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Article

Insight on Knowledge, Risk Perception and Practices to Prevent the Spread of COVID-19: A Cross-Sectional Study among Italian University Students

by
Francesca Licata
1,
Alessandra Oliverio
1,
Gianfranco Di Gennaro
2,
Carmelo Giuseppe Angelo Nobile
2 and
Aida Bianco
1,*
1
Department of Health Sciences, School of Medicine, University of Catanzaro “Magna Græcia”, 88100 Catanzaro, Italy
2
Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Cosenza, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2021, 11(19), 9031; https://doi.org/10.3390/app11199031
Submission received: 6 August 2021 / Revised: 10 September 2021 / Accepted: 24 September 2021 / Published: 28 September 2021
(This article belongs to the Special Issue Effect of COVID-19 on Public Health)
Versions Notes

Abstract

:
Addressing adherence to non-pharmaceutical interventions among young adults represents a public health priority since this age group did not directly experience a health risk from COVID-19. The study aims were to investigate the level of knowledge, risk perception and practices to prevent the spread of COVID-19 among undergraduate university students in Southern Italy. This cross-sectional study was conducted between the 1st and 31st of July 2020. An anonymous and structured questionnaire was sent via institutional email. Among the 1323 sampled students, more than two-thirds gave the correct answer to all the knowledge statements. Good knowledge about COVID-19 showed a positive association with those studying medical or life sciences majors. Almost two-fifths (38.5%) of the sample declared to have quite a bit/extreme fear of falling ill with COVID-19 and it was significantly more likely among females and those with good knowledge. Only 30.2% of the students did not touch their face mask while using it. Moreover, practicing respiratory etiquette was more likely among females, among respondents with higher levels of fear of falling ill with COVID-19 and among those who exhibited good knowledge about COVID-19. The study insights will be valuable for the ongoing mitigation of the current pandemic especially with regard to the correct use of face masks.

1. Introduction

Coronavirus disease 2019 (COVID-19) caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has spread to almost all countries and has affected more than 171 million people around the world, resulting in more than 3.68 million deaths [1]. In early March 2020, Europe became the epicenter of the COVID-19 pandemic. In Italy, the most severely affected European country in the early phase, an alarming number of cases posed a serious threat to the capacity of the national healthcare system [2]. National and international governments have suggested the systematic implementation of protective public health measures in an effort to delay the spread of COVID-19 [3]. Community isolation measures to increase social distancing, such as work restrictions and the closure of public places, were imposed to decrease the peak infection rate and delay the spread of the virus, in order to maintain high-quality hospital care. When these measures were sufficiently high, they have been described as a “lockdown”.
Communities can enact other non-pharmaceutical interventions (NPIs) to prevent and/or control SARS-CoV-2 transmission. Disinfection of hands and surfaces, face mask use, working from home and physically distancing from one another, are specifically geared to limiting the spread of SARS-CoV-2. NPIs are accessible, affordable, and effective, and the use of these interventions is important even when drugs and vaccines are available. Considerable cooperation is needed from the public to successfully implement the NPIs during an outbreak or pandemic, especially for individuals not directly experiencing a health risk such as healthy young adults as the decision to comply with the safety regulations is also a decision that benefits others. Starting last summer, epidemiological data have documented an increase in COVID-19 incidence among young adults [4], and addressing transmission among young adults represents an urgent public health priority.
Recent studies have reported information on the perceived impact of COVID-19 on health. These studies have shown that people’s risk perception of COVID-19 is correlated with the adoption of preventative health behaviors [5], but its level is not too high [6,7,8], and is lower than their concern for the future and economic and social consequences of the pandemic [7]. It is also worth noting that the compliance to NPIs reflects the interaction of a range of modifiable and non-modifiable factors. Given the relevant inequalities in factors related to this issue, we hypothesized that socio-demographic characteristics and academic major may affect the level of knowledge, the perceived risk of COVID-19 and adherence to NPIs, and that knowledge and the perceived risk may predict adherence to NPIs. To address our hypothesis, we investigated the level of knowledge, risk perception and practices to prevent the spread of COVID-19 among undergraduate university students in Southern Italy. We tested the relationship between potential drivers, such as socio-demographic characteristics and academic majors, and the outcomes in the study.

2. Materials and Methods

2.1. Study Design and Setting

This cross-sectional study was conducted over one month between the 1st and 31st of July 2020, after the lifting of the first Italian lockdown. The survey was intended for university undergraduate students of one public university in Calabria, Italy, that includes both medical or life science and non-medical or life science courses.

2.2. Sampling and Survey Instrument

An anonymous and structured questionnaire was developed based on previous similar studies [9,10,11,12,13] as well as on the World Health Organization (WHO) COVID-19 prevention and control measures [14]. A pilot survey was performed on a sample of 20 students prior to the main study to assess the relevance and understandability of the questionnaire. Minor revisions were made afterward. The online survey was sent via institutional email. We hypothesized that the academic major could have an effect on the students’ knowledge, risk perceptions and adherence to NPIs, so we conducted a stratified sampling. Hence, we used a random number generator to select a sample of 25 males and 25 females from a sampling frame that included students attending all the university’s majors (N. 28). The inclusion criteria required the participants to be undergraduate university students and to have voluntarily participated. The exclusion criteria included being under 18 and over 29 years of age.
Potential participants were informed at the beginning of the questionnaire on the purposes of the study, on its voluntary nature together with the condition that they could terminate their participation at any stage of the survey. No compensation, course credit or other incentives were offered to the student for their time spent. The questionnaire could only be submitted once for each electronic device in an effort to reduce potential repeat responses.
Participants were asked to respond to four questions relating to their socio-demographic characteristics (age, gender, marital status, academic major). Knowledge about routes of transmission and measures against the spread of COVID-19 were tested with six statements, rated on a 5-point Likert scale from strongly disagree to strongly agree. An overall knowledge score was calculated by assigning one point for each correct response and summing the scores for each statement (range 0–6). The overall median knowledge score of the respondents was then estimated and a total score of <50th percentile was interpreted as poor knowledge, whereas a score of ≥50th percentile as good knowledge. We assessed the perceived risk of COVID-19 according to three measured indicators on a 0–10 scale. The first indicator was an assessment of own personal risk of getting infected/getting infected again in case the respondent had already been ill from COVID-19 (vulnerability). The second indicator was an assessment of fear of falling ill with COVID-19. The third indicator corresponded to the expected prevalence of COVID-19 in the community. Adherence to preventive and control measures for COVID-19 (i.e., use of face mask; respiratory etiquette, such as covering mouth and nose with a flexed elbow when sneezing or coughing if they do not have a tissue; hand hygiene) were investigated by five questions on a 5-point Likert scale ranging from “never” to “always”. The last section (two items, closed-ended with multiple answers and open option) explored the main sources of information adopted to inquire about news regarding COVID-19 and if the students needed further information about it. Validity was investigated in terms of content validity and factorial validity. The content validity of the items was established by a panel of experts including one epidemiologist, one public health professional, one infectious disease specialist and one social and behavioral sciences consultant.
Ethical approval was granted by the Regional Human Research Ethics Committee (ID No. 101/2021/03/18). The research protocol did not encompass the collection of privacy-sensitive identity information data.

2.3. Statistical Methods

Data were summarized using frequencies and percentages for categorical data and mean and standard deviations for continuous data. Analyses were conducted using multiple logistic regression modeling techniques. The following outcomes of interest were investigated: having good knowledge about COVID-19 (Model 1); fear of falling ill with COVID-19 (Model 2); practicing respiratory etiquette (Model 3); adherence to hand hygiene (Model 4). The following variables were included in all models: gender (male = 0; female = 1); age (continuous); studying medical or life sciences majors (no = 0; yes = 1); marital status (married = 0; single = 1). In Models from 2 to 4 the variable having good knowledge (poor = 0; good = 1) was also included. In Models 3 and 4 the following variables were also included: vulnerability to COVID-19 (not at all/little/moderate = 0; quite a bit/extreme = 1) and fear of falling ill with COVID-19 (not at all/little/moderate = 0; quite a bit/extreme = 1). A significance level of 5% was used for hypothesis testing. Moreover, to assess whether the perceived risk of COVID-19 (i.e., vulnerability and fear of falling ill with COVID-19) acts as a mediator of the effect of knowledge on preventive behaviors (practicing respiratory etiquette and adherence to hand hygiene), we used the Baron and Kenny method [15]. The null hypothesis of no-indirect effect was rejected if both regressions (i.e., of the knowledge on perception and of perception on behavior) showed a statistically significant effect. This procedure was carried out considering the vulnerability and severity variables separately.
Statistical analysis was performed using the STATA software program, version 16 [16].
The data set was deposited in the Mendeley Data repository (doi:10.17632/7stvxrdznc.1).

3. Results

The exploratory factor analysis showed three factors with an eigenvalue higher than 1, explaining the 63.2% of data variance.

3.1. Participant Demographics

Respondents with a gender other than male or female were excluded due to the very small number of observations. Overall, 1323 students responded to the survey; more than half (70.6%) were female and the mean age was 22.9 years (SD ± 2.6). Almost all the students were single (94.9%). A total of 758 students (57.3%) studied medical or life sciences majors.

3.2. Knowledge about COVID-19

The knowledge about COVID-19 is detailed in Table 1. The majority of participants knew that SARS-CoV-2 can be transmitted by cough and/or sneeze (96.6%) and that transmission can occur through close contact with infected subjects (92.8%). Respondents appeared to be knowledgeable that social distancing reduces the risk of being reached by droplets (95.4%), and that ensuring good air exchange can reduce the transmission of COVID-19 (87.5%). More than two-thirds (68.6%) of the sample gave the correct answer to all the knowledge statements, with a median knowledge score of 6 (interquartile range 5–6). The results of the model predicting good knowledge about COVID-19 showed a positive association with having studied medical or life sciences majors (OR = 1.68, 95% CI = 1.33–2.12) and as the students’ age increased (OR = 1.06, 95% CI = 1.01–1.11) (Model 1 in Table 2).

3.3. Risk Perception Related to COVID19

Perceptions toward COVID-19 are detailed in Table 1. When students were asked about their vulnerability to COVID-19, only 26.2% believed themselves to be at high risk of getting infected. Furthermore, 38.5% of the participants declared to have quite a bit/extreme fear of falling ill with COVID-19. Results of multiple logistic regression analysis indicated that female gender (OR = 1.58, 95% CI = 1.24–2.01) and not studying medical or life sciences majors (OR = 0.79, 95% CI = 0.63–0.98) were significant predictors of having quite a bit/extreme fear of falling ill with COVID-19 (Model 2 in Table 2). Furthermore, having good knowledge showed an independent positive association with the outcome (OR = 1.29, 95% CI = 1.02–1.63). More than half (55.6%) of the respondents believed that the prevalence of COVID-19 in their community was ≤10%.

3.4. Adherence to NPIs

The adherence to NPIs is displayed in Table 3. Regarding the use of a face mask, 82.3% of the sample removed it by holding the ear loops or ties without touching the front, but only 30.2% did not touch the face mask while using it. Furthermore, two out of ten students (77%) did not maintain a distance of at least one meter from other people when wearing the face mask, and four out of five students (80%) self-reported practicing respiratory etiquette such as covering their mouth and nose with a flexed elbow when sneezing or coughing if they did not have a tissue. Practicing respiratory etiquette was significantly more likely in females (OR = 1.53, 95% CI = 1.15–2.05), and in respondents with higher levels of fear of falling ill with COVID-19 (OR = 1.5, 95% CI = 1.09–2.06). Furthermore, good knowledge about COVID-19 (OR = 1.78, 95% CI = 1.34–2.36) showed an independent positive association with practicing respiratory etiquette (Model 3 in Table 2). Almost all participants (95.5%) cleaned their hands by using alcohol-based hand rub or soap and water to prevent COVID-19 infection and female students displayed an independent positive association with this responsible practice (OR = 2.52, 95% CI = 1.48–4.31). Respondents with higher levels of fear of falling ill with COVID-19 (OR = 3.85, 95% CI = 1.73–8.53) and those who had good knowledge about COVID-19 (OR = 2.42, 95% CI = 1.41–4.15) were more likely to adhere to hand hygiene recommendations (Model 4 in Table 2). No mediating role between knowledge score and both explored preventive practices was found. Indeed, the knowledge score did not show a statistically significant association of either the vulnerability (OR = 1.12; CI = 0.85–1.47) nor the severity (OR = 1.1; 95% CI = 0.86–1.41) variables.

3.5. Sources of Information about COVID-19

Mass media (26.8%) and government organizations (24.4%) were the main sources of information about COVID-19, followed by social media (17.5%) and university health professionals (13.7%). More than half of the participants (59.9%) reported having received enough information regarding COVID-19.

4. Discussion

In this study we aimed to explore knowledge about, the risk perception level of, and adherence to preventive and control measures for, COVID-19, as well as potential barriers and facilitators among a large sample of Italian undergraduate university students. The consideration of factors unique to this age group is pivotal to inform the design, communication and implementation of public health interventions. These insights are not only valuable for the ongoing mitigation of the current COVID-19 pandemic but may also serve to inform prevention and control strategies of health decision-makers and public health organizations for possible future pandemics.
Our findings indicate that most study participants were knowledgeable about COVID-19, and the overall level of knowledge was quite comparable to similar national [17,18] and international studies [19,20]. Such figures did not come as a surprise, as the Italian government has taken all the appropriate actions in updating their webpage, providing information regarding prevention and guidelines to educate the public about the disease. Moreover, during this period, the mass media, the main source of information reported in the present study, have given continuous and timely updates on the pandemic. The mass media have a significant influence both on the knowledge and risk perception of the public. As expected, students studying medical or life science majors were significantly more knowledgeable than those studying other majors. Considering that a paucity of knowledge may lead to nonchalant behavior, making it difficult to curb the disease, health education programs aimed at improving COVID–19 knowledge in less aware groups may be helpful to support people in maintaining safe practices. Moreover, as a high-knowledge group, medical or life science university students can spread their knowledge and strong risk awareness to the individuals around them. Indeed, health literacy was found to protect medical students from fear [21]. Compared with students studying non-medical/life-science subjects, medical or life-science students have less fear of falling ill with COVID-19 as has been previously documented [22]. Therefore, enhancing health literacy skills should be considered a strategic approach to protect health.
The finding that the perceived risk of vulnerability to COVID-19 was relatively higher than the “fear of falling ill with COVID-19” could reflect to some extent the students’ attention to COVID-19, together with a false sense of confidence regarding their safety. In Italy, the mass media have documented young adults mingling with others in large groups, not wearing face masks and ignoring community pandemic guidelines, thinking they are less likely to have severe cases of COVID-19, and ignoring the possibility they may pass the infection to others unknowingly. Evidence exists that increased cases of COVID-19 among young adults are followed by increases among older adults four to fifteen days later, suggesting that younger people are transmitting COVID-19 to them [23].
The fact that only one-third of the sample did not touch their face mask while using it is a matter of concern. If potentially contaminated hands touch the face mask put over the mouth and nose, subjects are at risk for infection. Although face mask wearing was associated with reduced face-touching behavior, especially touching of the eyes, nose, and mouth, which may prevent contact transmission of COVID-19 [24], it has been demonstrated that face mask touching is frequent among the public and it is rarely followed by application of alcohol-based hand rub [25]. Further effort should be taken to disseminate evidence-based information to heighten public knowledge about how to properly wear a face mask.
As expected, the study findings showed that good knowledge was positively associated with practicing respiratory etiquette, emphasizing that knowledge can play a crucial role in enhancing the practice of public preventive behavior. Although it is difficult to say how much knowledge is sufficient for achieving desirable changes in health outcomes, the premise that the public can make ‘informed decisions’ about health behaviors by leveraging their knowledge about COVID-19 has been previously reported [26,27]. Moreover, being female was positively associated with appropriate practices toward COVID-19, like in previous studies [18,28,29,30]. It could be argued that female students were more anxious about being infected with COVID-19 than their male colleagues [5,13], and this may explain why this group exhibited better behavioral practices. Another possible reason for the disparity among the genders could be the higher perceived risk of the disease among females with respect to males. Evidence exists that women reported greater fear and more negative expectations about the health-related consequences of COVID-19 than men [31], and that the women, more than men, believed that this outbreak had impacted their study [20]. With this in mind, it is imperative that public health organizations promote gender-sensitive policy interventions to tackle the main determinants of gender inequalities.

Limitations

Readers should consider some important limitations when interpreting the study findings. First, we acknowledge the potential for selection bias, since we were not able to make contact with phone calls before mailing the initial survey, which would have allowed us to minimize the exclusion of eligible participants. However, an online survey was used to collect data as it was the most realistic and feasible method during the COVID-19 pandemic. Online surveys could be administered in a time-efficient manner, minimizing the period it took to get a survey into the field and for data collection. In addition, respondents could answer at a convenient time for themselves. Second, we cannot assume that our study population is representative of the possible over-representation of health-conscious individuals and those more informed or concerned about the outbreak. However, students are, on average, more homogeneous than non-student participants [32], and we enrolled a very large sample of participants. Third, our study was a cross-sectional design rather than longitudinal, thus, we are unable to estimate changes in risk perception and practices over time. In addition, our study was restricted to university students from one region, and therefore, one must be cautious in interpreting the results as generalizable for students in the whole country. However, it is reasonable to suppose that the findings of the study may be representative of the Southern regions of Italy. Moreover, there is a possibility of social desirability bias on the adherence to NPIs, where the respondents may give more favorable responses about their practice of public preventive behavior. This bias was limited by guaranteeing participants that their responses would be anonymous and could not be traced back to them. Fourth, we did not collect data on students’ living situations, and this missing information could have affected the adherence to NPIs, e.g., for students cohabiting with individuals with a weakened immune system or underlying medical conditions. Finally, we emphasize the aim of our study was descriptive, making the relationship between variables and outcomes of interest more tentative and we caution readers against drawing causal conclusions regarding the observed differences. However, this was not a primary goal of the study, since we aimed to assess knowledge about, the risk perception level of, and adherence to preventive and control measures for, COVID-19, among university students.

5. Conclusions

The study findings showed overall adequate knowledge and practices and a low perceived risk of contracting COVID-19 among university students. Healthy young adults self-perceived themselves as less susceptible to severe disease and death due to COVID-19 compared with elderly individuals or patients with pre-existing conditions. Equally true is that this age group is a crucial link in the chain of infection since they are usually involved in more high-risk behaviors. Insights from the present study will be valuable for the ongoing mitigation of the current pandemic, especially with regard to the correct use of face masks but may also serve to inform governments and public health organizations in their advice dissemination.

Author Contributions

Conceptualization, F.L., A.O., C.G.A.N. and A.B.; Data Curation, F.L. and A.O.; Formal Analysis, A.O., G.D.G. and A.B.; Funding Acquisition, C.G.A.N. and A.B.; Investigation, F.L. and A.O.; Methodology, F.L., A.O. and A.B.; Project Administration, A.B.; Resources, C.G.A.N.; Supervision, A.B.; Validation, F.L., A.O. and A.B.; Visualization, F.L. and A.O.; Writing—Original draft, F.L., A.O., G.D.G., C.G.A.N. and A.B.; Writing—Review and Editing, A.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the local Human Research Ethics Committee (protocol code 101, 18 March 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are openly available in the Mendeley Data repository at doi:10.17632/7stvxrdznc.1.

Conflicts of Interest

The authors declare no conflict of interest.

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Table
Table 1. Knowledge and risk perceptions about COVID-19.
Table 1. Knowledge and risk perceptions about COVID-19.
Knowledge Statements (1323)Correct Knowledge
N%
The virus causing COVID-19 can be transmitted by cough and/or sneeze127896.6
Social distancing reduces the risk of being reached by droplets126295.4
Social distancing must also be maintained in open spaces123793.5
SARS-CoV-2 transmission can occur through close contact (face to face, less than 1 m distance) with infected subject122892.8
Surgical masks prevent spreading of droplets in environment116087.7
Ensuring ventilation can reduce the transmission of COVID-19115887.5
Risk Perceptions Statements (1323)Not at All/LittleModerateQuite a Bit/Extreme
N%N%N%
Vulnerability to COVID-1920715.677058.234626.2
Fear of falling ill with COVID-1925419.256042.350938.5
Table
Table 2. Multiple logistic regression models for potential determinants of the different outcomes of interest.
Table 2. Multiple logistic regression models for potential determinants of the different outcomes of interest.
Model 1Model 2Model 3Model 4
Good Knowledge about COVID-19Fear of Falling Ill with COVID-19Practicing Respiratory EtiquetteAdherence to Hand Hygiene
Log Likelihood = −809.41; χ2 = 27.02; p < 0.0001Log Likelihood = −904.52; χ2 = 24.2; p = 0.0002Log Likelihood = −703.13; χ2 = 58.14; p < 0.0001Log Likelihood = −221.06; χ2 = 40.2; p < 0.0001
OR(95% CI)OR(95% CI)OR(95% CI)OR(95% CI)
Female gender (male as reference)1.07(0.83–1.39)1.58(1.24–2.01)1.53(1.15–2.05)2.52(1.48–4.31)
Age, years1.06(1.01–1.11)1.03(0.99–1.07)1.02(0.97–1.08)1.01(0.91–1.12)
Attending to medical or life sciences majors (no as reference)1.68(1.33–2.12)0.79(0.63–0.98)1.26(0.96–1.67)0.91(0.52–1.57)
Single status (married as reference)1.19(0.7–2.03)1.35(0.82–2.23)0.47(0.21–1.05)1.05(0.31–3.59)
Good knowledge about COVID-19 (poor as reference) 1.29(1.02–1.63)1.78(1.34–2.36)2.42(1.41–4.15)
Quite a bit/extreme fear of falling ill with COVID-19 (not at all/little/moderate as reference) 1.5(1.09–2.06)3.85(1.73–8.53)
Quite a bit/extreme vulnerability to COVID-19 (not at all/little/moderate as reference) 0.99(0.7–1.39)0.92(0.45–1.88)
Table
Table 3. Adherence to NPIs.
Table 3. Adherence to NPIs.
Statements (1323)Correct Answers
N%
When I sneeze/cough, I cover my mouth and nose with my elbow flexed if I don’t have a tissue105980
I remove the mask by holding the ear loops or ties without touching the front108982.3
I don’t touch the mask while using it40030.2
I keep a distance of at least one meter from other people when I wear the mask101977
I clean my hands by using alcohol-based hand rub or soap and water126495.5
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Licata, F.; Oliverio, A.; Di Gennaro, G.; Nobile, C.G.A.; Bianco, A. Insight on Knowledge, Risk Perception and Practices to Prevent the Spread of COVID-19: A Cross-Sectional Study among Italian University Students. Appl. Sci. 2021, 11, 9031. https://doi.org/10.3390/app11199031

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Licata F, Oliverio A, Di Gennaro G, Nobile CGA, Bianco A. Insight on Knowledge, Risk Perception and Practices to Prevent the Spread of COVID-19: A Cross-Sectional Study among Italian University Students. Applied Sciences. 2021; 11(19):9031. https://doi.org/10.3390/app11199031

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Licata, Francesca, Alessandra Oliverio, Gianfranco Di Gennaro, Carmelo Giuseppe Angelo Nobile, and Aida Bianco. 2021. "Insight on Knowledge, Risk Perception and Practices to Prevent the Spread of COVID-19: A Cross-Sectional Study among Italian University Students" Applied Sciences 11, no. 19: 9031. https://doi.org/10.3390/app11199031

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