Original Articles

Knowledge, Attitude, and Practices Associated with COVID-19 Among School Students in Bharatpur, Chitwan District of Nepal

Deepak Subedi¹², Suman Bhandari¹, Asmita Gaire¹, Milan Kandel², Sanju Subedi³, Surendra Karki⁴

doi: http://dx.doi.org/10.5195/ijms.2020.669

Volume 8, Number 3: 231-237
Received 25 07 2020: Rev-request 12 09 2020: Rev-request 03 11 2020: Rev-recd 22 09 2020: Rev-recd 16 11 2020: Accepted 24 11 2020

ABSTRACT

Background:

The virus causing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has reached pandemic proportions. Understanding people's perceptions of the disease will provide tools to improve strategies to limit its transmission. This study aims to assess the knowledge, attitude, and practices (KAP) associated with the disease among high school students.

Methods:

Cross-sectional study conducted among secondary level students (grade 8^th and 9^th) in an urban high-school at Bharatpur, Chitwan, Nepal to assess KAP using a pre-tested questionnaire. Data were analyzed using Epi Info 7.2.3.1.

Results:

We collected 101 surveys (response rate 100%). Most of the students were found to be knowledgeable about the timeline of the first outbreak (92.08%), and nearly three-fourths of participants knew about hand-washing for 20 seconds (73.27%). Information about the presence of the disease in Nepal (50.50%), its causative agent (65.53%), and symptoms (57.43%) showed that there is a knowledge gap among participants. Most of the participants were found to have a positive attitude towards the prevention and control of the disease. The majority of the respondents reported using face mask (77.23%) and adopting hand-washing measures (79.21%) as preventive strategies. The majority of the students were highly concerned about the disease.

Conclusion:

Secondary level students of Chitwan, Nepal were found to have fair knowledge and understanding of the disease, showed a moderately positive attitude towards preventive measures, and reported appropriate preventive practices against the disease. It is recommended that a similar study with a wider population be conducted to assess KAP of Nepalese people towards SARS-CoV-2.

Keywords: Health Knowledge, Attitudes, Practice; COVID-19; SARS-CoV-2; Students (Source: MeSH-NLM).

Introduction

Several cases of pneumonia of unknown etiology and origin was reported on December 31, 2019, in Wuhan City, Hubei province in China.¹ Patients with clinical symptoms of dry cough, dyspnea, and fever presented with a positive travel history to Wuhan's Huanan Seafood Wholesale Market.² On January 7, 2020, the causative agent for this unknown disease was identified as a novel type of coronavirus, and on February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) named it as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).³ Later, the World Health Organization (WHO) announced “COVID-19” as the name of the disease on February 11, 2020.³ On January 30, 2020, the WHO declared this epidemic as a Public Health Emergency of International Concern (PHEIC) under International Health Regulation (2005).⁴ On March 11, 2020, the WHO declared the COVID-19 outbreak as a pandemic.⁵ By Mid-September of 2020, this disease had spread to over 216 countries and territories across the world infecting more than twenty nine million people and nearly a million deaths. As the disease is still evolving, the magnitude of the infection and death are yet to be known.⁶

Nepal is no exception to this global threat. Nepal is particularly vulnerable as it borders with China from where the infection started and India where the disease is rapidly spreading.⁷ Likewise, thousands of Nepalese migrant workers are scattered throughout the world, including Gulf countries, European nations, USA, and Australia, who are struggling with COVID-19. In the Global Health Security Index, Nepal ranks 111^th among 195 countries and does not have adequate human and medical resources and weak health system to act upon such a medical emergency.⁸ As expected, the COVID-19 virus entered Nepal and the first case was confirmed on January 23, 2020⁹ in a 32-year-old male Nepalese student who returned from Wuhan, China on January 13, 2020.¹⁰ The second case was detected on March 22, 2020 in a Nepalese female who returned to Nepal on March 17, 2020 from France via Doha, Qatar.¹¹ After that, more than 64,000 confirmed cases and over 400 deaths have been identified until September 20, 2020.¹²

A study on knowledge, attitude, and practices (KAP) to understand the perception and behavior of people during an infectious disease outbreak can be pivotal to improve awareness and communication efforts by clinicians and public health officials.¹³ This study was undertaken to assess the knowledge, attitude, and practices associated with COVID-19 preventive measures among high school students in the Chitwan district of Nepal.

Methods

Study Design, Sample Size, and Sampling Protocol

This is a cross-sectional study conducted using a pre-tested and structured questionnaire among 101 students of grade 8 and 9 in one of the urban schools at Bharatpur, Chitwan district, during the second week of March 2020. There was no sample size calculation as we surveyed all the students in the two grades (response rate 100%).

Questionnaire Design and Administration

The questionnaire was prepared by the authors to understand the situation of COVID19 in Nepal and the target population. The survey was validated by pretesting it with 10% (n=10) of the students. At first, the school was purposively selected and the study was explained to the teachers and school principals. They agreed to conduct the survey among their students. The survey was self-administered and if there were questions about an item, the research team addressed them in the student's native language.

The following information was collected: demographic profile of the students such as age and sex; knowledge about COVID-19 including cause, signs and symptoms, mode of transmission, incubation period, vaccination and treatment; information related to the outbreak and the situation in Nepal, attitudes and perceptions towards the disease, its prevention, and control measures were assessed. In addition, participant's perception of government actions and precautions to be followed by the infected person were assessed through twelve statements with choices given as “strongly agree”, “agree”, “neutral”, “disagree”, or “strongly disagree”. The questions were close-ended. Questions were designed in English but asked in the Nepali language. After the questionnaire was filled, an awareness session was conducted on COVID-19 for an hour by veterinary interns. Ethical approval of the study was obtained from the Institutional Review Committee at Chitwan Medical College (CMC-IRC/077/078). Informed consent was obtained from the students under the supervision of teachers and after institutional approval was granted. Data were anonymized and analyzed at an aggregated level.

Data Management and Analysis

Collected data were entered in Microsoft Excel 2016, and statistical analysis was conducted using Epi Info 7.2.3.1 developed by the Center for Disease Control of the United States. Means and standard deviations (SD) were calculated for continuous variables, while frequencies and percentages with 95% confidence intervals (95%CI) were calculated for categorical responses.

Results

A total of 101 students (58 male and 43 female) participated in the survey. The mean age of the respondents was 14.8 years (Range 13-17 years). The survey showed that 67.3% of respondents had heard about COVID-19. The majority of the respondents (73.3%) were aware that COVID-19 is a viral infection while 8.9% of students thought it was caused by bacteria and 7.8% of students believed that it is caused by both virus and bacteria. More than two-thirds of the participants (69.3%) first came to know about COVID-19 from social media, while 8.9% heard from television and 5.9% from family members. Half of the participants (50.5%) were aware that a case of COVID-19 was also detected in Nepal. The majority (92.1%) were aware that this disease started in Wuhan, China.

Two participants had family members/relatives abroad who were infected with COVID-19. More than half of the participants considered it a fatal disease (58.4%) with respiratory signs (65.5%). The majority of students (54.5%) responded that they do not fear to go outside in public areas. Above 40% respondents (43.6%) believed that people with a weak immune system are at high risk of the disease, while 26.7% believed older people are at higher risk. A large part of the respondents (73.3%) was aware that the duration of the hand-washing should be at least 20 seconds to prevent the disease. Around one-third (28.7%) students believed that COVID-19 could be transmitted through infected animal to healthy human, carrier human to a healthy human, infected human to healthy human or carrier animal to healthy human. Nearly 40% respondents (39.6%) were neutral regarding the increasing risk of disease having pet animals in the home, while 17.8% strongly agreed, 18.8% agreed, 15.8% disagreed and 7.9% strongly disagreed. The majority of the respondents (59.4%) were not sure about treatment, and the 41.6% believed there is no vaccination of the disease (Table 1). Majority of the students believed that COVID-19 could be transmitted through the animal source (87.1%), contact with infected people who had no symptoms (53.5%), touching of contaminated surfaces (75.2%), infected droplets (96.0%), contaminated food and water (77.2%), contaminated fomites (64.4%), physical contact with an infected person (84.1%) and bite of the mosquito (50.5%) (Table 2).

Students' attitude regarding prevention and control of COVID-19 were found generally positive. More than half of the students strongly agreed to avoid contact with unhealthy people (57.4%), boosting immunity (52.5%), following hygienic practices (59.4%), use of proper medical service (53.5%), quarantine (51.5%) and hand wash with soap and water (59.4%) as prevention and control of the disease. Less than half of the respondents strongly agreed, avoiding touching of eyes, nose, and mouth with unwashed hands (39.6%), awareness (46.5%), education (46.5%), practice food safety (49.5%) and use of hand sanitizer (37.6%) for prevention and control. In total, 31.7% strongly agreed, 33.7% agreed, 24.8% were neutral, 5.9% disagreed and 3.9% strongly disagreed regarding unprotected contact with live wild or farm animals. 23.8% strongly agreed, 12.9% agreed, were neutral 28.7%, 19.8% disagreed and 14.9% strongly disagreed to avoid contact with healthy people for the prevention and control COVID-19 (Table 3).

Little above 50% of the students (52.5%) were adopting a high level of precautions, while 24.8% were following minimal precautions, 11.9% did not follow any precautions, and 10.9% believed in supernatural power to fight against COVID-19. More than half of the respondents (52.5%) stopped eating meat products; 60.4% were avoiding normal activities; and 73.3% were avoiding frequent touching of mouth, eye, and nose. A large number of students (77.2%) were reported using a face mask and adopting hand-washing measures (79.2%) to be protected from the COVID-19. The vast majority of the students (81.2%) were covering mouth and nose with a tissue while sneezing and using tissue paper while coughing (70.3%) and disposing of it in the trash after its use (Table 4).

More than half of the students (57.4%) strongly agreed that the government should restrict travel, isolate positive cases (34.7%), close the educational institutions if positive cases increases (47.5%), and restrict people arrival from the infected areas (46.5%). Likewise, one-third of the study population (38.6%) agreed on the isolation of positive cases. Less than half of the population (41.6%) strongly agreed, 15.8% agreed, while 20.8% were neutral and 14.9% strongly disagree on staying at home during a pandemic. (Table 5). The majority of the students strongly agreed on covering mouth and nose while cough and sneeze (63.4%) and seeking medical services (65.3%) if they are sick. Less than half of the respondents (41.68%) strongly agreed and 38.6% agreed to follow cleanliness and disinfection of frequently touched objects and surfaces. Almost half of the students (51.5%) strongly disagreed on travel of sick people (Table 6).

Discussion

This is the first KAP study towards COVID-19 among Nepalese students to the best of our knowledge. This study found that there is a significant knowledge gap related to COVID-19 among high-school students in Chitwan, Nepal and fair proportion of students were aware regarding the protective measures they need to take to prevent the spread of the disease. The finding showed that a good proportion of students need awareness regarding knowledge, their attitudes and practices.

This study shows that more than 72% of students were aware that virus is the causative agent for the COVID-19. In a similar survey conducted among high school students in Nepal on avian influenza, 52.5% of students had correctly answered virus as the cause of the disease.¹⁴ This shows that though this disease is relatively new, even good number of high school students are already aware of this. In our study, the majority of the students had general knowledge about COVID-19 like first outbreak, cases in Nepal, type of disease symptoms, and hand wash duration. This shows that most of them had good knowledge of the disease which might be due to the increased access to social media, from where 69.3% of responded acquired information on COVID-19. Consistent with our study, social media was the most pursued platform (74.8%) to acquire COVID-19 information among the young adults of Karachi, India.¹⁵ In a study conducted in China, the mean knowledge score was 90%,¹⁶ which makes sense as this disease started in China and awareness level among Chinese was higher. In a web-based cross-sectional study among Nepalese people conducted by Singh et al., 2020, knowledge score was 10.0 (±3.0 IQR) and only half participants knew about quarantine concept and safe distance to prevent disease transmission.¹⁷

Only one-third of students correctly responded on the incubation period of the disease which indicates though they have heard the name of the disease and causative agent, their depth of knowledge is limited. As the knowledge of incubation period is important from public health point of view and limited knowledge observed among students, it warrants for increased awareness program among the students who are also major source of information in several households in low-income countries like Nepal. In our study, 32.67% students knew that there was no specific treatment for COVID-19, while 59.41% were not sure about treatment. In a study among Italian undergraduate students, 70% respondents suggested there was no treatment of COVID-19.¹⁸

Our study also showed that majority of students had never heard about term zoonosis. As more than 70% of infectious disease in humans originate in animal population, mostly wildlife, it would be helpful to include one lesson on zoonotic diseases in the high-school curriculum. The majority of students were knowledgeable on disease transmission routes such as touching of contaminated surfaces, infected droplets, contaminated fomites and physical contact with an infected person. Similar to our study, majority of young adults of Karachi were knowledgeable in source of transmission and preventive measure.¹⁵

This knowledge level shall be helpful if the disease spreads to their community. A large portion of the student believed COVID-19 could be transferred through the animal source, and half of them were avoiding meat products. In the study of Singh et al., 70% participants responded that restricting consumption of poultry and other meat can prevent the spread of COVID-19.¹⁷ Though there is no scientific evidence that domestic animals play any role in SARS-CoV-2 transmission, the fake news circulating in social media that the disease may be transmitted by eating meat might have contributed to this misconception. This has caused huge losses in the livestock industy upon which the livelihood of tens of thousands of people depends on. This shows that government needs to convince people that eating meat of domestic animal is safe. More than half of the students believed mosquitoes can transfer COVID-19 which may be due to a recent outbreak of dengue, mosquito-borne disease, in Chitwan district.¹⁹

The attitude of school students toward prevention and control suggests that the majority of them had positive attitude towards the precautionary measures they need to take to protect themselves from the disease. The majority of the students strongly agreed to avoid contact with unhealthy people, boosting immunity, following hygienic practices, use of proper medical service, quarantine, and hand wash with soap and water as the preventive measure of the disease. Consonant to our study, majority of the respondents had positive perception towards universal preventive measure of COVID-19 in the study of Singh et al., 2020.¹⁷

The outbreak was rapidly spreading all over the world, and Nepal had only one recovered positive case when the survey was conducted. Many people were concerned about disease, they tried to acquire more knowledge about the disease through sources including social media. Online news was broadcasting about do's and don'ts of the disease. The reason for this observation might be associated with increased access of students to social media such as Facebook through smartphones.

In this study, the majority of the students claimed they were taking high precautions against COVID-19 which indicates practice level was satisfactory. The majority of them were using face masks (77.23%), a large portion of them claimed of regular hand-wash (79.21%) and were avoiding frequent touching of mouth, eye, and nose. However, it is not certain if they have been practicing it or not in real life. In a study among social media users in Jammu and Kashmir, India 87% participants reported washing hands with soap and water regularly and 73% reported wearing mask regularly.²⁰ In a study among medical students of Iran, 96.7% were washing hand more often, 93.8% decreased the use of public transportation, and 97.1% were avoiding coughing around people.²¹ However, in a study among public of Malaysia, only 51.2% participants were wearing mask and 87.8% were practicing hand washing.²²

Knowledge governs toward a positive attitude of the individual and their practices, but not always. Sometime fear may also play a crucial role as more than half think COVID-19 is a fatal disease, and 45.5% of students were already in fear to go in public areas. The majority of the students were highly concerned about the disease, (Table 5) and also most of them were aware of precautions need to be taken by an infected person (Table 6).

The limitations of this study are the relatively small sample size and the coverage of only one school. This was mainly due to the imposition of lockdown by the Government of Nepal on the second day of the survey, which restricted movement to survey students from other schools. As the sample size is relatively small, it may underestimate or overestimate the knowledge, attitudes, and practices among high school students.

Conclusion

This study showed that the secondary level students had basic understanding of COVID-19, had a moderately positive attitude towards preventive measures, and a good proportion of participants were adopting appropriate practices and were concerned toward the COVID-19 outbreak. There were some fundamental gaps in knowledge and attitudes among the students indicating the necessity of awareness campaigns. Furthermore, it is suggested to conduct a study in wider population including rural areas, people from different age group and education level to assess knowledge, attitude and practice toward the COVID-19 in Nepal.

Acknowledgments

We would like to acknowledge principal, teachers, and students of Vidya Bikash English Boarding School for facilitating and participating in this survey. We thank Santosh Subedi for his help in data entry. Also, we want to acknowledge to all frontline workers in the fight against the pandemic COVID-19.

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization: DS, MK, SS. Data Curation: DS, SB, AG, MK, SS. Formal Analysis: SK. Investigation: DS, SB, AG, MK, SS. Methodology: DS, SB, AG, MK, SS. Project Administration: DS. Resources: DS, SK. Software: DS, SK. Supervision: SK. Validation: DS, SK. Visualization: DS, SK. Writing – Original Draft Preparation: DS, AG, SK. Writing – Review & Editing: DS, SK.

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Deepak Subedi, 1 Bachelor of Veterinary Science and Animal Husbandry (BVSc & AH). Paklihawa Campus, Institute of Agriculture and Animal Science, Tribhuvan University, Rupandehi, Nepal
2 New Hope Agrobusiness Nepal Private Limited, Bharatpur, Chitwan, Nepal

Suman Bhandari, 1 Bachelor of Veterinary Science and Animal Husbandry (BVSc & AH). Paklihawa Campus, Institute of Agriculture and Animal Science, Tribhuvan University, Rupandehi, Nepal

Asmita Gaire, 1 Bachelor of Veterinary Science and Animal Husbandry (BVSc & AH). Paklihawa Campus, Institute of Agriculture and Animal Science, Tribhuvan University, Rupandehi, Nepal

Milan Kandel, 2 New Hope Agrobusiness Nepal Private Limited, Bharatpur, Chitwan, Nepal

Sanju Subedi, 3 Bachelor of Public Health (BPH). Chitwan Medical College, Tribhuvan University, Chitwan, Nepal

Surendra Karki, 4 PhD, Epidemiology. Department of Epidemiology and Public Health, Himalayan College of Agriculture Sciences and Technology, Kirtipur, Kathmandu, Nepal

About the Author: Deepak Subedi is a recent graduate of Bachelor of Veterinary Science and Animal Husbandry (BVSC & AH) from the Institute of Agriculture and Animal Science, Tribhuvan University, Rupandehi, Nepal. He is a registered veterinarian (NVC Reg No. 1301) under Nepal Veterinary Council and currently working in New Hope Agrobusiness Nepal Private Limited, Bharatpur, Chitwan, Nepal as a poultry technical executive. He is the founder president of Creative Veterinary Student Association, Nepal, and the recipient of the most inspirational Tunza Eco Generation Ambassador of the 21st Eco-generation Regional Ambassadors.

Correspondence: Deepak Subedi. Address: Siddarthanagar, Rupandehi, Lumbini Province, 32900, Nepal. Email: subedideepu26@gmail.com

Editor: Francisco J. Bonilla-Escobar Student Editors: Madeleine Jemima Cox, Abdul Basith KM, Lakshmimathy Subramanian Copyeditor: Sohaib Haseeb Proofreader: Ciara Egan, Yusuff Adebisi Layout Editor: Sushil Dahal

Cite as: Subedi D, Bhandari S, Gaire A, Kandel M, Subedi S, Karki S. Knowledge, Attitude, and Practice Associated with COVID-19 Among School Students in Bharatpur, Chitwan District of Nepal. Int J Med Students. 2020 Sep-Dec;8(3):231-7.

Copyright © 2020 Deepak Subedi, Suman Bhandari, Asmita Gaire, Milan Kandel, Sanju Subedi, Surendra Karki

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 8, NUMBER 3, December 2020