Knowledge, Attitude and Practice Associated with COVID-19 among University Students: a Cross-Sectional Survey in China


 BackgroundThe current COVID-19 pandemic is effectively constrained by intensified public health measures in China, among which ubiquitous education plays a vital part.ObjectiveThis survey aims to understand the status quo acquisition of the ongoing public health education campaign among university students. MethodsWe designed this cross-sectional survey to investigated the knowledge, attitude and practice (KAP) associated with COVID-19 among university students during their household isolation at the peak of this pandemic. 872 university undergraduates were recruited from 10 universities in Shaanxi Province, China, in a stratified cluster sampling method. A self-administered and close-ended questionnaire was answered by subjects online voluntarily and anonymously to collect their answers regarding their KAP associated with COVID-19.ResultsResults showed that appropriate knowledge was acquired by 82.34% subjects, but the level was significantly higher in students from public universities and medical programs than in their counterparts (P＜0.05). 73.81% subjects reported positive attitude, with level significantly higher in females (P＜0.01). Proactive practice was found in 87.94% subjects. Taken together, the score of KAP was 4.12±0.749, 8.54±1.201, and 8.91±1.431 respectively, suggesting a positive correlation between attitude and practice (r=0.319, P＜0.01). Total KAP score was 21.57±2.291, apparently correlated with gender (r=0.096, P=0.005) and major (r=-0.081, P=0.017).Conclusions﻿Most university students acquired necessary knowledge, positive attitude and proactive practice towards COVID-19, but their KAP score significantly varied by gender, major and school type.


Introduction
Since late December 2019, numerous viral pneumonia cases of unknown causes have been consecutively reported in Wuhan city, China. Then the pathogen was soon isolated, analyzed, performed viral genome sequencing and finally identified as a novel strain of coronavirus. Different from both MERS-CoV and SARS-CoV, this is identified as the seventh member of the coronaviruses family that infects human [1].
Increasing evidence shows that, COVID-19 is less lethal but more contagious than SARS-Cov and MERS-Cov [2][3] [4]. The outbreak soon spread to the whole country, reached beyond the boarder and was declared as a Public Health Emergency of International Concern by World Health Organization in late January, 2020 [5].
To curb the virus, China quickly announced first-level public health emergency response and adopted a series of extraordinary measures during the so called "massive isolation and disinfection" period in the extended Spring Festival holiday, ranging from the lockdown of epicenter city, ubiquitous public health education, massive disinfection, rigorous in-door quarantine and person-to-person health check-ups, as well as delayed school and workplace opening date, etc [6]. The outbreak impacted all stakeholders in education in an unprecedented way. Among them, university students represent a special group characterized by more autonomy and pressing need to live independently, but lack of life experience. Thus their perceptions and behaviors are presumably more affected by this pandemic. Therefore, the authors conducted a cross-sectional investigation on the knowledge, attitude and practice (KAP) associated with COVID-19 among university students to assess their current acquisition of this public health education campaign, which reflects the response of young people in China to a certain degree. We hope our investigation will provide evidence to help health authorities improve COVID-19 education and preventative measures in university.

Sampling of subjects
This survey employed a stratified cluster sampling method, enrolling 872 university undergraduates from 10 universities in Shaanxi Province, China, during February 23 to 28, 2020 when they were isolated and observed at home. Data were collected using an online convenient questionnaire tool named WJX (https://www.wjx.cn/). All subjects were informed of the survey purpose and the option that they may withdraw from the study at any time. They all volunteered to participate and written informed consents were obtained from all adult subjects or if subjects were under 18, from a legal guardian for inclusion before they started. This study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Xijing Hospital."

Survey tool
The questionnaire was developed with questions adapted from COVID-19

Diagnosis and Treatment Protocol (Tentative Version Six) issued by National Health
Commission of China [7]. The questionnaire included 6 demographic variables (age, name of university, grade, major, type of school, and birthplace), 7 variables about knowledge of COVID-19 (classification of infectious disease, major route of transmission, main clinical manifestation, incubation period, susceptible population, as detailed in Table 1), 5 variables about attitude towards COVID-19 (human-to-human transmission, wild animal consumption, endurance to emergency, impact on study, pandemic control measures, as detailed in Table 2) and 5 variables of practice related to COVID-19 (self-protection, help frontline rescue, meet cured patients, stay isolated, return to school, as detailed in Table 3).

Score grading
A common grading method was used for each variable in this KAP questionnaire as follows. 1 point was given to the correct option, and 0 for the incorrect answer in the Knowledge Section; 2 for positive, 1 for neutral and 0 for negative option in the Attitude Section; 2 for proactive, 1 for neutral and 0 for passive option in the Practice Section.

Data processing and analysis
Data were processed using SPSS 18.0 software. T test was used to compare mean values of variables. Chi square test was utilized to compare categorical variables and ratios. Spearman correlation analysis was employed to compare two variables; α=0.05, P＜0.05 was reckoned statistically significance in two-sided test.

Demographical characteristics of subjects
All the subjects were recruited from ten regular universities in Xi'an, Shaanxi The hometown of student was reported as covering 28 provinces, autonomous regions and municipalities of China.

Knowledge of COVID-19
COVID-19 related knowledge was assessed by 5 items. Each question and its options were described with graded scores in Table 1. Among the total 4,360 answers, 3,590 (82.34%) indicated correct knowledge. To further analyze, the female had significantly higher score for K5 than the male; public school students had significantly higher score for K1 and K4 than private school students. Other items were found with no statistically significant difference between groups (Table 4) 10 / 24

Attitude toward COVID-19
Items about COVID-19 attitude including 5 single choice questions. Each question and its options were described with graded scores in Table 2. Among all 4,360 answers, 3,218 (73.81%) indicated positive attitude. The female had scored significantly higher for A1 and A3 than the male. Students from public schools scored significantly higher for A2, A3 and A5 than those from private schools ( Table 5).

Practice related to COVID-19E
Practice related to COVID-19 was assessed by 5 single-choice questions. Each question and its options were described with graded scores in Table 3. Among the 4,360 answers collected, 3,834 (87.94%) indicated proactive practice. The female had significantly higher score for variables P2-P5, except P1. Students in higher graders had significantly higher score for P5 than freshmen ( Table 6).

Comparison of COVID-19 related KAP scores between different groups
KAP score related to COVID-19 was 4.12±0.749, 8.54±1.201, and 8.91±1.431 respectively. Knowledge level was significantly higher in students from public schools and medical programs than their counterparts from private schools and non-medical majors (P＜0.05); attitude level was significantly higher in females (P＜ 0.01); practice level was found with no statistically significant difference between groups by gender, grade, major or school style (Table 7).

Total KAP score related to COVID-19 among university students
Total KAP score was 21.57±2.291 among the subjects, in which a positive correlation was observed between the attitude and practice (r=0.319, P＜0.01). Total KAP score was notably correlated to gender (r=0.096, P=0.005) and major (r=-0.081, P=0.017).

Discussion
Since its outbreak in December 2019, COVID-19 has become the center of global concern. The strong affinity of SARS-Cov-2 to receptors in respiratory system [8] imposes a critical threat to global public health.  [9], indicating the outbreak is effectively controlled in China.
Public health education is recognized as an effective measure to prevent and control public health emergency by preparing the public against such situation. It may affect people's KAP by spreading appropriate knowledge, mitigating panic and encouraging positive attitude, and as well as keep people comply with aligned and desired practice.
All these KAP elements are crucial to ensure effective prevention and control of the emergency.
This cross-sectional survey on 872 university undergraduates found that most students were well informed with COVID-19 related knowledge, showed positive attitude and proactive practice against the outbreak, indicating that effective health education has been delivered by the administration through the massive public education campaign (especially via Internet), which consists with the results of investigations on H1N1 related KAP among university students in South Korea, UK and Hong Kong [10][11] [12]. This investigation also revealed that the female had significantly higher score on item "clinical manifestations of COVID-19", which consists with the result of a Saudi Arabian investigation on MERS [13]. We also found the female had a significantly higher score on attitude score and KAP total score. A few other study also reported that women was superior to men in terms of the knowledge and practice (hand hygiene, wearing a mask) related to infectious diseases  [17]. Our survey also revealed that, facing the risky human-to-human transmission, more females reported they will keep rational and can protect themselves. Besides, females showed more aversion to wild animal consumption and alleged they will accuse those eaters.
Moreover, the significantly higher score for COVID-19 related knowledge gained by subjects from public schools and medical programs may be explained by the characteristic educational situation in China that compared to private schools, public universities are innately superior in their numbers and scales, quantity and quality of students and teachers, as well as supports from the authorities, etc [18]. The significantly higher scores of knowledge gained by medical students can be further explained by their trainings in clinical medicine and public health. Their sense of duty and responsibility as a candidate medical professional may also drive them to present more positive attitude and proactive practice during this public health emergency [19].
This investigation has some notable limitations. First, the convenient sampling method, as opposed to random sampling, may not avoid subjective selection bias and thus diminishes the internal validity. Second, the nature of cross-sectional study design was not able to determine causality between the variables. At last, our subjects were enrolled from ten universities from a single locality, though they were staying at hometown in twenty-eight provinces and regions at the time of survey. Still, they may not reflect the whole picture of Chinese university students at large.
Despite these limitations, to our knowledge this study is the first investigation on the current KAP related to COVID-19 among Chinese university students, thus it provides invaluable insights and evidence to public health education and preventative measures at large in Chinese universities during the COVID-19 pandemic. Results revealed that the overwhelming majority of Chinese undergraduates had the basic knowledge of COVID-19, but their performance varied by school type and major.
Attitude towards COVID-19 was significantly different between genders. Taken together, these results suggest that gender, major and school style potentially affect student's response to COVID-19 outbreak and acquisition of public health education, which should be noticed by education and health authorities. These factors should also be considered when they formulate contingency plan or train the students against similar public health emergencies.

Conclusion
Most Chinese university students were informed of basic information, possessed positive attitude and proactive practice towards COVID-19, indicating the efficacy of present public health campaign. However, results also revealed that gender, major and school type should be taken into consideration when health and education authorities formulate tailored public health trainings and improve their preventative measures against the epidemic.

Declarations
Wang performed the survey; K Zhang critically reviewed and improved the manuscript; ZH Z and P Zhu improved data interpretation and revised the manuscript.
All authors substantially contributed to the study and approved its submission.