Knowledge, attitude, and practices regarding COVID-19 among college-degree students in Southern district of India

Background and aims: A case of coronavirus disease 2019 (COVID-19) was identified first in Wuhan, China in December 2019. To prevent the rampant spread of COVID-19, the behavioral change of people was crucial. This study aimed to determine the knowledge, attitude, and practice (KAP) toward COVID-19 among college-degree students in the southern district of India. Methods


Introduction
Several cases of pneumonia of unknown etiology were reported on December 31, 2019, in Wuhan, Hubei province, China (1).On January 7, 2020, the causative agent for this unknown disease was identified as a new type of coronavirus (2).On January 30, 2020, the World Health Organization (WHO) declared this epidemic as a Public Health Emergency of International Concern (PHEIC) under International Health Regulation (2005) due to its erratic growth (3).On March 11, 2020, the WHO declared the COVID-19 outbreak a pandemic (4).On March 15, 2021, 119 603 761 cases have been confirmed globally, of which 11 385 339 were reported from India (5) (including 980 898 cases in Karnataka, with 8512 dead and 412 266 treated) (6).
To achieve a victory over COVID-19 in India, effective planning and implementation of preventive measures was essential.The government of India has released various guidelines to create awareness regarding COVID-19 infection to protect all citizens.In addition, prevention and containment of the disease are possible only with a change in the behaviors of the society.
India comprises a large younger population, and students are part of it.Students are a powerful source of change.Creating awareness can encourage students to become advocates for disease prevention at home and in their community by communicating with others about how to prevent the spread of coronavirus (7).
After the first lockdown in India, instructions were given to institutions and students to continue the temporarily banned offline education with severe preventive measures, such as (a) washing hands regularly with soap and water or cleaning them with an alcohol-based hand rub, (b) maintaining at least a 2-m distance between people coughing or sneezing, (c) avoiding touching the face, (d) covering the mouth and nose when coughing or sneezing with a tissue and discarding immediately, (e) staying in a home if unwell, (f) refraining from smoking and other activities that weaken the lungs, (g) practicing physical distancing by avoiding unnecessary travels, and (h) staying away from large groups of people (5).
Therefore, it was crucial to examine students' knowledge, attitude and practice (KAP) regarding COVID-19.Since only a few studies have been conducted in India to assess the KAP among college-degree students, the present study was conducted to assess the KAP of COVID-19 among college-degree students in the Southern district of India.

Methods
A cross-sectional, online study was conducted in 400 college-degree students in a southern district of India from January to February 2021 to study their KAP of COVID-19.The three science and commerce college-degrees were randomly selected in the Kodagu district, and they were (a) Government Junior College, (b) Aided Field Marshal Cariappa College, and (c) Private Cauvery College-degree.
The college-degree students were chosen for the study due to 1.The colleges were about to reopen after the lift of the first lockdown, but the transmission of COVID-19 was still present.2. The colleges consisted of different degree branches, and the number of students was high.3.Because of the large number of students in the college, maintaining social distancing would be difficult, and a lack of knowledge about COVID-19 might lead to high transmission of infection and increase clusters of COVID-19.The college heads were presented with the significance of the study.Permission from the heads was obtained to conduct the study.Due to social distancing measures and restricted movement and lockdowns, a few students volunteered to participate in the study.Google forms links with informed consent forms were shared to participate in the study after assuring confidentiality as mentioned in informed consent form.We employed a snowball sampling technique to potentially recruit more respondents from their college-degree friend's circle.The respondents were motivated to refer study links to their contacts for participation.The participants were autodirected to the survey by clicking the link.Participation was voluntary, with no incentives.

Study tool
The questionnaire was created by reviewing the literature and similar studies published.The questionnaire was reviewed and evaluated by all the members of the research tram separately.The pre-validated and semi-structured questionnaire was used in the study (8)(9)(10)(11)(12).The pilot study was carried out, and the questionnaire was finalized.
The KAP questionnaire of COVID-19 had seven knowledge, seven attitude and eight practice items.The knowledge items were concerned with clinical presentations, transmission routes, prevention and control of COVID-19.These questions were answered on a true/false basis with an additional "I do not know" choice.A correct answer was assigned 1 point, and an incorrect/unknown answer was assigned 0. The total knowledge score ranged from 0 to 7, with a higher score denoting a higher knowledge of COVID-19.Attitudes towards COVID-19 were measured using a Likert scale (agree, undecided, disagree).A score of 1 was given to agree, 0 to undecided, and -1 to disagree.The total score ranged from -7 to 7, with a higher score denoting a more positive attitude towards COVID-19.The number of the practice items was eight and they were answered on a true/false basis.A correct answer was assigned 1 point, and an incorrect/unknown answer was assigned 0. The total practice score ranged from 0 to 8, with a higher score denoting better practice toward COVID-19 (8,10,11,13).
Cronbach's alpha was used to assess the internal reliability of the questionnaire.The Cronbach's alpha coefficient of the knowledge subscale was 0.854, the attitude subscale was 0.437, and the practice subscale was 0.27.
Data were entered in Excel and analyzed using Epi Info ver7.2.The quantitative variables were presented in a median and inter-quartile range.Chi-square test was applied to investigate the association.To examine the difference between two independent groups, Mann-Whitney U test was used.The P value of < 0.05 was considered significance level.

Knowledge regarding COVID-19 infection
Out of 400 participants, all the men (107, 100%) had good knowledge regarding COVID-19 infection whereas 276 (94.2%) women had good and 17 (5.8%) of them had average knowledge.The men had good knowledge score about COVID-19 infection compared to men, and the association between gender and knowledge score was statistically significant (P = 0.01).All the third-year (129, The students staying in urban areas had good knowledge than students from rural areas, and this association was statistically significant (P = 0.002, Table 2).

Attitude towards COVID-19 infection
Out of 293 female students, a majority of them (262, 89.4%) had a positive attitude, and 31 (10.6%) had a neutral attitude towards COVID-19 infection, whereas in male students, a majority of them (86, 80.4%) had a positive attitude followed by 14 (13.1%) with negative attitude and 7 (6.5%) with neutral attitude.The female students had no negative attitude but male students had, and this association between gender and attitude score toward COVID-19 infection was statistically significant (P < 0.0001).The majority of first-year 145 (88.4%) and second-year 74 (69.2%) degree students and all the third-year students had a positive attitude towards COVID-19 infection.The majority [299 (86.7%) and 49 (89.1%)] of science and commerce students had positive attitudes followed by neutral attitudes [32 (9.3%) and 6 (10.9%)], and negative attitudes [14 (4.0%) and 0 (0%)].The majority [129 (95.6%) and 219 (82.6%)] of students staying in urban and rural areas had positive attitudes followed by neutral attitudes [6 (4.4%) and 32 (12.1%)] and negative attitudes [0 (0%) and 14 (5.3%)] respectively.The students from rural areas had a negative attitude towards COVID-19 infection compared to those from urban areas who had no negative attitude.The residential location of stay was significantly associated with attitude scores of students (P = 0.0007, Table 4)

Practice toward COVID-19 infection
All the students (400, 100%) had good practices regarding COVID-19 infection, such as wearing a mask always (400, 100%) frequently washing hands using sanitizer or water and soaps (400, 100%) and obeying COVID-19 rules laid by the government (400, 100%).All the students reported that they knew about the proper way of wearing a mask (covering both nose and mouth) 400 (100%).
A total of 202 (50.5%) respondents consumed herbal medicine (turmeric, ginger, pepper, and tulsi) to prevent COVID-19.The majority of 339 (84.7%) students said that they would always ask their friends to wear masks, and 61(15.3%)would ask occasionally.
In the present study, all the participants (N = 400) had good practices against COVID-19 infection.In contrast, the study by Peng et al (19) stated that women had better practice than men.Whereas the study by Srivastava and Reddy (21), reported that always practicing appropriate COVID-19-related behaviors among the students was between 54.21% and Kumar et al (22) reported as 0.22% to 60.54%.The good practices in our study could be due to the government's consistent efforts to deliver the dos and don'ts about COVID-19 infection through all the media and platforms.However, COVID-19 practices could not be observed because of lockdown; hence we tried to determine the practices using a self-administered questionnaire.

Conclusion
In our study, the male students had better knowledge about COVID-19 infection, but the positive attitude towards COVID-19 was higher among female students.The practice regarding COVID-19 infection was satisfactory among all the students.

Table 1 .
Sociodemographic distribution of participants based on gender (N = 400)

Table 3 .
Distribution of median scores of knowledge and attitude towards COVID-19 infection and gender of the study participants (N = 400)