Knowledge, Attitude and Practices Towards COVID -19 Among University Level Students in Bangladesh

Background: SARS-CoV-2 a highly contagious virus causing the current global pandemic of COVID -19 is transmitted mainly through close physical contact and airborne transmission of respiratory droplets, and associated with significant morbidity and mortality. Objective: The study was carried out aiming to assess knowledge, attitude and practices (KAP) of university level (medical and nonmedical) students towards COVID-19. Methods: This online cross-sectional KAP study was carried out among university level students. The questionnaire used consisted of two main sections: demographic and knowledge, attitude and practic es (KAP) towards COVID-19 transmission and prevention. Demographic variables included gender, age, religion, marital status, type of education. KAP section consisted of 14 questions for assessment of knowledge regarding clinical symptoms, transmission route, vaccine, prevention and cont rol of COVID-19. The link of the online questionnaire was shared with students of three government and one private medical colleges and 8 universities of which 5 government and 3 private through their faculties with an invitation to participating in the study. Results: A total of 399 students participated in the study, 6 1.9% were non-medical and 38.1% were medical students; males accounted for 62.7% of the respondents. Knowledge and practice scores were signif icantly higher in females than in males (p< 0.05). KAP scores were significantly higher among medical students compared to non-medical students (p< 0.05). Though about 52.1% of total students had good knowledge, less than 25% had favourable attitude and 48.6% had good practices towards preventive m easures of COVID-19. Conclusion: There is need for more awareness campaign focusing the students to cover their knowledge gaps, motivation for appropriate practices and further improvement of attitude and practices towards preve ntion of COVID-19 transmission.


Introduction
The highly infectious novel corona virus disease that was first identified Wuhan, China, the causative agent was initially named as 2019 novel corona virus (2019-nCOV) which later was renamed as SARS-CoV-2 and the disease it caused was named as corona virus disease 2019(2019-nCOV). 1,2,3 On the 30 th January, 2020, the World Health Organization (WHO) declared that the outbreak constitutes a Public Health Emergency of International Concern (PHEIC) and as global pandemic on the 11 th March 2020 3, 4 The COVID-19 pandemic is associated with increasing morbidity and mortality and has impacted the lives of the global population. 3,5 SARS-CoV-2 is an enveloped non-segmented RNA virus. 1,6 Among the six corona viruses known to infect humans generally are responsible for mild respiratory symptoms similar to that associated with the common cold while SARS-CoV-2, SARS-CoV and MERS-CoV are implicated to cause lethal respiratory infection. 6 Though the natural reservoir of SARS-CoV-2 remains obscure bat has been implicated to be the source of SARS-CoV-2 based on its 96.2% genomic similarity with the bat corona virus COV Ra T-G 13. [6][7][8] The COVID-19 virus is transmitted mainly through close physical contact and respiratory droplets, while airborne transmission is possible during aerosol generating medical procedure. 9 SARS-CoV-2 invades lower respiratory tract cells using the angiotensin-converting enzyme 2(ACE-2) receptor. 10 The incubation period of the SARS-CoV-2 1-14 days and individuals with asymptomatic infection were found to spread the disease. 11 SARS-CoV-2 infection could result in mild to severe respiratory illness (often flu like)

Materials and Methods
This cross-sectional study was conducted from 11 th of July to 10 th of August 2020. Data collection was carried out through a Google form based questionnaire that had an interface which explained the objectives of the study, provided assurance to the participant regarding confidentiality and was informed that completing and submitting the form would indicate that he/she was a consenting participant. This study was approved by the IRB of Institute of Public Health, Mohakhali, Dhaka The questionnaire included a section for demographic information and sections for assessment of KAP (Knowledge, Attitude and Practice). Demographic variables included gender, age, religion, marital status, education, and residence type. KAP section consisted of 14 questions for assessment of knowledge regarding clinical symptoms, transmission route, vaccine, prevention and control of COVID-19, 3 questions for assessment of attitude and another 7 for assessing practice.The knowledge, attitude and preventive practice related questions that were developed using information from WHO COVID -19 advice for the public and other published studies. 17,18 The estimated sample size for the study was 384. The questionnaire link was sent to faculties of threeprivate and fivegovernment universities, and fourmedical colleges (1 private and3 government) for distributing to their students with a request of prompt response. To minimise the missing data, the participants were requested to fill all the items in the online questionnaire or else could not proceed to the next item. On completion the form, the participants were directed to write their email address and click the submit option. Data collection was closed when responses from 399 participants were obtained. Data retrieved from the online survey were transferred into the Microsoft Excel and then into the Statistical Package for Social Science (SPSS) version 20. For analysis, knowledge, attitude and practice responses were scored. Each correct answer/response was given one (1) point and wrong answer and don't know responses were assigned zero (0) point. The total knowledge score for the students varied from 0 (no correct answers) to 14 (all correct answers) while the highest possible scores for attitude could be 3 and 7 respectively. Bloom's cut-off 80% was used to determine the cut-off points to categorize knowledge as good (score ≥11.2) and poor (<11.2); attitude as favorable attitude (score ≥2.4) and disfavorable (score <2.4); and practice as good (score ≥5.6) and bad (score <5.6). 19 Thereafter frequencies, percentages and mean scores were commonly manifested by dry cough, fever, myalgia and in severe cases by difficulty in breathing and sometimes symptoms referable to other organ system. 12 Global Health Expert and South Asia governments have expressed concern about the spread of COVID-19 and potential for more than 7.6 million deaths in South Asia if no action taken. 5 As part of it's preparation for facing the pandemic the Government of Bangladesh had put in place several precautionary measures including limitation of on arrival visa, strengthening the health screening services at the point of entries. On the 1st of February 2020, 312 Bangladeshi returned from Wuhan and this group of returnees were placed under 14 day formal institutional quarantine before being allowed to go home. 13 Despite of all efforts taken by the country, Bangladesh reported its first case on March 8, 2020 there after each day increasing number of COVID-19 patients were detected. 14, 15 To limit the spread of disease, all educational institutes were declared closed from 17 th March 2020. In addition, different stakeholder initiated awareness building programme susing audio-visual methods radio, television, cable network and social media targeting prevention of COVID-19 throughout the country. Human knowledge and behaviour about a disease is often critical for the success in efforts for containing a disease outbreak.
Pandemic situations are often followed by infodemics, large amounts of fabricated, fictitious information circulate on social media relating to mode of infection, the disease itself and means of disease prevention, in such context knowledge and behavior assessment the public is essential for success of awareness programmes. 16 In the current context, a dearth of information regarding the knowledge, attitude and practices of students towards prevention of COVID-19 exists. Practicing meaningful social distancing, wearing mask, and growing habit of frequent hand washing by soap and water, avoiding spitting, could appear as a critical challenge when students are invited into a new normal way of life. Students are likely to adopt appropriate preventive measures for COVID-19 disease, if empowered by proper information relating to the disease agent, it's mode of entry into human body, risk factors, common disease manifestations, availability of treatment and means of preventing the disease. Therefore, the current study was carried out with the objective to assess knowledge, attitude and practices (KAP) of university level (medical and non-medical) students towards COVID-19 during the rapid rise period of Covid-19 pandemic.
obtained. Chi-square distribution was used to assess potential statistical relationships between demographic variable and knowledge, attitudes, and preventive practice categories. To detect significant differences in scores between groups t-test or ANOVA was carried out as applicable, p-values of less than 0.05 was considered as statistically significant.

Results
Among the 399 participants who completed the survey forms 62.7% were male and 83.2% were 18 to 23 years of age, 84.7% were Muslim, 38.1% were medical students and about 62% were students of universities located in Dhaka city and other districts (table-I).  Though, more than 95.0% used mask when they went outside and avoid shaking hands with others, 32.1% indulged in face-to-face chatting with friends in groups both within and outside their residences and 16.5% did go to restaurants with friends and family. Knowledge, attitude and practice scores of students by demographic characteristics were also calculated (table III). The mean knowledge, attitude and practice score for medical students were found to be significantly higher compared to that for non-medical students (table-IV).  (table V).
Poor knowledge, unfavourable attitude and bad practice were significantly higher among nonmedical students compared to medical students.

Discussion
Empowering the population with correct and adequate knowledge in the care and maintenance of their health actively often plays a remarkable role in disease prevention and control. As SARS-CoV-2 has caused a global pandemic of the century, it is important to encourage different population groups to adopt precautionary behaviors based on correct knowledge. Many studieshave examined the various levels of KAP about COVID-19 and limited information on KAP relating to COVID-19 was available. 12,16,[18][19][20][21][22][23][24][25] Currently,the country is bringing forward normalcy in daily life and is resuming different economic activities, opening offices and looking forward to open up educational institutions at the proper moment. Therefore, a web-based survey conducted to assess KAP of students relating to COVID-19 to provide baseline data to government taking up measures for prevention of future COVID outbreaks and keeping it down to a manageable level.This study revealed that more than 90% of the students had knowledge about the symptoms of COVOD-19 and availability of the vaccine. Of them, 76.4% knew about the nonavailability of effective treatment.These findings were almost similar to that of Alzoubi et al. 20 The mean knowledge score of the students was 11.18±1.60 and was significantly higher for medical students (11.53±1.40) than for non-medical students (10.96±1.68), about 52.1% of the students in the current study had good knowledge, compared to nonmedical students (41.3%) significantly higher proportion medical students of (58.6%) was found to have good knowledge. Alzoubi et al did not find any medical and non-medical students in Jordan. 20 A little more than 14% believed that smoking could prevent COVID-19 and only 29% believed that use of 3-layered cloth mask could prevent infection under general circumstances. The attitude score of the students was found to be 2.02±0.69 and was significantly higher for medical students (2.26±0.55) than for non-medical students (1.88±0.72). Moreover, attitude favourable for prevention/combatting disease was extremely low (22.8%) among the students, and was significantly lower among non-medical students (17.4%) in comparison to medical students (31.6%). Alzoubi et al observed similar findings about smoking but did not find any significant difference regarding attitude between medical and non-medical students in Jordan. 20 The practice scores for the student participants of this study was5.26±1.507 and it was significantly higher in medical (5.63±1.33) than in non-medical students (5.04±1.56). Good practice was prevalent in 48.6% of the participants, and it was significantly higher in medical students (59.9%) compared to non-medical students (41.7%). The Jordan study displayed favorable practices towards COVID-19 prevention such as hand washing, refraining from shaking hands, etc. 20 However, in the current study, the students were found to be continuing handshakes (10.8%) with others, to chat face-to-face (31.5%) and even visits with friends and family (16.5%) this possibly was because of the care free nature of the youths.

Conclusion
The current study revealed that there was urgent need to foster appropriate knowledge, positive attitude and practices towards prevention of COVID-19 among students in Bangladesh before reopens the educational institutions. The findings of this study are expected to help the policy maker about better planning for effective awareness campaigns targeting the specific group through well-planned and appropriate strategies. Hence the study result was based on limited sample size could not be generalised to all the students of Bangladesh. However, the study might be helpful in conducting further research of this kind.