways, and it seems to also have influences students’ willingness to study abroad. To date, much is still unclear about the exact effects of COVID-19 on Chinese students’ intentions to study abroad and whether that differs for different types of students. This is problematic, as for students, international study experience is of great importance for their further careers, while for HEIs, the share of foreign students greatly influences their resources. We collected and analyzed survey data from 14,385 Chinese students to examine (1) the unique effects of the COVID-19 pandemic on their intention to study abroad, and (2) the potential differential effects of the pandemic on students with different background characteristics. The results indicate that students from provinces with high COVID-19 pandemic exposure were more inclined to study abroad due to stringent preventive measures and heightened awareness of the virus’s severity. Moreover, the results show that the COVID-19 pandemic has had a greater impact on the intentions to study abroad of high-SES students and students with lower academic achievement than of low-SES and high achieving students. More concretely, due to the pandemic, both student groups were less willing to study abroad than their low-SES and high-achieving counterparts. In terms of student gender, no differential effects were found, suggesting that the COVID-19 pandemic has affected the studying abroad intentions of students of various genders relatively equally.

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Introduction

The COVID-19-pandemic that began in early 2020 disrupted the educational trajectories of students globally. This unprecedented event not only affected students’ academic achievement (Haelermans et al., 2022 ), motivation levels (Smith et al., 2021 ) and emotional and physical well-being (Meinck et al., 2022 ), but also profoundly affected their intentions to study abroad (De Boer, 2021 ). Amid the pandemic, numerous college students postponed or abandoned their plans to study abroad due to travel restrictions and college closures (De Boer, 2021 ). Consequently, higher education institutions (HEIs) in key destination countries such as the United States, the United Kingdom, and Australia experienced significant declines in international student enrollment (James,  2023 ). As international students constitute a substantial proportion of annual tuition fee revenue of HEIs in these nations (Cantwell, 2019 ), many institutions faced bankruptcy during the COVID-19 crisis (Crapo, 2021 ). Furthermore, the pandemic has greatly impacted HEIs’ educational quality and multiculturalism, as international students introduce skills and ideas that foster educational innovation and economic success (Zimmermann et al., 2021 ). As such, a reduced international student presence affects HEIs in several important ways.

However, studying abroad is not only important for the revenue, multiculturalism, and education of the host HEIs, but also for the students themselves. Numerous studies have demonstrated that studying abroad can bolster students’ knowledge of foreign culture and language (Edelstein & Douglass, 2012 ), enhance their intercultural adaptability and sensitivity (Root & Ngampornchai, 2013 ), and foster openness to experience, cooperation, and other interpersonal skills (Edelstein & Douglass, 2012 ). Moreover, studying abroad has been shown to contribute to the development of ‘global citizenship’ (Hunter et al., 2006 ) and democratic values (Spilimbergo, 2009 ) in students. Additionally, a positive correlation has been identified between studying abroad and subsequent labor market outcomes for university students, such as employability and earnings (Messer & Wolter, 2006 ). It is important to acknowledge that students from different regions may have distinct motivations and patterns of mobility. According to Brooks and Waters ( 2011 ), the mobility of East Asian students is primarily driven by the pursuit of prestigious education and the enhancement of career prospects, which is typically influenced by socio-cultural expectations. In contrast, students from mainland Europe pursue mobility predominantly for cultural and academic experiences, reflecting the diverse economic and educational landscapes across the region. Furthermore, UK students, who show lower mobility rates, are inspired by the desire for unique adventures and the prestige associated with global educational institutions. These trends highlight the complex interplay of regional, cultural, and economic factors in influencing the mobility of students from different regions. The present study specifically focuses on the intention of Chinese students to study abroad during the COVID-19 pandemic. China is the world’s largest supplier of international students (Bound et al., 2021 ). Before the COVID-19 outbreak, the number of Chinese students studying abroad had been steadily increasing since 2009. Despite the US-China trade conflict in June 2018, which intensified anti-globalization and nationalism trends in international higher education (Xiong & Mok, 2020 ), the number of Chinese international students grew by 9% in 2018 and by percent in 2019. Moreover, in 2020, Chinese students constituted 53% of all international students in the United States (Mason, 2021 ), 35% in the United Kingdom (HESA, 2020 ), and 38% in Australia (Mason, 2021 ).

Given this significant presence of Chinese students in international student mobility, it is crucial to understand their response to the COVID-19 pandemic in relation to study abroad. This information is valuable to international HEIs. These institutions faced not only a sharp decline in their annual tuition revenue but also the need to modify their study programs due to the sudden and substantial decrease in the number of their international students (Crapo, 2021 ). Considering Chinese students’ intention to study abroad, two important aspects play a role as well. First, concurrent with the COVID-19 pandemic, other critical international events transpired, potentially influencing Chinese students’ intentions to study abroad. For instance, deteriorating relations between China and the United States resulted in Chinese students being barred from participating in US technical study programs (Aaron et al., 2020 ). Additionally, Brexit has caused many international students from European nations to perceive the United Kingdom as less welcoming, due to increased tuition fees and diminished employment opportunities. This development has created greater opportunities for Chinese international students to continue their studies in the UK (Peters et al., 2021 ). Therefore, it is important to study the unique contribution of the COVID-19 pandemic to the intention of Chinese students to study abroad, something which remains unexamined to date.

Another aspect that warrants clarification is whether the COVID-19 pandemic has affected the intention to study abroad of all Chinese students in a similar way. It is already known that the pandemic has exacerbated pre-existing inequalities among students. For example, the pandemic has been found to have had a much stronger impact on the educational achievement of low-socioeconomic status students, low-achieving students, and female students (Haelermans et al., 2022 ; Meinck et al., 2022 ). Regarding students’ intention to study abroad, it is still unknown whether pre-existing inequalities between certain student groups have been magnified as a result. However, this knowledge is crucial, as it will inform targeted support for these groups in future comparative circumstances.

In light of these two aspects, the present study aims to address the following research questions:

How has the COVID-19 pandemic uniquely affected Chinese students’ intention to study abroad, independent of other contemporary international tensions?

To what extent has the COVID-19 pandemic exacerbated pre-existing inequalities related to socioeconomic status (SES), academic achievement, and gender among Chinese students in their intentions to study abroad?

Literature review

The impact of covid-19 on students’ intentions to study abroad.

The COVID-19 pandemic has profoundly reshaped the global landscape of higher education and the dynamics of international student mobility, presented unprecedented challenges and influencing students’ decisions worldwide (James, 2023 ). In the context of China, the pandemic introduced various factors that may have significantly shaped Chinese students’ intentions to pursue educational opportunities abroad. The stringent pandemic measures and social restrictions within China, for example, may have served as catalysts for Chinese students to seek education in countries perceived to have more freedom and superior pandemic management (Lin et al., 2021 ). However, at the same time the COVID-19 pandemic adversely affected students’ ability to engage in international studies. The enforcement of social distancing measures led HEIs across the globe to shift from traditional in-person instruction to online platforms, with some institutions even closing their campuses (Watermeyer et al., 2021 ).

According to a 2020 report by Quacquarelli Symonds (QS), a renowned ranking agency that evaluates university strengths and weaknesses, 60% of university students responding to their annual survey reported that the pandemic led them to postpone or reconsider their plans for enrollment in a foreign university (QS, 2020 ). This trend is notably pronounced among Chinese student; research conducted by Mok et al. ( 2021 ), which analyzed survey data from university students in Mainland China and Hong Kong, discovered that the pandemic had not only significantly reduced the volume of Chinese students pursuing education abroad, but had also redirected their destination preferences towards East Asian regions such as Japan and Taiwan. Additionally, Zhao and Mok ( 2024 ) reported that the pandemic had significantly influenced post-graduation decisions of Chinese elite graduates, with an increased number opting for further education within China, often at the same university where they completed their undergraduate degree. Furthermore, the 2020 survey by the British Council, which included over 10,000 Chinese students, showed that about 24% of respondents were less likely to continue their overseas study plans, 39% remained undecided, with the primary concerns being ‘health and well-being’ (79%) and ‘personal safety’ (87%) (Durnin, 2020 ). Finally, prior research has also highlighted the negative impact of the COVID-19 pandemic on students’ actual decisions to study abroad, offering substantial evidence on the changing patterns of Chinese students’ international mobility, including to countries like the United States (Baer & Martel, 2020 ), the United Kingdom (Yang et al., 2020 ), and Australia (Tan et al., 2021 ).

The impact of the Covid-19 pandemic on intentions for studying abroad of students with different background characteristics

Despite its many benefits, research indicates that students from different backgrounds exhibit different preferences and decisions when it comes to studying abroad (Toncar et al., 2006 ). More concretely, the decision to study abroad has been related to student background characteristics such as SES, academic achievement, and gender. More specifically, high-SES, high-achieving and female students have been found to be more inclined to spend (part of) their studies abroad (Salisbury et al., 2009 ). There are a number of reasons to assume that the COVID-19 pandemic may have further influenced these disparities, by affecting different student groups in distinct ways.

First, SES has been found to play a crucial role in students’ decisions to study abroad, with high-SES students being more likely to participate in these programs (Findlay et al., 2006 ; Salisbury et al., 2009 ; Simon & Ainsworth, 2012 ). Different reasons have been put forward for this finding. For example, the financial burden associated with studying abroad has been found to act as a significant barrier for low-SES students (Simon & Ainsworth, 2012 ). Additionally, low-SES students have been found to lack the social capital and family support necessary to facilitate study abroad opportunities (DeVoretz, 2006 ). Finally, cultural capital, such as knowledge about study abroad programs and application processes, has found to be unequally distributed among students from different socioeconomic backgrounds, with low-SES students facing significant barriers in accessing information about study abroad programs (Ecker-Lyster & Kardash, 2022 ).

There are several reasons to believe that the COVID-19 pandemic has further affected the existing disparities between low- and high-SES students concerning their intentions to study abroad. To commence, financial constraints due to the pandemic have disproportionately limited international education opportunities for students from lower socioeconomic backgrounds (Frechette & Reilly, 2021 ). Furthermore, health and safety concerns may disproportionately impact low-SES students, who often have limited access to healthcare and support systems abroad (Schoon & Henseke, 2022 ). Additionally, the shift to online learning has affected students’ perceptions of study abroad value, with some questioning the need for international travel when educational content is available online (Al-Mawee et al., 2021 ). This may have impacted lower-income students who are more price-sensitive (Savoca, 1990 ). Lastly, the pandemic’s disruption of labour markets and heightened concerns about future employment prospects, may have lead low-SES students to prioritize domestic education and work experience more than high-SES students (Browning et al., 2021 ).

Also, academic achievement has been observed to impact a student’s intention to study abroad. The literature supports this notion, with Pietro and Page ( 2008 ) stating that students with weaker academic backgrounds are less likely to study abroad than high-achieving peers. Given the limited availability of spots, institutions use past achievements for selection procedures. Lorz et al. ( 2016 ) found in a German School Leavers Survey that reduced intentions to study abroad can be partially linked to poorer academic preparation. Furthermore, confidence to be fit to study abroad is influenced by language ability (Findlay et al., 2006 ) and academic learning capacity (Bracht et al., 2006 ), which can deter low-achieving students from pursuing such opportunities.

It is very likely that the COVID-19 pandemic has exacerbated the existing differences in the intentions to study abroad of students with different academic achievement levels. For example, throughout the course of the pandemic, it has been observed that students with lower academic proficiency have encountered greater difficulties adapting to the shift towards online education compared to their high-achieving counterparts, consequently amplifying the disparities in academic achievement between these two groups (Aucejo et al., 2020 ; Engzell et al., 2021 ; Haelermans et al., 2021 ). This widening gap in academic achievement, may have created additional barriers for low-achieving students to study abroad.

Finally, studies have consistently shown that women are more likely to study abroad than men (Cordua & Netz, 2022 ; Salisbury et al., 2010 ). Several factors have been proposed to explain this gender gap. First, women may perceive greater benefits from studying abroad, such as enhanced career prospects and personal growth (Salisbury et al., 2010 ). Second, women may be more likely to choose majors that encourage or require study abroad experiences, such as the humanities or social sciences (Cordua & Netz, 2022 ). Lastly, societal norms and expectations might contribute to this disparity, with women potentially feeling more pressure to expand their horizons and gain international experience (Van Mol, 2022 ).

There are a number of reasons to suspect that during the Covid-19 pandemic, the differences between men and women in their intention to study abroad have diminished. For example, research suggests that the COVID-19 pandemic has affected female students more adversely, as they exhibit higher levels of anxiety and more negative expectations compared to their male peers (Alsharawy et al., 2021 ). This increased anxiety may have hindered their intention to study abroad. Another recent study investigating the potential decrease in income due to COVID-19 identified a marked difference between male and female students, with a higher proportion of female students reporting decreased income (Gewalt et al., 2022 ). This may also have decreased their intention to study abroad.

From the preceding literature review, it is evident that numerous studies have investigated the impact of COVID-19 on students’ intention to study abroad and the influence of these characteristics on their intention to study. However, only a limited number of studies have endeavored to synthesize these aspects and examine the individual-level effects of student characteristics on the intention to study abroad within the context of the COVID-19 pandemic. Understanding the interplay between students’ SES, academic achievement, and gender in shaping their intentions to study abroad is crucial in guiding efforts to promote equal access and inclusive opportunities for students from diverse backgrounds during these unprecedented times.

Data and methodology

Main variables, outcome variable.

In the present study, Chinese students’ intentions to pursue international education, serves as the primary dependent variable of interest. To measure this, we utilize a survey item that inquired about their post-graduation plans. The available response options for this item encompass the following alternatives: “seeking employment within China,” ‘continuing further studies within China,” “engaging in overseas education,” “establishing a business,” and “sustaining current employment.” Subsequently, a binary variable was constructed to classify these responses, assigning a value of “1” to indicate the selection of “engaging in overseas education” and “0” otherwise.

COVID-19 exposure

The COVID-19 exposure variable is operationalized based on the incidence of COVID-19 confirmed cases at the province level, following the methodology employed by Fu et al. ( 2021 ). During the period spanning from mid-January to March 31, 2020, six Chinese provinces (Hubei, Guangdong, Henan, Zhejiang, Hunan, and Anhui) reported the highest numbers of confirmed cases, accounting for 90% of the total COVID-19 cases in mainland China. Subsequently a significant decline in daily new cases was observed from April 2020 onwards. For purposes of this study, the students’ sample is divided into two groups: the treatment group consisting of students from the six aforementioned provinces (experiencing high exposure to COVID-19) is coded as “1”, while the control group comprised students from the other 25 Chinese provinces (experiencing low exposure to COVID-19) and is coded as “0”.

Socio-economic status (SES)

SES is assessed based on their family’s annual income, utilizing a survey item that requested participants to provide their household’s total yearly income, encompassing additional bonuses and allowances. Within this study, we categorize students into distinct SES-groups: those with an annual family income exceeds 500kCNY(69.3kUSD) are classified as having the highest SES, denoted by the value 1. Students whose family’s annual income fell within the range of 150kCNY(20.9kUSD) to 500kCNY(69.3kUSD) received value 2; students get value 3 if their family’s annual income ranged from 30kCNY(4.2kUSD) to 150kCNY(20.9kUSD), and value 4 if the family’s annual income below 30kCNY(4.2kUSD). Footnote 1

Student Academic Achievement

Student academic achievement is assessed by using the following survey question “Please indicate your academic achievement in your class?” Participants were provided with five response options: “top 5% of the class,” “top 6–25% of the class,” “top 26–50% of the class,” “top 50–75% of the class,” and “bottom 25% of the class.” These academic achievements are categorized into five distinct levels, denoted by numbers 1 through 5, wherein academic achievement-1 corresponds to the “top 5% of the class” and academic achievement-5 represents the “bottom 25% of the class.”

A binary variable is incorporated into the analysis to evaluate the gender disparity in the inclination towards pursuing international study opportunities. The value of 1 is assigned to males, while females are assigned a value of 0.

Control variables

Finally, the statistical model includes several control variables. Firstly, students’ prior overseas education experience is considered, which is binary (1 for students with the experience; 0 for those without).

Secondly, the variable of intention to pursue a doctoral degree is included, represented as a binary indicator (1 for students expressed the intention; 0 for those not expressed). Additionally, the major of the students is incorporated, using a binary variable (1 for majoring in STEM fields; 0 for other fields).

Moreover, the study controls for students’ foreign language proficiency, which was assessed through a survey item comparing their proficiency to the average proficiency within their age group. This measure encompassed languages required by the universities in the host countries, extending beyond English to languages such as German, Japanese, Dutch etc. Foreign language proficiency is coded as follows: 3 for above-average proficiency, 2 for average proficiency, and 1 for below-average proficiency.

Furthermore, the study considers university selectivity, where the highest selectivity universities (985-project) are coded as 4, and the low selectivity universities (private universities) are coded as 1.

These control variables are crucial in the analysis as they may help to mitigate potential confounding factors and allow for a more comprehensive examination of the relationships under investigation.

Data description

This study utilizes data derived from the “Longitudinal Survey of College Student in China”. The survey includes not only basic information, financial status, study experiences, but also their study and career aspirations of students. The survey employed a stratified probability sampling method to ensure a representative cross-section of the diverse student population in China’s higher education system. It encompassed 72 four-year universities across all 31 provinces in China. Our sampling approach sought to reflect the demographic composition of the entire student population. Due to data limitations, this can only be tested for gender. Our sample comprises 55.6% female respondents, which closely aligns with the national gender distribution of 51.6% in higher education. Unfortunately, we were unable to create a more comprehensive comparison based on additional variables due to the absence of detailed national educational statistics and the limitations in data collecting. Two survey rounds were conducted: the initial survey was administered to first-year university students before the COVID-19 pandemic in 2018, followed by a second survey during the COVID-19 pandemic in 2021, to follow-up on responses from those who participated in the 2018 survey, and were in their fourth year of study.

A total of 90,027 students completed the 2018-suvey and 17,958 of these students (24.9%) participated in the 2021-survey. For the present study, specifically the matched 2021-data is of interest. After excluding any missing or incomplete responses from either survey, the final sample for this study consisted of 14,385 valid responses. Among the respondents, 55.6% were female, while 44.4% were male (See Table  1 ).

Table  1 further shows, 2,798 students (19.5%) attended high selective universities (985-project universities), 3,235 students (22.5%) attended selective universities (211-project universities), 5,478 students (38.1%) attended ordinary universities (medium selective universities), and 2,874 students (19.9%) attended private universities (low selective universities). Footnote 2  Considering to students’ academic achievement, our sample consisted of 2,188 students (15.2%) in academic achievement-1(highest), 2,268 students (15.8%) in academic achievement-2, 3,546 students (24.7%) in academic achievement-3, 3,680 students (25.6%) in academic achievement-4, and 2,703 students (18.8%) in academic achievement-5(lowest). Moreover, 1,216 students (8.5%) rated their foreign language proficiency as above average, 9,493 students (66.0%) rated as average, and 3,676 students (25.6%) rated as below average.

1,110 students (7.7%) in our sample came from low-income families, 8,284 students (57.6%) from lower-middle-income families, 3,176 students (22.1%) from upper-middle-income families, and 1,815 students (12.6%) from high-income families. Additionally, 6,124 students (42.6%) in our sample pursued STEM majors, while 8,261 students (57.4%) had other majors. Lastly, 949 students (6.6%) in the sample possessed prior overseas education experience, and 3,500 students (24.3%) aspire to doctoral degree in the future.

Methodology

This study employs a Difference-in-Differences (DID) approach to investigate the impact of the COVID-19 pandemic on Chinese students’ intention to study abroad, considering background characteristics. The DID-estimation is a widely used quasi-experimental research methodology for evaluating the effects of specific interventions or treatments (Goodman-Bacon, 2021 ). In DID-analyses, two time periods and two groups are considered: during the first period, no individual receives treatment, while in the second period, a portion of the sample is treated, and the rest remain untreated (the control group). By comparing the average change in outcomes experienced by the treated group with that of the control group, researchers can estimate the average treatment impact for the treated subpopulation (Lechner, 2011 ).

To be accurately assess the effect of the COVID-19 pandemic on the propensity of Chinese students to pursue education abroad within our DID framework, we opted for Linear Probability Modeling (LPM) Footnote 3 in conducting our regression analysis. This choice was predicated on the model’s superior interpretability and its efficacy in managing interaction effects, which are pivotal in the DID context. LPM stands out for its straightforward interpretation of coefficients as marginal changes in probability, a feature that proves invaluable for dissecting the nuances of policy impacts and interaction dynamics (Ai & Norton, 2003 ; Angrist & Pischke, 2008 ; Wooldridge, 2010 ). Moreover, LPM’s compatibility with the direct application of conventional econometric techniques for inference, such as the use of heteroscedasticity-robust standard errors, enhances its suitability for our analysis, particularly given the substantial sample size of our study (Angrist & Pischke, 2009 ).

In our study, the differential exposure of the COVID-19 pandemic across provinces in China during 2020 justifies the use of a difference-in-differences design to estimate the causal effects of the pandemic on the intention of Chinese students to study abroad. Specifically, we considered 2018 and 2021 as the first and second time periods, respectively. We classified students from the six provinces with concentrated COVID-19 cases as the treated group (experiencing high exposure to COVID-19), while the remaining students constituted the control group (experiencing low exposure to COVID-19). Additionally, to account for the influence of other variables on the intention to study abroad, we included appropriate control variables such as pursuing a doctoral degree, majoring in STEM, having overseas experience, university selectivity, and foreign language skills. The DID specification is as follows:

In Eq. ( 1 ), Treat is set to 1 if students originate from provinces with high exposure to COVID-19, and 0 otherwise. Time is equal to 1 if the response is provided in 2021, and 0 if it is provided in 2018.

In addition to examining how the COVID-19 pandemic affects students from diverse socioeconomic backgrounds, academic achievement groups, and genders, we introduce an interaction term of Treat, Time, and SES/Academic achievement/Gender. The equation is represented as follows:

As inherent to any difference-in-differences design, our approach identifies the causal effect of COVID-19 exposure under the assumption that the intention of Chinese students to study abroad would have followed similar trends in the treated and untreated states in the absence of the COVID-19 pandemic (Cordero et al., 2018 ). One limitation of our data is that it was only collected twice. Consequently, the data does not provide information about pre-existing trends prior to 2018. Since this assumption cannot be directly tested with our data, we gathered six datasets from the National Bureau of Statistics of China (NBSC), encompassing, at the province level, GDP statistics, the number of graduates and institutions, changes in education expenditure and income, as well as disposable income data—indicators closely associated with students’ intentions to study abroad (see Appendix 1 ). All six datasets demonstrate parallel trends between the treatment and control groups, thereby providing robust evidence that the underlying growth trends are irrelevant factors.

Descriptive results

Table  2 shows the percentages within the different categories of the independent and control variables of students that were willing to study abroad, in both 2018 and 2021. As can be seen, between 2018 and 2021, in all categories students are less willing study abroad. Furthermore, Table  2 shows that in both years, high-SES students (SES-1) were more willing to study abroad than low-SES students. Remarkably, while in 2018 the highest achieving students were most inclined to study abroad, in 2021 students from the second lowest achievement group (Academic Achievement-4) were most inclined to do so. Regarding gender, in both years, female students were more inclined to study abroad in both years than male students. In 2018, students attending higher selectivity universities were more willing to study abroad, whereas in 2021, students from the second highest category (211-project universities) were more willing to do so. Finally, in both 2018 and 2021, students with a higher level of foreign language proficiency, increased interest in pursuing a Doctoral Degree, with prior overseas education experience, and majoring in non-STEM fields were all related to a higher intention in studying abroad.

Difference-in-differences results

Table  3 presents the results of the DID-analysis. The estimated coefficient of “Treated” demonstrates a negative relationship, indicating that in both time periods, students from the six provinces with the higher COVID-19 exposure were generally less inclined to study abroad compared to students from other provinces. Furthermore, the negative coefficient for “Time” indicates an overall decrease in students’ inclination to study abroad in 2021 compared to 2018. However, the estimated coefficient of “Treat*Time” is both statistically significant and positive. This finding indicates that between 2018 and 2021, students from the six high COVID-19-exposure provinces exhibited a smaller decline in their intention to study abroad than their counterparts in other provinces, most likely influenced by their experience with the pandemic.

Difference-in-differences with interaction results

Tables  4 , 5 and 6 report the results of the DID-analysis incorporating the triple interaction terms of Time*Treated*SES, academic achievement, and gender, respectively. This approach enables us to isolate the impact of the pandemic’s exposure on students’ intention to study abroad. It’s crucial to interpret these findings within the specific circumstances of the high-COVID-19 exposure context. By conducting this analysis, we could determine the nuanced impacts of COVID-19 pandemic on the intentions of students with different characteristics to study abroad.

The estimated coefficients for Treated*Time*SES-1 and SES-2 in Table  4 are negative and statistically significant, which implies that the COVID-19 pandemic has diminished the intention of students from high-SES families to study abroad, but at the same time has increased the intention of low-SES students to study abroad.

For academic achievement, Table  5 demonstrates that the triple interaction coefficients on all levels of students’ achievement groups are negative, indicating that students from academic achievement groups other than the top 5% are less likely to study abroad than students from the top 5% academic achievement group, as a result of COIVD-19 exposure although only significant for achievement groups 2 and 4.

Finally, Table  6 indicates that exposure to COVID-19 has no significant effect on the intention of studying abroad among students from different genders.

We created two figures in conjunction with Tables  4 , 5 and 6 to enhance the clarity of our results and facilitate a better understanding, these figures can be found in Appendix 2 .

SES-4 serves as the reference category for SES in this DID analysis. The effects associated with SES-1, SES-2, and SES-3 are measured in comparison to SES-4. Thus, the coefficients for these categories indicate the magnitude and direction of their differences from the baseline category (SES-4).

Academic Achievement-1 serves as the reference category for Academic Achievement in this DID analysis. The effects associated with Academic Achievement-2, Academic Achievement-3, Academic Achievement-4, and Academic Achievement-5 are measured in comparison to Academic Achievement-1. Thus, the coefficients for these categories indicate the magnitude and direction of their differences from the baseline category (Academic Achievement-1).

Gender-0(female) serves as the reference category for Gender in this DID analysis. The effects associated with Gender-1(male) are presented relative to Gender-0 (female). Thus, the coefficients for these categories indicate the magnitude and direction of their differences from the baseline category Gender-0 (female).

The COVID-19 pandemic has significantly impacted the flow of Chinese students pursue educational opportunities abroad. Prior research has investigated the effects in Chinese student mobility by considering factors such as health-related issues (Mok et al., 2021 ), alterations in diplomatic and visa regulations (Aaron et al., 2020 ; Zhao & Mok, 2024 ), and increased discrimination (França et al., 2024 ; Ma & Miller, 2021 ). However, these studies often examine these variables in the context of the COVID-19 pandemic and failed to identify the specific effects of this global health crisis on their intentions for international education, as well as whether different groups of students have been affected differently. This absence of knowledge poses challenges for both students and HEIs. Students highly value international study experiences for their future careers, while HEIs heavily depend on foreign students for resources. To address this gap, our research utilizes Difference-in-Differences (DID) analysis on a dataset including 14,385 Chinese students. Our objectives were to investigate the specific impact of the pandemic on their study abroad intentions and explore potential differential effects based on students’ SES, academic achievement, and gender. We elucidated the complex relationship between the pandemic and Chinese students’ intention for studying abroad.

The impact of COVID-19 on Chinese students’ intentions to study abroad

The findings of this study revealed several significant insights into the impact of the COVID-19 pandemic on Chinese students’ intention to study abroad. Firstly, the DID-results revealed that provinces with higher COVID-19 exposure exhibited reduced inclination to study abroad in both 2018 and 2021. However, intriguingly, between 2018 and 2021 students from high-exposure provinces displayed a greater increase in their intention to study abroad compared to their counterparts in other provinces. This positive effect counteracted the slightly diminished intention observed among students in the high-exposure provinces, indicating that their experience with the pandemic influenced their decision-making process.

To the best of our knowledge, this is the first study to demonstrate the differential impact of the COVID-19 pandemic on study abroad intentions among Chinese students from provinces with varying levels of exposure. By uncovering the complexity of COVID-19 exposure effects across provinces, our research contributes to a more comprehensive understanding of the decision-making processes of students. Previous studies predominantly focused on the negative consequences of the pandemic on Chinese students’ study abroad intentions (e.g., Bista et al., 2021 ). In contrast, our findings present a more nuanced perspective, highlighting that the pandemic’s influence on study abroad intentions are not uniformly negative across all provinces in China.

“Institutional escapism” may be a plausible explanation for this finding. In provinces that were severely affected by the pandemic, the Chinese government has implemented stringent measures. For instance, during the lockdown period in Wuhan, all air, rail, and bus travel was suspended, and access to highways and local roads was restricted with exceptions made for emergency and medical workers. Residents were not allowed to leave their homes, and food supplies were ordered via phone apps and delivered to the doorsteps by community organizations (Fang et al., 2020 ). The unprecedented severity of these measures may have influenced individuals to reconsider residing in such high-pressure environments.

The impact of the Covid-19 pandemic on the studying abroad intentions of Chinese students with different background characteristics

The present study additionally explored the impact of the pandemic on pre-existing inequalities related to SES, academic achievement, and gender. The results firstly demonstrated that the COVID-19 pandemic had a more negative effect on the intention of students from high-SES families than on students from low-SES families to study abroad. Furthermore, students from academic achievement groups other than the top 5% were also found to be less likely to study abroad due to COVID-19 exposure. Finally, the study found no significant effect among students from different genders.

We can only speculate for why the pandemic have a relatively more negative effect on the study abroad intentions of high-SES students, even though they are still more willing to study abroad. Potential reasons include that as the COVID-19 pandemic has caused an economic recession, high-SES families experience more psychological panic and economic loss (Xie et al., 2021 ), which may reduce their intention to study abroad. Moreover, the number of jobs and education opportunities was limited during the pandemic, high-SES students may have more options for both studying abroad and remaining in China. Consequently, they are more likely to reconsider their decision to study abroad and choose to abandon or postpone their plans in the face of the COVID-19 pandemic. Additionally, the very strict measures implemented by the Chinese government to combat COVID-19, which may have been more challenging for low-SES students due to their generally lower-quality living conditions, increase their intention to study abroad. Further research is required to delve into these factors in more detail.

Furthermore, our finding that the COVID-19 pandemic has had positive effects specifically for the highest-achieving students’ intention to study abroad may be explained by the fact that, throughout the course of the pandemic, it has been observed that these students have had fewer difficulties adapting to the shift towards online education than their counterparts, resulting in higher achievement levels than before the pandemic (Engzell et al., 2021 ). Since high academic achievement is frequently a key admission requirement of foreign universities, it is reasonable to assume that the students with the highest academic achievement will conclude that their chances of being admitted to a foreign university have increased. Quite possibly, this realization has led to a strong intention to study abroad.

Limitations

We believe that the present study has provided valuable insights into the effects of the COVID-19 pandemic on Chinese students’ intentions to study abroad, as well as whether students with various background characteristics have been affected differently. However, some limitations should be noted. The first concern is the use of DID-methodology. This study’s data only includes two time periods, limiting the ability to analyze the best-fitted pre-treatment trends for the treated and control groups to rule out the possibility that other unobserved factors affect the outcome variable and thereby bias the DID-estimator. Such bias may be caused by failure to control for unobserved confounding variables, which in this case could be policy changes, international relationship shocks, or even social events that differentially affect treated and control groups. This is a typical DID-method issue that cannot be resolved with the current data. A different study design, such as implementing this survey multiple times in the future or collecting data on the number of Chinese students studying abroad at the provincial level could help in resolving this issue by providing a reliable analysis of pre-treatment trends. Nonetheless, as a second best, the study at hand uses six datasets that are closely associated with students’ intentions to study abroad to provide strong evidence that the underlying growth trends are irrelevant factors.

Second, although this study takes into consideration the most significant variables, such as SES, academic achievement, and gender, it does not account for all potential disparities among Chinese students. There may be additional variables, such as regional differences, cultural background, and the individual attitudes of students that influenced the intention to study abroad differently due to COVID-19 and warrant further investigation. Additionally, because students’ SES and academic achievement were measured categorically, some variations within variables were not considered. It is possible that small variations within the different categories may have led to small differences in the results.

Furthermore, the utilization of self-reported academic achievement is recognized as a limitation due to the possibility of disparities between self-assessment and actual performance as evidenced in the literature (Li & Zhang, 2021 ). The use of self-reported measures may not fully capture the nuanced relationship between actual academic standing and the decision to study abroad. Future research could improve the accuracy by cross-checking self-reported rankings with objective academic records.

Conclusions

In conclusion, this study illuminates a nuanced impact of the COVID-19 pandemic on students’ intention to pursue education overseas. Specifically, we found that those students who had a high exposure to the pandemic were paradoxically more motivated to study abroad after the pandemic. However, this pattern was complicated by the disparate effects observed among high-SES students and those with lower academic achievement. We found that both these groups were more negatively affected in terms of their interest in studying abroad.

Our findings necessitate several policy actions. While our results indicate that the COVID-19 pandemic had a more negative effect on the intentions of students from high-SES families to study abroad, implementing safety measures and enhancing communication channels post-pandemic are crucial for all students, regardless of their SES. This is because studying abroad presents significant opportunities for personal and academic growth, which are particularly valuable for students from low-SES backgrounds, emphasizing the need for equitable access to these transformative educational experiences It is imperative that these measures are tailored to meet the unique concerns and needs of students from varied backgrounds, thereby fostering an inclusive environment and ensuring equal access to information for all, highlighting the importance of equitable opportunities in international education. Additionally, it is vital for the Chinese government to adopt policies aimed at stimulating the economy to mitigate financial losses experienced by families across all SES levels, thereby reducing their anxiety and increasing their interest in studying abroad.

Furthermore, to address the specific challenges faced by low-SES students, creating targeted financial aid programs, offering cultural integration support, and fostering a supportive academic environment are crucial to diminish the enduring gaps in access to international education opportunities. These initiatives should create equal opportunities and guarantee that students from ensure that students underprivileged backgrounds have the essential resources and support to pursue their international education aspirations.

Additionally, as high-achieving students continue to have the greatest intention to study abroad, it is imperative for destination countries and HEIs to focus on this group and facilitate visa policy support to avoid rejections. For students with low-academic achievements, targeted interventions, such as academic and language skill support are required to encourage their pursuit of international education.

Overseas universities could consider the possibility of establishing long-term partnerships with Chinese institutions. The decline in potential applicants in 2020 due to the COVID-19 pandemic may be an indication that the number of prospective Chinese international students continues to decline in the coming years. As such, institutions should not only focus on immediate recruitment efforts but also plan for sustained engagement over the long term.

Finally, for most Chinese students, studying abroad is a considerable investment. It is vital for international institutions to not only provide financial incentives but also to cultivate enriching social and cultural experiences. In this sense, studying abroad is considered as a comprehensive life experience, rather than merely an educational opportunity. Therefore, institutions should establish strategies for students to engage in social and cultural activities outside of their academic courses.

Educational institutions and policymakers are tasked with creating an inclusive, comprehensive strategy to adjust to these changing dynamics. Their goal should be to sustain and promote equitable access to international education, thereby fostering global awareness among future generations.

As SES is often defined based on multiple background characteristics, and not just on one characteristic, we also conducted a robustness check utilizing a composite measure of SES that integrated family annual income, parents’ education, and parents’ careers. The results of this robustness check, which are consistent with our initial findings, are detailed in Appendix 3 .

Chinese universities are classified into four tiers according to their prestige and admission criteria. Tier 1, also known as the 985-project universities, which are the most prestigious and have the highest entry requirements and consists of top 1.5% of higher education institutions in China. Tier 2 denotes the 211 project universities, which have lower rank than 985-project universities, and consists of 4.4% of higher education institutions in China. Tier 3 indicates ordinary universities, which have medium entry requirements, and consists of 68.6% of higher education institution, and Tier 4 refers to private universities, which have lower entry requirement, and consists of 25.5% of higher education institutions in China (Gu et al., 2018 ; Kang et al., 2021 ).

We acknowledge potential concerns regarding the use of a LPM in a DID framework, given that the dependent variable in our analysis is binary. However, the adoption of LPM is well-documented within existing literature that incorporates interaction terms within DID models (Ai & Norton, 2003 ; Greene, 2010 ; Puhani, 2012 ; Deschacht & Goeman, 2015 ). Furthermore, the coefficients are easy to interpret in terms of probabilities (Angrist & Pischke, 2009 ; Li et al., 2014 ). To ensure the robustness of our approach, we have conducted a robustness check using a Logistic model in the DID framework (see Appendix 4 ). The results of the Logistic model in the DID framework are consistent with those of the LPM in the DID framework, supporting the robustness of our findings.

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COVID ‐19: Assessment of knowledge and awareness in Indian society

Ashish kumar singh.

1 Department of Management Studies, Raj Kumar Goel Institute of Technology, Ghaziabad India

Bharti Agrawal

2 Department of Computer Science, Shri Vaishnav Institute of Management, Indore India

Anukriti Sharma

3 School of Business, University of Petroleum and Energy Studies, Dehradun India

Prayas Sharma

COVID‐19, which was initiated regionally at Wuhan of China, has become a global pandemic by infecting people of almost all the world. Human civilizations are facing threat for their survival and livelihood. No country are getting any substantial relief and solution from this pandemic rather to convince their citizens to make aware and taking precaution by changing their living style. In view of this, this study attempted to assess the awareness, threat, symptoms and its prevention among people of India about the COVID‐19. A total of 522 responses from all over India were received. The respondents have adequate awareness for COVID‐19 outbreak and its preventive measures, out of total, 98% (513) answered that the virus spreads from one person to another, 95% (494) answered that the disease is caused by a virus. Peoples understand the importance of social distancing and other preventive measures prescribed by the government with good attitude for coronavirus. Peoples are following trusted sources for corona information, having confidence to defeat disease but showed their concern for corona threat, are aware about the virus, its common symptoms and prevention, govt. testing and medical facilities. Principal component analysis was used to identify the latent dimensions regarding people's preventive measures and was found that they are majorly adopting three methods, that is, lockdown, naturopathy and social distancing. This study will help government and peoples to understand and handle this coronavirus pandemic effectively and in prevention of COVID‐19, which is crucial for the awareness of society in coming time.

1. INTRODUCTION

COVID‐19 started from one city of China in December 2019, but in a short span of time, it covered almost all over the world (WHO, 2020b ). Nearly 216 countries of the whole world are struggling for their civilization and livelihood against the coronavirus pandemic. On January 11, 2020, China declared first death of their 61 years old citizen due to COVID‐19, who was exposed to the seafood market (WHO, 2020b ), but now death reached exponentially to 357,736 on 29th May 2020 (WHO, 2020a ).

On February 11, 2020, WHO announced this coronavirus disease as COVID‐19 (WHO, 2020c ) and pandemic on March 11, 2020, after reaching the virus infection to 114 countries across the world.

COVID‐19 and SARS coronavirus are similar and because it is becoming a big threat to human civilization as consequences, online awareness programs were initiated and conducted worldwide by WHO ( 2020c ).

Proper strategies and funds were set up by WHO globally to protect the countries with special focus to poor and weaker health infrastructure developing countries. The aim was to reduce the virus communication in society, dissemination of crucial information, providing proper healthcare and to minimize social and economical loss. WHO also focused on establishing an easy and effective diagnostic system to prevent infection (WHO 2020 c ).

To prevent the infection socially, the lockdown was imposed globally, which resulted in the halt of all economic and social activity in society. This led to cease global supply chains badly resulting in the global economy in bad shape (Ebrahim, Ahmed, Gozzer, Schlagenhauf, & Memish, 2020 ). In India, the Central Government also imposed a nationwide lockdown for the first time on March 22, 2020 and continued it up to till date, that is, on May 30, 2020. All transport, manufacturing, hotel industry, educational sector, service industry and so forth were closed immediately, people were left to remain as to where they were at the time of lockdown announcement and during lockdown people started working from home, school and colleges classes are running online, a large number of people shifted on a digital platform (McCloskey et al., 2020 ).

But on May 30, 2020, this situation of coronavirus disease (COVID‐19) outbreak has become worse, as it contains 5,704,736 confirmed cases, 357,736 confirmed deaths across 216 countries. India also has 165,799 confirmed cases with 4,706 casualties (WHO, 2020d ).

Now it is very clear that COVID‐19 is creating very disaster effects globally with India, people are getting panicked, emotionally unsecured, depressed and in a stage of confusion, unaware about facilities provided by the government, regarding reliable news sources, symptoms of COVID‐19 and its prevention with the cure.

Some parts of the North East, India people are taking coronavirus infection as a social stigma, so as a consequence people are hiding their illness and showing their unwillingness to approach hospitals. In this connection, WHO are trying their level best to offer technical guidance and solving public queries, to mitigate their fear, social discrimination and stigma regarding COVID‐19 (WHO, 2020c ). On the counterpart, our Indian government is also making aware of the people by disseminating information through various reliable sources and providing medical facilities and trying to reduce the losses due to coronavirus. But, in India, we have a very huge dense population without well‐established medical facilities, which is a matter of concern Sohrabi et al. (2020); Surjadi & Surja (2019); Sharma, Singh, Agrawal, & Sharma, 2020 ). Large numbers of people are illiterate, isolated, migrants, live remotely and are below the poverty line, struggling hard for their daily needs are raising the government's concern during the lockdown. Migrant workers are bound to migrate from one state to their home without any proper transport facilities and precaution such as a face mask, social distancing, meal, cleanliness, hygiene, which are triggering to increase more infection in society. Amid the above havoc situation, the anxiety and worries among society are at the top, people who are kept in quarantine centers at isolated places are also feeling serious uneasiness, discomfort ness, irritated, ignored and in traumatic stress (li et al.(2020)). Many celebrities, sportspersons, media persons, politicians, other responsible citizens are trying to aware and change the attitude of the public, to take self and families protection and motivating them to avail medical facilities by cooperating with medical personnel, which ultimately leads to reducing coronavirus infection in society (Anderson et al. (2020); Wang et al. (2020) & Zhu et al. (2019)). Hence, it is very crucial to study the following factors in the Indian population and their effects in society.

As the cases of infected people are increasing rapidly, this article will help the public and government to plan and decide the strategies for fighting the coronavirus. This article aims to estimate the level of exposure people get while going to their workplace and number of people they daily interact, what are the trusted source of information in society regarding coronavirus, how serious is the perception of threat for the virus in society, the awareness level of health facilities provided by the government, general awareness about coronavirus, their symptoms for infection and prevention to common people. There is very little research in India covering the above factors, so this study is crucial for planning and adopting the preventive measures by public and government officials during this pandemic. Hence, this study will help in future to design necessary strategies in Indian society to fight against viruses.

2. METHODOLOGY

Our study was cross‐sectional, carried out by a convenience, nonprobability sampling technique in India. We adopted this sampling because, due to movement constraints during a lockdown, it was impossible to approach a common man in the population. This technique of convenience sampling, which is a nonprobability sampling technique, allows researchers to select respondents directly from the population as per their convenience. This technique was cost‐effective and time‐saving. Researchers choose these samples just because they are easy to fix, approach and train. A semistructured questionnaire was developed in straightforward, understandable English by using Google form. The questionnaire was disseminated to known through WhatsApp, e‐mails and other social media platforms. The participants showed enough interest in giving their responses and forwarded it to their contacts, which resulted in getting responses from all over the country. Participants who possess smartphones with internet connectivity have participated in this study, which is very common in modern society. Participants above 15 years and comfortable in English filled the response with willingness. Total, we received 533 responses, but some were filled incomplete, so we eliminated them. Finally, we analyzed 522 responses to draw our results. The respondents' sociodemographic profile was accessed by a questionnaire, which includes gender, age, education, place of residence, domicile, marital status and so forth.

The questionnaire used for the survey have a separate section to know how they commute and interact to peoples, what are their trusted source of information, two questions were to evaluate the threat level of virus, one dichotomous question for awareness about health facility, six questions to estimate awareness level of coronavirus in society, 11 questions for accessing symptoms, 12 questions for perception about prevention from coronavirus. The process of data collection was held from April 11, 2020 to April 28, 2020.

Factor analysis with principal component analysis was used to describe the unobserved underlying latent variables with 12 observed variables (items) of prevention methods adopted by people for coronavirus. Bartlett's test of sphericity was used to check interdependency among the items and KMO (Kaiser–Meyer–Olkin measure of sampling adequacy) was used to inspect the sample sufficiency (Kaiser, 1974 ). The criterion of Eigenvalue > 1 with factor loading greater than 0.5 was used to decide the number of factors (latent variables; Kaiser, 1960 , Sharma, 1996 , Hair, Anderson, Tatham, & Black, 1995 ). To check the items' internal consistency (reliability index), Cronbach's α (Cronbach, 1984 ) value was calculated and checked.

3. RESULTS AND DISCUSSION

This study presents the key findings from a total of 522 respondents (Table ​ (Table1), 1 ), with a majority of them, 321 (61.7%) are male and the remaining 201 are female, so we got the balance response gender wise. The vast majority of the respondents, 258 (49.6%) belongs to age range of 15–25 years, 151 (29%) are in age group of 26–35 years, 72 (14%) are lying in a group of 36–45 years, 29 (6%) are in the age range of 46–55 years and rest 11 are above 55 years. Notably, maximum 321 (81.8%) are from urban background and rest 95 are from rural area. In addition, 338 (65%) of our respondents are single or never married, 177 (34%) are married, rest 5 and 2 are divorced and widowed. Most respondents are having postgraduation 265 (51%), 164 (32%) are UG, 57 (11%) are Ph.D., 5 are having diploma and 33 are having other qualifications. So, by education qualification, it is quite confirmed that they have easily understand the question while responding (Figure ​ (Figure1 1 ).

Demographic information of respondents

Distribution of Respondents

Furthermore, a substantial proportion of the respondents 238 (46%) are students, 152 (29%) are private salaried, 63 (12%) are government salaried, 16 (3%) are having other occupation, 15 (3%) are home makers and 6 (2%) are retired (Figure ​ (Figure2 2 ).

Distribution of respondents' occupation

This study depicts that the respondents belong to 23 states of our country with maximum representation (193) from Uttar Pradesh, followed by Madhya Pradesh 116 and Uttarakhand 45.

When people were asked about how they commute, the overall result precipitate that a majority of the respondents 227 (44%) commute by two wheelers, which are open to threat of getting infections, 74 (14%) use their personal cars, so they can manage hygiene factors, 54 (10%) use bus, which are prone to maximum exposure, 48 (9%) uses college bus. Thus, we can say that in society, most of the respondents are having the threat of getting exposed for infection (Figure ​ (Figure3 3 ).

Number of Interaction per day

On the result of question asking regarding the numbers of people they generally interact and do you walk through crowded place daily?, finding of the study indicates that out of total, 199 (38%) respondents reported that they daily interact with more than 10 peoples, 86 (16%) interact to 10 people's daily. 166 (32%) walk regularly through crowded places and 77 (15%) visit occasionally to crowded places, so they are threat to have infection of COVID‐19 virus (Figure ​ (Figure4 4 ).

Trusted Source of Imformation about COVID‐19

On the question of trusted source of information for coronavirus, the study shows that majority of the respondent's 357 (68.3%), trusted on Television (357), 323 (62%) showed their trust on official government Websites and 258 (49%) says Newspaper, so in majority, people trusted on above sources as most authentic sources of news dissemination (Figure ​ (Figure5 5 ).

How big is the threat?

When we tried to appraise that how big is this threat of COVID‐19 virus to human civilization among the respondents, majority of the respondents 443 (85%) were extremely or somewhat worried for the virus, which is a serious threat. Thus, the government needs to increase the confidence level of people in society (Figure ​ (Figure6 6 ).

Awarness about health facilities

We also tried to assess the awareness level of health facilities provided by government among society, 429 (82%) respondents reported that they have the information regarding health facility where they can test for coronavirus. It's really a matter of relief that people in society know in case of emergency where they have to contact. In this matter our government did commendable jobs to aware the people about health facility available.

On asking, what do you know about coronavirus, we came to know that majority number of respondents were adequately aware for basic information of the virus. Out of total participants, 98% (513) answered that virus spreads from one person to another, 95% (494) answered that the disease is caused by a virus. The study showed, 79% (414) respondents are confident that the disease can be prevented and 60% (315) reported that symptoms of COVID‐19 virus are worse among diabetic persons (Table ​ (Table2 2 ).

Awarness about COVID‐19

Source : Data computed through survey (Table ​ (Table2 2 ).

The outcome regarding awareness about coronavirus symptoms, study revealed that considerable numbers of respondents were aware of the common symptoms of COVID‐19. Most respondents 514 (98%) acknowledge fever as a common symptom of COVID‐19, 456 (87%) acknowledge persistent cough, 452 (87%) sore throat, 394 (75%) tiredness and 366 (70%) running nose (Table ​ (Table3 3 ).

Common Symptons

Source: Data computed through survey (Table ​ (Table3 3 ).

3.1. Perception about prevention from coronavirus

On the question about whether respondents are preventing from virus, out of the total participants, 515 (98.6%) admit that social distancing is crucial to finish virus from transmission. However, 505 (96.7%) admitted washing hands during certain period of time and 510 (97%) felt the need of wearing mask. Almost 501 (96%) agreed that they should avoid face to face meeting (Table ​ (Table4 4 ).

Prevention from Corona virus

Source : Data computed through survey (Table ​ (Table4 4 ).

4. FACTOR ANALYSIS

The investigators applied the factor analysis using principal component analysis as extraction method, with varimax rotation to describe the underlying unobserved latent variables of respondent's perception for methods to prevent from COVID‐19. The objective of factor analysis was to know that what are the major ways through which people's were preventing themselves from virus Table 5.

The KMO measure was 0.834 > 0.5 (as recommended value of 0.5; Hair, Black, Babin, & Anderson, 2010 ; Tabachnick & Fidell, 2007 ). In addition to this, Bartlett's test of sphericity was significant ( χ 2 [66] = 1,965.169, p = .000) (Table ​ (Table6). 6 ). In addition, the sample size 522 is more than 10 times the number of variables 12 (Kaiser, 1974 ), considering N:p ratio to be at least 10, where N is sample size and p is number of variable to be analyzed. All these above results show that factor analysis is suitable and useful for our data. All the items are standardized to ensure the proper interpretation on a common scale. Scree plots and Eigen values were used to extract the suitable number of factor solutions.

Identified factors from the study and their item loadings

Source : Data computed.

Three latent factors were fixed after the analysis of Kaiser normalization criteria (Pett, Lackey, & Sullivan, 2003 ) and scree plots (Baldridge & Veiga, 2001 ; Balser, 2007 ; Balser & Harris, 2008 ; Cleveland, Barnes‐Farrell, & Ratz, 1997 ; Colella, 2001 ; Stone & Colella, 1996 ). These factors are labeled as latent variables F1: follow the lockdown , combination of (avoid travelling by any medium, avoid going to market, avoid morning walk, avoid going to office), F2: naturopathy , is a combination of (exercise and yoga, eating ginger, garlic, chilies, drinking warm water, avoid going to cold weather) and F3: social distancing is combination of (avoid face to face meeting, wash hand and face regularly, wear mask and sanitize, social distancing) and loadings of all about items were greater than 0.5, explaining 34.59%, 14.07% and 10.94% of the variances, respectively. The total variance explained by three factors is 59.16%. Table ​ Table6 6 describes each of the three factors and their factor loading. We also conducted reliability test of the selected 12 factors to test how well they measures what they are intended to measure. How reliable they are to measure latent variable, that is, perception to prevent from virus ?, value of Cronbach's alpha ( α ) for above is 0.812 (Table ​ (Table5), 5 ), which is good enough to meet the purpose.

Reliability statistics

5. LIMITATIONS

This study also has some limitations such as questionnaires filled by people who can understand English and possess smartphones with internet connectivity. These educated population segments are mainly restricted to an urban area only, so this cannot be generalized to the whole community. The results drawn from rural people can be different from the findings of our study. The time duration of the data collection was a little bit less.

6. CONCLUSION

During this coronavirus pandemic, mostly literate urban people were aware of this pandemic, which also similar to the outcome of a study done by (Ray et al., 2020). They are aware of virus infection symptoms such as fever, cough, sore throat, tiredness, running nose and possible infection method from one person to another, so government and celebrities should encourage the ordinary people and boost their morale in this tough time. People showed confidence that disease can be prevented but are concerned for loss due to pandemic. The majority of people in society are commute by their two‐wheelers or public bus, prone to infection, so the government should take extra care to sanitize public places and coaches. They have adopted their prevention methods such as lockdown, naturopathy and social distancing, so the government should make necessary arrangements. The majority of people daily interact either to 10 or more people, which is the biggest threat to community transmission, so people should be discouraged from associating with others. Peoples are following trusted sources of information such as TV, newspapers and official government website, so the government should broadcast all relevant information to these platforms. Common men in society are well aware of medical facilities' government initiatives, which are vital to cease the infection. Worries and anxiety among the public regarding COVID‐19 disease can be checked and quickly reduce by counseling, their levels to be measured in some research. There is a need to intensify the awareness program during this COVID‐19 pandemic, raised by other researchers (Ray et al., 2020).

So this article will help common men to understand the intensity of infection and its symptoms and precaution. It will help common people to understand the threatens level of virus in society and counsel him that it's with everyone, rather than only with him. He will adopt the necessary precautionary measure to avoid infection from illness by getting proper and reliable information from time to time. The government will also get an idea of common man psychology, problems and worries of ordinary people to formulate a better and effective strategy.

Biographies

Ashish Kumar Singh is a Faculty at Department of Management Studies, Raj Kumar Goel Institute of Technology, Ghaziabad. He has more than ten years of academic experience in management education and gives training at statistical tools with hands‐on exercises. He holds a Ph.D. in Business Management and Entrepreneurship from Department of Business Management and Entrepreneurship, Dr. Ram Manohar Lohia Avadh University, Faizabad (U.P.) and having Executive Certificate in Business Analytics and Big Data from Indian Institute of Management (IIM) KASHIPUR & Certificate in “Data Science: R Basics” from Harvard University, Massachusetts Hall Cambridge, MA. He has contributed number of research papers and articles in various national and international journals indexed in Scopus (Elsevier) index, Web of Science (Clarivate Analytics), ABDC Category.

Dr. Bharti Agrawal is an assistant professor in Shri Vaishnav Institute of Management, Indore (MP). Her area of research is Design of Experiments. She has 7 years of teaching and research experience. She has published 14 research papers in leading peerreviewed journals.

Dr. Anukriti Sharma is Ph.D. in Energy Economics (Applied Economics) and visiting faculty in variaous institute/universities. Dr. Anukriti has published 5 research papers in reputed indexed journals.

Dr. Prayas Sharma is currently working as Assistant Professor in the area of Decision Sciences, School of Business at University of Petroleum and Energy Studies, Dehradun, India. Dr. Sharma has more than 8 years of academic experience, both in the domain of teaching and research. His research interest includes Artificial Intelligence, Business Analytics, Estimation Procedures, and Measurement Errors. Dr. Sharma has published more than 35 research papers in reputed National & International journals along with one book and two chapters in book internationally published. He is serving more than 30 journals as editorial board member & reviewer.

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