Current Medical Issues

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 19  |  Issue : 2  |  Page : 70--77

Knowledge, attitude, and practice of university students toward COVID-19 in Sudan: An online-based cross-sectional study


Safaa Badi1, Muhammad Abdou Abdulraheem1, Anas Albagir Mustafa1, Mazin Sayed Matar1, Bashir Alsiddig Yousef2,  
1 Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Omdurman, Sudan
2 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan

Correspondence Address:
Dr. Bashir Alsiddig Yousef
Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, Khartoum 11111
Sudan

Abstract

Background: On March 11, 2020, the WHO has declared that coronavirus disease 2019 (COVID-19) is a global pandemic infection. People's commitment to the recommended control measures is generally affected by their knowledge, attitudes, and practices (KAPs) concerning COVID-19; hence, this study aimed to assess the KAPs of university students in Sudan regarding COVID-19. Materials and Methods: This was an online descriptive cross-sectional study, performed between April and June 2020 among Sudanese students enrolled in 10 universities in Khartoum state. The study was conducted using an online questionnaire designed in Arabic. The sample size in this study was 657 students. Data were collected by a convenience sampling method and were analyzed using the Statistical Package for the Social Sciences. Results: More than 60% of the participants were females, around two-thirds (68.1%) aged between 18 and 23 years. More than 81% of the participants live in urban areas; approximately two-fifth (59.5%) of them were medical students. About 59% of the participants have sufficient knowledge. Twenty-two percent of the participants reported a positive attitude, while 71% of them reported a fair attitude, and only 3.8% reported a negative attitude. Nearly 94% of them do not go out of home, and 95% do use disinfectants, solutions, and face masks to prevent contacting and spreading COVID-19. Knowledge was significantly associated with age, gender, study level, being medical or nonmedical students, attending online lectures or webinars about COVID-19, and educational level, while attitude was significantly associated with gender. Conclusion: More than half of the participants had sufficient knowledge, and the minority of them had a negative attitude toward COVID-19, while most of them had a good practice. Gender and attending online lectures or webinars about COVID-19 were the predictors for participant's knowledge.



How to cite this article:
Badi S, Abdulraheem MA, Mustafa AA, Matar MS, Yousef BA. Knowledge, attitude, and practice of university students toward COVID-19 in Sudan: An online-based cross-sectional study.Curr Med Issues 2021;19:70-77


How to cite this URL:
Badi S, Abdulraheem MA, Mustafa AA, Matar MS, Yousef BA. Knowledge, attitude, and practice of university students toward COVID-19 in Sudan: An online-based cross-sectional study. Curr Med Issues [serial online] 2021 [cited 2021 May 13 ];19:70-77
Available from: https://www.cmijournal.org/text.asp?2021/19/2/70/313816


Full Text



 Introduction



Coronavirus disease 2019 (COVID-19) became an outbreak, declared by the WHO as a public health emergency that is explicitly threatening the globe.[1],[2] Early, the virus was called 2019 novel coronavirus. Currently, it is named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).[3],[4] Coronaviruses (subfamily Orthocoronavirinae, family Coronaviridae, order Nidovirales) are single-strand, enveloped, positive-sense RNA viruses, by which illness ranging from a common cold to severe symptoms can be caused such as severe acute respiratory syndrome (SARS) as well as the Middle East respiratory syndrome.[5],[6]

COVID-19-positive patients may present asymptomatic or develop flu-like symptoms, fever, dry cough, malaise, shortness of breath olfactory, gustatory dysfunction, and in some cases, can progress to severe form and death due to alveolar damage by the virus.[7],[8] Furthermore, human-to-human transmission of SARS-CoV-2 through droplets or direct contact has been evidently demonstrated;[9],[10],[11] the incubation period is 1–14 days, mostly 3–7 days. More importantly, it is contagious during the latency period.[12] The elderly and patients with comorbidities are more prone to be infected and more likely to be concerned about complications, which can be associated with cytokine storm and acute respiratory distress syndrome. The primary control measures against the disease include social distancing, regular handwashing, and respiratory hygiene (covering nose and mouth while coughing or sneezing).[13]

On March 11, 2020, the WHO has declared that COVID-19 is a global pandemic infection.[14] Till December 29, the total number of confirmed cases in the world reached 79,931,215, and the death toll is 1,765,265. In Sudan, above 23,316 cases were diagnosed, and above 1468 cases died.[15] Rapid transmission and the probability of developing serious complications illustrate how dangerous COVID-19; to date, there is no antiviral curative treatment recommended for COVID-19.[16] People's commitment to the recommended control measures is paramount, which is generally affected by their knowledge, attitudes, and practices (KAPs) concerning COVID-19.[17],[18] To the best of our knowledge, no study has been made in Sudan to evaluate KAPs toward COVID-19, specifically among students. Therefore, this study aimed to assess the KAPs of university students in Sudan regarding COVID-19.

 Materials and Methods



Study design and site

This was an online descriptive cross-sectional study, performed between April and June 2020 among Sudanese students enrolled in 10 universities in Khartoum state. The universities have been selected according to their high capacity of students, and to their geographical distribution; they are distributed in different Khartoum localities.

Study population

All students (medical and nonmedical students) who were enrolled in these selected universities within Khartoum state were included in this study.

Data collection

The study was conducted using an online questionnaire designed in Arabic, the native language in Sudan. To ensure the questionnaire's reliability, we administered the questionnaire to two observers and rated the consistency of the questionnaire's questions separately, and then, we compared their feedback and modified the questionnaire accordingly.

The pilot study was conducted, designated with 10 students, and then, the questionnaire was reevaluated and standardized according to the response of the respondents. All ten questionnaires of the pilot study were excluded.

Questionnaire structure, variables, and interpretation

The edited questionnaire contains four parts as following: eight questions for sociodemographic characteristics, ten questions for knowledge, nine questions for perception, and ten questions for practice. Due to the lockdown process at the time of data collection, the questionnaire was entered in a Google Forms and distributed to students through a link shared on social media.

Part A contained data about independent variables including sociodemographic characteristics (age, gender, residence, kind and level of education, and sources of information on COVID-19).

Part B assessed the respondents' knowledge toward COVID-19 on 10 items. Each correct answer for a knowledge's question was given one point, and a false answer or a 'I don't know' answer was given a zero. The overall score of knowledge for each participant was then calculated, with a median cut off point of 9. The participants were divided into two categories: those who have sufficient knowledge (whose knowledge score was ≥9) and those who have insufficient knowledge (whose knowledge score was <9).[19]

Part C assessed the respondents' attitude toward COVID-19 on nine items. The items were rated on a three-point Likert scale, that is, disagree –0, neutral –1, and agree –2. The nine Likert scale items were summed together to give a total score ranging from 0 to 18, in which a higher score reflects a more positive attitude. Then, the attitude' scores were categorized as those having negative attitude (whose scores ranged 0–6), fair attitude (whose scores ranged 7–12), and positive attitude (whose scores ranged 13–18).[20]

Sampling and sample size

As the number of the target population was not known, we used the following equation to estimate the sample size

[INLINE:1]

where Z: Confidence limit = 1.96, p: Proportion = 0.5, q: 1−p = 0.5, e: Margin of error = 0.05, and n = 385.

Then, we planned to take more than the estimated sample size to ensure the generalizability of the results. Hence, the actual sample that was collected in this study was 657 students, who were enrolled from different 10 universities located in Khartoum state. The data were collected by a convenience sampling method in a period of 3 weeks from May 10 to 30, 2020.

Data analysis

Data were analyzed using the computerized program, the Statistical Package for the Social Sciences, version 26 (IBM, SPSS, Chicago, IL, USA). Results were presented as tables. A Chi-square test was used for cross-tabulation at 0.05 margins of error (P value). Descriptive statistics (frequency tables, median, histogram, means, and standard deviation) and inferential statistics (Chi-square test and binary logistic regression test) were performed.

Ethical consideration

Ethical approval (OIU-FP-6/2020) was obtained from Ethical Committee, Omdurman Islamic University, Faculty of Pharmacy. Agreement to participate in the study was obtained from each participant by click yes in the first question about he/she is ready to participate in the study before starting the survey.

 Results



Sociodemographic characteristics of the participants

Six hundred and fifty-seven university students from 10 different Sudanese universities completed the survey, with 22 years as median age, and 435 (68.1%) were aged between 18 and 23 years. Females represented 60.4% of the population. Most of the respondents (81.6%) live in urban areas. Furthermore, more than four-fifth (81.0%) of the participants were undergraduate bachelor students, and 59.5% were medical students. Regarding COVID-19, only 7.8% have tested positive or been considered as a suspected case for COVID-19. About 70% of them did not attend any workshops or online lecture regarding COVID-19. [Table 1] demonstrates the sociodemographic characteristics of the participated students.{Table 1}

Knowledge toward coronavirus disease 2019

Nearly, three-fifth (58.9%) of the participants have sufficient knowledge. Seven questions were answered correctly by more than 92% of the respondents. Nevertheless, only 44% of the participants correctly answered the question of coronavirus's common gastrointestinal symptoms, such as vomiting and diarrhea. In addition, 78.7% provided the wrong answer regarding taking antibiotics as a preventive measure against coronavirus infection [Table 2].{Table 2}

Attitude toward coronavirus disease 2019

Around one-fifth (22%) of the participants reported a positive attitude, while 71% reported a fair attitude, and only 3.8% reported a negative attitude. As shown in [Table 3], 81.1% of the students agreed that the novel coronavirus disease is dangerous. Correspondingly, 82.8% agree that lockdown can prevent the spread of COVID-19. Nearly 85% of the students agreed that COVID-19 had impacted their study. Furthermore, 93.3% did not agree that being infected with this virus is associated with stigma. Nonetheless, 46.9% thought that traditional medicines, e.g., Acacia nilotica, can reduce the severity of coronavirus's symptoms. In addition, approximately one-third agreed that media coverage about this disease is exaggerated, and 12.8% thought that this virus is a fabricated political phenomenon [Table 3].{Table 3}

Practice toward coronavirus disease 2019

As demonstrated in [Table 4], the majority of the participants (93.8%) do not go out of the home, to prevent getting infected by SARS-CoV-2. Comparably, about 95% use disinfectants, solutions, and face masks to prevent contracting and spreading COVID-19. On the other hand, 60.0% of the participants take Vitamin C as a preventative measure against disease. Moreover, 27.1% of the students use herbal products and traditional medicine such as soaked A. nilotica to protect themselves from COVID-19 [Table 4].{Table 4}

When Chi-square and Fisher's exact test were performed, we found that knowledge was significantly associated with age, gender, study level, being medical or nonmedical students, attending online lectures or webinars about COVID-19, and educational level, while attitude was only significantly associated with gender [Table 5]. Furthermore, logistic regression analysis indicated that increasing one unit of age will increase the probability of having sufficient knowledge by one fold (odds ratio [OR]: 1.049; 95% confidence interval [CI]: 0.975–1.129; P = 0.2). In addition, females were more likely to have sufficient knowledge than males by 1.5 times (OR: 1.397; 95% CI: 1.032–2.170; P = 0.033). Whereas, master students were more likely to have sufficient knowledge by 2 times than diploma students (OR: 2.102; 95% CI: 0.553–7.993; P = 0.276). Moreover, medical students were more likely to have sufficient knowledge by 1.2 times than nonmedical students (OR: 1.248; 95% CI: 0.864–1.802; P = 0.238). Fifth-year students were more likely to have sufficient knowledge by 1.8 times than the 1st-year students (OR: 1.797; 95% CI: 0.921–3.506; P = 0.085). Students who attended online lectures/workshops regarding COVID-19 were more likely to have sufficient knowledge by 1.7 times than those who did not (OR: 1.729; 95% CI: 1.222–2.449; P = 0.002) [Table 6].{Table 5}{Table 6}

 Discussion



On March 13, the first confirmed case of COVID-19 has been announced in Sudan. Since that time, the health authorities have designed and formulated many strategies to manage this critical threat. However, the number of confirmed cases and deaths has steadily increased to date, indicating the failure to control the outbreak in Sudan. One of the main strategies to control the outbreak is to educate the population about the disease, increase the knowledge and perception about preventable measures, and try to make the people comply with the proper practice. Thus, assessing KAPs about the disease can provide us with the current situation and help put a suitable policy to control the disease.[21] There are very few studies that measure the KAPs about this disease among students globally.

In the current cross-sectional study, 657 university students were enrolled in this survey. Due to the education system in Sudan, the median age of university entry is around 18 years. Hereby, the majority of the students were undergraduate students and aged between 18 and 23 years. Furthermore, females demonstrated higher frequency, as the girls represent the more immense proportions in Sudanese schools in recent years. Furthermore, because of the limited Internet access in many Sudan regions, 81.6% of the participants in this survey were found to live in urban areas. On the other hand, attending scientific workshops and webinars about COVID-19 will help increase the knowledge about control and prevention of the disease properly, as there are many misleading and unverified information found in social media.[22] However, globally, social media is still considered the main source of information about COVID-19, even for health-care professionals.[21],[22],[23],[24] In the current study, 39.1% attended workshops or webinars regarding COVID-19, and most of these students were in the medical field, which was significantly associated with the participants' knowledge (P = 0.001).

In general, knowledge is essential to provide positive attitudes and behaviors, appropriate practice toward prevention, and control of any diseases, including COVID-19. In order to improve the knowledge, since the first detected COVID-19 case, the Sudanese government has been persistently disseminating information about COVID-19 using radio, television, and verified social media pages. Many studies showed that media represent the main source of information about this disease for the public, including the health-care workers.[13],[23] In our study, 58.8% of Sudanese students had sufficient knowledge of COVID-19. This overall knowledge score was far below shown in the Chinese population, US citizens, Indian people, Jordan students, and Chinese students.[4],[25],[26],[27],[28] This may due to late appearance of Covid 19 in Sudan compared to other countries. Interestingly, female students were shown to have more knowledge about COVID-19 than males by 1.5 times (P = 0.033, CI = 1.032–2.170). This might be attributed to higher care and curiosity behaviors for females over males. Similar findings were observed in Chinese and Indian reports.[25],[27] Medical students are taught about viruses during their undergraduate training. Therefore, medical students showed significant higher knowledge scores (P = 0.004) than nonmedical students, as well as in the high-level students (P = 0.001) and elderly students, as the increment of one unit age will lead to an increase the knowledge by one fold (P = 0.01, CI = 975–1.129). Similarly, postgraduate students revealed a better score (P = 0.001) than undergraduate and diploma students. These findings are consistent with the previous study which explained that medical students are more knowledgeable about COVID-19 than nonmedical ones.[28]

Based on the results, the majority of the students responded well to the knowledge questions related to the transmission of the disease, the preventable measures, and the respiratory symptoms (fever, dry cough, and difficulty in breathing). However, their knowledge about the gastrointestinal symptoms was inadequate (44%). On the other hand, in order to prevent the development of antimicrobial resistant, antibiotics should not be used for prevention or treating the COVID-19.[29],[30] Nonetheless, 78.7% of the students felt that prophylactic antibiotics would be useful for Covid 19. Thus, in order to improve knowledge and perception, further training and education on transmission, symptoms, and management about COVID-19 are required in our population.

The knowledge about the disease has a high impact on health crisis attitudes, such as the COVID-19 outbreak.[31] Due to the low level of knowledge in the current study, most of the Sudanese students (71%) showed to have a fair attitude toward the disease. In contrast, other studies revealed that most participants (students or health-care professionals) have a positive attitude toward COVID-19.[22],[23],[28] Since the WHO declared the COVID-19 is a global pandemic,[14] it is considered a dangerous infection that might lead to xenophobia worldwide.[32] However, around 19% of the participants have not considered COVID-19 a dangerous disease, and around one-third of them thought that media coverage about the disease is exaggerated, and 12.8% of them have regarded the disease politically fabricated. On the other hand, due to the emergence of this outbreak, the Sudanese government has closed all universities and schools in the country. However, Sudanese universities have not implemented and used the online learning educational step until now. Thus, most students agreed that the disease has a significant impact on the progression of the study. Furthermore, approximately eight out of ten participants believed that they could not return to the college soon, as the outbreak will not finish within a short time. Therefore, we highly recommend the universities to initiate the online learning system to resume their study. The social stigma associated with COVID-19 remains one of the biggest challenges. Therefore, in order to reduce the stigmatization, the WHO has published a report for mental health and psychosocial considerations during the COVID-19 outbreak.[33] Interestingly, here 93.3% of the students did not agree that being infected with this virus is associated with stigma. Statistically, the overall attitude was only significantly associated (P = 0.004) with the gender; females showed a better attitude than males toward the COVID-19 due to the same reasons mentioned above.

Regarding the practice of Sudanese students, our study indicated that the majority of the students had proper practices to avoid SARS-CoV-2. Staying home is the most crucial step in controlling the transmission of the disease; interestingly, we found that the majority of them do not go out of home and avoid the crowds and do not use transportation. Furthermore, the majority of the students (95%) showed a perfect practice against SARS-CoV-2 transmission by following precautionary measures such as using disinfectants and wearing face masks in public places. Such measures are strongly recommended by the WHO and the Ministry of Health to prevent COVID-19 transmission.[30],[34] Our findings are in line with previous reports about the importance of using these measures in COVID-19 prevention.[21],[35] Collectively, these practice data reflected the government's success in disseminating the preventive guides toward the disease. In addition, the Sudanese government has applied many rules to control further the spreading of diseases, such as lockdown and the prohibition of the gathering.

Furthermore, many people try to use supplementary and traditional herbs for prevention and treatment purposes against COVID-19. Vitamin C is an antioxidant that is supportively used in treating various respiratory infections,[36],[37],[38] which may potentially be used for COVID-19 treatment and prevention.[39] Here, 60% of the students are taking Vitamin C as a preventable agent. Moreover, traditional herbal medicine has attracted more attention and has become an alternative approach to treating COVID-19 in the near future.[40] In Sudan, A. nilotica is one of the herbs that have been used extensively to manage cold and respiratory infections since a long time ago, as it is a potential antiviral activity.[41],[42] In the current study, we found 46.9% thought that A. nilotica could reduce the severity of coronavirus's symptoms, while only 27% of them are using the soaked A. nilotica to protect themselves from the disease.

The current study has some notable limitations. First, the cross-sectional design may not allow for determining the relationship between the outcomes and other factors. The study was conducted in only Khartoum state universities, so the findings cannot be generalized to all students in the country. Second, the study was carried out using the convenient sampling technique; therefore, the subjective selection bias is not avoidable, which can affect the study's internal validity. Furthermore, due to the lockdown role, the universities were closed; therefore, an online survey was used. In this regard, the study was not fully representative, as some areas in Khartoum have Internet connection problems that may limit the questionnaires' distribution. The third limitation is the limited number of questions to assess the level of KAP. Therefore, additional KAP studies with more detailed and updated questions are required to evaluate students' real situation and general population in Sudan. Despite these limitations, to our knowledge, this study is the first report that assessed the knowledge and attitude toward COVID-19 among university students in Sudan. Besides, this study is extremely important, because the number of health-care care workers is insufficient in Sudan; therefore, having knowledgeable university students will help a lot in improving the public awareness on COVID-19.

 Conclusion



More than half the participants had sufficient knowledge, and the minority of them have a negative attitude toward COVID-19 while the majority of them had a good practice. Knowledge was significantly associated with age, gender, study level, being medical or nonmedical students, attending online lectures or webinars about COVID-19, and educational level, while attitude was significantly associated with gender. Gender and attending online lectures or webinars about COVID-19 were the predictors for participant's knowledge.

Research quality and Ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board / Ethics Committee review, and hence prior approval was obtained (IRB Min. No. OIU-FP-6/2020) from Ethical Committee, Omdurman Islamic University, Faculty of Pharmacy. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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