https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article Knowledge and Attitudes about Precautionary Measures of COVID-19 among Undergraduate Students: A Comparative Study ABSTRACT INTRODUCTION The pandemic of Novel Coronavirus Dis- ease 2019 (COVID-19) was declared a pub- lic health emergency concern by the World Health Organization (WHO) in De- cember 2019 [1]. COVID-19 is an infec- tious respiratory illness caused by a new coronavirus that first appeared in China at the end of December 2019 and quickly spread worldwide [2].The incubation peri- od of COVID-19 is 2–14 days, and it causes respiratory infection (like the flu), with major clinical symptoms including dry cough, fever, pain or pressure in the chest, fatigue, and in more severe cases, myal- gia, arthralgia, confusion, difficulty breath- ing and bluish lips or face. COVID-19 Background and objective: The pandemic caused by novel Coronavirus Disease 2019 (COVID-19) is an infectious respiratory illness caused by a new coronavirus that first ap- peared in China at the end of December 2019 and quickly spread worldwide. The aims of this study are to assess undergraduate students’ knowledge and attitudes of the precau- tionary measures toward COVID-19. Methods: A descriptive comparative study design was used from 2nd January to 1st March 2022. A purposive sampling technique was used to collect the data. All students (240 students) in second grade from the nursing department and the English depart- ment at Gasha Technical Institute, Kurdistan Region/Iraq, were recruited and completed a self-reported questionnaire. Result: Around 70% of nursing students and 69% of students in the English department were males, and most students in both fields were aged between 18 and 22 years old. A total of 83.3 % of students in nursing and 77.5% of students in the English department were single. However, the rate of married students (21.7%) was higher in the English de- partment. More than half of the nursing students (63.3%) showed good knowledge, 31.7% showed medium knowledge, and 5.0% showed poor knowledge. Nursing stu- dents’ good attitude was 15.8%. In contrast, 30.0% of students in the English depart- ment had good knowledge, 50.8% had medium knowledge, and 19.2% had poor knowledge. Good attitude of students in the English department was 5%. Conclusion: Overall, a higher level of knowledge was observed in nursing students than students in the English department. Also, positive attitude toward COVID-19 was higher among nursing students. Keywords: COVID-19; Knowledge; Attitude; Precautionary measures; Students. Halmat Authman Rasheed; Department of Nursing, College of Nursing, Hawler Medical University and Tishk Interna- tional University, Erbil, Iraq. (Correspondence: halmat.rasheed@hmu.edu.krd) 79 Received: 23/03/2022 Accepted: 30/07/2022 Published: 30/11/2022 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article is a highly contagious virus with a high death rate, and it was designated as a class B infectious illness in China in January 2020 [3].According to the available research da- ta, the COVID-19 virus is transmitted be- tween humans by close contact and drop- lets, not through airborne transmission. Those in close contact with a COVID-19 pa- tient or who care for COVID-19 patients are the most vulnerable to infection [4].Following the pandemic nature of the diseases, countries implement various pre- ventative measures, such as restricting people's movement, requiring them to stay at home, and closing schools and other so- cial services [5]. The most effective preven- tative strategies/measures include closing schools, staying at home, maintaining so- cial distance, avoiding touching your face, practicing respiratory hygiene when cough- ing or sneezing, wearing a medical mask, and appropriate hand-washing in public areas such as banks, markets, and mosques [6].As the risk of COVID-19 spreads rapidly, individuals should take precautions to pro- tect themselves and others from infection. Though medical students are not actively involved in the managing infected patients with COVID-19, they can serve as an infor- mation provider for the community about the importance of personal hygiene, the main clinical symptoms of COVID-19, and how to limit its spread by following precau- tionary measures [7]. The crowded class of students in school, institution, and college eases the transmission of COVID-19 [8]. To decrease the number of infected students with COVID-19, undergraduate students must have a basic knowledge and under- standing of the new Coronavirus, which is essential to limit the spread of the virus and should be able to clear common mis- conceptions regarding COVID-19 [9]. With this background, the study is aimed to as- sess the undergraduate students’ knowledge and attitudes toward precautionary measures about COVID-19 in Erbil City, Kurdistan Region of Iraq. This descriptive comparative study design aimed to assess undergraduate (medical and non-medical students) students’ knowledge and attitudes toward the pre- cautionary measures to prevent COVID-19 infection. The study was conducted at the Gasha Technical Institute in Erbil, Kurdistan Region of Iraq, from 2nd January to 1st March, 2022. The sample included a total of 240 students. Students from the nursing department in the 2nd grade (120 medical students) and students from the English department (120 non-medical students) were recruited to participate in the study. The Scientific and Ethical Committee ap- proved this study at Hawler Medical Uni- versity/ College of Nursing, No (5) 16, De- cember 2021. Before data collection, per- mission was obtained from the director of administration of the Gasha Technical In- stitute. At the beginning of the study, the details and the objectives were explained to the study participants. Then, written informed consent was obtained. Partici- pants were assured that their information will be kept confidential using codes in- stead of personal information .After re- viewing the related literature, a self- reported structured questionnaire was adopted from other published articles with a few modifications [10,11]. The question- naire was designed in English language and then translated to the Kurdish language with the assistance of a native Kurdish pro- fessional. The self-reported questionnaire consisted of three sections: socio- demographics, knowledge, and attitudes toward COVID-19. The first part deter- mined undergraduate students’ socio- demographic characteristics, including sex, age, marital status, degree or certificate, and area of residence. The second part 80 METHODS Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 77.5% of students in the English depart- ment, were single. The rate of married stu- dents (21.7%) was higher in the English department. Most study participants in both departments lived in urban areas, less than 7% of nursing students lived in rural areas, and 5% of English students lived in suburban areas. The rate of students in- fected with COVID-19 was higher among nursing students than English students. As demonstrated in Table 2, more than half (63.3%) of nursing students showed good knowledge, 31.7% showed medium knowledge, and only 5.0% showed poor knowledge. 93.3% of nursing students had a positive attitude about COVID-19. In con- trast, 68.3% of students in the English de- partment had positive. Negative attitude toward COVID-19 was higher among Eng- lish students (31.7%) than nursing students (6.7%). measured students’ knowledge regarding COVID-19 comprising 18 questions. The third part was measured students’ atti- tudes regarding COVID-19 comprising 18 questions. The scientific committee at the college of nursing extensively reviewed the questionnaire for its validity and relevancy. A small pilot study was done to check for simplicity and difficulty. The samples of the pilot study were excluded from the actual study sample.Students were given the fol- lowing options to answer the questions: correct, incorrect, never, rarely, often. A question scoring system was used to meas- ure the knowledge level of undergraduate students as follows: one point for a correct answer and zero point for the incorrect an- swer for each question. Students’ knowledge was classified as poor (<50%), fair = (50-75%) and good (>75%). Students’ attitude was classified as negative (<50%) and positive (³50%). Statistical Package of Social Science SPSS (Version 23.0) were used to analyze the collected data. The so- cio-demographic features of the study par- ticipants were analyzed using descriptive statistics. Person’s Chi-square (X2) test was used to investigate the association be- tween study participants’ socio- demographic variables and their knowledge level and attitude toward pre- cautionary measures against COVID-19. A p -value of less than and equal to 0.05 was considered significant. Table 1 illustrates the socio-demographic characteristics of study participants. Around 70% of nursing students and 69% of students in the English department were males. Most of students in both depart- ments were between 18 and 23 years old, and only 8.3% and 25% were between 24 and 30 years old in the nursing and English departments, respectively. The highest per- centages, 83.3 % of students in nursing and 81 RESULTS Table 1: Nursing and English students’ dis- tribution according to their socio- demographic characteristics Characteristics Nursing students N (%) English students N (%) Sex Male 35 (29.2) 37 (30.8) Female 85 (70.8) 83 (69.2) Age group 18-24 110 (91.7) 90 (75) 25-31 10 (8.3) 30 (25) Marital status Single 100 (83.3) 93 (77.5) Married Divorced 20 (16.7) 26 (21.7) 1 (0.8) Degree or certifi- cate Diploma 120 (100) 120 (100) Area of residence Urban 79 (65.8) 94 (78.3) Rural 8 (6.7) 20 (16.7) Sub-urban 33 (27.5) 6 (5.0) Did you infected with covid-19 Yes No 51(42.5) 69 (57.5) 46 (38.3) 74 (61.7) Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article Table 3 shows the relationship between participants’ socio-demographic character- istics, knowledge level and attitude. No sig- nificant differences were observed among nursing students’ knowledge with sex, mar- ital status, and area of residence. There was a highly significant association be- tween knowledge and age (p= 0.001). Also, no significant differences were observed among nursing students’ attitudes with sex, age, marital status, and area of residence. Regarding students in the English depart- ment, there were no significant differences between knowledge level with age, marital status, and area of residence. Significant associations were noticed between knowledge and sex (p= 0.02), and attitude with age (p= 0.044).Overall, a higher knowledge level was observed in nursing students than students in the English de- partment with a mean score (14.59 ± 2.43 and 12.66 ± 2.88, respectively). 82 Table 2: Percent distribution of students’ knowledge and attitude. Knowledge and Attitude Category Students in Nursing Department (n=120) F.(%) Students in English Department (n=120) F.(%) Knowledge Poor 6 (5.0) 23 (19.2) Fair 38 (31.7) 61 (50.8) Good 76 (63.3) 36 (30) Attitude Positive 112 (93.3) 82 (68.3) Negative 8 (6.7) 38 (31.7) Table 3: Participants’ socio-demographic-characteristics relationship with knowledge lev- els and attitude. Variable Students in Nursing field Students in English field Knowledge p-value Attitude p-value Knowledge p-value Attitude p-value Sex 0.211 0.501 0.02 0.756 Marital status 0.777 0.479 0.613 0.1 Age 0.001 0.216 0.617 0.044 Area of residence 0.593 0.495 0.170 0.761 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 83 residencies. This is in agreement with the study done by Akalu et al., 2020, the rea- son being explained as inadequate infor- mation about human health is not availa- ble online due to poor internet connec- tion and weak mobile network systems in rural areas [20]. More than 90% of nurs- ing students and 60% of students in the English field had a positive attitude to- ward COVID-19. This is similar to a study conducted in Egypt [21], which stated that more than 80% of the study partici- pants had a positive attitude toward COVID-19. The result of this study showed that 13.3% of students in nursing and 29.2% in the English department did not wear a surgical face mask. Also, 73.3% of nursing students and 69.2% of participants in the English field did not always practice physical distancing of two meters. Maheshwari et al., 2019, report- ed that more than 9% of the participants did not wear a surgical mask to protect themselves against COVID-19 [2]. In general, nursing students in our re- search had higher good knowledge level and positive attitudes than participants in the English department towards using precautionary measures against COVID- 19. This basic information is vital to de- crease the spread of the disease. Less than half of participants in nursing and around two-thirds of participants in the English department believed that vac- cines could not be effective in preventing infection transmission. We recommend seminars and workshops about COVID-19 vaccination for undergraduate students in all fields of study, especially for non- medical students. Also, the government needs to clarify the benefits of COVID-19 vaccines for the community, in order to increase the societies’ positive attitudes about vaccines. DISCUSSION To the best of our knowledge, this is the first comparative study among undergradu- ate medical and non-medical students, as- sessing the knowledge and attitudes of pre- cautionary measures toward COVID-19. A good knowledge level has been shown by nursing students. This is consistent with the finding of other studies done recently [12,13]. Nursing students were more knowledgeable than non-medical students. This result is consistent with research con- ducted in Jordon [14], which found that students in colleges of medical science had higher knowledge levels on COVID-19 than students in other fields of study. The knowledge level of students between 24 to 30 years old was higher than others be- tween 18 to 23 years old. This finding is consistent with the study by Olaimat et al., 2020, which explained that knowledge in- creases as age increases. Female nursing students have a greater level of knowledge than male students. Male English students had higher knowledge levels than female English students. Our findings are con- sistent with research conducted in China and Italy [15, 16]. However, studies done in Ethiopia, Malaysia, and Saudi Arabia found the reverse of this study’s findings [17,18,19]. Nursing students who were married had higher knowledge than single students. However, divorced non-medical students had higher knowledge levels than single and married students in the same field of study. A study conducted by Abate and Mekonnen in 2020, showed that di- vorced individuals were less likely than sin- gle participants to have inadequate knowledge levels [4]. In our study, nursing students in urban residency were more knowledgeable than rural residency. In contrast, non-medical students of subur- ban residency had a higher knowledge lev- el of COVID-19 than rural and urban CONCLUSION Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article [9] Batra K, Urankar Y, Batra R, Gomes AF Kau- rani P. 2021, May. Knowledge, protective behaviors and risk perception of COVID-19 among dental students in India: A cross- sectional analysis. Multidisciplinary Digital Publishing Institute. In Healthcare. 2021;9 (5): p.574. [10] Almofada SK, Alherbisch RJ, Almuhraj NA, et al. Knowledge, attitudes, and practices to- ward COVID-19 in a Saudi Arabian popula- tion: a cross-sectional study. Cureus. 2020;12(6). [11] Saadatjoo S, Miri M, Hassanipour S, Ameri H, Arab-Zozani M. Knowledge, attitudes, and practices of the general population about Coronavirus disease 2019 (COVID-19): a sys- tematic review and meta-analysis with policy recommendations. Public Health. 2021; 194: pp.185-195. [12] Taghrir MH, Borazjani R, Shiraly R. COVID-19 and Iranian Medical Students; A Survey on Their Related-Knowledge, Preventive Behav- iors and Risk Perception. Archives of Iranian Medicine. 2020; 23: 249–254.[PubMed]. [13] Nemati M, Ebrahimi B, Nemati F. Assess- ment of Iranian Nurses’ Knowledge and Anx- iety toward COVID-19 during the Current Outbreak in Iran. Archives of Clinical Infec- tious Diseases. 2020; 15: e102848. [14] Olaimat AN, Aolymat I, Shahbaz HM, Holley RA. Knowledge and information sources about COVID-19 among university students in Jordan: a cross-sectional study. Frontiers in Public Health. 2020; 8: p.254. [15] Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, Li Y. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional sur- vey. International Journal of Biological Sci- ences. 2020; 16: 1745–1752. [CrossRef] [PubMed]. [16] Gallè F, Sabella EA, Da Molin G, De Giglio O, Caggiano G, Di Onofrio V, Ferracuti S, Montagna MT, Liguori G, Orsi GB, Napoli C. Understanding knowledge and behaviors related to Covid–19 epidemic in Italian undergraduate students: the EPICO study. International Journal of Environmen- tal Research and Public Health. 2020; 17(10): p.3481. [17] [17]Kebede Y, Yitayih Y, Birhanu Z, Mekonen S, Ambelu A, Tu WJ. Knowledge, perceptions and preventive practices towards COVID-19 early in the outbreak among Jimma 84 CONFLICT OF INTEREST The author reports no conflict of interests. The authors (s) report no funding support. [1] Tadesse DB, Gebrewahd GT, Demoz GT. Knowledge, attitude, practice and psycho- logical response toward COVID-19 among nurses during the COVID-19 outbreak in northern Ethiopia. New Microbes and New Infections. 2020; 38: p.100787. [2] Maheshwari S, Gupta PK, Sinha R, Rawat P. Knowledge, attitude, and practice towards coronavirus disease 2019 (COVID-19) among medical students: A cross-sectional study. Journal of Acute Disease. 2020; 9(3): p.100. [3] Alimohamadi Y, Sepandi M, Taghdir M, Hosamirudsari H. Determine the most com- mon clinical symptoms in COVID-19 pa- tients: a systematic review and meta- analysis. Journal of Preventive Medicine and Hygiene. 2020; 61(3): p.E304. [4] Abate H, Mekonnen CK. Knowledge, atti- tude, and precautionary measures towards covid-19 among medical visitors at the uni- versity of gondar comprehensive special- ized hospital northwest Ethiopia. Infection and Drug Resistance. 2020; 13: p.4355. [5] Saadeh D, Sacre H, Hallit S, Farah R, Sala- meh P. Knowledge, attitudes, and practices toward the coronavirus disease 2019 (COVID‐19) among nurses in Leba- non. Perspectives in Psychiatric Care. 2021; 57(3): pp.1212-1221. [6] Sajed AN, Amgain K. Corona virus disease (COVID-19) outbreak and the strategy for prevention. Europasian Journal of Medical Sciences. 2020; 2(1): pp.1-3. [7] Khasawneh AI, Humeidan AA, Alsulaiman JW, Bloukh S, Ramadan M, Al-Shatanawi TN, et al. Medical students and COVID-19: knowledge, attitudes, and precautionary measures. A descriptive study from Jor- dan. Frontiers in Public Health. 2020; 8: p.253. [8] Stein-Zamir C, Abramson N, Shoob H, Libal E, Bitan M, Cardash T, et al. A large COVID- 19 outbreak in a high school 10 days after schools’ reopening, Israel. Eurosurveillance. FUNDIN REFERENCES Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article university medical center visitors, South west Ethiopia. PLoS One. 2020;15(5): e0233744. doi:10.1371/ journal. pone.023374419. [18] Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Novel corona- virus (COVID-19) knowledge and percep- tions: a survey on healthcare workers. MedRxiv. 2020; 29. [19] Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E, Tu W-J. Public knowledge, atti- tudes and practices towards COVID-19: a cross-sectional study in Malaysia. PLoS One. 2020;15(5): e0233668. doi:10.1371/ journal.pone.023366831. [20] Akalu Y, Ayelign B, Molla MD. Knowledge, attitude and practice towards COVID-19 among chronic disease patients at Addis Zemen Hospital, Northwest Ethiopia. Infec- tion and Drug Resistance. 2020; 13:1949. doi:10.2147/IDR.S25873615 [21] Abdelhafiz AS, Mohammed Z, Ibrahim ME, Ziady HH, Alorabi M, Ayyad M, Sultan EA, Knowledge, perceptions, and attitude of Egyptians towards the novel coronavirus disease (COVID-19). Journal of Community Health. 2020; 45(5): pp.881-890 85 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/