Evaluation and Program Planning 100 (2023) 102327

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Evaluation and Program Planning

journal homepage: www.elsevier.com/locate/evalprogplan

Performance of two educational approaches in increasing knowledge of

high-school students about COVID-19 during the first wave of pandemic
Zahra Janbani a, Freshteh Osmani b, c, *, 1
a
Master of surgical technology,Faculty member, Faculty of Paramedical Sciences, Birjand University of Medical Sciences, Birjand, Iran
b
Infectious diseases Research center, Birjand University of Medical Sciences, Birjand, Iran
c
Assistant Professor,Department of Epidimiology and Biostatistics, Faculty of Health, Birjand University of Medical Science, Birjand, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: The coronavirus disease (COVID-19) pandemic has greatly altered peoples’ daily lives. Teachers and
Adolescent health students were found quite unprepared for the emergence of the first COVID-19 wave. So, improving the
Covid-19 knowledge of students about COVID-19 is an important issue.
Coronavirus
Methods: In this study, 240 high students attended. Two interventions with the same contents, but in different
Intervention study
Audio-visual media
ways, were delivered. A structured questionnaire was utilized to collect data on demographic information, and
Knowledge information about the behavioral intention toward COVID-19 before and after the educational interventions as
well as a control group that received no educational intervention.
Results: students in all arms had similar baseline knowledge of COVID-19. The results of the post-analysis showed
the efficiency of educational techniques in increasing students’ knowledge about COVID-19. So the audio-visual
training method performed significantly better than the visual training method (p = 0.03). Both approaches
achieved better scores than the control group (P < 0.001).
Conclusion: During the outbreak of COVID-19, multimedia-based learning is a more effective educational
approach and can improve the learning outcomes related to COVID-19 and achieve learning goals without close
contact than written materials.

1. Introduction
The new 2019 Coronavirus epidemic is more extensive in compari­
son to previous human Coronaviruses, indicating the extremely high
transmission power of this virus (Farnoosh, Alishiri, Zijoud, Dorostkar
& Farahani, 2020). Knowing to create healthy behaviors is the first
necessary element for changing the belief and behavior of people (Tian,
Rong, Nian & He, 2020). So, one of the proper procedures for decreasing
the spread and mortality rate of Covid-19 disease is increasing people’s
awareness about the ways of transmission and prevention of the disease
(Hewitt et al., 2020). However, social networks, have considerably
increased the propagation of information about this disease. But, this
platform may publish and extend false or fake information. Valid and
accurate information is essential to help individuals to cope with this
pandemic (Farnoosh et al., 2020). On the other hand, schools have been
central in the debate about COVID-19. On the one hand, many have
argued that they should be kept open, given their importance to
youngsters and the future of the country, and the effort many countries
have made in establishing protocols to keep them safe (Alfano, Ercolano,
& Cicatiello, 2021). Lockdown policies have had a positive impact on
the pandemic, and they have been able to reduce the number of
COVID-19 cases in the countries that implemented them.
Iran is one of the youngest countries (Rahaei, Mirzaei Alavijeh,
Soltanei, Bakhshi, & Shadkam, 2012) and adolescence is a critical period
for health promotion. (Mirzaii & Olfati, 2015). On the other hand, stu­
dents are considered the vulnerable group (Jamshidian, Hasanpour, &
Najafi, 2017). Also, teaching can cause learning in the learner, and
learning is a process for acquiring awareness and skills that can lead to
improving their ability in making the right decisions to change to pre­
ventive healthy behaviors (Stanhope & Lancaster, 2004). Also, due to
the COVID-19 pandemic, online learning has been adopted in all stages
of education. One of the available methods of teaching is using educa­
tional pamphlets (Ewles & Simnett, 2003). Among all the approaches
used in health education, none of them was as penetrating as printed

* Corresponding author at: Infectious Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran.
E-mail address: dr.osmani68@gmail.com (F. Osmani).
1
ORCID: https://orcid.org/0000-0002-6112-7131

https://doi.org/10.1016/j.evalprogplan.2023.102327
Received 6 September 2021; Received in revised form 10 May 2023; Accepted 26 May 2023
Available online 29 May 2023
0149-7189/© 2023 Elsevier Ltd. All rights reserved.
Z. Janbani and F. Osmani Evaluation and Program Planning 100 (2023) 102327

educational materials (Barnes, Neiger, Hanks, Lindman, & Trockel,
2000). Also, video tutorial is created indirectly and have advantages
such as durability of information, simplicity of use, and
cost-effectiveness (Asselin & Cullen, 2001). Now, social media has been
able to impressively change the social system of different countries
(Soleimani Pour, 2012). Also, using social media is growing rapidly in
most fields of healthcare and education (Lee & Lee, 2010). Research has
proven that advances in information technology positively affect the
approach of high school students on learning in contemporary educa­
tional environments. The effectiveness of online education has shown
several advantages such as easy access to experts and exposure to
educational environments. There are also several disadvantages of on­
line education, such as: computer compatibility, or technical issues
(Alfano & Ercolano, 2020). This pandemic is leading to social distancing
policies worldwide (Bayham & Fenichel, 2020). While the first policy is
aimed at strengthening the capacity of the health system to deal with the
effects of COVID-19, the latter aims to ease the burden on the health
system by reducing the probability of contracting the virus for all citi­
zens (Alfano, 2022). School closures are some of the highest-profile
social distancing measures used to slow the spread of an infectious
disease. Many countries in Asia and Europe have instituted a nationwide
school closure. These closures prevent contact among children and
reduce cases (Bayham & Fenichel, 2020). Social media provide infor­
mation about the pandemic to adolescents and may influence prevention
behaviors. Owing to the need for strategies for dealing with COVID-19,
schools can be considered as a center to raise adolescence awareness.
Hence, this study aimed to assess the performance of two educational
interventions about knowledge of protective strategies of COVID-19
among high school students in 2020 and determine students’ behavior
change on the pandemic as a randomized controlled trial study.
ways of virus transmission, and conditions that require home quaran­
tine. So, each correct answer was given one point. The same question­
naire was distributed at the end of the intervention after the educational
content was removed from the reach of the students.
The scoring of questions was 1 for the correct answer and 0 for an
incorrect or "I don’t know" answer. The total score of students’ knowl­
edge was expressed as the percentage of correct answers over a range of
0–100 %.
Some items of the questionnaire such as satisfaction measurement
items ranked by a 5-point Likert scale, ranging from 1 = completely
disagree, to 5 = agree; then the total score of these questions was
expressed as Mean±SD.
All survey questions were optional and took participants approxi­
mately 7 min to complete.
Primary endpoints for the study included participants’ improvement
in knowledge. Improvement in knowledge was defined as the
improvement in knowledge between the baseline and the end of the
study. The secondary endpoint was satisfaction with the educational
materials.
2.4. Data analysis
Paired t-test and analysis of variance (ANOVA) were used to analyze
continuous variables. The chi-square test was used for examining the
homogeneity of demographic categorical variables in groups. For all
statistical tests, p < 0.05 was considered statistically significant.
3. Results
3.1. Demographic characteristics of participants

2. Methods
Totally, from the four high schools, 240 students were included in
the analysis. Overall, all students were female, with an average age of
2.1. Participants
16.4 ± 1.4 years (SD) ranging from 13 to 18 years. The majority of
students (27.5 %), were in the 11th grade of education level. Among
All procedures were approved by the lead author’s university insti­
students, 37 % stated that they have a history of disease among their
tutional review board of Birjand University of medical science, Iran
family members. Also, according to the answers given, the most used
before the recruitment of the first participant. This interventional study
source of information receiving about covid-19 was social networks (35
was implemented in two months June and July 2020 at one of the high
%), after that, radio and TV (30 %), friends and acquaintances (21.1 %),
schools in Birjand. Two-stage random cluster sampling was applied to
and websites (14.9 %) were other using sources respectively. The
include all eligible students who need to have internet access. Totally,
mother’s level of education of the majority of respondents (49 %) was
240 students in three groups of 80 were randomized in a simple, non-
secondary education. A preliminary examination of the groups showed
stratified randomization scheme as a control group and two interven­
that there were no significant differences in baseline characteristics
tional groups.
including baseline knowledge and demographic variables between the

2.2. Study setting

Table 1
Comparison of demographic factors between the study groups.
The audio-visual group was taught instructions on how to access the
online designed video, which addressed all the characteristics of COVID- Variable Written audio- control p
group visual group value
19, transmission ways, preventive measures, and guidelines during
group
home quarantine. The same educational content was prepared as written
History of No 32(40) 44(55) 45(56.25) 0.81
but delivered in a pamphlet. The control group received no educational
disease in
intervention. Participants were instructed to view the material at least their family
once during the study and were allowed to view the material as many as Yes 48(60) 36(45) 35(43.75)
desired. Source of Radio and TV 24(30) 28(35) 21(26.25)
information
about
2.3. Assessment of knowledge covid-19
Website 12(15) 10(12.5) 14(17.5)
At the beginning of the survey, baseline knowledge regarding covid- Social 26(32.5) 23(28.75) 29(36.25) 0.21
19 was evaluated with a standard questionnaire, consisting of several networks
Friends and 18(22.5) 19(23.75) 16(20)
questions. It is worth mentioning that demographic and socioeconomic
acquaintances
information including (age, family income level, grade, parent’s edu­ University 39(48.7) 32(40) 37(46.2)
cation, and the most used source of information) were collected once education
during the study. Mother Secondary 36(45) 41(51.2) 39(48.7) 0.36
Different parts of the questionnaire included knowledge assessed by education education
Read and write 5(6) 7(8) 4(5)
questions containing characteristics of COVID-19, signs and symptoms,

2
Z. Janbani and F. Osmani Evaluation and Program Planning 100 (2023) 102327

groups (p.value>0.05), therefore, the study groups were homogenous.
(Table 1).
3.2. Assessment of performance of educational interventions
The results of the ANOVA analysis showed that there were no sta­
tistically significant differences between the three studied groups in all
dimensions of knowledge evaluated before intervention. In contrast,
after the intervention implementation, significant differences were
observed between the control group against the two intervention groups
in all of the questionnaire dimensions. Among written and audio-visual
interventions, the obtained results showed more effectiveness in the
audio-visual group based on increasing knowledge, but this improve­
ment wasn’t statistically significant according to Tukey’s test result (p.
value=0.08). The mean knowledge scores were 84.31 ± 11.31, 76.41 ±
8.43, and 48.1 ± 15.41 in written, audio-visual interventions, and
control groups respectively with a significant difference (p.value<0.05)
(Table 2).
3.3. Students’ satisfaction regarding appeal with used educational tools
The mean satisfaction score in the audio-visual group regarding ap­
peal with their material was 8.6 ± 0.8, significantly higher than the
written pamphlet group (7.1 ± 1.4) (p < 0.001). Also, at the end of the
study, all educational content was delivered to all students, and the
results of the survey showed that students rated the efficiency of the
educational video higher than educational written content significantly
(p < 0.001).
3.4. Relationship between students’ COVID-19 knowledge and
sociodemographic characteristics
There was a statistically significant difference between the mean
score of students’ knowledge based on their assessed sociodemographic
characteristics in this study(P ≤ 0.05), except for the family history of
coronavirus variable (P = 0.52).
4. Discussion
The Covid-19 pandemic significantly disrupted the lives of people. As
well as improving the quality of life, training programs can reduce the
incidence of the disease, mortality, and cost of treatment. Due to the lack
of proper planning and inadequate educational programs to increase
public awareness of disease prevention, the incidence rate of infectious
diseases such as COVID-19 is high. In this regard and to reduce the
mortality rate education should be tried to increase public awareness.
So, to address these issues, we designed two educational tools aimed to
increase high school students’ knowledge of covid-19 and affect
behavioral changes in students.
This study investigated the effectiveness of the performance of these
designed educational tools in improving high school students’ knowl­
edge about Covid19. It is worth mentioning that a high proportion of all
students in three arms initially had little knowledge about preventive
measures for COVID-19.
Although early research has suggested that adolescents may be less
susceptible to severe symptoms from COVID-19, there is concern that
adolescents who do not perceive themselves as high-risk or do not
believe that the virus is of serious consequence may be less likely to
engage in social distancing and disease prevention behaviors (Neidhöfer
& Neidhöfer, 2020; Shao, 2020).
The results of this study showed that both designed educational tools
could improve students’ knowledge. However, the results showed more
effectiveness in the audio-visual group than in a pamphlet, showing the
superiority of the audio-visual over the written one. In line with the
results of the present study, another study showed that educational
videos could increase knowledge significantly; so, well-designed videos
can help to increase knowledge about HPV infection (Ali, Ping, Praja­
pati, Padmapriya, & Nazer, 2017). In another study, the effectiveness of
the pamphlet educational tool in promoting students’ knowledge and
attitudes about AIDS was confirmed (Bastami, Zareban, Beiranvand, &
Vahedi, 2012). The results of another study expressed that female high
school students’ awareness about AIDS had increased after training with
educational videos (Shahid et al., 2020). Several studies showed that
audio-visual materials were effective in training about HPV (Krawczyk
et al., 2012; Huang et al., 2020; Guan et al., 2020).
Zhong et al. showed that educational programs are a great tool to
enhance public awareness of COVID-19. Also, their results expressed
that the right awareness leads to appropriate preventive practices
(Zhong et al., 2020).
The strengths of educational audio-visual tools can be explained by

Table 2
Comparison of COVID-19 Knowledge before and after the interventions in the studied group (n = 240).
Area of Knowledge Before intervention After intervention

Pamphlet Video Control Pamphlet Video Control

(n = 80) (n = 80) (n = 80) (n = 80) (n = 80) (n = 80)

Definition Correct 22.2 % 20.18 % 26.18 % 72.2 % 78.28 % 29.1 %

I don’t know 32.3 % 40.3 % 37.9 % 12.3 % 13.3 % 31.9 %
Incorrect 43.5 % 30.6 % 35.9 % 15.5 % 8.46 % 30 %
2 2
Significance test/p value Х = 12.18, p.value= 0.52 Х = 43.24, p.value= 0.003
Signs and symptoms Mean±SD 3.2 ± 1.6 4.1 ± 2.9 3.8 ± 0.1 12.4 ± 3.6 14.1 ± 5.9 4.8 ± 3.1
Significance test/p value F= 6.21, p.value= 0.27 F= 68.19, p.value< 0001
Infection control Mean±SD 4.4 ± 2.6 5.2 ± 1.3 4.9 ± 2.3 10.5 ± 3.6 9.2 ± 2.9 4.6 ± 7.3
measures for COVID19
patients
Significance test/p value F= 5.14, p.value= 0.17 F= 46.15, p.value= 0.036
Mode of transmission Mean±SD 8.7 ± 1.4 7.2 ± 2.9 8.3 ± 1.2 17.3 ± 4.2 15.2 ± 3.1 8.3 ± 1.2
Significance test/p value F= 6.21, p.value= 0.27 F= 73.31, p.value< 0001
Nutrition during Corona Mean±SD 10.2 ± 7.7 9.2 ± 4.6 10.6 ± 4.2 21.2 ± 8.3 18.4 ± 2.9 11.6 ± 2.3
Significance test/p value F= 14.21, p.value= 0.81 F= 56.21, p.value= 0.016
How to use protective equipment Mean±SD 16.2 ± 3.6 16.3 ± 5.2 15.7 ± 3.6 29.5 ± 4.5 27.3 ± 3.6 13.7 ± 9.4
Significance test/p value F= 7.91, p.value= 0.67 F= 65.21, p.value= 0.013
High risk groups Mean±SD 7.56 ± 2.3 8.5 ± 3.6 8.15 ± 5.1 19.8 ± 7.3 16.5 ± 6.2 7.18 ± 8.1
Significance test/p value F= 12. 1, p.value= 0.43 F= 46.32, p.value< 0.001
Preventive methods Mean±SD 11.2 ± 3.3 12.3 ± 1.7 11.4 ± 6.6 21.7 ± 8.3 18.3 ± 6.4 12.4 ± 3.9
Significance test/p value F= 9.24, p.value= 0.33 F= 32.12, p.value= 0.021
Total awareness Mean±SD 43.98 ± 15.18 44 ± 13.98 47 ± 15.53 76.41 ± 8.43 84.31 ± 11.31 48.1 ± 15.41
Significance test/p value F= 98.34, p.value= 0.53 F= 164.14, p.value< 0001

3
Z. Janbani and F. Osmani
the fact that they were appropriate to the age of adolescents with simple
and understandable content. Hence, it can play an efficient role in
conveying information to high-school students and can be used to in­
crease their knowledge about preventive measures for covid-19.
Dissemination of information about the prevention of COVID-19
among people by using informative/educational materials such as
pamphlets may be a valuable tool as an adjunct to healthcare service
protocols and control programs. Pamphlets are generally valuable
informative tools, useful for disease control programs; however, they
should be used within the context of a continuing educational process.
Pamphlets can be used to generate effective changes and strengthen
control, health, and educational measures. Pamphlets are more afford­
able since they do not require access to computers or software.
Pamphlets are informative published subjects containing training
information. Designing and developing educational pamphlets is very
simple and low-cost and can be widely distributed among people.
The result of Krawczyk et al. showed that written and video in­
terventions were effective in educating about HPV and increasing young
adults’ vaccination intentions.
Furthermore, the result showed that most students received news
and information about COVID-19 from social networks.
Also, a significant association between the total score of students’
knowledge and their mother’s education level was observed, so that, the
students with university education mothers had higher knowledge than
other students. It seems that these students had more self-efficacy
(Mahmoodpoor, Valadkhani, Ozayi, & Asayesh, 2017).
Moreover, the obtained results showed that by increasing the grade,
students’ knowledge scores increased.
According to the results reported by Karimi et al., with increasing age
and grade, students’ awareness about AIDS increased.
One limitation of the study was despite our best efforts at randomly
assigning students, nearly, 20 % of them in the video were older than age
14 compared with those in two other groups.
5. Conclusion
The findings of this study expressed that education by tools such as
audio-visual and written materials could increase students’ knowledge
about the symptoms and preventive measures of covid-19. Also, it can be
concluded that online audio-visual educational tools may become an
innovative and efficient way to deliver education requiring long-term
health behaviors. Audio-visual educational tools can be widely distrib­
uted and easily available has the potential to improve behavioral out­
comes over current traditional methods. Also, the school-age is one of
the best ages to teach the symptoms and ways of transmission and
prevention of this disease. It is better appropriate education in­
terventions be used as a way to deal with COVID-19. Also, this study
suggests adolescents are obtaining COVID-19 knowledge from different
sources, including social media. Increases in screen time and reduced
physical activity may impact long-term health among adolescents.
Ethics approval
All procedures in this study were approved by the ethics board
committee of Birjand University of Medical Sciences, reference number:
IR.BUMS.REC.1399.185.
Funding
None.
CRediT authorship contribution statement
ZJ and FO designed the experiments. FO collected data and per­
formed the statistical analyses and wrote the results section. ZJ inter­
preted the results.FO wrote the initial manuscript. ZJ critically reviewed
4
Evaluation and Program Planning 100 (2023) 102327
and modified the manuscript. Both authors approved the final
manuscript.
Declaration of Competing Interest
The authors of this article declare they have no conflicts of interest.
Acknowledgment
We would like to thank all the study subjects for their participation
and also thank the dentistry clinical research development unit, Birjand
University of Medical Science, Birjand, Iran for their consultation.
Code availability
Not applicable.
Consent to participate
Participation in the study was completely voluntary.
Consent for publication
Not applicable.
Human Subjects Approval Statement
All procedures in this study were approved by the ethics board
committee of Birjand University of Medical Sciences, reference number:
IR.BUMS.REC.1399.185. It was also registered in the Iranian Registry of
Clinical Trials ( IRCT20150405021601N2).
Appendix 1. : Knowledge questionnaire
1. The corona is a disease transmitted from animals to humans and
the routes of transmission, animal reservoirs, ways to prevent not
specified.
2. This disease publish through respiratory droplets of coughs who
have Covid-19 from people who have no symptoms, is very high.
3. The incubation period means the time of infection with the virus
and the onset of symptoms.
4. The maximum estimate for this course is 1–10 days for Covid-19.
5. The most effective way to prevent Covid-19 is to disinfect your
hands with soap and water or alcohol-based disinfectant
solutions.
6. Hand washing time to prevent corona is 10 s
7. To prevent Covid-19, only the use of a mask is sufficient.
8. After applying the mask, make sure that there is no gap between
the mask and the face.
9. Hands should be disinfected as soon as the front of the mask is
touched.
10. To remove the mask, take the front of the mask and take it out and
throw it in the closed bucket.
11. Regular rinsing of the nose with saline solutions will prevent you
from getting the Corona virus.
12. Maximum consumption of one serving of fruit as a snack during
the day or before meals is effective in preventing corona.
13. Antibiotics can be used to prevent and treat the corona virus.
14. To prevent from getting corona, seasonal fruits contain antioxi­
dants like pomegranate, orange and grapefruit can be effective.
15. During the corona, it is recommended to eat vegetables such as
carrots, squash and spinach, beet leaves and lettuce leaves, which
contain vitamin A.
16. To prevent the corona, taking 2–3 large meals a day is
recommended.
Z. Janbani and F. Osmani
17. To remove the second glove from the hand, dip the fingers of the
right hand into the outside of the glove of the left hand and pull it
out.
18. When sneezing or coughing can only be in front of your mouth
with a tissue and throw the tissue in a closed area.
19. The most common symptoms of Corona, are dry cough, nasal
congestion.
20. COVID-19, is a heavy small virus and therefore cannot remain
suspended in the air.
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Freshteh Osmani Born in 1989/06/25 in Birjand. Parents were Mohsen and Fatemeh.
Studied Biostatistics Phd in tarbiat Modares University. Overcame studied statistics in
Ferdowsi University and MSc of Biostatistics in tarbiat Modares University. Worked as
Assisstant professor in Biostatistics. Personal traits were Quiet /Curious /creative. Always
Researching and doing new ideas. Never improvidence. Known for Active with new idea.