This study revealed that 62.7% of respondents across the 26 countries were classified as having “good” COVID-19-related knowledge. It further revealed that at country level Romania had the highest proportion of respondents classified as “good” knowledge (89%), while the lowest proportion was seen in Russia (31.8%). Previous studies conducted in the general population and among health care professionals have shown that advanced training and work experience is associated with COVID-19 related knowledge [21,22,23]. These findings might explain our result, as Romania had the highest proportion of health field students and hence the highest level of COVID-19 related knowledge. Our finding is consistent with a study conducted in India solely among dental students that found adequate COVID-19 related knowledge was 83% [10]. Although the finding in the aforementioned study is higher than the total COVID-19 related knowledge across the 26 countries, it is comparable to countries such as Romania and Portugal which have very high proportion of health students. In contrast, Our findings with regards to COVID-19 related knowledge were much higher compared to a study conducted in Romania (10.8%) among oncology patients [24]. The discrepancy observed between the two studies maybe due to the fact that our study was conducted solely among HE students while the former was conducted with patients where the majority of whom (66.6%) had no formal education. Other reasons for the high percentage of COVID-19 related knowledge in countries such as Romania and Portugal may be related to their early public health responses to curb the spread of the pandemic which may have included governments actively communicating and engaging with those specific communities before introducing a particular measure. This action might have created awareness of COVID-19 early on leading to higher knowledge levels [25]. According to public health measures data from European Union (EU) countries, both Romania and Portugal closed educational institutions early. In comparison the Czech Republic, which had the lowest COVID-19 related knowledge level among EU countries, did not close educational institutions and this may have contributed to low COVID-19 related knowledge [25].
There is limited research about the association of knowledge and fear about COVID-19. Our study revealed that, after adjusting for potential confounders, COVID-19 related knowledge is independently associated with both fear about SARS-COV-2 infection and severe COVID-19. The odds of being afraid about acquiring SARS-COV-2 infection and severe COVID-19 among those who had good knowledge was lower compared to those who had poor knowledge.
Our findings suggest that increasing comprehensive COVID-19-related knowledge, might be associated with both lower fear about severe COVID-19 as well as SARS-COV-2 infection. The reason might be that respondents with more COVID-19 related knowledge will possess a greater sense of control over the pandemic, and thus will not feel threatened enough to fear too much. This is reflected by a study conducted in China which found that those with low self-control were more likely to have exaggerated perception of seriousness to COVID-19 [26]. This finding is also consistent with other variables in our study such as field of study where the odds of being fear about acquiring either SARS-COV-2 or severe COVID-19 among health field students was lower compared to non-health students. The reason behind such finding might be because health students are expected to have more COVID-19 related knowledge and thus high self-control leading to less fear compared to their non-health students counterparts. Another important reason might be related to the infodemic specifically misinformation spread through mainly social media platforms during the pandemic which non-health students are vulnerable to compared to health students [12]. This is especially true among the adolescent age group because they are the major consumers of social media and are exposed to problematic social media use with misinformation as one of its consequences [13].
It is also worth noting that the odds of being afraid of acquiring either SARS-COV-2 infection or severe COVID-19 in those students who strongly agreed receiving timely government information concerning the COVID-19 pandemic was lower, as compared to those who strongly disagreed. This finding is similar to a study conducted in Turkey where satisfaction with specific up-to-date and accurate health information provided was associated with a lower level of anxiety and stress [27]. Our findings, therefore, indicate that factors such as field of study and timely government information that increase COVID-19 related knowledge are associated with lower fear about acquiring SARS-COV-2 infection and severe COVID-19. Additionally, receiving timely information from credible sources such as the government might also be specifically associated with lower fear about acquiring SARS-COV-2 infection and severe COVID-19 as it helps fight the infodemic and decrease the misinformation which usually leads to exaggerated fear [12].
The negative burden of the COVID-19 pandemic especially on the mental health of HE students has been documented [16, 17]. Fear about acquiring severe COVID-19 and SARS-COV-2 infection and lack of sufficient knowledge could further contribute to higher level of depression amongst this population group, which is a leading public health concern.
Increase in smoking was negatively associated with both fear about SARS-COV-2 and severe COVID-19. The myth that smokers are protected against SARS-COV-2 infection has received wide attention on media and has led to some confusion even among the medical community [28]. Thus, erroneous claims communicated about a protective effect of smoking might be the reason behind the peculiar finding in our study. Physical activity particularly increase in moderate physical activity was also negatively associated with both fear about SARS-COV-2 infection and severe COVID-19. Our finding was similar to a study conducted in the United States which found that increase change in physical activity is associated with a reduction in fear about COVID-19, post-traumatic stress disorders and other mental health outcomes due to the COVID-19 pandemic [29]. However, independent association was not observed between vigorous physical activity and fear about SARS-COV-2 infection or severe COVID-19. This might be because the lockdown measures in place were not conducive for performing vigorous physical activity while these measures were suitable for conducting moderate physical activity. Additionally, it is worth noting other studies indicating that the transition to virtual learning environment due to the lock down measures introduced during the pandemic can all in itself further trigger mental health issues [17, 30]. Lastly, increase alcohol use was positively associated with both fear of SARS-COV-2 infection and severe COVID-19. This finding echoes Reynolds et al. [31] study in Ireland where fear during the COVID-19 lockdown period was associated with increased alcohol consumption.
The limitation of this study is that it is cross sectional and does not allow an examination of the possible causal effect of knowledge deficit on fear about SARS-COV-2 infection and severe COVID-19. Additionally, the study used convenience sampling which is not representative of the study population. In addition as the study includes behavioural related questions, social desirability bias is possible as the potential confounders.
The strengths of this study however are: it is a cross-country survey, has a large sample size, examined the random effects in 26 countries and observed the differences between them. In addition it assessed the fear about both SARS-COV-2 infection and Severe COVID-19.
The findings of this study will inform HEIs about the COVID-19 related knowledge level of their students, and provide a basis for action to increase awareness and understanding among the student body. It will also aid to tackle exaggerated fear about severe COVID-19 and SARS-COV-2 infection which can lead to psychological problems such as depression. In addition, by providing targeted and timely interventions to inform, solve COVID-19 knowledge deficit and fight infodemic, will promote psychological well-being and prevent mental health issues in HE students both in the current but also in future pandemics.
Intervention by all stakeholders to tackle fear should not only be implemented by increasing COVID-19 related knowledge level, but also by focusing on timely information through media sources, scaling up intervention on healthy behaviours such as moderate physical activity. More importantly, government bodies in addition to providing timely, up-to-date and accurate information should implement national public health measures that targets both general and specific population groups such as HE students as early as possible, since this action could increase COVID-19 related knowledge, counter the infodemic and reduce fear.
A follow up study is recommended to assess the current level of students’ knowledge and fear 16 months post initial lockdown, as well as such relationship in low income countries. We also recommend to further explore the relationship between physical activity specifically moderate physical activity and fear as it has been found to be associated in our study. Furthermore, the future studies should also assess the causal effect of COVID-19 related knowledge deficit and fear about COVID-19.