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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 406-411
Are saudi healthcare students aware of COVID-19, and do they behave safely during viral outbreaks?
ZS Natto1, HK Alshaeri2
1 Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
Correspondence Address:
Dr. Z S Natto
Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_259_20
Abstract
Aims: The purpose of this study is to understand healthcare students' knowledge of COVID-19 and the precautionary behaviors they practiced in Saudi Arabia during the MERS-CoV2 outbreak. Subjects and Methods: This cross-sectional study utilized an online questionnaire consisting of 29 items and three sections. The first section collected demographic information, including age, gender, location, and level of education. The second section assessed their knowledge of clinical characteristics, treatments, and disease prevention. The third section addressed the students' behaviors. Results: Respondents included 223 students, of which 37.2% were males and 62.8% were females. The largest group of respondents included medical students (44.8%), followed by dental students (41.3%). Overall, students demonstrated a thorough knowledge of disease transmission, diagnosis, prevention, and treatment of COVID-19. However, some of the respondents could not identify the full name of the disease, Coronavirus Disease 2019 (64.6%), or provide a current estimate of the number of cases diagnosed globally (49.8%). Additionally, most of the survey respondents (93.3%) reported that they had followed social distancing guidelines issued by the Ministry of Health. Conclusion: While most health students were knowledgeable about most aspects of COVID-19, others did not follow universal precautions during the outbreak, which identifies better incorporation of such information in students' academic programs.
Keywords: Awareness, behavior, COVID-19, SARS-CoV-2, Saudi Arabia; students
Introduction 
COVID-19 is an infection caused by a virulent virus named SARS-CoV2, which recently appeared in humans and has a mortality rate of approximately 2–4%.[1],[2] The disease belongs to a family called coronaviruses,[3] which are positive single-stranded RNA.[3],[4] On March 2, 2020, the index, or first, case of COVID-19 was reported in Saudi Arabia from a man returning home from Iran.[5] Within days, several additional patients became infected due to either contact or travel.[5] Globally, the mean age of individuals infected was 45 years, and the majority was over the age of 60 (80%).[3],[6] Additionally, more than two-thirds were males (71%), and three-fourths (75%) had pre-existing health conditions. Estimates of the incubation period have ranged from 2 to 14 days,[3],[6] and bats are believed to be the most likely primary host for SARS-CoV2.[3],[6]
The most common symptoms presented with COVID-19 include a fever, followed by a dry cough, then shortness of breath, although some patients are asymptomatic.[3],[6] Additionally, about 20% of patients require hospital treatment. The treatment for COVID-19 is restricted to supportive care because there is currently no specific treatment available.[3],[6] The spread of SARS-CoV2 affected the worldwide health economy and social life. The chance of obtaining the infection is high when one comes into contact with an infected person or surface. The virus is also transmitted through droplets during coughing or sneezing, which can contaminate surfaces, items, or hands with the virus.[1],[2],[3],[4],[6] The absence of personal hygiene and regular hand washing increases the chances of infection when one touches the eyes, nose, or mouth. The severity of the disease can range from mild to severe illness with the possibility of death, primarily if associated with chronic co-morbidity.[3],[4],[6] Moreover, no prevention or treatment vaccine is available, nor is there any specific recommended antiviral therapy. Therefore, using methods of prevention, such as implementing precautions in the management of infected patients, using personal hygiene procedures like hand washing, wearing masks, and cleaning and disinfecting surfaces to manage the disease, are the best ways to reduce infection.
Medical professionals of any field often face exposure to diseases to a certain degree. However, as health science students, they learn ways to shield themselves and minimize exposure in their respective fields. These students can help to support public awareness by increasing the public's knowledge and understanding of potential risks during a virulent disease outbreak. Their behaviors regarding health issues are taken into account as a model from the public's health perspective.[7],[8] However, little is known about the awareness and behaviors of Saudi health students concerning coronaviruses,[9] and there is a need to identify any potential knowledge gaps. So, the research question was: Are Saudi healthcare students aware of COVID-19? do they behave safely during the curfew? The purpose of this study is to gauge the knowledge and behaviors of health students toward COVID-19 in Saudi Arabia.
Methods This cross-sectional study used a convenience sample of healthcare students attending university in the Kingdom of Saudi Arabia, who volunteered to participate by completing a questionnaire, and after the ethical approval was released (# 31-04-2020) from The Research Ethics committee, Faculty of Dentistry, King Abdulaziz University. Data collection was performed during the COVID-19 outbreak the first two weeks of April 2020. During this time, the Saudi Ministry of Health introduced a public health education campaign focused on COVID-19 to increase the public's awareness via television, social media, newspapers, posters, online lectures, and other internet-based resources. The campaign utilized various methods and materials to transmit knowledge about how to prevent spreading of the disease (e.g., signs and symptoms, methods of transmission, and preventive approaches like avoiding contact with infected individuals, maintaining social distance, using tissues when sneezing and coughing, using correct handwashing procedures, using masks, and avoiding touching one's mouth, nose, and eyes.[10]
Data for the study were obtained via an online questionnaire consisting of 29 items divided into three sections. The first section collected demographic information, including age, gender, location, and level of education. The second section assessed their knowledge of clinical characteristics, treatments, and disease prevention. The third section addressed the students' behaviors and explored the relationships between their knowledge, behaviors, and demographics. Most of the survey questions came from another study related to SARS-CoV2 and were previously validated.[9],[11] However, the questionnaire used in this study was adapted to address COVID-19, and new items about specific behaviors were added in light of the current status of the disease. Each knowledge question had a single correct answer based on the current evidence based. Some questions had more than one answer such as method of COVID-19 transmission, symptoms and treatment, Participants got partial correct if they did not select all the correct answers. The questionnaire was reviewed, and the content was validated by five experts in health education, clinical infectious disease, infectious epidemiology, pharmacology, and biostatistics. The pilot study showed a reliability of 0.82 with Kappa statistics.
All data analyses were conducted using SPSS (version 22). Descriptive analyses were conducted by reporting the frequency and percentages of several variables. The relationship between knowledge/behavior and gender were evaluated using a Chi-square or Fischer exact test. A P value < 0.05 was considered for determining statistical significance.
Results Two hundred twenty-three Saudi students, including both males (n = 83 or 37.2%) and females (n = 140 or 62.8%) were participated in this study. Respondents included students from 13 universities. [Table 1] summarizes the demographic characteristics of the participants. The largest group of respondents included medical students (44.8%), followed by dental students (41.3%). Among all respondents, 72.6% reported that they had heard about the novel coronavirus before the COVID-19 outbreak became widely known, and their main sources of information included social media followed by the local healthcare community. During the outbreak, they came to rely primarily on information from the Saudi Ministry of Health, followed social media. Higher education institutions and their faculty were the least utilized sources of information for respondents.
Overall awareness of COVID-19
Generally speaking, the students responding to the questionnaire demonstrated adequate knowledge of COVID-19. The second part of the questionnaire, summarized in [Table 2], evaluated their awareness of and knowledge about prevention and treatment of COVID-19. The respondents were knowledgeable about the most important aspects of COVID-19, like its modes of transmission, diagnosis, prevention, and treatment. However, a majority of the respondents (64.6%) could not state what COVID-19 stands for, and 49.8% were unable to estimate the number of new cases diagnosed globally in March 2020.
Regarding the clinical aspects of the disease, 94.6% of the respondents were aware of asymptomatic patients and knew the incubation time of the COVID-19. Additionally, 62.3% of the respondents indicated that bats were the most likely primary host for COVID-19. Regarding the most common mode of disease transmission, 62.8% selected all or nearly all of the correct options, while 37.2% selected at least one incorrect answer, such as food, blood, or sexual intercourse; 80.7% correctly identified the most common symptoms such as cough, fever, and shortness of breath.
Among the respondents, 94.2% knew that swab from nose or throat, or blood collection, were the most common ways of diagnosing COVID-19, although 5.8% selected incorrect answers such as the use of X-ray, urinalysis, or stool samples. Also, 76.7% successfully identified the possible treatment options, including antimalarial and antiviral medication, isolation, or no treatment yet available. For the questions about preventive measures, most respondents (85.7%) correctly identified the practices of handwashing, wearing a mask when sick, covering coughs and sneezes, avoiding close contact with others, and staying home when sick; 85.6% were also aware that vaccines were not currently available yet, though 40.8% correctly identified the disease's mortality rate.
Awareness of COVID-19 based on gender
Survey data regarding the awareness of COVID-19 by gender appears in [Table 2]. More males than females knew the possible primary host of COVID-19 (P = 0.001) and the approximate mortality rate for the average-risk patient (P = 0.044). However, more female students correctly identified methods of diagnosis when compared to male students (P = 0.019). No other statistically significant differences were found between both genders.
Behavior during the COVID-19 outbreak
Most respondents reported that they followed the Saudi Ministry of Health's instructions during the outbreak regarding social distance and other precautionary practices [Table 3]. However, 6.5% indicated that they had attended at least one social event during the current outbreak, and 8.5% attended a gathering with more than 10 people present. Moreover, 21.1% left their homes for nonessential business (besides going to the hospital or grocery store), and 39% did not wear a facemask outside their home. Additionally, 22.9% shook hands with others, and more than half (55.2%) reported that they did not always wash their hands or clean the surfaces they touch (57%). Male students attended events with more than 10 people (P = 0.003) and left their homes for nonessential business (P = 0.001) more frequently than females did. Overall, female students were more likely to obey precautionary instructions than were their male counterparts.
Discussion This study assessed healthcare students' knowledge and behaviors relative to COVID-19 (e.g., mode of transmission, management of COVID-19, disease prevention, and treatment options), as well as their behaviors during this pandemic. Previous studies have shown a high level of awareness among healthcare students, which was also supported by the findings of the present study.[7],[9],[12],[13],[14] This awareness, at least in part, came from social media and the Saudi Ministry of Health. In another study during the previous MERS-CoV2 outbreak, researchers found that the primary source of health information regarding MERS was the internet.[14],[15] However, respondents' awareness regarding the COVID-19 stands for what, the approximate mortality rate, and number of latest cases worldwide in March 2020 was half of the participants or below, which may be due to an absence of either interest or resources for the scholars to stay themselves updated with new events, as reported by one study during MERS-CoV2.[14]
Other research has found that Saudi healthcare students had much higher knowledge and awareness during a pandemic, including signs, symptoms, and incubation time of the disease.[9],[11],[12],[13] The results from this study indicated they had less knowledge when compared to previous research, possibly because the last outbreak took longer to spread, and students were about to know more about it in the following year, as compared to the current novel coronavirus. They were also more informed about the primary source of the infection and how to manage it when compared to the overall Saudi population.[16] This difference likely relates to their area of study, making them more knowledgeable and able to improve the knowledge and awareness within their local communities. However, other studies have shown that both healthcare students and the general population had sufficient awareness of disease signs and symptoms, methods of transmission, and ways to enhance protection,[11],[12],[16] which could result from the efforts made by the Ministry of Health and other groups in explaining these items.
The results of this study revealed a statistically significant difference for three items when comparing male and female students. While there is no specific justification for any specific gender difference, the results may indicate that males were more aware of the suspected primary host and mortality rate, while females were more likely to spot the proper diagnostic assay.
The results also revealed that a small percentage of respondents did not follow guidelines from the Saudi Ministry of Health regarding the importance of remaining at home and avoiding contact outside the home except for an emergency or essential business. Female respondents were more likely than males were to follow these roles. The key to preventing COVID-19 infection includes wearing a mask and gloves, avoiding close contact with infected persons, and practicing hand washing.[1],[2],[3],[4] However, some healthcare students did not take these precautions seriously. Reports have shown that several health care workers died of the coronavirus[17] Medical workers are at a significantly higher risk of infection than the overall population is. In Italy, over 100 doctors died from COVID-19 in February, and 19 percent of all individuals infected were employed in the healthcare industry. Globally, over 200 doctors and nurses have died combating coronavirus, most of whom became infected at work.
We recommend that healthcare students seek awareness for themselves, particularly regarding the consequence of not following universal guidelines.[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28] By reading CDC or WHO materials during a course, students can learn about various aspects of the disease and the negative consequences of disregarding guidance.[3],[4],[29] Courses on new and evolving diseases, as well as infectious epidemiology, should be introduced to healthcare students to prepare them and inform them of standard infection control measures in these kinds of health emergencies.[30]
This study targeted the COVID-19 pandemic because it can help to assess whether healthcare students have adequate potential preparation to play a role as health promoters in their communities. Additionally, this study identified a need to improve students' knowledge and behaviors, which can help to educate the overall population. Finally, it will be valuable to assess how new and emerging infectious diseases trigger students' curiosity and the extent to which they read and react to such events.
Our study has several limitations. First, there are no previously published studies of Saudi healthcare students in the context of COVID-19 as a comparison. Second, this study used a convenience sample consisting of random healthcare students who volunteered to participate in the current study, which does not represent the entire healthcare student population. Thus, future studies should utilize a larger sample size and address the recommendations above.
Conclusion Healthcare students have appropriate knowledge of most clinical aspects of COVID-19. However, their awareness of some aspects was lower than expected, and some deliberately acted against the universal guidelines during an outbreak, suggesting an opportunity to address such challenges within the students' academic programs.
Acknowledgment
This project was funded by the Deanship of Scientific Research (DSR) at King Abdulaziz University, Jeddah, under grant no. GCV 19-32-1441. The authors, therefore, acknowledge with thanks DSR for technical and financial support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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