A Multi-Country Cross-Sectional Study of Knowledge and Worry About COVID-19 Among Higher Education Students During the First Wave of the Pandemic

doi:10.21203/rs.3.rs-895816/v1

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Research Article

A Multi-Country Cross-Sectional Study of Knowledge and Worry About COVID-19 Among Higher Education Students During the First Wave of the Pandemic

https://doi.org/10.21203/rs.3.rs-895816/v1

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Background

Public health measures such as physical distancing and distance learning have been implemented during the COVID-19 pandemic. Having inadequate COVID-19 related knowledge can lead to excessive worrying as well as negative COVID-19 outcomes. Our study aimed to assess COVID-19 related knowledge and its association with worries among higher education (HE) students during the first wave of COVID-19.

Methods

A cross sectional survey, COVID-19 International Students Well-being Study (C-19 ISWS) was conducted in 133 Higher Education Institutions (HEIs) in 26 countries between April 27 and July 7, 2020. A stratified convenience sampling technique was used. Descriptive, bivariate, mixed effect logistic regression analysis were conducted using R software.

Results

Out of 127,362 respondents, 72.1 % were female, and 76.5% did not report a previous history of confirmed COVID-19. Majority of those without the previous infection 81,645 (83.7%) were from 21 European countries while the rest 15,850 (16.3%) from 5 non-European countries. The most frequent correct response to COVID-19 related knowledge questions among respondents was having the virus without having symptoms (94.3%). Compared to participants with good knowledge, the odds of being worried of acquiring SARS-COV-2 infection with poor knowledge was 1.05 (95%CI:1.03,1.08) and the odds of being worried of contracting severe COVID-19 was 1.36 (95%CI:1.31,1.40).

Conclusion

COVID-19 related knowledge was independently associated with both worry of acquiring SARS-COV-2 infection as well as contracting severe COVID-19. We recommend scaling up of awareness campaigns through media to increase the comprehensive COVID-19 related knowledge in order to tackle excessive worries about acquiring severe COVID-19.

Health Economics & Outcomes Research

Infectious Diseases

Health Policy

COVID-19

Knowledge

Worry

Multi-country

Students

Mixed-effect logistic regression

Coronavirus disease (COVID-19) generated a world-wide public health emergency which WHO declared a pandemic on 11th of March 2020¹. In response, governments have introduced a range of public health measures aimed at limiting the spread of infection alongside the provision of treatment for those who fall ill. However, the effectiveness of these measures is largely dependent on the cooperation of the population in general and specific risk groups in particular². The extent to which public health measure is adhered to vastly depends on disease-related knowledge of the individual. Incorrect, misleading or inadequate COVID-19 related knowledge can lead to anxiety, rejection of measures in place, depression and negative COVID-19 outcomes^2–5. A previous study carried out on COVID-19 patients found a negative association between level of education and worry for family and others contracting the disease (2) while other studies have found a positive association between knowledge on COVID-19 and level of education^5–7. An assessment of COVID-19 related knowledge and its association with worry about COVID-19 is especially important in young adults as misleading information about the vulnerability of this age group to COVID-19 has been highlighted by various influential groups⁸. Additionally, higher education (HE) students have high mobility and contribute significantly to the spread of the infectious COVID-19⁹ which may also have a substantial impact on their social and mental wellbeing with possible long-term consequences^3,9,10. No study assessing COVID-19 related knowledge and worry about COVID-19 among HE students has to our knowledge been published so far. Such a study would help addressing this gap and have the potential to increase adherence to public health measures^3,5,10. Therefore, the study aimed to assess the COVID-19 related knowledge and its association with worries about both Severe COVID-19 and SARS-COV-2 (severe acute respiratory syndrome coronavirus 2) infection among HE students in 26 countries.

Aim, design and Setting

This study aimed to

describe the knowledge level about COVID-19 during the first wave of pandemic among students in 133 HEI in 26 countries.
assess the association between COVID-19-related knowledge and worry about acquiring SARS-COV-2 infection among HE students
assess the association between COVID-19 related knowledge and worry about contracting severe COVID-19 among HE students

Study design was cross-sectional, using Qualtrics online survey software (Qualtrics, Provo, UT). An online questionnaire was the only feasible method of data collection during the pandemic. Data were collected between 27 April and 7 July, 2020. 133 HEIs in 26 countries agreed to take part and participated in COVID-19 International students’ well-being study (C-19 ISWS)¹¹.

Sampling and characteristics of participants

The C-19 ISWS applied a stratified convenience sampling design. HEIs were selected in

Western Europe: Belgium, France, Germany, The Netherlands, Switzerland, UK,
Central Eastern Europe: Czech Republic, Slovakia,
Eastern Europe: Romania, Hungary, the Russian Federation,
Northern Europe: Sweden, Finland, Norway, Iceland, Denmark,
Southern Europe: Spain, Italy, Portugal, Greece, Cyprus,
Other high, and upper-middle-income countries: Canada, Israel, South Africa, Turkey, USA.

Students aged 18 years or above were eligible to take part irrespective of their level of study. Those who had been officially diagnosed with COVID-19 were excluded as the aim was to assess worries about infection and not re-infection.

A consortium partner was appointed in each HEI to take responsibility for seeking ethical approval. The consortium partners were also responsible for distributing a link to the survey within their HEI via e-mail to all students. Alternative recruitment methods were; student-specific social media platforms, and newspapers¹¹. This link led to information about the study and the consent form. Students were informed that participation was voluntary and of their right to withdrawal. No identifying personal details were collected to ensure participant anonymity. Participants were asked to indicate consent by ticking a box before starting the survey. A reminder e-mail was sent after one week.

Data measurement/Operational definition

Worry about SARS-COV-2 infection

refers to whether respondents are worried about having mild illness and/or asymptomatic infection of COVID-19 clinical manifestation¹².

Worry about Severe COVID-19

refers to whether respondents are worried about having severe and critical illness of COVID-19 clinical manifestation¹².

COVID-19 related knowledge (Exposure Variable)

Eight questions were used to capture COVID-19-related knowledge. To address aim 1, respondents’ knowledge was categorized as “Good” if more than five questions were answered correctly, and as “poor” if they scored four or less. To address aims 2 & 3, mixed-effect logistic regression coefficients were used for each “correct” response and the mean values were used to categorize total knowledge score. Respondents’ knowledge level above the mean value were categorized as “Good”, and below or equal to the mean value as “Poor”.

Worry about SARS-COV-2 infection ( outcome variable 1 )

was measured using a scale ranging from 0 to 10. 0 indicated “not worried” and 10 “very worried” about SARS-COV-2 infection. The mean value was utilized to classify variables into “Worried” and “Unworried”. Respondents with a scale response of equal or less than 4.2 were classified as “unworried”. Scores above 4.2 were classified as “worried”.

Worry about Severe COVID-19 (Outcome variable 2)

was measured using a scale ranging from 0 to 10. 0 indicated “not worried” and 10 “very worried” about Severe COVID-19. The mean value was utilized to classify variables into “Worried” and “Unworried”. Respondents with a scale response of equal or less than 3.1 were classified as “unworried”, Scores above 3.1 were classified as “worried”.

Confounders: Socio-economic factors were considered potential confounders in our study: age, sex, educational level, field of study, financial resources, underlying medical conditions, personal networks, infection history, adherence to public health measures, risk perception, alcohol use, smoking, moderate and vigorous physical activity. Respondents were asked what these were like in the month before public health measures were introduced and what they were like in the week before completing the questionnaire. The difference between the two was used to calculate the degree of change.

Data analysis

All analyses were carried out using the statistical package R (R Foundation for Statistical Computing©, version 3.5.3). Descriptive statistics on key characteristics of respondents and COVID-19 related knowledge across the 26 countries were displayed using tables and graphs. Polychloric correlation matrix for the eight COVID-19 related knowledge (categorical variables) was carried out to assess the need for conducting exploratory factor analysis (EFA). Missing data were handled using the multiple imputation chained equation(MICE) package in R. Due to some behavioural variables and sensitive questions there were missing data in the study(< 10%) in each variable. Variables were assumed to be missing at random(MAR). Results from the primary analysis conducted using the MICE package were compared with the complete case analysis as a sensitivity analysis. Worry about getting SARS-COV-2 infection, acquiring severe COVID-19, and COVID-19 related knowledge along with other independent variables using the DAG was included in the imputation model (total of 22 variables) (Supplementary: Figure S1&S2). Missing data for each variable was explored for patterns and the percentage of that was missing (Supplementary: Figure S3). Bivariate analysis was used to assess the association between dependent and independent variables. Directed acyclic graph (DAG) with a priori assumption minimal sufficient adjustment set was used to introduce variables into the multivariable model¹³. Mixed-effect logistic regression model, accounting for possible random effects at country level, was implemented to assess the independent significant association between COVID-19 related knowledge and worry about SARS-COV-2 infection (aim 2) as well as worry about severe COVID-19 (aim 3). As the COVID-19 situation and public health measures taken in various countries were different, especially during the start of the pandemic, such an approach accounting for variability was appropriate. Bivariate, as well as mixed effect logistic regression analysis, were based on the pooled estimates from 20 imputed datasets, and p-values of < .05 were considered to be statistically significant. A seed value of 600 and using iteration of 20 was done.

A total of 22 variables were introduced into the imputation model consisting of exposure, outcome, potential confounders to explore missing data. Respondents with missing values were 1.6% while 98.4% of the data was available for the respondents of the study (Supplementary: Figure S4).

Missing value in each of the variables that were introduced into the imputation model was below 5 percent. The variable with the highest missing value was a potential confounder (field of study) with a percentage of 3.95 while change of smoking habit (during & before the COVID-19 pandemic) and presence/absence of underlying medical conditions variables 3.41% and 3.39% missing values, respectively. The complete case analysis was not different from the multiple imputed analyses. Both the estimate and the standard error of the variables were the same in both analyses.

1-Characteristics of study participants

A total of 127,362 responses were received; 70,365 (72.1%) of participants were female. The majority of respondents 97,495(76.5%) did not report a previous history of confirmed COVID-19 infection, of those 81,645(83.7%) were from 21 European countries and the rest 15,850(16.3%) were from 5 non-European countries. The highest number of respondents 21,099(22%) were from Belgium, while the least number 161 (0.1%) were from USA. The majority of participants were aged 21–24 (45.7%) followed by under 21 years (29.9%) and above 24 years of age(24.1%) respectively (see Table 1, for detailed information).

Table 1

Characteristics of study participants by country
Country	Age (in years)			Total n(%)	Gender
Country	17–20 n(%)	21–24 n(%)	>=25 n(%)	Total n(%)	Male n(%)	Female n(%)	X n(%)
Belgium	9234(9.5)	9110(9.3)	2753(2.8)	21099(21.6)	5493(5.6)	15508(15.9)	98(0.1)
Canada	768(0.8)	1414(1.5)	1904(2.0)	4096(4.2)	1221(1.3)	2826(2.9)	49(0.1)
Czech	1382(1.4)	3853(4.0)	1792(1.8)	7027(7.2)	1943(2.0)	5050(5.2)	34(00.1)
Denmark	104(0.1)	995(1.0)	1175(1.2)	2275(2.3)	487(0.5)	1774(1.8)	14(< 0.01)
Finland	101(0.1)	434(0.4)	545(0.6)	1080(1.1)	224(0.2)	839(0.9)	17(< 0.01)
France	2202(2.3)	1650(1.7)	499(0.5)	4351(4.4)	1194(1.2)	3124(3.2)	33(< 0.01)
Germany	867(0.9)	2269(2.3)	1833(1.9)	4972(5.0)	1467(1.5)	3449(3.5)	56(0.01)
Greece	183(0.2)	300(0.3)	115(0.1)	598(0.6)	175(0.2)	419(0.4)	4(< 0.01)
Hungary	614(0.6)	1158(1.2)	764(0.8)	2537(2.6)	795(0.8)	1730(1.8)	12(< 0.01)
Iceland	37(0.001)	132(0.1)	339(0.3)	514(0.5)	105(0.1)	403(0.4)	6(< 0.01)
Israel	52(0.1)	153(0.2)	210(0.2)	416(0.4)	99(0.1)	316(0.3)	1(< 0.01)
Italy	2082(2.1)	5017(5.1)	2266(2.3)	9374(9.6)	2362(2.4)	6960(7.1)	52(0.1)
Netherland	3556(3.6)	5790(5.9)	2102(2.2)	11450(11.7)	3330(3.4)	8038(8.2)	82(0.1)
Norway	297(0.3)	1305(1.3)	1582(1.6)	3186(3.2)	1012(1.0)	2160(2.2)	14(< 0.01)
Portugal	359(0.4)	324(0.3)	181(0.2)	865(0.8)	138(0.1)	723(0.7)	4(< 0.01)
Romania	202(0.2)	409(0.4)	59(0.1)	670(0.6)	140(0.1)	530(0.5)	0(< 0.01)
Russia	1561(1.6)	1033(1.1)	120(0.1)	2714(2.7)	642(0.7)	2072(2.1)	0(< 0.01)
Slovakia	194(0.2)	481(0.5)	159(0.2)	835(0.8)	237(0.2)	596(0.6)	2(< 0.01)
South Africa	508(0.5)	405(0.4)	221(0.2)	1134(1.1)	275(0.3)	849(0.9)	10(< 0.01)
Spain	274(0.3)	398(0.4)	234(0.2)	908(0.9)	267(0.3)	630(0.6)	11(< 0.01)
Sweden	136(0.1)	494(0.5)	625(0.6)	1262(1.2)	428(0.4)	824(0.8)	10(< 0.01)
Switzerland	559(0.6)	1937(2.0)	1109(1.1)	3607(3.6)	941(1.0)	2625(2.7)	41(< 0.01)
Turkey	3035(3.1)	4808(4.9)	2197(2.3)	10043(10.3)	2994(3.1)	6994(7.2)	55(0.1)
UK	634(0.7)	727(0.7)	670(0.7)	2039(2.0)	436(0.4)	1588(1.6)	15(< 0.01)
USA	81(0.1)	61(0.1)	19(0.001)	161(0.1)	28(0.01)	128(0.1)	5(< 0.01)
Cyprus	104(0.1)	124(0.1)	54(0.1)	282(0.2)	71(0.1)	210(0.2)	1(< 0.01)
Total	29126 (29.9)	44781 (45.7)	23527 (24.1)	97495(100)	26504(27.2)	70365(72.1)	626(0.006)

Romania had the highest proportion of responses from health field students 641(95.6%) and Cyprus had the lowest 20(0.07%) (Supplementary: Figure S5).

2- COVID-19 related Knowledge

COVID-19 related knowledge was “good” in 61,145 (62.7%) but only 5,615 (5.7%) answered all the 8 COVID-19 related knowledge questions correctly, while the rest of participants were categorized as “Poor” COVID-19 related knowledge (Table 2).

Table 2

COVID-19 related knowledge responses
COVID-19 related Knowledge questions	Response			% of correct response
COVID-19 related Knowledge questions	True(%)	False(%)	Don’t know(%)	% of correct response
The virus survives for days outside the body in open air. (Knowledge question A)	19600(20.1)	57195(58.6)*	18338(18.8)	58.6
The virus survives for a week outside the body on a plastic surface. (Knowledge question B)	26695(27.3)*	44329(45.4)	23859(24.4)	27.3
Most people who get COVID-19 get very ill. (Knowledge question C)	7003(7.1)	83507(85.6)*	4743(4.8)	85.6
A possible vaccine will take around 12 to 18 months to produce(from the time of data collection)(Knowledge question D)	65928(67.6)*	6099(6.2)	23008(23.5)	67.6
Smokers who get COVID-19 are more likely to get severely ill than non-smokers.(Knowledge question E)	59301(60.8)*	11855(12.1)	23913(24.5)	60.8
You can have the virus without any symptoms. (Knowledge question F)	91966(94.3)*	1214(1.2)	2113(2.1)	94.3
On average, children get less ill from the virus than adults. (Knowledge question G)	78052(80)*	7281(7.4)	9748(9.9)	80
Only elderly people die from COVID-19.(Knowledge question H)	1702(1.7)	91783(94.1)*	1803(1.8)	94.1
Asterix(*) – indicate the correct response for the respective COVID-19 related knowledge question

The most frequent correct response was to the question about having the virus without having symptoms (94.3%). While the least frequent correct response was the question about the duration of virus survival on plastic surfaces (27.3%).

Romania, Portugal and Finland had the highest respondents with “good” COVID-19 related knowledge with 89%, 88.2% and 77.8%, respectively. Russia, South Africa and Israel had the lowest “good” scores on COVID-19 related knowledge with 31.8%, 45.9% and 47.9% respectively (Supplementary Figure S6).

Polychloric correlation matrix was used to check the correlation among COVID-19 related knowledge variables. Low correlation was observed among the variables. EFA was not possible for COVID-19 related knowledge variables in our study. Regression coefficients obtained from each of the 8 COVID-19 related knowledge questions were used to weigh total COVID-19 related knowledge (Supplementary: Table S1&S2 ).

3-Association of COVID-19 related knowledge with both worry about SARS-COV-2 infection and severe COVID-19

COVID-19 related knowledge was independently associated with both worry about SARS-COV-2 infection and severe COVID-19, accounting for the variability across country (Table 3 & Table 4). The mean for the weighted COVID-19 related knowledge using the coefficients of the logistic regression for worry about SARS-COV-2 infection and worry about severe COVID-19 were 1.012 and 1.258, respectively.

Table 3

Association between COVID-19 related knowledge and worry of SARS-COV-2 infection
Variables	Catagory	Worried	Unworried	P Value	Crude OR	95%CI lower	95%CI upper	Adjusted OR*	95%CI lower	95%CI upper
Age group	17–19 years	6606	8126	< 0.01	1	ref	Ref	1	ref	ref
	20–22 years	18161	22183	0.71	1.007	0.96	1.04	1.03	0.98	1.08
	23-25years	9534	12563	0.01	0.93	0.89	0.97	1.01	0.96	1.07
	26–28 years	3257	4050	0.70	0.98	0.93	1.04	1.10	1.02	1.18
	>= 29 years	4823	4860	< 0.01	1.22	1.15	1.28	1.20	1.12	1.28
Sex	Male	9026	16424	< 0.01	1	ref	Ref	1	Ref	ref
	female	33071	35033	< 0.01	1.71	1.66	1·76	1.68	1.63	1.74
	X	284	325	< 0.01	1.59	1.35	1.86	1.45	1.21	1.75
Educational level	Bachelor	27883	33093	< 0.01	1	ref	ref	1	ref	Ref
	Master	9365	12539	< 0.01	0.88	0.85	0.91	0.97	0.93	1.01
	PhD	1746	2146	0.29	0.96	0.90	1.03	0.94	0.86	1.02
	other	2428	3040	0.06	0.94	0.89	1.002	0.96	0.90	1.03
Field of study	Non- health field	32530	38912	< 0.01	1	ref	ref	1	Ref	ref
Field of study	Health	7975	10903	< 0.01	0.87	0.84	0.90	0.77	0.74	0.80
Underlying medical condition	None	34319	45043	< 0.01	1	ref	ref	1	ref	Ref
	present	6960	5717	< 001	1.59	1.54	1.66	1.53	1.46	1.60
	Prefer not to say	1036	966	< 001	1.40	1.29	1.54	1.53	1.37	1.71
Personal network infection history	Yes	17123	19482	< 001	1	ref	ref	1	ref	ref
Personal network infection history	No	25178	32205	< 001	0.88	0.86	0.91	0.99	0.96	1.03
Govt Timely info.	Strongly agree	4234	6187	< 0.01	ref	ref	ref	1	ref	ref
	agree	14007	18941	0.007	1.08	1.03	1.12	1.11	1.05	1.17
	Neither agree nor disagree	8947	10495	< 0.01	1.24	1.18	1.30	1.21	1.15	1.29
	disagree	9688	10327	< 0.01	1.37	1.30	1.43	1.34	1.26	1.42
	Strongly agree	4543	4672	< 0.01	1.42	1.34	1.50	1.42	1.32	1.52
Total knowledge	Good	29576	36435	0.013	ref	ref	ref	Ref	ref	ref
Total knowledge	Poor	12790	12472	0.013	0.96	0.94	0.99	1.05	1.01	1.08
Variables	Mean	β	SD	P-value	Crude OR	95%CI lower	95%CI upper	Adjusted OR*	95%CI lower	95%CI upper
Risk perception	4.14	0.19	0.003	< 0.01	1.197	1.190	1.20	1.21	1.20	1.22
Alcohol use increase*	-0.34	0.09	0.009	< 0.01	1.09	1.03	1.11	1.09	1.07	1.11
Smoking increase*	-0.097	-0.03	0.01	< 0.01	0.94	0.92	0.96	0.96	0.95	0.98
Moderate physical activity increase*	-0.42	-0.02	0.004	< 0.01	0.94	0.94	0.95	0.97	0.96	0.98
Vigorous physical activity increase*	-0.144	-0.001	0.005	0.79	0.99	0.98	1	0.99	0.98	1.00
Sufficient Financial resources increase*	-0.379	-0.12	0.007	< 0.01	0.86	0.85	0.87	0.88	0.87	0.89
Measurement adherence	8.023	0.16	0.004	< 0.01	1.20	1.19	1.21	1.17	1.16	1.18
* Increase– refers to the positive increase in a variable during the COVID-19 minus before the COVID-19 pandemic measurements

Table 4

Association between COVID-19 related knowledge and worry about Severe COVID-19
Variables	Category	Worried	Unworried	P Value	Crude OR	95%CI lower	95%CI upper		Adjusted OR*	95%CI lower	95%CI upper
Age group	17–19 years	7293	7439	0.22	1	ref	ref		1	ref	ref
	20–22 years	18713	21631	< 0.01	0.88	0.84	0.91		0.98	0.94	1.03
	23-25years	9631	12466	< 0.01	0.78	0.75	0.82		1.00	0.94	1.05
	26–28 years	3239	4068	< 0.01	0.81	0.76	0.85		1.11	1.03	1.19
	>= 29 years	4926	4757	0.03	1.05	1.003	1.11		1.24	1.16	1.33
Sex	Male	9305	16145	< 0.01	1	ref	ref		1	Ref	Ref
	female	34216	33888	< 0.01	1.75	1.70	1.80		1.73	1.67	1.79
	X	281	328	< 0.01	1.48	1.26	1.74		1.40	1.16	1.68
Educational level	Bachelor	29272	31704	< 0.01	1	ref	ref		1	ref	Ref
	Master	9483	12421	< 0.01	0.82	0.80	0.85		0.90	0.87	0.94
	PhD	1690	2202	< 0.01	0.83	0.77	0.88		0.90	0.83	0.98
	other	2446	3022	< 0.01	0.87	0.82	0.92		0.94	0.88	1.01
Field of study	Non- health field	33534	37908	< 0.01	1	ref	ref		1	Ref	Ref
Field of study	health	8070	10908	< 0.01	0.84	0.81	0.87		0.80	0.77	0.84
Underlying medical condition	None	34459	44903	< 0.01	1	ref	ref		1	ref	Ref
	present	1082	920	< 001	2.38	2.28	2.47		2.50	2.38	2.62
	Prefer not to say	8192	4485	< 001	1.53	1.4	1.67		1.71	1.54	1.91
Personal network infection history	Yes	17631	18974	< 001	1	ref	ref		1	ref	ref
Personal network infection history	No	26085	31298	< 001	0.89	0.87	0.92		1.04	1.01	1.07
Govt Timely info.	Strongly agree	4186	6235		ref	ref	ref		1	ref	ref
	agree	14341	18607	< 001	1.08	1.03		1.12	1.12	1.06	1.18
	Neither agree nor disagree	9533	9909	< 001	1.24	1.18		1.30	1.24	1.17	1.32
	disagree	10015	10000	< 001	1.37	1.30		1.43	1.28	1.21	1.36
	Strongly agree	4748	4467	< 001	1.42	1.34		1.50	1.33	1.24	1.42
Total knowledge	Good	29576	36435	< 0.01	ref	ref		ref	ref	ref	Ref
Total knowledge	Poor	12790	12472	< 0.01	1.26	1.22		1.30	1.36	1.31	1.40
Variables	Mean	β	SD	P-value	Crude OR	95%CI lower		95%CI upper	Adjusted OR*	95%CI lower	95%CI upper
Risk perception	4.14	0.15	0.003	< 0.01	1.16	1.15		1.17	1.166	1.15	1.17
Alcohol use change*	-0.34	0.08	0.009	< 0.01	1.06	1.04		1.08	1.08	1.06	1.10
Smoking increase*	-0.097	-0.02	0.01	< 0.01	0.95	0.92		0.96	0.97	0.95	0.99
Moderate physical activity increase*	-0.42	-0.01	0.004	< 0.01	0.96	0.95		0.97	0.98	0.97	0.99
Vigorous physical activity increase*	-0.144	0.002	0.005	0.55	1.006	0.99		1.01	1.00	0.99	1.01
Sufficient Financial resources increase*	-0.379	-0.11	0.007	< 0.01	0.86	0.85		0.88	0.89	0.88	0.90
Measurement adherence	8.023	0.11	0.004	< 0.01	1.148	1.14		1.15	1.12	1.11	1.13
* Increase– refers to the positive increase in a variable during the COVID-19 minus before the COVID-19 pandemic measurements

The odds of being worried of acquiring SARS-COV-2 infection in those with poor knowledge was 1.05 times the odds of those respondents with good knowledge, accounting for variability across 26 countries. Meanwhile, the odds of being worried about getting severe COVID-19 in those with poor knowledge was 1.36 times the odds of those respondents with good knowledge.

The country level random effect had a variance of 0.25 and standard deviation of 0.50 for the association between COVID-19 related knowledge and worry about SARS-COV-2 infection (Table 3) while country level random effect had a variance of 0.30 and standard deviation of 0.54 for the association between COVID-19 related knowledge and worry about severe COVID-19 (Table 4).

Field of study was independently associated with both worry about SARS-COV-2 infection and severe COVID-19, accounting for the variability across country. The odds of being worried about acquiring SARS-COV-2 infection among health field students was 0.77 times the odds of those respondents who were non-health students. Concurrently, the odds of being worried about getting severe COVID-19 among health field students was 0.80 times the odds of those respondents who were non-health students.

Timely information given by government sources was also independently associated with worry about SARS-COV-2 infection as well as severe COVID-19. The odds of being worried about acquiring SARS-COV-2 infection among those who strongly disagreed to have received timely information was 1.42 times the odds of those who strongly agreed to have received timely information. Meanwhile, the odds of being worried about contracting severe COVID-19 among those who strongly disagreed to have received timely information was 1.33 times the odds of those respondents who strongly agreed.

Modifiable risk factors: Smoking and moderate physical activity were independently associated with both worry about SARS-COV-2 infection and severe COVID-19. For a unit increase in average cigarette smoking per day and moderate physical activity (average 30 min. session/week), the odds of being worried about acquiring SARS-COV-2 infection decreased in average by 0.96 and 0.95 times, respectively. Simultaneously, for a unit increase in the average smoking per day and moderate physical activity (average 30 min. session/week), the odds of being worried about contracting severe COVID-19 decreased in average by 0.97 and 0.98 times, respectively.

Alcohol use was also independently associated with worry about SARS-COV-2 infection as well as severe COVID-19. The odds of being worried about acquiring SARS-COV-2 infection was 1.09 times higher for a unit increase while the odds of being worried about contracting severe COVID-19 was 1.08 times higher for a unit increase during the COIVD-19 pandemic

This study revealed that 62.7% of respondents across the 26 countries were classified as having “good” COVID-19-related knowledge. It further revealed that at country level Romania had the highest proportion of respondents classified as “good” knowledge (89%), while the lowest proportion was seen in Russia (31.8%). No study could be found assessing the COVID-19 related knowledge status among HE students. Previous studies conducted in the general population and among health care professionals have shown that advanced training and work experience is associated with COIVD-19-related knowledge^14–16. These findings might explain our result, as Romania had the highest proportion of health field students and hence the highest level of COVID-19 related knowledge. Our findings with regards to COVID-19 related knowledge were also much higher compared to a study conducted in Romania (10.8%) among oncology patients¹⁷. The discrepancy observed between the two studies maybe due to the fact that our study was conducted solely among HE students while the former was conducted with patients where the majority of whom (66.6%) had no formal education. Other reasons for the high percentage of COVID-19 related knowledge in countries such as Romania and Portugal may be related to their early public health responses to curb the spread of the pandemic which may have included governments actively communicating and engaging with those specific communities before introducing a particular measure. This action might have created awareness of COVID-19 early on leading to high knowledge levels¹⁸. According to public health measures data from European Union (EU) countries, both Romania and Portugal closed educational institutions early. In comparison the Czech Republic, which had the lowest COVID-19 related knowledge level among EU countries, did not close educational institutions and this may have contributed to low COVID-19 related knowledge.

There is limited research about the association of knowledge and worry about COVID-19. Our study revealed that, after adjusting for potential confounders, COVID-19 related knowledge is independently associated with both worry about SARS-COV-2 infection and severe COVID-19. The odds of being worried about acquiring SARS-COV-2 infection and severe COVID-19 among those who had good knowledge was lower compared to those who had poor knowledge.

Our findings suggest that increasing comprehensive COVID-19-related knowledge, might be associated with both lower worry about severe COVID-19 as well as SARS-COV-2 infection. The reason might be that respondents with more COVID-19 related knowledge will possess a greater sense of control over the pandemic, and thus will not feel threatened enough to worry too much. This finding is consistent with other variables in our study such as field of study where the odds of being worried about acquiring either SARS-COV-2 or severe COVID-19 among health field students was lower compared to non-health students. The reason behind such finding might be because health students are expected to have more COVID-19 related knowledge and thus high self-control leading to less worrying compared to their non-health students counterparts. This is reflected by a study conducted in China which found that those with low self-control were more likely to have exaggerated perception of seriousness to COVID-19 ¹⁹.

It is also worth noting that the odds of being worried of acquiring either SARS-COV-2 infection or severe COVID-19 in those students who strongly agreed receiving timely government information concerning the COVID-19 pandemic was lower, as compared to those who strongly disagreed. This finding is similar to a study conducted in Turkey where satisfaction with specific up-to-date and accurate health information provided was associated with a lower level of anxiety and stress²⁰. Our findings, therefore, might indicate that factors such as field of study and timely government information that increase COVID-19 related knowledge are associated with lower worrying about acquiring SARS-COV-2 infection and severe COVID-19. Additionally, receiving timely information from credible sources such as the government might also be specifically associated with lower worrying about acquiring SARS-COV-2 infection and severe COVID-19 as it can decrease the misinformation which usually leads to exaggerated worrying.

Increase in smoking was negatively associated with both worrying about SARS-COV-2 and severe COVID-19. The myth that smokers are protected against SARS-COV-2 infection has received wide attention on media and has led to some confusion even among the medical community²¹. Thus, erroneous claims communicated about a protective effect of smoking might be the reason behind the peculiar finding in our study. Physical activity particularly increase in moderate physical activity was also negatively associated with both worrying about SARS-COV-2 infection and severe COVID-19. Our finding was similar to a study conducted in the United States which found that increase change in physical activity is associated with a reduction in worrying about COVID-19, post-traumatic stress disorders and other mental health outcomes due to the COVID-19 pandemic²². However, independent association was not observed between vigorous physical activity and worrying about SARS-COV-2 infection or severe COVID-19. This might be because the lockdown measures in place were not conductive for performing vigorous physical activity while these measures were suitable for conducting moderate physical activity. Lastly, increase alcohol use was positively associated with both perceived worry of SARS-COV-2 infection and severe COVID-19. This finding echoes Reynolds et al²³ study in Ireland where worrying during the COVID-19 lockdown period was associated with increased alcohol consumption.

The limitation of this study is that it is cross sectional and does not allow an examination of the possible causal effect of knowledge on worry about SARS-COV-2 infection and severe COVID-19. Additionally, the study used convenience sampling which is not representative of the study population. The possible source of bias is the fact that since this survey was invitation based, people who are more worried might be the ones to respond. In addition as the study includes behavioural related questions, social desirability bias is possible in the potential confounders

The strengths of this study however are: it is a cross-country survey, has a large sample size, examined the random effects in 26 countries and observed the differences between them. In addition it assessed the worry about both SARS-COV-2 infection and Severe COVID-19.

The findings will inform HEIs about the possible COVID-19 related knowledge level of their students, and inform a basis for action to increase awareness and understanding among the student body. It will also aid in developing intervention programmes to tackle exaggerated worries about severe COVID-19 and SARS-COV-2 infection which can lead to psychological problems such as depression. Additionally the findings can be transferable to similar settings for future pandemics.

A follow up study is recommended to assess the current level of students’ knowledge and worry 16 months post initial lockdown, as well as such relationship in low income countries. We also recommend to further explore the relationship between physical activity specifically moderate physical activity and worry as it has been found to be associated in our study. Furthermore, the future studies should also assess the causal effect of COVID-19 related knowledge and worry about COVID-19.

Intervention by all stakeholders to tackle worries should not only be implemented by increasing COVID-19 related knowledge level, but also by focusing on timely information through media sources, scaling up intervention on healthy behaviours such as moderate physical activity. More importantly, government bodies in addition to providing timely, up-to-date and accurate information should implement national public health measures that targets both general and specific population groups such as HE students as early as possible, since this action could increase COVID-19 related knowledge and reduce excessive worries.

The study explored that there are large differences of COVID-19 related knowledge across countries. Furthermore, the study revealed that total COVID-19 knowledge is independently associated with worry about severe COVID-19 as well as SARS-COV-2 infection after accounting for the variability across 26 countries. Lastly, exploring and implementing interventions early to increase the comprehensive and updated COVID-19 related knowledge should be entertained in order to tackle exaggerated worrying and its psychological as well as social complications.

COVID-19 ------------------------------- Coronavirus disease

C-19 ISWS ------------------------------- COVID-19 International students’ well-being study

DAG --------------------------------------- Directed acyclic graph

EFA ---------------------------------------- Explanatory factor analysis

HE -------------------------------------------- Higher education

HEI ------------------------------------------- Higher education institutions

MICE ----------------------------------------- Multiple imputation chained equation

SARS-COV-2 ------------------------------- severe acute respiratory syndrome coronavirus 2

Ethics approval and consent to participate

The study was conducted in accordance with the guidelines of Helsinki Declaration. Ethical approval was obtained from the Ethics Committee for the Social Sciences and Humanities of the University of Antwerp, the Ethics Committee for the Social Sciences of Ghent University and each participating HEI. Informed consent was obtained from all participants.

Consent for Publication

Not Applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article (and its supplementary information files).

Competing interests

We declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article

Author’s contribution

NMB (corresponding author) formulated the research question, performed literature review, conducted data analysis, interpreted & wrote the results, and wrote the manuscript. GVH and SVV contributed to the formulation of the research question, data collection, and critically appraised the written manuscript. FRK critically appraised the written manuscript. CVH, PV, and EW contributed to the data collection of the study. All authors read and approved the manuscript.

Acknowledgement

Our gratitude to all consortium partners for their hard work in carrying out this survey, and to all participants of this survey as without their input this study would not have been completed. We are grateful to Prof. Annelies Van Rie and Prof. Lidia Casas Ruiz for their valuable comments & contribution in the analysis part of our study. We also thankful for Prof. Cherent Hailu for his valuable comments. Our special thanks to Prof Paula McGee for her valuable comments and proof reading this paper.

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No competing interests reported.

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A Multi-Country Cross-Sectional Study of Knowledge and Worry About COVID-19 Among Higher Education Students During the First Wave of the Pandemic

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Abstract

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Introduction

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Aim, design and Setting

Sampling and characteristics of participants

Data measurement/Operational definition

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1-Characteristics of study participants

2- COVID-19 related Knowledge

3-Association of COVID-19 related knowledge with both worry about SARS-COV-2 infection and severe COVID-19

Discussion

Conclusion

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