Undergraduate health sciences students’ response regarding COVID-19 pandemic in Saudi Arabia: an observational study

ABSTRACT Background The coronavirus disease 2019 (COVID-19) pandemic represents a major health problem, and its influences may persist with emerging viral variants. The current work was to evaluate the knowledge, attitude, and learning satisfaction of health sciences students (HSS) regarding the COVID-19 pandemic. Methods A questionnaire-based cross-sectional study was conducted from 20 February 2021 to 20 March 2021. Participants were undergraduate HSS at Prince Sattam bin Abdulaziz University in Al Kharj, Saudi Arabia. The questionnaire has been generated and distributed via online form. The questionnaire used was based on previous studies and included demographic information and knowledge, attitudes, perception, and learning satisfaction related to the COVID-19 pandemic. Results Out of the 400 questionnaires distributed to eligible students, the current study included a total of 330 HSS (82.5% response rate) from colleges of medicine (25.5%), dentistry (11.8%), pharmacy (33.6%), and Applied Medical Sciences (29.1%) of participants. The mean scores of knowledge, attitude, and learning satisfaction attained by students were 5.63 ± 0.65 out of 6, 4.22 ± 1.01 out of 5, and 11.28 ± 2.9 out of 19, respectively. Results show an association between the knowledge score of students and their age-group and specialty-college. Students with chronic diseases reported lower attitude scores and rate of COVID-19 vaccine-willingness. Younger HSS had a higher learning satisfaction score than the older participants. Conclusion Overall, participants show high knowledge level and positive attitude toward COVID-19 but fair learning satisfaction during the pandemic. Further studies are needed to improve the learning satisfaction and attitude of HSS in the future.


BACKGROUND
The coronavirus disease-2019 (COVID-19) continues to be a major health burden since declaration as a pandemic by the World Health Organization (WHO) [1], and its influences may persist for years with emerging new viral variants. Despite the recommendations and precautions to contain COVID-19 in China, cases were reported in Thailand and then other countries. The first case of COVID-19 infection in Saudi Arabia was reported on 2 March 2020 [2]. Yet, unfortunately, there is no effective cure for the highly contagious COVID-19 disease, with subsequent morbidity and mortality. The tool available to control the spread of the COVID-19 include preventive measures (e.g. face-masks, hand-washing, distancing) and possible vaccination options [3]. The adequate knowledge and understanding of COVID-19 are cornerstones for healthcare workers' perceptions of risk and their ability to provide medical care. There is a gap in information among healthcare workers with improper levels of COVID-19 awareness.
Keeping health sciences students (HSS) with adequate awareness would ensure that future health-care providers are sufficiently educated and prepared to deliver the correct information and essential patient care [4,5].
In order to contain the COVID-19 infection, the Saudi authorities took several precautionary and preventive measures as early as increment of case was reported [6]. The taken measures characterized by immediacy and strength that impacted the social and educational aspects of university students' lives [7]. Among these measures was the suspension of physical attendance in educational institutions with transition from onsite to online education for all students [8]. The E-learning and online teaching methods, before the pandemic, were not so commonly applied across the educational system. The emergency use of online education tools is challenging regarding students' and/or teachers' level of technical competence and preparedness [9]. The medical education system and healthcare systems worldwide have been unprecedentedly disrupted by COVID-19 pandemic [10]. The extremely infectious nature of SARS-COV2 virus has made it difficult for teaching activities to proceed as normal, thereby affecting the process of medical education [11]. The COVID-19 pandemic puts both learners and teachers at risk of life-threatening situations, posing major safety challenges while maintaining the quality and continuity of the medical education system. Due to the emphasis on hospitals, these difficulties have resulted in reduced availability for medical students of bedside teaching opportunities [12].]. Multiple studies have been conducted among HSS addressing the impact of the COVID-19 pandemic [13][14][15][16][17]. There are incomplete data on the levels of learning satisfaction and its relation to awareness during the COVID-19 pandemic among HSS in Saudi Arabia [18,19]. Being HSS means that they will educate, but also provide medical care to the public during COVID-19 and/or possible future pandemics. Hence, the current study was to investigate the status of knowledge, attitude, and learning satisfaction of HSS in AlKharj regarding the COVID-19 pandemic.

Methods
The ethical committee in Prince Sattam Bin Abdulaziz University in Alkharj, Saudi Arabia with the committee certificate of approval NO. (REC-HSD-53-2021), approved the current study. An online acceptance was taken from the study participants, after brief description about the researchers and the study to them. The sampling technique used was nonprobability convenience sampling as has been done in a similar study [15].
Study design and population: An electronic questionnaire-based cross-sectional study was conducted. The current work targets the undergraduate HSS from the Colleges of Medicine, Dentistry, Pharmacy, and Applied Medical Science at Prince Sattam bin Abdulaziz University. This public university is in Al-Kharj, a governorate in central Saudi Arabia, and is southeast of the capital, Riyadh. This university caters to more than 9,000 students in the fields of health, humanities, and sciences.
Sample size calculation: The total recorded undergraduate HSS in Al-Kharj for the academic year 2020-2021 (second semester) is 2173 students. We intended a sample size with a Margin of Error of 5%, a Response Distribution of 50% and a Confidence Level of 95%. The estimated sample size of the current study was 327 as calculated using RaoSoft website.

Questionnaire
A first draft of the questionnaire was constructed from previous work [20,21]. The questionnaire provided was in English and Arabic to ensure comprehensibility to the respondents, though the official language of instruction in the setting of the study is English (Supplementary file). The English version of the questionnaire has been translated by two independent translators separately who were native Arabs able to speak and read English fluently. Back translation of the questionnaire was also performed. The Arabic version was back-translated by two independent English translators. Issues between the Arabic and English questionnaires were resolved by comparing the versions and reaching a consensus after consulting a linguistic expert [16]. The questionnaire used had high internal consistency, based on the computed Cronbach's alpha values of 0.879 and 0.83 for the English and Arabic versions, respectively [16].
The researchers have distributed the link of the online questionnaire to the undergraduate HSS via e-mails and social media platforms with the help of student leaders and course coordinators. The questionnaire has been generated on Google Forms. Messages which served as reminders were sent to the eligible students to help in ensuring the highest response rate. This online questionnaire was self-administered without any intervention from the investigators, or any other person involved in the study. After a short description about the questionnaire, the consent has been taken from respondents before their participation in the study. The questionnaire responses were anonymous. Data did not contain any identifying information to ensure confidentiality. Since this was an online questionnaire, the respondents can answer any time and at any place convenient to them during the data collection period of the study. Responses that were incomplete or with missing dates were not included in the statistical analysis. The online form of the questionnaire accepted the responses of the students from 20 February 2021 to 20 March 2021.
Briefly, the questionnaire was constructed in three sections. The first section of the questionnaire included demographic data on age, gender, residency, and specialty-college of the student, and whether they have any chronic diseases (mention the name of chronic disease if any). Whether or not they have had a confirmed COVID-19 disease? Whether or not they intend to get COVID-19 vaccine?. The second section of the questionnaire included data regarding learning satisfaction of the students involving the clarity of student study plan, benefit of student from (online lecture, practical training, and learning activities) in addition to the fairness of assessment during COVID-19 pandemic. The clarity of the study plan can be answered with 'unclear,' 'fairly clear,' and 'clear' while the benefit of the student from the online lectures, practical training, and learning activities, as well as the fairness of the assessment, can be answered with 'poor,' 'fair,' 'good,' and 'excellent.' Also, respondents were asked of the amount of stress that accompanied studying during the pandemic. This can be answered with the following choices: 'a great stress,' 'some stress,' 'a little bit,' and 'almost nothing.' The third section of the questionnaire included data about the knowledge, attitude and perception of HSS regarding COVID-19. The knowledge part involved answering true or false to six statements about the description of COVID-19 as a respiratory infection caused by a new species of the coronavirus family, mode of transmission, preventive measures (hand washing, personal hygiene, and mask), the importance of vaccination, and treatment with antiviral drugs. The attitude part involved answering yes or no to five statements regarding attitudes related to transmission, preventive measures, and intention to get the vaccine. Lastly, the perception part involved a question on the main barrier to COVID-19 vaccination with choices as efficacy, safety, cost, or others. In addition, four statements on the spread of the disease, how concern about the disease is unnecessary, its origin as natural, and how it is successfully controlled were also included. These statements can be answered with 'strongly agree,' 'agree,' 'neutral,' 'disagree,' and 'strongly disagree. ' Each correct answer in the knowledge part was scored as 1; the highest possible score was 6. A score of ≥4 was considered to be 'high' while a score of <4 was 'low.' In terms of attitude, each correct answer was scored as 1 and the highest possible score was 5. A score of >3 was considered 'good' and a score of ≤3 was 'poor.' Lastly, for learning satisfaction, the statements were scored on a Likert scale and a score of >11 was considered 'high' and a score of ≤11 was considered 'low.'

Statistics
Data were collected via Excel (Microsoft Office software) sheet, then cleaned and managed using the Statistical Package for the Social Sciences (SPSS v.25) software. The percentage, frequency for data were calculated. Chi-square test was used to study the association between personal characteristics and either learning satisfaction, knowledge, or attitude of the study participants. p-Values less than 0.05 were considered significant.

RESULTS
Out of the 400 questionnaires distributed to eligible students, a total of 330 HSS from Prince Sattam University completed the survey (response rate of 82.5%). Most of our participants were men compared to women. Slightly more than half of the total participants were younger than 23 years, while 43% were 23 years or more. The residency of participants was reported to be 48.2% in Riyadh, 46.7% in Alkharj and 5.2% for others. Regarding our students' colleges, Pharmacy was the highest by one/third of participants followed by Applied Medical Sciences, Medicine and then Dentistry. The students who have reported confirmed COVID-19 infection was around one/tenth, while students who mentioned that they have known chronic disease were around one/sixth of the participants. Some of them reported the disease with the highest frequency as respiratory followed by diabetes mellitus, anemia, dermatitis, cardiac, and other diseases (Table 1).
In the current work, the participant knowledge level about COVID-19 was very high and 96.7% of the students did know that the virus infects primarily the respiratory system. Those who had knowledge that the virus is transmitted through droplets were 98.8%. Similarly, the vast majority reported that mask would be useful for preventing the spread of infection. Almost 90% agreed that hand washing and personal hygiene would prevent the spread of this virus. Regarding management, 82.1% denied that the disease can be treated with available usual direct antiviral drugs and 96.4% of the respondents reported that vaccination against COVID-19 is important for public health in society. However, only 63% showed intention to get the COVID-19 vaccine in the current year. The mean knowledge score of participants was 5.63 ± 0.65 out of 6 (the maximum attainable score). As shown in Table 2, the difference in the means of the knowledge scores of the participants was significant when it comes to their age group and specialty college (p-value = 0.01 and p-value = 0.004, respectively). Participants aged 23 years old or older and those from the college of dentistry have significantly higher knowledge mean scores than those who were less than 23 years old and participants from other colleges.
Proportions of participants based on their overall knowledge according to COVID-19 vaccine intention in the current year are shown in Figure 1. Results show that participants with a low knowledge level tend to decline vaccination approximate to 40%, whereas those with a high knowledge level tend accept vaccinations approximate to 60% but the association was not statistically significant (p-value = 0.714).
The current work looked for participant attitudes during the COVID-19 pandemic and most students reported the importance of preventive public health measures against COVID-19. Ninetythree percent of the surveyor reported that they will go into quarantine if they come in contact with a patient with COVID-19 infection. The mean attitudes score of participants was 4.22 ± 1.01 out of 5 that is the maximum attainable score. Table 3 shows that the difference in the means of the attitude scores of the participants was significant when it comes to their specialty college and whether they have chronic diseases or not (p-value = 0.006 and p-value < 0.001, respectively). Respondents from the College of Medicine and those who did not have chronic diseases have higher mean attitude scores. In addition, the difference between those with poor attitude scores (≤3) and good attitude scores (>3) was significant when it comes to their age group (p = 0.006), specialty college (p = 0.002), whether they have chronic disease or not (p = 0.001), and whether they have confirmed COVID-19 or not (p = 0.05). There were significantly more respondents with good attitude scores among these subgroups. Specifically, the number of respondents with good attitude scores who were 23 years old or older, from the college of dentistry, without chronic disease, and no confirmed COVID-19 disease was significantly higher compared to the other subgroups. Proportions of participants based on their overall attitude according to COVID-19 vaccine intention in the current year are shown in Figure 2. The latter shows that all the participants with the lowest attitude score show hesitancy to vaccination, whereas all the participants with the highest attitude score accept to uptake vaccination. Thus, there was a statistically significant association between the willingness to get  vaccinated and overall attitude scores (p < 0.000) with a higher score corresponding to more willingness to get vaccinated. Regarding learning satisfaction, the amount of stress that accompanied studying during COVID-19 was rated as a great stress in 48.8% followed by some stress in 37.9%, a little bit stress in 10.3% and no stress in 3.0% of the participants. The clarity for the study plan during COVID-19 pandemic was reported to be unclear in 32.7% of students. Benefits from online lectures, practical training and fairness of assessment were described to be poor in 13%, 28.8% and 24.8% of students, respectively. The mean learning satisfaction score of participants was 11.28 ± 2.9 out of 19 in all subscales. There was a significant difference in the means of the learning satisfaction scores of the students when it comes to their age group, as shown in Table 4. Those who were less than 23 years old have higher mean learning satisfaction scores. In addition, the difference between those with low learning satisfaction scores (≤11) and high learning satisfaction scores (>11) was significant when it comes to their age group (p = 0.002) and specialty college (p = 0.03). There were significantly more respondents with higher learning satisfaction scores among these subgroups. Specifically, there was a significantly higher number of participants with high learning satisfaction scores who were aged 23 years old and older and from the college of dentistry compared to the other subgroups.
Proportions of participants based on their history of chronic disease compared to their COVID-19 vaccine intention in the current year are shown in Figure 3. Results show that participants who did not report chronic disease show intention to  uptake COVID-19 vaccine, whereas those with chronic disease show hesitancy toward vaccination (p-value = 0.019). The overall assessment of the respondents in terms of learning satisfaction, knowledge and attitude is shown in Figure 4. Additional data on the assessment of learning satisfaction, knowledge, attitude, and perception during COVID-19 are provided in Supplementary Table 1.

DISCUSSION
HSS must gain sufficient knowledge about the public health crisis. COVID-19 pandemic has caused many challenges in medical-education systems. The current work explores the status of health science student regarding their preparation and satisfaction during the pandemic. The participant students reported high knowledge with few gaps regarding COVID-19. Also, the vast majority of HSS showed a positive attitude regarding the COVID-19 pandemic. However, a significant portion of students reported only fair learning satisfaction levels during the pandemic. The majority of the participants of the current work reported high level of knowledge regarding the COVID-19 infection. A high level of basic and preventive knowledge regarding COVID-19 in HSS is expected as previously shown in health-care professionals and/or students [20,[22][23][24].
In the current study, we observed a positive attitude in most of the HSS about COVID-19 preventive measures. We found high attitude scores in students from colleges of Medicine, Applied Medical Sciences, and Dentistry followed by students from  Pharmacy colleges. High levels of attitude regarding COVID-19 preventive measures including mask-wearing, hand-washing is required for personal hygiene and physical distancing were formerly reported in medical students [25][26][27]. Results of the current work show that students with chronic diseases reported lower attitude scores compared to students who do not report having chronic diseases. Moreover, students with chronic diseases showed a lower rate of COVID-19 vaccine acceptance than the students without chronic illness. These findings are the opposite of what we expected in students having chronic diseases as a group that is more knowledgeable of their specific benefit from vaccination. The expected higher positive attitude of adult patients with chronic disease toward COVID-19 compared to those without chronic disease has been reported. As shown, populations who had a chronic illness were more likely to accept the COVID-19 vaccine than those without the chronic disease [28,29]. In the current work the overall attitude score was lower in participants having a chronic illness. Similarly, a substantial number of patients with chronic disease had poor attitude and practice toward COVID-19 [30]. The pandemic affected the medical visits of patients with chronic diseases. It has been reported that the respondents with chronic medical conditions reported significantly lower quality of life scores that may be linked to more anxiety and psychological distress during the pandemic [31,32]. Healthcare students had adequate knowledge of the basic & preventive measures; however, they reported high levels of anxiety and depression during the COVID-19 pandemic. The same study reported that the general knowledge of the participants toward the pandemic was not associated with the psychological impact [33]. In a study on medical students the presence of chronic disease in the participants was found to be a factor that increased anxiety [34]. Findings of the current study show that 63% of the students intended to receive the COVID-19 vaccine during the application of the study. A finding comes along with a web-based self-administered questionnaire that reported that about two/thirds of the participants agreed to uptake the COVID-19 vaccine [35]. The current work shows a significant association between the level of attitude, but not knowledge, of the HSS and their COVID-19 vaccine willingness. The responders with the highest attitude score accept vaccination, whereas the responders with the lowest attitude reported hesitancy. Despite the high national and worldwide rates of infection and mortality, there was hesitancy/resistance toward the COVID-19 vaccines that may be due to vaccine lack of information and vaccine misinformation [36]. The acceptance rates of COVID-19 vaccine showed variability among studies across different population and regions worldwide [37][38][39]. In a study among health professional students show that their willingness to uptake the COVID-19 vaccine was reported in 72% of the participants [40]. There was a low level of acceptance toward the COVID-19 vaccine among medical students, and many had relied on social media that provided them with negative information [41]. Also, less than 30% of respondents, in a survey among Arab countries, stated that they would get the available vaccine showing high rates of COVID-19 vaccine hesitancy that may be associated with conspiracy beliefs [42]. A scoping review of healthcare workers reported a prevalent COVID-19 vaccine hesitancy when studying its nature and extent among them [43]. Even caregivers of children with chronic illness reported lower rate of intent to vaccinate their children against COVID-19 [44]. Public health programs better target the educational efforts to correct misinformation and highlight the importance of COVID-19 vaccine protection among populations especially those with chronic diseases.
Learning satisfaction is vital for keeping the motivation level of HSS for better understanding and awareness about a pandemic or health crisis. Our results show that the overall learning satisfaction score of participants was fair in all subscales. Similarly, students experienced moderate satisfaction with their e-learning experience through the learning management system [45]. Responders from Saudi medical and dental colleges students were at a moderate level of satisfaction with e-learning and around half of them preferred blended (combined traditional and electronic) learning [46]. The online classes were well-accepted by the medical students with their overall satisfaction level found to be high. Most of the participants were satisfied especially with basic medical or preclinical subjects with decreased effectiveness of online learning in clinical courses [47]. In our work the knowledge score of the students was associated with their age-group as the older students had slightly higher knowledge scores than younger students. Literature data also shows that senior students have higher knowledge than their juniors and younger students as reported in former studies [48,49]. Also, in the current study, there was a significant association between learning satisfaction during COVID-19 and the age of the participant. The current study shows that younger HSS had higher learning satisfaction scores than the older participants. Similar finding was reported as the medical students in higher education phases have lower evaluations of and satisfaction with online education after COVID-19 pandemic [50]. A possible reason is that older students need more practical & clinical sessions that may be reduced during the pandemic. In our research more than half of our participants described their benefit from practical sessions as poor or fair. Follow-up and gaining feedback from HSS will direct medical educators in the future improvement and raising the learning satisfaction level.
The current study showed some limitations being a survey relaying on self-reported data may allow for the subjective opinion of each participant. Also, the participation of women is lesser than the participation of men as two out of the four colleges do not include female students yet. It is difficult to generalize every data of the current work to all general population in Saudi or worldwide.

CONCLUSION
Overall, undergraduate HSS report high knowledge and a positive, but not the optimal attitude toward COVID-19 and its vaccine. A significant portion of students reported fair learning satisfaction during the pandemic. Further studies are needed to improve the learning satisfaction and attitude of HSS in the future.