key: cord-0984803-3xb4lumz
authors: Souli, Dafni; Dilucca, Maddalena
title: Knowledge, attitude and practice of secondary school students toward COVID-19 epidemic in Italy: a cross selectional study
date: 2020-05-09
journal: bioRxiv
DOI: 10.1101/2020.05.08.084236
sha: 0bc8e8a168e0494844ef69720fa8ad6be16c76b0
doc_id: 984803
cord_uid: 3xb4lumz

The coronavirus disease (COVID-19) is a highly transmittable and pathogenic viral infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which emerges in December 2019 in Wuhan, China and spreads around the world at the beginning of 2020. The World Health Organization declares the outbreak a Public Health Emergency of International Concern on the 30th of January, and a pandemic on the 11th of March. On the 4th of March, the Italian government orders the full closure of all schools and universities nationwide. The aim of this study is to investigate the knowledge, practice and attitudes (KAP) of secondary school at the time of COVID-19 pandemic in Italy. In this cross-sectional, web-based survey, conducted among the high school student population with age ranging from 14 to 19 years old, a questionnaire with 19 items regarding the KAP toward COVID-19 is asked. Study participants are recruited from several secondary schools of different areas. Frequencies and histograms are computed for descriptive purposes. Statistical analysis is computed with Chi square test, utilized to depict relevant difference between geender. Among a total of 2380 students who answers the questionnaire, 40.7% are male and 59.3% are female. Level of knowledge about generical characteristics of COVID-19 is quite similar among gender. Students present a good level of knowledge about the clinical presentation of the disease, the basic hygiene principles, the modes of transmission and the method of protection against virus transmission. The knowledge about number of this pandemia and easy scientific correlation with COVID-19 is quite confused. The most frequently reported source of knowledge about COVID-19 is television, whereas the less is the school. Our findings suggest that student population shows appropriate practice, and positive attitude towards COVID-19 at the time of its outbreak. More emphasis should be placed on education of the student partecipants about biological meaning of this infection and relative preventive or future measures.

Coronavirus disease 2019 (officially known as SARS-CoV-2 or COVID-19) is an 2 emerging acute respiratory illness that is caused by a novel coronavirus and is first 3 1/11 reported in December 2019 in Wuhan, Hubei Province, China, [1] from where it spread 4 rapidly to over 198 countries [2, 3] . In response to this serious situation, the World 5 Health Organization (WHO) declares it a public health emergency of international 6 concern on 30th of January and calls for collaborative efforts of all countries to prevent 7 the rapid spread of COVID-19. It is declared as a global pandemic by WHO on 12th of 8 March [4, 5] . 9 The outbreak of coronavirus in Italy is officially confirmed to be on 31th of January, 10 when two Chinese tourists in Rome tested positive for the virus [6] . One week later an 11 Italian man repatriated back to Italy from the city of Wuhan, China, is hospitalised and 12 confirmed as the third case in Italy [7] . A cluster of cases is later detected, starting with 13 16 confirmed cases in Lombardy [8] . As of 7th of May 2020, over three million cases of 14 COVID-19 has been reported with a death toll of over 270.000 patients [9] . Among the 15 top ranking countries, Italy is reported to be in the third position, after America and 16 Spain, with over 215.000 confirmed cases and over 26.000 deaths [9] . 17 Health authorities in Italy have made substantial efforts to control the disease 18 through various measures. On 8th of March, Prime Minister of Italy extends the 19 quarantine lockdown to cover the whole region of Lombardy and 14 other northern 20 provinces. On 10th of March, he increases the quarantine lockdown to cover all of Italy, 21 including travel restrictions and a ban on public gatherings [10]. Public education is 22 considered as one of the most important measures that could help control the diseases, 23 as has been the case regarding MERS [11] or SARS [12, 13] . In fact, On 4th of March, 24 the government announces the closure of all degree of schools. 25 The main aim of our present study is to investigate the level of knowledge, attitude, 26 and practice of young subjects attending secondary schools toward COVID-19 infection. 27 This study is interesting to detect variables associated with a satisfactory level of them 28 and to explore how knowledge about the disease has affected their lifestyles or health 29 behaviors. For the purpose of this study, a questionnaire self-administered is developed especially 33 for this research in native spoken language (Italian). A small subgroup of twenty male 34 and twenty female students are asked to complete the questionnaire and then to ask 35 some questions on whether the questionnaire is easy to understand, to complete and to 36 submit. Reliability of the questionnaire in its translated form is measured by calculating 37 Cronbach's alpha for each total scale. In our case, a value of Cronbach's alpha > 0.8 is 38 considered significative.

After validation questionnaire, we develop the final version with 19 items, featured 40 in the form of a multiple choice answers. The questionnaire consists of two parts: 41 demographics and KAP [14] . The questionnaire is subdivided as following questions: 42 demographic information (items 1-4), knowledge of signs and symptoms of the disease, 43 the methods of transmission of the disease and of prevention (items 5-16), the impact of 44 the disease orientation on participants' lifestyles and their sources of information (item 45 17-19) [15] . This takes approximately 5 minutes to fill out. The cover page of the questionnaire includes a short introduction regarding the 50 2/11 objectives, the procedures, the voluntary nature of participation, the declarations of 51 confidentiality and anonymity. The inclusion criteria regard Italian nationality younger 52 with age ranging to 14 from 19 years old attending secondary high school.

The questionnaire is answered by over 2300 participants anonymously from the 1st 54 to the 5th of May, in the first days of the second phase in Italy (it begins on the 4th of 55 May). Demographic variables are recorded along with other factors regarding the 56 populations' knowledge, attitude, practice, and risk assessment concerning 57 COVID-19 [16] . is used to compare categorical data between gender. The statistical significance level is 63 considered with p-values < 0.05 (two-sided) [17] . 64 3 Results and discussion answers of fever in the following Table 1 ). It is strange to note that more than a quarter 90 rispectevely of males and females links the phenomenon of COVID-19 to nasal 91 congestion. This wrong answer may be due to the common use of linking fever with 92 symptomes of a cold [19, 20] . show as 2% of males and 0.3% females thinks that the risk of infection is connected by 101 being outdoors.

As illustrated in Table 3 , the most frequently reported method of protection against 103 virus transmission is hand washing. Nevertheless, a higher proportion of students 104 remarks the importance of wearing tissues protect hands. Almost no percentage believes 105 that it is appropriate to touch the nose or eyes or not wear face mask protection. Even 106 in these questions, there is a similar level of knowledge method of protection against 107 virus transmission among gender [21] .

According to recent statistics, COVID-19 affects more the male population. So, we 109 ask students if they know about this information: 66.8 % of them answers correctely, 110 8% answers that females risk more and the remaining replies that does not know. An 111 other question is about the number of deaths with COVID-19 in world and Italy. We 112 know that estimating the correct number of deaths is a sensitive topic especially related 113 to the number of swabs made on patients and so, we consider correct answers only those 114 relating to official data (see website [9] ). Unfortunately, only 15% responds correctly, 115 identifying at least the order of measurement of the number both nationally and 116 worldwide. Then we consider which age group is most affected in the population (see 117 Figure 3 ). 120/2380 (5% ) answer that people with class of age 50-60 risk a lot, Figure 3 with official data to 120 understand that students answer incorrectly in this question. In Italy major percentage 121 of deaths is in class over 80 and the second class is 70-80. 2306/2380 (96.9%) students 122 answer that the area most affected in Italy is Lombardia (correct answer), whereas 123 74/2380 (3%) answer that is Piemonte. 

In the second part of the questionnaire, we ask for generic information about COVID-19 126 vaccines [22] .2058/2380 (86.5%) answer that does not still exist a vaccine, 123/2380 127 (5.2%) answer that they do not know and the remaining 8.3% that vaccine exists and 128 that soon it will be possible to do it. We know that COVID-19 vaccine is a hypothetical 129 vaccine against coronavirus disease. Although no vaccine has completed clinical trials, 130 there are multiple attempts in progress to develop such a vaccine. In April 2020, 115 131 vaccine candidates are in development [23, 24] . On 7th of May first COVID-19 vaccine 132 test on animals successful. to visit family or friends (about 70%). In second place, students answer about the 156 possibility to going to school. It is interesting is that the two activities more favourite 157 by male students: going to the park and playing a sport. 158 Figure 5 . Social activities.The activity most affected is the possibility to visit family or friends (about 70%). In second place, students answer about the possibility to going to school.

Students have spent most of their free time on school online activities (see Figure 6 ). 159 Italy is one of the first country in Eruope that immediately stars a new teaching . It is interesting to note that although the 165 students declare that they spend most of the hours online in the presence of teachers, 166 they have previously answer that their main source of information is TV and the lesser 167 school. An other important phenomenon is to highlight that the major of students has 168 spent its time watching a film or chatting and video-calling. The presence of technology 169 7/11 in these lock-down months has been a key point of their knowledge and maturation 170 phenomenon [27] . Reading a book is one of the activities chosen in a clear minority. Figure 6 . Free time. The students declare that they spend most of free time in DaD (online school lessons). A lot of them has spent its time watching a film or chatting and video-calling.

To the best of our knowledge, this is the first study in Italy investigating the KAP In the other part of the questionnaire, we ask for generic information about 201 COVID-19 vaccine. Although no vaccine has completed clinical trials, there are multiple 202 attempts in progress to develop such a vaccine. The major part of students answer that 203 does not still exist a vaccine, only 5% answers that they do not know and the remaining 204 8.3% that vaccine exists and that soon it will be possible to do it. The other two 205 questions correlated with vaccine are about the knowledge of antibodies. About 98% 206 claims to know antibodies, but in the next question when they have to answer how to 207 check for antibodies, only 65% answers with blood analysis. The remaining answers 208 pharyngeal swab or urine analysis and aa minority of 5% answers that flu is a necessary 209 symptome to check antibodies. These three questions with uncorrect answers are 210 related to the above discussion. It is very important for young students to have a Finally, students declare that they have spent most of their free time on school 220 online activities. In Italy from the first days of lock-down, the Minister of Education 221 introduces a new learning methods for students, based on remote lessons in platforms, 222 upload of sources and materials on web and formal or informal communication on blog 223 or online groups. The presence of technology in these lock-down months has been a key 224 point of their knowledge and maturation phenomenon and helps students to continue 225 their formative learning. Perhaps more attention should be given to utilizing tecnhology 226 and particularly social media resources, especially Facebook or Whatsapp, as techniques 227 of promoting public health education in adolescents, in collaboration with teachers and 228 specialists.

229 Acknowledgement(s) 230 We warmly thank all the study participants for their voluntary participation and for 231 providing essential information. 

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