Article

Assessing the Knowledge, Attitude Journal of Health Management

22(2) 281–290, 2020
and Practices of Students Regarding © 2020 Indian Institute of
Health Management Research
the COVID-19 Pandemic
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DOI: 10.1177/0972063420935669
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Jagajeet Prasad Singh1, Anshuman Sewda1
and Shiv Dutt Gupta1

Abstract
Introduction: The coronavirus disease (COVID-19) pandemic has impacted everyone, including stu-
dents. Accurate information about the disease, its spread, preventive measures and government-issued
advisories is critical for containing an outbreak. We evaluated the knowledge, attitudes and practices,
and the key behavioural determinants of clinical outcomes, among university students. Materials and
methods: We conducted a cross-sectional study among IIHMR University students (31 March to 10
April 2020), soon after the nationwide lockdown in India. Through purposive sampling, we enrolled 529
students, who completed a semi-structured questionnaire (44% completion rate). Knowledge level of
the participants was assessed using a scoring system, and chi-squared test and t-test were performed
to detect significant (p < 0.05) differences among various groups. Results: More than 70 per cent of
students had good knowledge of COVID-19 symptoms, mode of transmission and preventive measures,
and 66 per cent knew about treatment approaches. Social media (83%) and TV (77%) were their pri-
mary sources of information. Most students showed a willingness to follow social distancing and lock-
down guidelines; however, only 27 per cent perceived the risk of infection. Nearly all students reported
compliance with government health advisories. Conclusions: We evaluated COVID-19 awareness
and impacts of various information sources on effective outbreak containment. Improved community
engagement activities and effective communication are needed during widespread disease outbreaks.

Keywords
COVID-19, knowledge, attitude, practice, coronavirus

Introduction
Since the first reported case of coronavirus disease 2019 (COVID-19) in December 2019, in Wuhan,
China, it has quickly spread globally, prompting the World Health Organization (WHO) to declare it a

1
IIHMR University, Jaipur, Rajasthan, India.
Corresponding author:
Jagajeet Prasad Singh, Institute of Health Management Research, IIHMR University, 1, Prabhu Dayal Marg, Jaipur, Rajasthan 302029,
India.
E-mail: jpsingh@iihmr.edu.in
282 Journal of Health Management 22(2)

pandemic on 12 March 2020 (WHO, 2020a). As of 6 May 2020, the WHO had reported 3,588,773
COVID-19 cases (including 247,503 deaths) in more than 210 countries and regions (WHO, 2020b).
India reported its first COVID-19 case on 30 January 2020, in Kasaragod town in the state of Kerala,
and had reported 49,391 cases (including 1,694 deaths) by 6 May 2020 (WHO, 2020b). To contain the
disease, a nationwide lockdown was declared in India on 25 March 2020, which has been extended at
least until 31 May 2020. The citizens were advised to stay at home and maintain social distancing.
COVID-19 is caused by a previously unreported strain of coronavirus, officially named Severe Acute
Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It primarily spreads person to person through
close contact and contaminated surfaces, often via small droplets produced by the infected person
through coughing, sneezing or talking (CDC, 2020a; WHO, 2020c). COVID-19 is most contagious
immediately after the onset of symptoms, although the spread through asymptomatic cases has been
reported (Bi et al., 2020). The incubation period is around 5 days (range, 2–14 days) and common
symptoms include fever, cough and shortness of breath (CDC, 2020b, 2020c; Chen et al., 2020;
Elsevier, 2020). There is no known vaccine or effective antiviral treatment for COVID-19 (WHO,
2020c), but only symptomatic management and supportive therapy (CDC, 2020d). Therefore, it is
important to empower people by educating them and effectively communicating accurate information
about the preventive measures (e.g., handwashing, covering one’s mouth while coughing or sneezing,
maintaining social distancing and self-isolation).
As researchers continue to study COVID-19 pathogenesis, new information is being generated daily.
However, the pandemic-induced panic has led to rapid spread of myths and misinformation. Therefore,
governments have urged citizens to confirm the authenticity of information before sharing it with others.
University students represent a special subset of the student population that has more autonomy and
pressing needs to live independently but lacks life experience. Furthermore, university students are
among the most active members of various social media platforms. Their perceptions and behaviours
could have a massive impact on the spread of a pandemic (Peng et al., 2020). Therefore, it is important
to evaluate their understanding of the COVID-19 pandemic. We conducted a cross-sectional study to
access the knowledge, attitude and practices (KAP) associated with COVID-19 among a group of
university students.

Materials and Methods

Study Design
This cross-sectional study enrolled student participants from the Indian Institute of Health Management
Research (IIHMR) University, Jaipur, Rajasthan, India, between 31 March and 10 April 2020. After
obtaining consent of each participant, a semi-structured questionnaire was administered using the Lime
platform (https://www.limesurvey.org/). The permission for conducting this study was obtained from the
Academic Dean of the IIHMR University.

Sampling
Purposive sampling technique was applied to collect data from 529 students who were currently enrolled
in the IIHMR University. A total of 231 students (43.7%) who had access to the Internet during the
lockdown period and had agreed to participate completed the survey.
Singh et al. 283

Data Collection
The questionnaire was developed using the Risk Communication and Community Engagement (RCCE)
tool, which was modified according to the local setting. The RCCE tool was developed by the China
International Famine Relief Commission publication, United Nations Children’s Fund (UNICEF) and
WHO, to develop, implement and monitor an action plan for effective communication and community
engagement. This tool aided in preparing and protecting individuals, families and their health during the
early response to COVID-19 (WHO, 2020d).
The questionnaire consisted of four sections, namely demographic background (4 questions),
knowledge (17 questions), attitude (5 questions) and practices (3 questions) regarding COVID-19. The
questionnaire consisted of closed-ended questions requiring either one or multiple responses from the
choices provided. The link to the questionnaire was emailed to the participating students. They received
a system-automated email, which clearly mentioned that after starting the survey, the students could take
up to an hour to record their responses to survey questions, in order to capture their real knowledge about
COVID-19. After reading a brief introduction of the study and providing informed consent, participants
responded to a set of questions that appeared sequentially on their screen.

Data Analysis
The data were analysed using the Statistical Package for Social Sciences (SPSS) version 22 (Chicago,
Illinois, USA). Descriptive univariate analysis of the demographic characteristics was performed.
Categorical variables were summarised through frequencies and percentages, while continuous variables
were expressed as means and their standard deviations and 95 per cent confidence intervals. The correct
knowledge level was assessed using a scoring system, where each correct response earned the participant
one point; thus, the score ranged from 0 to 15 points. Students’ correct knowledge levels were defined as
‘good’ or ‘poor’ based on an arbitrary cut-off point (70%). Inferential statistics (chi-squared test and
t-test) were used to measure differences in responses and average scores between different groups of
participants. A p-value of less than 0.05 was considered statistically significant.

Results

Cohort Characteristics
A total of 231 students participated in the study. Distribution of the students by age (mean, 25.3 ± 4.1
years; range, 20–47 years), sex, degree programme and subject undertaken at graduation is summarised
in Table 1. The majority of respondents were females (65%).

Table 1. Demographic Characteristics of the Study Cohort (n = 231 Students)

Variable Count (%)

Age Mean (standard deviation)
Female 25.1 (3.4)
Male 25.8 (5.0)
(Table 1 Continued)
284 Journal of Health Management 22(2)

(Table 1 Continued)
Variable Count (%)
Sex
Female 151 (65.4)
Male 80 (34.6)
Stream
MBA-HM 159 (68.8)
MBA-PM 39 (12.6)
MBA-RM 25 (10.8)
MPH 9 (3.9)
PhD 9 (3.9)
Subject in graduation
BSc 82 (35.5)
BDS/BDA 77 (33.3)
BPharma 29 (12.6)
BA/BCom 15 (6.5)
MBBS 8 (3.5)
BBA 8 (3.5)
Others 12 (5.1)
Source: The authors.
Notes: MBA: Master of business administration; MBA-HM: MBA in hospital and health management; MBA-PM: MBA in
pharmaceutical management; MBA-RM: MBA in rural management; MPH: master of public health; PhD: doctor of philosophy; BSc:
bachelor of science; BDS: bachelor of dental surgery; BPharma: bachelor of pharmacy; BA: bachelor of arts; BCom: bachelor of
commerce; MBBS: bachelor of medicine and bachelor of surgery; BBA: bachelor of business administration.

Awareness and Source of Information

Almost all participants (99.6%) had heard about COVID-19. Social media (81.4%) and TV (75.3%)
were the main sources of receiving COVID-19-related information. Over 50 per cent of the respondents
mentioned friends, family members and WhatsApp as the source of information of COVID-19. Health
units/healthcare workers/outreach frontline workers were reported as the source by over one-third of
students. Other sources mentioned were community leaders (20%) and radio (17%) (Table 2).

Table 2. Awareness and Source of Information Among the Participating Students Regarding COVID-19 (n = 231)

95% Confidence
Indicator n (%) Interval
Awareness
Heard about the coronavirus disease 2019 (COVID-19) 230 (99.6) (98.7–100.0)
Source of awareness*
Social media 188 (81.4) (76.4–86.4)
Television 174 (75.3) (69.8–80.9)
Friends 129 (55.8) (49.4–62.2)
Family members 122 (52.8) (46.4–59.3)
(Table 2 Continued)
Singh et al. 285

(Table 2 Continued)
95% Confidence
Indicator n (%) Interval
WhatsApp 121 (52.4) (45.9–58.8)
Health unit/Healthcare worker/Outreach Front line workers 79 (34.2) (28.1–40.3)
Community leaders 47 (20.3) (15.2–25.5)
Radio 38 (16.5) (11.7–21.2)
Other (newspaper, religious leaders, traditional healers, any other community 33 (14.3) (9.8–18.8)
member)
Source: The authors.
Notes: *Multiple responses possible. Therefore, the total may exceed 100%.

Knowledge
The average knowledge-level score was 9.97 ((±2.27; range, 0–15), suggesting an overall average level
(66% or [9.97/15] × 100) of COVID-19 knowledge (Table 3). According to the arbitrary cut-off point,
60 per cent had poor and 40 per cent had good knowledge levels. More than a fifth of students acquired
10 points; however, only 15 students got a full score.

Table 3. Correct Knowledge and Mean Score of Students Regarding Indicators Related to Protective Means,
Treatment and General Awareness about COVID-19 (n = 231)

95% Mean Score 95%

Confidence (standard Confidence
Indicator n (%) Interval deviation)* Interval
Indicators related to awareness on protective means of COVID-19
Common symptoms 211 (91.3) (87.7–95.0)
Mode of transmission 156 (67.5) (61.5–73.6)
Preventive measures of infection 218 (94.3) (91.4–97.3)
transmission or spread
4.33 (1.178) (4.18–4.48)
Persons who are likely to become sick 76 (32.9) (26.8–39.0)
Duration of survival of the virus on various 136 (58.9) (52.5–65.2)
surfaces
Contagiousness of virus 204 (88.3) (84.2–92.5)
Indicators related to the treatment of COVID-19
Family of coronaviruses 86 (37.2) (31.0–43.5)
Incubation period 213 (92.2) (88.8–95.7)
Availability of any vaccine to prevent 212 (91.8) (88.2–95.3)
COVID-19 3.93 (1.304) (3.76–4.10)
Availability of current treatment 117 (50.6) (44.2–57.1)
Antibiotics effective in treating or 153 (66.2) (60.1–72.3)
preventing COVID-19
(Table 3 Continued)
286 Journal of Health Management 22(2)

(Table 3 Continued)
95% Mean Score 95%
Confidence (standard Confidence
Indicator n (%) Interval deviation)* Interval
Availability of test 127 (55.0) (48.6–61.4)
Indicators related to general awareness on COVID-19
Name of the country of origin and when 222 (96.1) (93.6–98.6)
this outbreak was first reported
Name of the five countries with the highest 26 (11.3) (7.2–15.3)
1.71 (0.631) (1.63–1.79)
number of cases
Name of the country with the highest case 147 (63.6) (57.4–69.8)
fatality rate
Total score 9.97 (2.273) (9.68–10.30)
Source: The authors.
Notes: *The mean score for the three indicator domains is calculated based on the total score of all the indicators in the
respective domain.

Various knowledge indicators were broadly categorised into three domains, namely protective
measures, treatment and general awareness about COVID-19. The mean score (4.33 ± 1.178) for the
protective measures domain was the highest, followed by the treatment (3.93 ± 1.304) and general
awareness domains (1.71 ± 0.631). No significant difference was identified for any domain (protective
means: χ2 = 0.667, p = 0.414; treatment χ2 = 0.305, p = 0.581; and general awareness χ2 = 1.252, p =
0.263). No significant sex differences were identified (protective means: t = −0.184, p = 0.854; treatment:
t = 0.332, p = 0.740; and general awareness: t = −0.916, p = 0.360).
Ninety-one per cent of students knew that fever, cough, shortness of breath and breathing difficulties
are the main symptoms of COVID-19. Two-thirds (68%) of the students knew that droplets from infected
people, direct contact with infected people and touching contaminated objects or surfaces are modes of
person-to-person transmission. A vast majority (94%) of students knew that regular handwashing using
soap and water, the use of alcohol-based hand sanitizers, covering mouth and nose while coughing or
sneezing and avoiding close contact with anyone who has a fever or cough prevent disease transmission.
Most students (92%) were aware that no COVID-19 vaccine is available. Only about half the students
knew about the diagnostic test and symptomatic treatment available. Eighty-eight per cent of the students
knew that COVID-19 is highly contagious. Almost all (96%) students knew that COVID-19 was first
reported in Wuhan city of China in December 2019. More than 90 per cent (92%) students selected 2–14
days as the incubation period of COVID-19.
The results indicated misconceptions among students regarding the COVID-19 symptoms, transmission,
prevention and treatment. Twenty per cent reported that one of the modes of getting infected was eating
contaminated food, and 16 per cent marked airborne transmission. Twenty-two per cent of students felt that
COVID-19 could be prevented by consuming cooked meat and eggs, followed by drinking treated water
(11%). About a third of the students felt that antibiotics are effective in treating or preventing COVID-19.

Attitude and Practices

Risk perception, prevention intentions and self-reported prevention practices were analysed (Table 4).
Slightly more than one-fourth of the students believed that they were at risk of getting infected with
Singh et al. 287

SARS-CoV-2. Almost all students agreed that they considered it very important to take action for
preventing the spread of COVID-19 in their communities and felt that social distancing was an important
step to prevent the spread of COVID-19. Considering the situation in India, the lockdown was considered
a good strategy. Forty-two per cent of the students suggested alternative steps to prevent the spread of
COVID-19 in the community. Suggestions included creating awareness about social distancing and
hygiene practices; door-to-door screening; performing more tests; making wearing a mask compulsory;
sealing the hotspots; extending the lockdown period; and ensuring the availability of personal protective
equipment, masks and gloves for health workers.
Nearly all students reported regular handwashing and sanitisation, covering mouth and nose while
coughing or sneezing, avoiding close contact with anyone who had fever or cough and following the
stay-at-home advisory. Thirty per cent of the students reported that they were avoiding unprotected direct
contact with live animals and surfaces that come in contact with animals. Around one-fifth of the students
reported that they were consuming well-cooked meat and eggs. Most students (87%) reported that they
would go to a health facility if a family member experiences disease symptoms.

Table 4. Attitude and Practices of Students Regarding COVID-19 (n = 231)

95% Confidence
Indicator n (%) Interval
Attitude
Likely to become infected with the new coronavirus 63 (27.3) (21.5–33.0)
Important to prevent the spread of coronavirus in the community 227 (98.3) (96.6–100.0)
Social distancing is important to prevent the spread of COVID-19 226 (97.8) (96.0–99.7)
Lockdown is a good strategy considering the situation in India 229 (99.1) (97.9–100.0)
Other strategies could be used to control the spread of COVID-19 in India 98 (42.4) (36.1–48.8)
Practices
Steps you and your family have taken to prevent coronavirus infection in recent days
Regular handwashing/sanitizing using alcohol-based cleaner or soap and 228 (98.7) (97.2–100.0)
water
Covering mouth and nose while coughing or sneezing 225 (97.4) (95.4–99.5)
Avoid close contact with anyone who has a fever or cough/social distancing 224 (97.0) (94.8–99.2)
Avoid unprotected direct contact with live animals and surfaces in contact 70 (30.3) (24.4–36.2)
with animals
Cook meat and eggs well 49 (21.2) (15.9–26.5)
Follow the advisory of staying at home 226 (97.8) (96.0–99.7)
Steps you will take if someone in your family has symptoms of COVID-19
I will go to the hospital/health unit 201 (87.0) 82.7–91.3)
I would stay in quarantine 135 (58.4) (52.1–64.8)
Other steps 32 (13.8) (9.4–18.3)

Source: The authors.

288 Journal of Health Management 22(2)

Discussion and Conclusions

For a highly contagious disease like COVID-19, protecting self and others depends on complying with
the recommended protocols. The KAP are important determinants of desired protective behaviours and
may ultimately influence the clinical outcomes at individual and community levels. This study focused
on evaluating the extent of KAP about the COVID-19 pandemic. The data were collected a week after
the formal nationwide lockdown was implemented in India; therefore, almost universal or a high level of
awareness was expected.
The Digital India initiative by the Government of India resulted in the country’s digitally connected
population amounting to approximately 688 million active users as of January 2020 (Diwanji, 2020a).
Around 35 per cent of the Indian Internet user base was between 20 to 29 years of age, the highest among
all age groups (Diwanji, 2020b). Students are likely to be carriers of infection due to their lifestyle and
close proximity with fellow students. Additionally, many students are information givers to their
respective family members, and thus play an important role in information dissemination. Therefore, this
survey aimed to provide appropriate recommendations to policymakers to facilitate effective
communication of correct information to other segments of the population.
Receiving a very high percentage of correct responses in our study is very encouraging. However,
information on the modes of transmission and the contagious nature of the disease was relatively low at
68 per cent and 88 per cent, respectively. The score was even lower (59%) about the knowledge of the
survival of SARS-CoV-2 on different surfaces. The other indicator of concern was that only 33 per cent
of the respondents knew about the vulnerable population for COVID-19. These three indicators are
important in the prevention of the disease. The elderly, people with co-morbidities and healthcare
workers were reported to be at the highest risk of contracting the disease and needed special care. The
above results support the curative approach, whereby the treatment would probably be sought early in
case of symptoms due to high knowledge; however, the preventive approach needs further strengthening.
Prevention definitely assumes the highest place for personal protection, and the knowledge in this aspect
was high. However, a poor understanding of whom to protect from infection and modes of transmission
and survivability of the virus weaken the protective approach. The results of other KAP studies done on
COVID 19 are comparable (Zhong et al., 2020); however, the difference in knowledge by sex could not
be substantiated. Additionally, low perception of disease risk reduces pandemic-induced panic; however,
inadequate knowledge of disease transmission, non-compliance to the stay-at-home guidelines and
complacency due to lower risk perception could put these individuals and others at risk. This low
perception of risk was found high among those with low knowledge of transmission, suggesting that
correct and adequate knowledge is the key to keep oneself and others safe. Non-pharmaceutical public
health measures are being promoted for mitigating the risk and impact of epidemic and pandemic
influenza (WHO, 2019).
A deeper analysis of correct knowledge, including filtering out incorrect responses, resulted in a
drastic reduction in the proportion of correct responses for those reporting symptoms, modes of
transmission and preventive measures. This reduced to an even lower level of 7 per cent among those
who were knowledgeable about the contagious nature of the disease, its survivability on different
surfaces and high vulnerability. This was alarming and indicated the need for more awareness among
the youth.
This study was conducted during the early period of the spread of disease (Stage 1) to know about the
KAP of university students. As expected, social media was the primary source of information for most
students. It is noteworthy that healthcare workers, who could be the source of correct and reliable
information, were reported as the source by only one-third of the responders. This study underscores the
Singh et al. 289

importance of social media as an important source of receiving and disseminating information. Therefore,
the health system could improve its social media platform and visibility to effectively disseminate
information to the masses.
In conclusion, our results show the degree of adherence to personal protective measures and provide
evidence to healthcare authorities and university administrations to improve communication with the
students. This study provides a valuable and early insight into the areas that need attention and issues that
need to be prioritised and improved for correctly sharing information and preventing the spread of
misinformation about an outbreak, which dilutes the effectiveness of health policies. Community
engagement activities, including communication initiatives, need to incorporate these modifications in
their awareness generation activities.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of
this article.

Funding
The authors received no financial support for the research, authorship and/or publication of this article.

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