The Extent of Adherence to the Precautionary Measures Among University Students in Palestine During COVID-19 Pandemic

: (COVID-19) pandemic has rapidly spread across the globe causing massive disruptions to everyday life. This study aimed to assess the extent of adherence to the Precautionary measures among university students in Palestine during COVID-19 Pandemic. Research design: A cross-sectional sample survey consisted of 2094 male and female university students. Setting: the study was conducted at Modern University College, An-Najah National University, Palestine Polytechnic University, Al-Quds Open University, Ibn Sina College of Health Sciences and Arab American of University /West Bank / Palestine. The data collected was from the participant university students and started in first November 2020 to late November 2020 Subjects: A convenience sample consisted of 2094 female and male students with different Bachelor degree programs. Tools: A self-designed questionnaire was used for data collection and included the following parts. Part 1: demographic of the university students, Part II. Knowledge of university students about Coronavirus, knowledge among isolation for patient with COVID-19 at home, also their knowledge regarding following for Precautionary measures outside home, Part III: precaution practices were assessed for university students outside home Part IV: assessed University student attitude toward COVID-19. Results: the current study reveals that 80.2% of the studied sample of students had a satisfactory total knowledge regarding precaution measures outside home, 91% of them had a satisfactory total knowledge regarding precaution measures inside home among patient with COVID-19, and 95.5% of them had a satisfactory total knowledge regarding COVID-19 disease. There was a statistically highly significant relation between total knowledge and total practices outside home (p-value<0.001), and statistically significant relation between total knowledge and total attitudes (p-value 0.005). Conclusion: based on the current study, students were observed to have substantial knowledge, practices for precautionary measures, and a positive attitude toward COVID-19. Recommendation: continuing Government programs should aim to educate individuals from other sectors of the society to ensure the proper dissemination of knowledge on preventive safety measures, as this will help restrict and control the pandemic.


Introduction
The pandemic coronavirus disease (COVID-19) is a highly infectious disease, the first to be reported in Wuhan city of China and is still swiftly spreading and infecting public all over the world. It is caused by a virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [17]. On December 31st of 2020, WHO declared this outbreak as a Public Health Emergency of International Concern and University Students in Palestine During COVID-19 Pandemic publicized a name for the new coronavirus disease as COVID-19 and on 11th of March 2020, WHO confirmed COVID-19 as pandemic [25].
According to the Palestinian Ministry of Health (MOH), the first cases had been detected at a hotel in Bethlehem area, where a group of Greek tourists had visited the hotel in late February 2020, with two later diagnosed with the virus [27].
According to The United Nations Relief and Works Agency (UNRWA), the prolonged blockade imposed has severely impacted the socioeconomic and health conditions of the Occupied Palestinian Territories and Gaza strip [29]. The longstanding movement restrictions have undermined Gaza's economy and the checkpoints in West Bank to high levels of unemployment, food insecurity, aid dependency, and poor standards of hygiene and sanitation [3]. Consequently, the government response was swift and immediate, started by launching a social media campaign encouraging people to stay at home and to follow the ministry of health instructions.
Coronavirus disease 2019 which is abbreviated "COVID-19" is a developing respiratory disease that is triggered by a new coronavirus. The newest member of the coronavirus family (COVID -19) has been recently identified as acute and severe respiratory syndrome in humans. It was established that in China, 18.5% of the patients with COVID-19 developed to the severe stage, which is characterized by acute respiratory distress syndrome, septic shock, difficult-totackle metabolic acidosis, and bleeding and coagulation dysfunction [5]. Some of the unparalleled measures adopted to control the COVID-19 transmission in Hubei and other provinces of China and other parts of the world, including the suspension of public transportation, the closing of public places, management of communities, and isolation and care for infected people and suspected cases [22].
The symptoms of COVID-19, some infected people may asymptomatic, whereas others may have mild symptoms. Around 80% of patients recover without treatment, while one out of six patients develop more severe symptoms, not limited to difficulty breathing. These patients are most likely to be elderly or with underlying medical conditions, such as hypertension, heart problems or diabetes [20]. Additionally, young people are not invincible against coronavirus; world data have shown that a large number of the patients were young, among which many needed hospitalization [5,4,7].
Globally, a total of 8,236,326 cases were identified with 40,598 new cases in more than 170 countries till 1st April 2020. The European region is more affected than the rest of the continents. About 464,212 cases were reported with 30,089 deaths in European region, followed by Regions of America with 188,751 cases along with 3,400 causalities. The cases of Western Pacific region, Eastern Mediterranean region, South-East Asia region and African regions are 106,422 cases (3,701 deaths), 54.281 cases (3,115 deaths), 5,175 (195 deaths) and 4,073 cases (91 deaths) respectively [28]. Highest no. of cases was reported in United State (163,199 cases), followed by Italy, Spain, China, France and Germany. However, the mortality rate is greater in Italy (11.7%), followed by Spain (8.7%), United Kingdom (7.11) and France (6.8%). As a result of traveling, an outbreak occurred in several countries especially the European regions are more affected than the rest of world. [24].
The use of face masks and hand sanitizers, a ban on social events, and working from home, etc., were among the measures that were followed to curb the spread of COVID-19. Taiwanese people panic-bought nearly all available mask and hand sanitizer stocks within 2 weeks of the first case in Taiwan 21 January 2020. Movie theatres, restaurants, and malls had diminishing crowds [21].
The awareness and knowledge of health literacy skills permit patients to manage their own well-being by improving their communication with doctors, and making smart healthcare decisions [16,19]. Nevertheless, public adherence to control COVID-19 is influenced greatly by their knowledge, attitudes, and practices (KAP). Therefore, the present study was aimed to explore the KAP (knowledge, attitude and practice) adopted by the university students of Madhya Pradesh (India) towards prevention of COVID-19 pandemic [20].

Subjects and Methods
Aim: the aim of this study is to assess the extent of adherence to the Precautionary measures among University Students in Palestine during COVID -19 Pandemic.
Research Design: A cross-sectional sample survey consisted of (2094) male and female university students (aged from 18 >20 years) freshman and sophomore. Using online electronic data collection, the survey method was used because the study wanted to assess the knowledge level, attitude, practices and preventive measures of COVID -19 among Palestinian University Students.
Setting: The study was conducted at Modern University College, An-Najah National University, Palestine Polytechnic University, Al-Quds Open University, Ibn Sina College of Health Sciences and Arab American of University /West Bank / Palestine.
Sample: A convenience sample. The study included 2094 participants with different Bachelor degree programs, from six previous mentioned university and divided into 965 from health sciences, 382 financial and administrational sciences, 249 engineering, and 498 participated from social sciences. All participants responded to the online Google form link sent to their Whats-App groups. The study was conducted between November and December, 2020. University students used a Google form shared through email and mobile messages.
Tools for data collection: Tool I.: A self-designed questionnaire was used for data collection and included the following parts: Part I.-: Demographic particulars of the participant. The demographic variables consist of age, gender, speciality, place of residence, family income and number of family.
Part II. Knowledge was assessed for university student using a 20-item questionnaire adapted from [14] and [15] slightly customized to suit college students. The items were attributed to knowledge about Coronavirus pandemic disease (10 Questions), knowledge among isolation for patient with COVID-19 at home (7 Questions), knowledge regarding following for Precautionary measures outside home (3 Questions). 3-point scale were fixed as complete correct= (3), incomplete correct = (2) and incorrect= (1). The total score was recorded as satisfactory> 85%, unsatisfactory < 85%. All knowledge questions were based on Centers for Disease Control and Prevention (CDC) fact sheets. Part III: Precautionary measures were assessed for practices university students outside home like hand washing, mask wearing, avoiding crowded places; keeping social distance and avoiding unnecessary travelling etc. The questionnaire was constructed on the basis of the published literature from the WHO (2020) (https://main.icmr.nic.in/) for prevention of SARS-Cov-2 transmission. The responses were fixed as always= (2), occasional= (1), and never= (0) respectively. The total score was recorded as satisfactory> 85%, unsatisfactory < 85%.
Part IV: Assessed the University students' attitude toward COVID-19: approximately eleven items from a previous survey were used to assess the student's attitude. The questions were related to agree that successfully controlled in elimination of COVID-19 changed for someone if affected with COVID-19. Do you: ask for consult from responsible authorities in the event of emergency symptoms, think the local authorities will succeed in reducing the spread of disease, think the preventive measures of the government are early, think the preventive measures of the government were enough, think you do not get off the COVID-19, think it is not necessary to take precautionary measures for children and older. Isolation of affected people is an effective way to reduce the spread of the COVID-19, and early treatment is the effective way to control the prevalence of COVID-19 as well. The scoring choice is the option "agree" which added two points, the option "not agree" added one, while zero was added for the "don't know" option in each behaviour-related question.
Content Validity & reliability: Content validity was done to identify the degree to which the tools measure what was supposed to be measured. The translated tools were examined by a panel of three experts in the field of community who agreed that it is valid and relevant with the aim of the study. Internal consistency was measured to identify the extent to which the items of the tools measure the same concept and the extent to which the items are correlated with each other. The internal consistency which estimated reliability by Cronbach's Alpha was 0.862.
Statistical analysis: descriptive statistical measures including frequency, percentage, and mean score were used to report the findings. The chi-square test was used to determine the association between the categories. Statistical analysis was performed using SPSS (IBM SPSS Statistics for Windows, Version 25.0; IBM Corp., Armonk, NY). P-value < 0.05 was considered not statistically significant& P-value <0.001 was considered statistically highly significant.
Ethical consideration: Ethical approval was obtained from the previous six mentioned Universities to conduct the study. All participants provided informed consent before participating in the study by using a Google form shared through email, mobile messages, and in print with students from the previous mentioned setting.        Table 4: clarifies that 91.1% of studied students have correct answers regarding followed the precautionary measures outside home and 4.5% have incorrect answers regarding followed the precautionary measures for respiratory hygiene to protect from COVID-19. Also, 83.6% of them have correct answers regarding using personal protective equipment. Figure 1: illustrates that 80.2% of the studied students have a satisfactory total knowledge regarding followed the precaution measures outside home, 91% of them had a satisfactory total knowledge regarding isolation of patient affected with COVID-19 inside home and 95.5% of them have a satisfactory total knowledge regarding COVID-19 disease.   Table 5: this table shows that 85.4% of studied students are always not found in crowded places, 11% occasional while 3.6% are rarely found. 59.2% of them always wear facemasks outside home, 39.2% occasional and 1.6% never wear mask. Furthermore, 57.2% always clean their hands by antiseptic, 33.9 were occasional and only 5.7% never. Also, 55.8% of the studied students always use tissue papers to cover mouth and nose during sneezing or coughing, 38.5% occasional and 5.7% never. 72.7% always don't visit their relatives during spread of COVID-19, 19.5% occasional and 7.8% ever. In addition, 38.5% of the studied students occasionally use specialized personalized equipment, 46.9% of them occasionally use the appropriate methods in hand washing and 28.7% use the appropriate methods in mask-wearing.  outside the home. While, unsatisfactory practices the results clarified that, 48.5% had always, 12.3% had occasional, and 39.2 never adherence to the precautionary measures regarding COVID-19 disease. As seen in table 6, 61.5% of the studied students agree that Palestinian governorate successfully controlled the inelimination of COVID-19, 28% do not agree and 10.5% do not know, 56.7% agree that social communication platforms are our fears, a higher percentage of students 80.9% would seek assistance from the authorities' responsible if the person or a family member develops symptoms of COVID-19. 68% of students considered that the preventative measures taken by the Palestinian government at the beginning were sufficient and on a timely manner. 53.8% were worried toward COVID-19. 59.2% of them remarkably agree that precautionary measures for children and older are not necessary & thought that COVID-19 preventative measures should be applied by everyone to reduce spread the COVID-19. In addition, 58.3% of the students would seek assistance from the authorities' responsible if the person or a family member develops symptoms of COVID-19. * Statistically significant P < 0.05 ** highly statistically significant P < 0.001. Table 7: there was a statistically highly significant relation between total knowledge and total practices outside home P-value<0.001, and statistically significant relation between total knowledge and total attitudes P-value 0.005.

Discussion
University students play an important role in the community. During the COVID-19 pandemic crisis, university students are expected to spread attentiveness of key health and hygiene messages amongst communities. Even staying at home, retaining social distance, wearing face masks, washing hands, etc. are quite a few measures that the governments' health department propagate. So, it is so important that university students across the country have many knowledge and awareness about all aspects of the disease including prevention strategies [18]. Therefore, the study aimed to assess the extent of adherence to the Precautionary measures among University Students in Palestine during COVID-19 Pandemic. [9] Regarding socio-demographic characteristics of the studied university students, the results of the current study showed that, near to one third of them were in age group 17 to less than 19 years; with the average age 19.56 ± 3.069 years. This finding was similar with the result of [12] in the study about the impact of the COVID-19 epidemic on mental health of undergraduate students in New Jersey, who reported that average age was 19.18 ± 2.9 years old. The finding of the present study illustrated that more than half of studied students were male students, this finding was unsupported by [18], found that more than three quarter of the studied students were female.
In accordance to knowledge of university students about COVID-19, the current study showed that the great majority of the studied students have correct answers about the meaning of COVID-19, its causes & the treatment. All of them have correct answers about transmission of COVID-19; also, the majority of them have correct answers regarding signs and symptoms & protection methods from infection. A similar study conducted on a Chinese population reported an overall knowledge of 90% [26]. The same table also reported 56.3% of students only know the time for repetition tests, more than one-tenth has incomplete answers, and more than one-third did not know the time. Regarding test to discover the virus & anticoagulation drugs showed that more than three-third of university student have correct answers. In addition, more than two-third have correct answers about timing to give anticoagulation. This result agrees with another study conducted on an Egyptian population comprising 559 participants reported the mean and standard deviation of knowledge score as 16.39±2.63, ranging from 7 to 22, which corresponds to approximately 74.5% overall knowledge among participants regarding COVID-19 Ahmed [2].
Concerning to knowledge of university students according isolation the patients with COVID-19 at home this result reveals that the great majority of studied students have correct answers regarding the determination of the patient who needs isolation at home, meaning of home isolation, types of medication used during isolation, precaution for visitors, and precautions measures for patients with COVID-19 isolation. Furthermore, environmental cleaning & with 80.2% of the studied students had a satisfactory total knowledge regarding followed the precaution measures outside home. Our findings may be the current state of public health awareness and to determine the need for proper dissemination of knowledge and awareness. In addition, the easy access to highly recommended mass media, medical articles and journals available at the university's library which is the major source of information about COVID-19 epidemics.
Regarding knowledge of university students followed precautionary measures outside home, the current study found that the majority of students had a correct answer regarding following the precautionary measures outside home and negligible number of them had incorrect answers regarding followed the precautionary measures for respiratory hygiene to protect from COVID-19. Also, great number of them has correct answers regarding using personal protective equipment. This results was confirmed with Hussain [10], who studied knowledge, attitudes and practices towards COVID-19, and found positive and cautious knowledge towards the COVID-19 epidemic were the vast majority of participants knew the precaution measures for respiratory hygiene and using the personal protective equipment, and avoid contact with others during the rapid rise period of the COVID-19.
In accordance to students' practices for precautionary measures regarding COVID-19 disease outside home, the current study denoted that majority of them always are not found in crowded places, two-third always wear the face mask outside home, Furthermore, more than half of them always clean their hands with antiseptic solutions. Also, more than half of the studied students always use tissue papers to cover mouth and nose during sneezing or coughing, near to three quarter of them always do not visit their relatives during spread of COVID-19. In addition, more than one third of the studied students occasionally use specialized personalized equipment. This result agrees with [13] who said in his study, throughout COVID-19 outbreak, results have shown that two-third of participants did not wear face masks when out in public, whereas fifth did not maintain physical distancing. Compliance with the pandemic restrictions is essential and crucial in this phase, and failure to adhere to preventive measures-even if by a minority-would only lead to uncontrolled spreading of the disease. Positive practices towards COVID -19 pandemic were found to be significantly associated with the gender and major of the precipitant. This suggests may be that the students have a slightly positive preventive behaviour and attitude toward COVID -19. [9] Regarding the attitudes of university students among COVID-19 pandemic disease, the current study showed that more than two third of the sample agree that Palestinian governorate successfully controlled in-elimination of COVID-19, more than quarter did not agree, approximately two third agree that social communication platforms are our fears, a higher percentage of students would seek assistance from the authorities' responsible if the person or a family member develops symptoms of COVID-19. 68% of students considered that the preventative measures taken by the Palestinian government at the beginning were sufficient and on a timely manner. More than half were worried toward \ COVID-19 and two third of them remarkably thought that precautionary measures for children and older are not necessary & thought that COVID-19 preventative measures should be applied by everyone to reduce spread the COVID-19. As for the preventive measures applied by the government, showed that approximately two third of the students would seek assistance from the authorities' responsible if the person or a family member develops symptoms of COVID-19. Concerning the performance of the local authorities, two thirds of participants considered the authorities' attempts successful in controlling the spread of COVID-19, and around half of them thought that the preventative measures were sufficient. Furthermore, less than a quarter of the participants believed that local authorities have sufficient tools to deal with the suspected cases of COVID-19. These findings disagree with other studies among different communities [26,17,3], that might be due to the lack of economic and medical resources and the shortage within the health system compared to developed countries. This indicates the importance of continuous health education that could improve the prevention behaviour toward COVID-19 in society.

Conclusion
Based on the current study, the university students have substantial knowledge, practices for precautionary measures, and a positive attitude toward COVID -19. A majority of them also expressed their optimism regarding the control of COVID -19. In addition, there was a statistically highly significant relation between total knowledge and total practices outside home p-value <0.001, and statistically significant relation between total knowledge and total attitudes p-value 0.005.

Recommendation
These study findings supported the study research question. Based on the findings of the present study, it was recommended that: 1) The primary action to create awareness among the population can be undertaken through social media, electronic media and other possible means. 2) Continuing Government programs should aim to educate individuals from other sectors of the society to ensure the proper dissemination of knowledge on preventive safety measures, as this will help restrict and control the pandemic. 3) It is the responsibility of the state to take all precautionary measures for the safety of the community and public. There is an urgent need for research to address burden of the COVID-19 pandemic on college students.