Knowledge,attitudes,and practices of secondary school students towards COVID-19 in Sana’a City,Yemen: A cross-sectional study

Abstract

Background:

Understanding of public awareness on public health issues is very crucial, including the current health crisis of COVID-19. This research aimed to examine the Knowledge, Attitudes and Practices among Students towards COVID-19.

Design and methods:

A cross-sectional survey was conducted among secondary school students in grades 10–12. Proportional sample allocation was used in 16 randomly selected schools. Moreover, the schools were recruited by using a systematic random sampling technique. Socio-demographic data and questions of the knowledge, attitude and practice were collected by interview. Logistic regression analyses were employed to identify the associated factors and p-value < 0.05 was considered statistically significant.

Results:

Among the 357 participants the level of good knowledge, positive attitude, and optimal practice were 65.2%, 66.7% and 89.4% respectively. Regression analyses showed that being in the adolescent age group (15–16 years old), living with >5 family size, and family with a good income effectively predicted knowledge level. Attitudes towards COVID-19, male students were pessimistic about COVID-19 prevention and control measures as opposed to their female counterparts [aOR = 0.39; 95% CI: 0.21–0.71). Students with awareness of the virus demonstrated greater (two-fold) odds of a positive attitude as opposed to their less-conscious counterparts. The urban-area male students were demonstrated a higher (three-fold) odds of good practice level towards COVID-19 prevention and control measures as opposed to their rural-area female counterparts.

Conclusion:

A good knowledge level denoted a positive attitude despite the lack of information. Meanwhile, good preventive measure practices and behaviours reflected high levels.

Keywords

Coronavirus disease-19 COVID-19 knowledge attitude practice school students Sana’a Yemen

Background

The current pandemic resulting from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first documented in Wuhan, China in December 2019, poses a global health threat in the form of COVID-19. Notably, the World Health Organization (WHO) declared COVID-19 as a pandemic on 11 March 2020 with 118,320 confirmed cases recorded in 114 countries.¹ This number has escalated to 293,207,113 cases and 5,468,186 fatalities documented in 224 nations and territories as of 4 January 4 2022.² Specific countries effectively controlled or limited the viral spread through stringent and national-level infection control measures: lockdowns, social distancing, compulsory wearing of masks, and other hygiene practices.³ Assumably, the prevalent spread of COVID-19 could instigate high death rates and economic downturns despite variances in Infection and death rates across nations based on patient population and healthcare system preparedness.⁴ The COVID-19 virus began spreading rapidly in the Middle East, specifically in Iran. Delayed response to the pandemic and insufficient resources in nations resembling Yemen could be justified by the inadequacy of essential resources and regional-level political conflicts, which inevitably undermined the healthcare infrastructure.

Meanwhile, Gulf countries with a good preparedness plan entailed optimal resources and high political stability.^5,6 The COVID-19 disease is primarily transmitted through coughing, sneezing and touching a virus-contaminated surface.⁷ Clinical COVID-19 features typically involve fever, fatigue, cough, shortness of breath and pneumonia.⁸ Following the WHO report, most COVID-19 patients who experience mild symptoms recuperate without specified treatment while 20% of them were severely infected with a 2% mortality rate.⁹ Health complications were primarily perceived in patients with cardiovascular diseases, diabetes and hypertension parallel to Yang et al. ’s systematic review.¹⁰

The first confirmed COVID-19 case in Yemen was officially announced on 10 April 2020 in Hadhramaut. Yemeni health authorities in Aden went on to officially document five new cases on 29 April 2020. Despite the insufficiency of adequate data, several COVID-19 cases were detected in Sana’a at the same time. The means by which this virus spread to Yemen (whether from neighbouring countries, such as Saudi Arabia or other state borders) is relatively underexplored. On another note, Yemeni passengers were returning home from various countries despite border closures and international flight shutdowns during the initial weeks of COVID-19 cases. Concrete data on the COVID-19 situation in Yemen remain lacking.^11,12 Several research teams strived to develop vaccines that render people immune to SARS-CoV-2 in under 12 months following the advent of COVID-19. The current challenge lies in distributing the vaccine to protect the global population regardless of its economic well-being.¹³ A total of 10,123 confirmed COVID-19 cases and 1984 fatalities were recorded in Yemen from 3 January 2020 to 29 December 2021 and duly reported to WHO. Overall, 786,027 vaccine doses have been administered as of 2 December 2021.¹⁴

Relevant Yemeni authorities declared a nationwide health emergency and enforced stringent preventive measures, not unlike those adopted on a global scale, in addressing the current health crisis. Multiple countermeasures involving school closure, working or studying from home, social distancing, and hand-washing practices in public places were implemented by the local authorities through public education: one of the most crucial means of disease control. Regardless, the Yemeni government has reopened schools and resumed educational activities with strict adherence to COVID-19 protocols. Published research on COVID19 from Yemen context is limited. Thus, this research presenting KAP status of secondary school students in Sana’a with regards to COVID-19 given the paucity of knowledge involving their awareness level.

Methods

Study design and setting

This is a cross-sectional survey design was conducted between January and March 2022. The research location is high school’s students in Sana’a capital, Yemen. Sana’a is situated at an altitude of 2300 m in the centre of Yemen and experiences a dry and mild climate with an annual rainfall of 200 mm and a monthly (average) minimum-maximum temperature of 6°C–30°C. Based on the 2004 Sana’a City administrative division authority, the capital area (spread over 10 districts) is approximately (5.6) square kilometres and houses 3,181,655 individuals,¹⁵ out of which 73,927 and 37,239 were public and private secondary schoolchildren, respectively from 371 secondary schools.¹⁶

All the secondary school students studying in Sana’a city and were available and willing and enrolled participate in secondary schools in this city were part of the study population. As for this study all the secondary schools in the city of Sana’a were involved in this study.

Study variables

The independent variables in this study implied socio-demographic attributes (age, gender, residence, grade, school type, household members, total family size, and monthly family income) while the dependent counterparts involved students’ knowledge, attitude and practice (KAP) levels.

Study development

The single population proportion formula, which was used to determine the study sample size by assuming p = 36%,¹⁷ revealed a sample size of 347 secondary school students. Essentially, the final sample size was 357 with a 5% non-response rate. A total of 16 (eight public and eight private) secondary schools out of the overall 250 schools were selected through simple random sampling. The number of research participants sampled from the chosen schools was identified with the proportionate-to-population size method. Overall, 7258 students were identified in four selected public schools (2491 in Ma’an, 1634 in Al-Wahdah, 1772 in Shoub and 1361 in Al-Sabeen), whereas 1755 counterparts were identified in four selected private schools (1231 in Ma’an, 223 in Al-Wahdah, 168 in Shoub and 133 in Al-Sabeen) (Figure 1). Systematic sampling was incorporated to choose the research participants from each selected school. The interval (K) value was computed for each of the chosen schools by dividing the overall number of students in each school by the corresponding proportional sample size calculated for each school. The initial participants were arbitrarily chosen using the lottery approach, while other counterparts were selected at every Kth interval with a list of students in every grade obtained from the school administration.

Figure 1.

Flowchart showing the sampling process.

Recruitment and data collection

Socio-demographic details were gathered with a pre-tested, structured, and self-administered questionnaire. Notably, this instrument was adopted from the Yemeni surveillance system for COVID-19. The questionnaire was prepared in English language and back-translated to the local language Arabic to ensure its consistency. The accuracy of the tool was checked by back translating to English by experts who were blind to the original instrument. Before starting the data collection, the pre-test was done on 10% of the total sample size in one secondary school, and an amendment was made accordingly. To maintain the quality of the data, training was provided for data collectors on the aim of the study and methods of data collection. Field level supervision was done to control the data collection and data quality.

The study data were gathered by physically interviewing secondary school students to evaluate their KAP towards COVID-19. The questionnaire utilised in this interview entailed socio-demographic attributes (gender, residence, age, grade or section, household members and monthly family income) and students’ KAP towards COVID-19. All the necessary personal protective equipment was applied during the data gathering purposes.

Study outcomes and measures

The primary outcome of interest was COVID-19 knowledge level was evaluated through 14 general questions that analysed clinical COVID-19 manifestations and transmission, prevention, and control modes. The questionnaire was addressed on a ‘true or false’ basis where ‘1’ implied an accurate answer, whereas ‘0’ denoted an inaccurate or unknown answer. Essentially, the scoring ranged between 14 and 0. Individuals’ scores were computed and summarised to derive the participants’ COVID-19-oriented knowledge. The secondary outcome of interest was attitude which was evaluated with 10 questions. Each question encompasses five-point Likert scale responses: ‘5 = Strongly agree; 4 = agree; 3 = neural; 2 = disagree; 1 = strongly disagree’. For assessment purposes, ‘strongly agree’ and ‘agree’ were recoded to 1 while ‘neural’, ‘disagree’ and ‘strongly disagree’ were recoded to ‘0’. The scores were subsequently summarised to obtain students’ overall attitude towards COVID-19. Likewise, 10 questions on COVID-19 preventive practices were posed to students, whose responses were scored as 1 for ‘Always/often/sometimes’ and 0 for ‘Never/almost never’. The practice scoring spanned from 10 to 0 (smallest to largest). Participants’ preventive practice scores were duly computed and summarised for the overall practice score.

Socio-demographic information collected included (gender, residence, age, grade or section, household members, and monthly family income). Health related history included any pre-existing health conditions and information on COVID-19 infection. The Cronbach’s alpha values for knowledge, attitude and practice were found to be greater than 0.70.

Data analysis

The study data were cleaned, coded, and fed into an Excel Sheet to be exported to SPSS version 25.0 for evaluation purposes. Additionally, the outcomes elicited from the descriptive analysis were presented in the form of texts, frequency tables, figures, mean, and standard deviation (SD). Bivariate logistic regression analysis was also performed to assess the dependent-independent variable link. Socio-demographic elements and the KAP of preventive measures against COVID-19 were incorporated into the bivariate analysis. As such, independent study variables with a p-value under 0.25 were regarded in the final model. The independent variable relationships were analysed to identify any associations between their dependent counterparts. The model fitness was ascertained through the Hosmer-Lemeshow model fitness test. Lastly, multivariable logistic regression analysis functioned to control potential confounders and determine the aspects related to students’ KAP towards COVID-19. A statistical significance level was discovered at a p-value under 0.05.

This study received approval from the Al Razi University Research Ethics Board [G 10/90).

Results

Socio-demographic characteristics of participants

Notably, 357 (93.9%) out of the 380 gathered questionnaires proved valid. The participants’ age, which ranged between 15 and 20 years old, was 16.5 on average. Specifically, 220 (61.6%) of the individuals were male, 136 (38.1%) were in first secondary grade and 350 (98.0%) resided in urban areas (see Table 1).

Table 1.

Sociodemographic characters of students in Sana’a capital city, Yemen, 2022.

Variable/Factor	Frequency (n = 357)	Percentage (%)
Sex of student
Male	220	61.6
Female	137	38.4
Age of student (years)
15–16 year	182	51.0
17–18 year	166	46.5
19–20 year	9	2.5
Mean, SD	16.5 ± 1.09
Residence of student
Urban	350	98.0
Suburban	7	2.0
Level of secondary study
First grade	136	38.1
Second grade	110	30.8
Third grade	111	31.1
School type
Public	257	72.0
Private	100	28.0
Living with
Family	346	96.9
Relatives	7	2.0
Alone	4	1.1
Total family size (including extended families)
1–3	11	3.1
4–6	148	41.5
7–9	130	36.4
10–12	45	12.6
>12	23	6.4
Mean, SD	7.61 ± 3.526
Family monthly income (YR)
<70,000	145	40.6
70,000–120,000	111	31.1
>120,000	101	28.3
Mean, SD	119,693.28 ± 109,423.434

SD: standard deviation; YR: 1 Yemeni Real = 251 $.

Source of information on COVID-19

Overall, 241 (67.5%) of the study participants have obtained COVID-19-oriented knowledge from digital platforms, such as Facebook, Instagram, WhatsApp and Telegram, whereas 50 (52.7%) counterparts received information from mass media, including television or radio (see Figure 2).

Figure 2.

Source of information regarding COVID-19 pandemic for students in Sana’a city, Yemen, 2021. Other *(include newspaper, religious, leaders).

Student knowledge of protection methods against COVID-19 virus transmission

Resultantly, 351 (98.3%) of the participants conceded that avoiding crowded areas prevented the spread of COVID-19, 342 (95.8%) mentioned that quarantining individuals who tested positive for COVID-19 could limit the viral transmission, 341 (95.5%) concurred that wearing face masks deterred the transmission of COVID-19, 337 (94.4%) implied that frequent hand-washing hampered the spread of COVID-19, 326 (91.3%) stated that social distancing mitigated COVID-19 transmission and 122 (34.2%) implied that efficient vaccine usage reduced the COVID-19 spread (see Figure 3).

Figure 3.

Students knowledge on the protection methods against virus transmission of COVID-19.

Student knowledge of the situation in which they would wash their hands

Based on the research result, most (86.8%) individuals responded that regular hand-washing before eating potentially prevents the spread of COVID-19 while a low proportion (42.9%) of them implied washing hands after coughing or sneezing (see Figure 4).

Figure 4.

Students knowledge on the which of the following situation you will wash their hands.

Student knowledge level and associated factors

In line with the study finding, 274 (76.8%) [95% CI: 72.4%−81.1%] of the participants demonstrated a good knowledge level regarding COVID-19. The bivariate logistic regression analysis in this research revealed that specific variables, such as age group (years), grade, monthly family income and individuals with awareness of COVID-19 were related to secondary school students’ COVID-19-oriented knowledge level. Variables with a p-value under 0.23 were fitted to multivariable logistic regression analysis, thus confirming the significance of students’ young age (aOR: 4.9; 95% CI: 1.04–23.0), first grade (aOR: 2.3; 95% CI: 1.2–4.6), high monthly family income (aOR: 2.2; 95% CI: 1.1–4.4), and individuals with awareness of COVID-19 (aOR: 0.40; 95% CI: 0.11–1.5) in terms of their good COVID-19-oriented knowledge (see Table 2).

Table 2.

Factors associated with knowledge level of students towards COVID-19, Sana’a city, Yemen, 2022.

Variables/Factors	Total n (%)	Knowledge levels		COR (95% CI)	aOR (95% CI)
Variables/Factors	Total n (%)	Good (N = 274) n (%)	Poor (N = 83) n (%)	COR (95% CI)	aOR (95% CI)
Age of student (in years)
15–16	182 (51.0)	153 (55.8)	29 (34.9)	6.60 (1.67–26.04)*	4.89 (1.04–22.96)*
17–18	166 (46.5)	117 (42.7)	49 (59.0)	2.99 (0.77–11.59)	2.74 (0.65–11.43)
19–20	0	4 (1.5)	5 (6.0)	1.00	1.00
Sex of participants
Male	220 (61.6)	166 (60.0)	54 (65.1)	0.83 (0.50–1.38)	0.90 (0.52–1.58)
Female	137 (38.4)	108 (39.4)	29 (34.9)	1.00	1.00
Residence
Urban	350 (98.0)	268 (97.8)	82 (98.8)	0.55 (0.07–4.59)	0.58 (0.07–5.09)
Suburban	7 (2.0)	6 (2.2)	1 (1.2)	1.00	1.00
Grade				2.93
Grade 1	136 (38.1)	118 (43.1)	18 (21.7)	2.46 (1.28–4.71)*	2.31 (1.16–4.60)*
Grade 2	110 (30.8)	80 (29.2)	30 (36.1)	1.00	1.00
Grade 3	111 (31.1)	76 (27.7)	35 (42.2)	0.81 (0.46–1.45)	1.22 (0.60–2.47)
School type
Public	257 (72.0)	195 (71.2)	62 (74.7)	0.84 (0.48–1.46)	0.95 (0.49–1.85)
Private	100 (28.0)	79 (28.8)	21 (25.3)	1.00	1.00
Living with
Family	346 (96.9)	265 (96.7)	81 (97.6)	0.73 (0.15–5.43)	0.78 (0.14–4.26)
Relatives	11 (3.1)	9 (3.3)	2 (2.4)	1.00	1.00
Family size
1−5	88 (24.6)	68 (24.8)	20 (24.1)	1.50 (0.63–3.56)	0.96 (0.51–1.79)
6−10	233 (65.3)	181 (66.1)	52 (62.7)	1.53 (0.71–3.32)	0.73 (0.32–1.68)
>10	36 (10.1)	25 (9.1)	11 (12.3)	1.00	1.00
Family monthly income
<70,000	145 (40.6)	115 (42.0)	30 (36.1)	1.77 (1.00–3.11)*	1.36 (0.72–2.56)
70,000–120,000	111 (31.1)	76 (27.7)	35 (42.2)	1.00	1.00
>120,000	101 (28.3)	83 (30.3)	18 (21.7)	2.12 (1.11–4.06)*	2.16 (1.07–4.36)*
Family history with COVID-19
Yes	86 (24.1)	66 (24.1)	20 (24.1)	1.00 (0.56–1.78)	0.96 (0.52–1.80)
No	271 (75.9)	208 (75.9)	63 (75.9)	1.00	1.00
Heard about Novel COVID-19
Yes	327 (91.6)	247 (90.1)	80 (96.4)	0.34 (0.10–1.16)*	0.40 (0.11–1.49)*
No	30 (8.4)	27 (9.9)	3 (3.6)	1.00	1.00

COR: crude odds ratio; aORb: adjusted odds ratio.

p-Value <0.05, and bold font means statistically significant.

Student attitude towards COVID-19 and associated factors

Resultantly, 284 (79.6%) [95% CI: 75.0%−83.6%] of the participants reflected a positive attitude towards COVID-19 prevention and control methods. The multivariable logistic regression model in this study was performed with backward elimination techniques. Specifically, male participants with a 39% odds of having a positive attitude were 39% less likely to be optimistic towards COVID-19 prevention and control strategies as opposed to their female counterparts [aOR = 0.39; 95% CI: 0.21–0.71). Meanwhile, individuals with awareness of COVID-19 demonstrated greater (two-fold) odds of a positive attitude as opposed to those with less consciousness (aOR = 2.43; 95% CI: 1.08–5.45). Notwithstanding, the students’ age, dwelling, gender, grade, household members, family size, and monthly family income were insignificantly related to their level of attitude towards COVID-19 prevention measures (see Table 3).

Table 3.

Factors associated with attitude of students towards COVID-19, Sana’a city, Yemen, 2022.

Variables/Factors	Total n (%)	Attitude level		COR (95% CI)	aOR (95% CI)
Variables/Factors	Total n (%)	Positive (N = 284) n (%)	Negative (N = 73) n (%)	COR (95% CI)	aOR (95% CI)
Age of student (in years)
15–16	182 (51.0)	147 (51.8)	35 (47.9)	2.1 (0.50–8.810	3.18 (0.59–17.10)
17–18	166 (46.5)	131 (46.1)	35 (47.9)	1.87 (0.45–7.86)	2.68 (0.56–12.77)
19–20	9 (2.5)	6 (2.1)	3 (4.1)	1.00	1.00
Sex of participants
Male	220 (61.6)	163 (57.4)	57 (78.1)	0.38 (0.21–0.69)*	0.39 (0.21–0.71)*
Female	137 (38.4)	121 (42.6)	16 (21.9)	1.00	1.00
Residence
Urban	350 (98.0)	278 (97.9)	72 (98.6)	0.64 (0.07–5.43)	0.46 (0.05–4.64)
Suburban	7 (2.0)	6 (2.1)	1 (1.4)	1.00	1.00
Grade
Grade 1	136 (36.1)	106 (37.3)	30 (41.1)	0.82 (0.44–1.54)	0.63 (0.28–1.47)
Grade 2	110 (30.3)	88 (31.0)	22 (30.0)	0.93 (0.48–1.82)	0.56 (0.24–1.28)
Grade 3	111 (31.1)	90 (31.7)	21 (28.8)	1.00	1.00
School type
Public	257 (72.0)	197 (69.4)	60 (82.2)	0.49 (0.26–0.94)*	0.63 (0.30–1.33)
Private	100 (28.0)	87 (30.6)	13 (17.8)	1.00	1.00
Living with
Family	346 (96.9)	278 (97.90	68 (93.2)	3.41 (1.01–11.50)*	2.11 (0.55–8.10)
Relatives	11 (3.1)	6 (2.1)	5 (6.8)	1.00	1.00
Family size
1−5	88 (24.6)	67 (23.6)	21 (28.8)	1.06 (0.43–2.62)	0.97 (0.37–2.58)
6−10	233 (65.3)	190 (66.9)	43 (58.9)	1.47 (0.65–3.36)	1.59 (0.65–3.92)
>10	36 (10.1)	27 (9.5)	9 (12.3)	1.00	1.00
Family monthly income
<70,000	145 (40.6)	107 (37.7)	38 (52.1)	1.00	1.00
70,000–120,000	111 (31.1)	88 (31.0)	23 (31.5)	1.36 (0.75–2.45)	1.00 (0.51–1.99)
>120,000	101 (28.1)	89 (31.3)	12 (16.4)	2.63 (1.30–5.34)*	1.54 (0.65–3.63)
Family history with COVID-19
Yes	86 (24.1)	75 (26.4)	11 (15.1)	2.02 (1.01–4.05)*	1.52 (0.72–3.18)
No	271 (75.9)	209 (73.6)	62 (84.9)	1.00	1.00
Heard about Novel COVID-19
Yes	327 (91.6)	266 (93.7)	61 (83.6)	2.91 (1.33–6.35)*	2.43 (1.08–5.45)*
No	30 (8.4)	18 (6.3)	12 916.4)	1.00	1.00

COR: crude odds ratio; aOR: adjusted odds ratio.

p-Value <0.05, and bold means statistically significant.

Student practice level towards COVID-19 and associated factors

Parallel to the research outcomes, 280 (78.4%) [95% CI: 73.8, 82.6%] of the participants demonstrated an optimal level of prevention practice with regards to COVID-19. Male students reflected a greater (three-fold) odds of good practice level towards COVID-19 prevention and control measures as opposed to their female counterparts [aOR = 2.67; 95% CI: 1.17–6.09). In this vein, individuals residing with relatives implied greater (eight-fold) odds of good practice level towards COVID-19 prevention and control measures as opposed to counterparts residing with their family members [aOR = 7.64; 95% CI: 1.80–32.38). Regardless, the students’ age, dwelling, grade, family size, monthly family income, family history with COVID-19, and individuals with awareness of COVID-19 were insignificantly connected to their practice level towards COVID-19 prevention measures (see Table 4).

Table 4.

Factors associated with practice level of students in Sana’a, Yemen, 2020.

Variables/Factors	Total n (%)	Practice levels		COR (95% CI)	aOR (95% CI)
Variables/Factors	Total n (%)	Good (N = 280) n (%)	Poor (N = 77) n (%)	COR (95% CI)	aOR (95% CI)
Age of student (in years)
15–16	182 (51.0)	140 (50.0)	42 (54.5)	0.98 (0.12–8.31)	1.82 (0.14–23.01)
17–18	166 (46.5)	133 (47.5)	33 (42.9)	1.29 (0.15–10.77)	1.83 (0.16–20.72)
19–20	9 (2.5)	7 (2.5)	2 (2.6)	1.00
Sex of participants
Male	220 (61.6)	169 (60.4)	51 966.2)	2.32 (1.11–4.87)*	2.67 (1.17–6.09)*
Female	137 (38.4)	111 (39.6)	26 (33.8)	1.00	1.00
Residence
Urban	350 (98.0)	275 (98.2)	75 (97.4)	0.34 (0.06–1.81)	0.32 (0.05–1.89)
Suburban	7 (2.0)	5 (1.8)	2 (2.6)	1.00	1.00
High school grades
Grade 10	136 (38.1)	106 (37.9)	30 (39.0)	0.89 (0.44–1.82)	1.01 (0.38–2.72)
Grade 11	110 (30.8)	82 (29.3)	28 (36.4)	0.43 (0.18–1.05)	0.42 (0.15–1.20)
Grade 12	111 (31.1)	92 (32.9)	19 (24.7)	1.00	1.00
School type
Public	257 (72.0)	201 (71.8)	56 (72.7)	0.92 (0.46–1.84)	1.08 (0.45–2.56)
Private	100 (28.0)	79 (28.2)	21 (27.3)	1.00	1.00
Living with
Family	346 (96.9)	272 (97.1)	74 (96.1)	1.00	1.00
Relatives	11 (3.1)	8 (2.9)	3 (3.9)	6.56 (1.91–22.50)*	7.64 (1.80–32.38)*
Family size
1−5	88 (24.6)	75 (26.8)	13 (16.9)	0.71 (0.22–2.28)	1.09 (0.30–3.98)
6−10	233 (65.3)	179 (63.9)	54 (70.1)	0.92 (0.33–2.54)	1.74 (0.55–5.50)
>10	36 (10.1)	26 (9.3)	10 (13.0)	1.00	1.00
Family monthly income
<70,000	145 (40.6)	111 (39.6)	34 (44.2)	0.66 (0.31–1.42)	0.53 (0.19–1.45)
70,000–120,000	111 (31.1)	90 (32.1)	21 (27.3)	0.83 (0.38–1.81)	0.78 (0.32–1.91)
>120,000	101 (28.3)	79 (28.2)	22 (28.6)	1.00	1.00
Family history with COVID-19
Yes	86 (24.1)	72 (25.7)	14 (18.2)	1.56 (0.79–3.10)*	0.52 (0.24–1.12)
No	271 (75.9)	208 (74.3)	63 (81.8)	1.00	1.00
Heard about Novel COVID-19
Yes	327 (91.6)	256 (91.4)	71 (92.2)	1.10 (0.37–3.33)	1.39 (0.31–6.15)
No	30 (8.4)	24 (8.6)	6 (7.8)	1.00	1.00

COR: crude odds ratio; aOR: adjusted odds ratio.

p-value <0.05, and bold means statistically significant.

Discussion

The COVID-19 pandemic has induced global complexities and imposed various national-level burdens, including school closures, continuous war, economic downfalls, high pressure on healthcare providers, and public outcries. This research involved 357 students from secondary schools in the city of Sana’a, Yemen to determine their current KAP status with regards to COVID-19. Only half of the hospitals in Yemen remain fully operational while two-thirds of Yemenis are deprived of access to healthcare owing to ongoing war and civil unrest over the last 7 years. Humanitarians encounter various challenges in such circumstances owing to bureaucratic delays and associated complexities.¹⁸ Essentially, 62% out of the 357 study participants are male and the remaining female. The students ranged between 15 and 20 years old with a mean age equivalent to 17 and SD = 1.09. Approximately 38.1% of the individuals were in the first secondary grade while 98.0% resided in urban areas.

Resultantly, 76.8% (95% CI: 72.4%−81.1%) of the students revealed good knowledge of COVID-19, which proved encouraging as concrete and sufficient knowledge could render one protected.¹⁹ The current research outcome was lower empirical works performed in Egypt,²⁰ and India²¹ where 90% and 90.4% of the students, respectively, possessed good COVID-19-oriented knowledge. Contrarily, research in China implied that 74.1% of the participants gained a specific comprehension of COVID-19.²² In this work, students’ good knowledge about COVID-19 might occur following the delay in confirmed COVID-19 case reports in Yemen, which could have provided sufficient time to internalise the disease. Furthermore, the WHO declaration of COVID-19 as a pandemic might have also have increased their knowledge.²³

Optimal education imparted by WHO and the Yemeni government and proactive knowledge-seeking regarding COVID-19 by students and frontliners from the Ministry of Health Yemen through multiple information sources potentially facilitate the acquisition of relevant knowledge. Furthermore, 77.8% of the individuals were aware that adult patient groups are at high risk of contracting COVID-19. Secondary school students from 19 to 20 years old belonging to a high grade (Grade 3) depicted lower knowledge levels than their younger (Grade 1) counterparts between 15 and 16 years old. School categories implicitly represented students’ age. Research on young individuals in Hong Kong during the severe acute respiratory syndrome (SARS) epidemic revealed improved preventive behaviours among younger students.²⁴ Generally, secondary school students in higher grades were less inclined to learn and gain knowledge. Both junior and senior high school students were hard-pressed for time to acquire COVID-19-oriented knowledge following heavy academic pressure. Meanwhile, secondary school students in lower grades experienced lighter study loads, higher learning adherence and a heightened capacity to obtain novel information.

Participants with a high monthly family income of (>120,000 YR) demonstrated good knowledge of COVID-19. This outcome parallelled a study in the USA,²⁵ where the gradients were partially explained by the fact that low-income earners tended to report circumstances that render the adoption of self-protective behaviours more challenging, such as an inability to telework. Additionally, students with an awareness of COVID-19 proved to be 40% more knowledgeable about COVID-19 than their counterparts. Research in Egypt similarly denoted an enhancement in secondary school students’ knowledge compared to that of pre-educational intervention,²⁰ which could be associated with the implications of teaching COVID-19-related programmes with regards to relevant information, students, and booklets on all the ascertained requirements and literature gaps on the topic among secondary school students.

Interestingly, 79.6% of the individuals disclosed a positive attitude towards COVID-19 prevention and control measures. This outcome proved to be lower than research performed among eight teaching hospitals in Ethiopia (86.3%),²⁶ Nepal school students (90.1%),²⁷ Malaysian residents (83.1%)²⁸ and Sudan (88.8%),²⁹ among primary and middle school students, China (80%).²² Following the present study outcomes, male students’ positive level of attitude towards COVID-19 was substantially lower than their female counterparts owing to a higher degree of sensitivity and concern regarding external environmental changes.³⁰

Study participants with an awareness of COVID-19 demonstrated a positive attitude towards COVID-19 prevention measures as opposed to their less conscious counterparts. The student attitude-knowledge relationship denoted that optimal knowledge demonstrated individuals’ positive attitudes towards COVID-19. The empirical outcomes parallelled an empirical work in Egypt,²⁰ where male students reflected a greater (three-fold) odds of good practice level towards COVID-19 prevention and control measures as opposed to their female counterparts [aOR = 2.67; 95% CI: 1.17–6.09). A significant association was revealed in this study between the male gender and potentially hazardous COVID-19-related practices following past literature.³⁰

Parallel to the research outcome, students dwelling with relatives demonstrated a greater (eight-fold) odds of good practice level towards COVID-19 prevention and control measures as opposed to counterparts residing with family members [aOR = 7.64; 95% CI: 1.80–32.38). This empirical outcome did not correspond to a school-oriented work in Northwest Ethiopia,²⁶ where most of the students across the country resided with their families following school closures. This situation could provide family members with an opportunity to firmly facilitate and impart sufficient knowledge of COVID-19 to the students. In the current study context, students preferred to receive COVID-19-related knowledge from their families apart from digital platforms and television.

The current work encountered several limitations despite extensive efforts to mitigate the potential drawbacks of this survey. First, the general attributes of the population aged between 9 and 18 years old were incomplete as this research only secondary school students were employed in this study. Notwithstanding, the outcomes are proved to be significant/valid. Second, the notably small sample size utilised in this work could lead to lower power, which implies a possibly unidentified risk factor. Lastly, the present research was performed in the city of Sana’a, Yemen during the COVID-19 pandemic. The overall performance of KAP under examination may prove higher than the general mean level in Yemen due to the high levels of education and information delivery network within the capital. As such, future works could perform multicenter studies entailing large samples nationwide for more precise data.

Strengths and limitations of the current study

Based on the sample sizes used, the findings of the study cannot be generalised to the entire population of Yemen. However, the study can certainly contribute to raising awareness about Knowledge, Attitudes and Practices (KAP) regarding COVID-19 in the specific governorate and the country as a whole. It is important to note that there is a possibility of misrepresentation of information and recall bias among participants due to the self-administered nature of the questionnaire. Additionally, the cross-sectional design of the study prevents us from establishing a cause-effect relationship. Considering these limitations, it is crucial to conduct further studies in the future to assess the knowledge, practices and attitudes towards COVID-19 among various societal groups.

Conclusions

The level of knowledge, attitude, and practice regarding COVID-19 among the participants during the early phase of the pandemic was found to be below the recommended scores set by the World Health Organization (WHO). However, a majority of the respondents demonstrated positive behaviour when it came to preventing COVID-19.

In light of this, it is crucial for the Ministry of Sciences and Higher Education (MOSHE) and local government authorities to implement effective strategies and interventions to address the knowledge, attitude, and practice gap among students regarding COVID-19 preventive measures. These interventions should take into account the different educational enrolment types and academic years of the students. Additionally, it is important to focus on health promotion and education efforts targeting subgroups with low levels of knowledge, attitude, and practice regarding COVID-19, such as students in rural areas and those in non-medical fields. This approach will ultimately help students adopt appropriate behaviours during the pandemic.

Significance for public health

This study has important public health impact in relations to the current COVID-19 pandemic. It exhibits the importance of a tailored health education strategies to specific target groups. It also shows the lack of KAP towards COVID-19 pandemic among students in Sana’a City which need to be addressed.

It also presented recommendations for the education officials to promote the knowledge, attitude, and practice of the students through implement the prevention and control measures during the upcoming waves of the infectious diseases.

Footnotes

Acknowledgements

The authors extend their gratitude to all the study participants for their collaboration and support and to the people who facilitated the completion of this manuscript in various ways.

Authors’ contributions

Ahmed H Al Shahethi: Database establishment, statistical analysis, and manuscript writing. Hakim M Al-Shahethi, Emad A. Al-Shameri, Amar Ali Al-Dhahari, Ahmed. Mohammed Al-Soofi; Mohammed Abdo Abkar: Study design and manuscript modification. Ahmed Alhidary, Gamil Ghaleb Alrubaiee, Fawz Mohammad Abol Gaith, Khaled Al-Surimi: Study design, data collection, direction of statistical analysis, and manuscript writing and modification.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study received approval from the Al Razi University Research Ethics committee [G 10/90]. All methods were performed in accordance with the Declaration of Helsinki with the relevant guidelines and regulations. Informed consent was obtained from all participants. Participants were alerted about their privileges to withdraw from the study at any stage without punishment, and that their withdrawal would not affect.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ahmed H Al-Shahethi

Gamil Ghaleb Alrubaiee

Fawz Mohammad Abol Gaith

Amar Ali Al-Dhahari

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