Knowledge, Attitudes, and Safety Practices About COVID-19 Among High School Students in Iran During the First Wave of the Pandemic

Background: School closures have inevitably deprived students of their traditional source of information. The objective of this study was to determine knowledge, attitudes, and safety practices about COVID-19 among high school students in Iran. Methods: This study was conducted from March 24th-April 3rd, 2020. Data were collected via an online-parent-administrative questionnaire. Results: Responses of 704 students were analyzed. Students' mean (SD) knowledge score was 21.5 (4.6) of 30. More than 90% of students knew about the cause of the disease, the routes of transmission, and the most renowned symptoms: dyspnea and cough. Social-and- audiovisual-media were the leading information source. Most students believed that people need to keep safe physical distancing, everyone should isolate themselves upon symptoms onset, people should avoid unnecessary in-person contact with family and friends, and that cities need to go under lockdowns if needed. Students' mean (SD) practice score was 20.2 (2.5) of 24. Most students did not go on a trip, and more than 80% said they would wear facemasks when going outside. Conclusions: High school students' knowledge and safety practices about COVID-19 were somewhat satisfactory, and their attitudes toward the disease were mainly positive. Nevertheless, some witnessed knowledge gaps, negative attitudes, and unsafe practices in the study highlighted the need for targeted education on the pandemic. Social and mass media's significant role and potential could be utilized to battle misinformation and deliver proper knowledge to young adolescents.

direct victims of the adverse health effects of COVID-19. However, the pandemic has the potential to deeply affect young children's development worldwide profoundly, especially their mental and physical well-being, the short-term and long-term repercussions of which are yet to be understood (3,4).
Schools have been closed due to the COVID-19 pandemic in Iran. School closures inevitably increased the use of online learning platforms (3). The deprivation of students of their traditional source of information has increased their risk to online threats such as the spread of misinformation primarily via social media, which could fuel the potential misunderstandings (5). Accurate information about the disease and the current situation could prevent irrational worries and concerns of children and minimize their anxiety or fear (6). There have been reports of negative stigmatizing attitudes and irresponsible safety practices toward COVID-19. Higher knowledge regarding COVID−19 is associated with a lower likelihood of negative attitudes and potentially dangerous practices (7). Safe health practices and adherence to controlling measures are especially essential and could determine the future course of the pandemic (8).
As an early step toward facilitating the outbreak management and ensuring safe practices, high school students' educational needs need to be addressed to provide training programs via the appropriate media by public health authorities. Therefore, current knowledge, attitudes, and safety practices need to be rapidly investigated, especially in the early days of school closures due to lockdown in Iran. The objective of this study was to determine the knowledge, attitudes, and safety practices of the high school students in Iran about COVID-19 via a rapid online survey administered by students' parents.

METHODS
This study was approved by the Ethical Committee of Shahid Beheshti University of Medical Sciences under code IR.SBMU.RETECH.REC.1399.412. Participation was anonymous and upon students' and parental consent.

Setting and Sampling
This study was conducted from March 24th to April 3rd, 2020, in Iran. Data were collected via an online parentadministrative questionnaire in the Google Docs platform. The questionnaire's link was posted on popular social networks in Iran, including Telegram, WhatsApp, Instagram, and Twitter. The questionnaire instructed that parents of high school students read the questions to their children and fill in the questionnaire on their behalf strictly based on their answers. It was emphasized that parents do not change the answers so that we could have a better understanding of their children's educational needs about COVID-19. Participants were high school students, grades 6-12, who lived in the 31 provinces of Iran. Participants who were studying in primary school or were not currently living in Iran were excluded from the study.
Abbreviations: COVID-19, The coronavirus disease 2019; ANOVA, One-way analysis of variance; SD, Standard deviation. Variables included sociodemographic characteristics, knowledge  about COVID-19, attitudes toward COVID-19, and safety  practices during the pandemic. Sociodemographic characteristics  included students' age, sex, ethnicity, high school grade, knowing  someone with COVID-19, and the province of residence in Iran. The questionnaire was in plain Persian and consisted of four main sections: sociodemographic characteristics, knowledge, attitudes, and safety practices about COVID-19.

Variables and the Questionnaire
The knowledge section assessed students' knowledge about cause, transmission, symptoms, red flags, prevention, treatment, sensitive groups, and follow-up for COVID-19; studens' selfevaluation on their level of knowledge, their source of information, and their felt need for further training.
The attitudes section included statements about participants' attitudes toward COVID-19. In response to these statements, participants chose an item from the five-point Likert scale.
The safety practices section assessed students' self-isolation, care-seeking, preventive measures, and going to public places during the pandemic.
A panel of experts evaluated the content validity of the questionnaire. An item discrimination analysis was conducted for each scale to eliminate too tricky or easy items. Factor analysis was performed for factor structure. A separate test-retest over 2 weeks was held for the three scales of the questionnaire. The test-retest correlation for the knowledge scale was 0.89; Kuder-Richardson-20 was used to prevent the overestimation of internal consistency; the coefficient was 0.83. The test-retest correlation for the attitudes scale was 0.91; the coefficient alpha was 0.87. The test-retest correlation for the practice scale was 0.87; the coefficient alpha was 0.88. The pilot survey was conducted on fifty female and fifty male students. The English and Persian versions of the questionnaire are available in Supplementary Table 1.

Data Analysis
One point was awarded to each correct answer to score students' knowledge about COVID-19. To analyze students' attitudes, "I strongly agree" and "I agree" were considered as "I agree"; and "I strongly disagree" and "I disagree" were considered as "I disagree." To analyze students' safety practices, one point was awarded to taking each right measure or not taking each wrong measure. The 95% confidence interval (95% CI) was reported for the key proportions using the exact binomial distribution. Categorical variables were analyzed by the Chi-Square test. For analyzing the differences among means of two groups and three groups or more, independent-sample t-test and one-way analysis of variance (ANOVA) test were used. Statistical analyses were performed using IBM SPSS Statistics 21. A probability level of <0.05 was considered significant.

Symptoms and Red Flags of COVID-19
More than 90% of students recognized that COVID-19 could present itself with dyspnea and cough. Although some 98% knew that worsening dyspnea could be a red flag, some 68% considered persistent fever dangerous. As many as 26 (3.8%) and 33 (4.6%) reported they did not know what the symptoms of and red flags of severe disease were, respectively ( Table 2, Supplementary Figures 1, 2).

General Knowledge About COVID-19
More than 90% of students correctly recognized the cause of COVID-19, its routes of transmission, and the necessity of self-isolation ( Table 3). The mean (SD) knowledge score was 21.5 (4.6), range = 1-30, which is 71.6% of 30. No significant differences were observed between students' knowledge scores and their age, sex, province, knowing someone with COVID-19, having a household member with COVID-19, having the disease, or having a family member passing away from COVID-19.
Students' Self-Evaluation on Their Level of Knowledge About COVID-19 As many as 203 (28.8) students considered their level of knowledge sufficient, 450 (63.9) fair, and 51 (7.2) insufficient.
Subsequently, when asked about their felt need for further training, 429 (60.9) said yes. As indicated in Table 4, audiovisual media and Telegram were the leading sources of information about COVID-19 among students, and online school classes had less contribution in this regard (Supplementary Figure 3).
Most students had positive attitudes toward COVID-19. They believed that people need to keep safe physical distancing, everyone should isolate themselves upon symptoms onset, and that cities need to go under lockdowns if needed. However, more than 20% thought the pandemic is divine retribution for the sins of humankind, and they were most uncomfortable to be around a person who has recently recovered from COVID-19 (Table 5).

Safety Practices
Self-Isolation and Care-Seeking Among students, 3 (0.4) reported they had become COVID-19 positive, 603 (85.7) reported they did not get the disease, and 98 (13.9) reported they had some symptoms but took no measures.

Leaving the House
The mean (SD) times of going outside the house during the past week were 1.8 (3.2), median (IQR) = 1 (0-2). About the reason to leave the house, 269 (38.2) reported grocery shopping, 44 (6.3) shopping items other than groceries, 69 (9.8) visiting family and friends, 67 (9.5) sightseeing, and 19 (2.7) going to healthcare facilities. As many as 254 (36.1) reported they did not leave the house. Among male students, 78 (25.4%) stated they did not leave the house during the pandemic, which was 176 (44.3%) among female participants, p < 0.001.

General Safety Practices About COVID-19
The mean (SD) score for general safety practices about COVID-19 was 20.2 (2.5), range = 4-24, which is 84.1% of 24 ( Table 6). No significant differences were observed between practice scores of students and their age, sex, province of residence, whether they knew someone with COVID-19, whether they had a household member with COVID-19, whether they caught the disease, or whether a family member had passed away from COVID-19.

DISCUSSION
Students' knowledge and safety practices about COVID-19 were somewhat adequate, and their attitudes toward the disease were positive. Most students knew that dyspnea and cough could be symptoms of COVID-19. In comparison, only half of the young adults in Karachi in a study recognized fever as a disease symptom (9). Almost all students recognized respiratory droplets as a transmission route, similar to a study among senior pharmacy students in Egypt (10). The majority of students said there were no medications available for the disease at the time, which was higher than the undergraduate students in a study in Italy (11). There were misbeliefs about COVID-19 among students. Although hand hygiene with soap and water is strongly recommended for disease prevention (12), some students said that washing hands without soap is sufficient for disinfection. Furthermore, some said that using hand dryers could effectively kill the pathogen, which is considered a myth (13).
Some 40% of students were unsure if COVID-19 could be transmitted via insects. There was no evidence of COVID-19 transmission by blood-feeding arthropods such as mosquitoes at the study time (14). However, it is now known that SARS-CoV-2 fails to infect or replicate in mosquitoes (15). The witnessed level of uncertainty regarding transmission routes calls for education campaigns by education and healthcare authorities.
While Telegram and the audiovisual media were the sources of information for most students, only 12% mentioned online school classes as their source of information about COVID-19. No studies were available which investigated the usage pattern of social media among Iranian adolescents. Our results illustrated the lack of school engagement in increasing students' awareness regarding different aspects of COVID-19. It is worth mentioning that the lockdown could have provided a more significant opportunity to watch television and surf the internet while staying at home (16). Mass media are valuable resources for efficiently forming people's knowledge and attitudes, improving their risk perception, and adequately informing people about risks and precautions (17). Although social media has played a significant role in information dissemination, its contribution to disseminating misinformation is noticeable (18). Social media provides a unique platform for engagement with experts. However, the lack of scientific peer review can contribute to mass hysteria rather than alleviating it. Since filtering the knowledge from the misinformation is hugely challenging in social media, the focus must be on reliable sources which avoid personal opinion or conjecture (19). This calls for extensive collaboration among public health authorities and the media outlets to provide and deliver specific health information to all the sectors of the society, especially children and young adolescents whose level of contribution to COVID-19 transmission on a community level has remained controversial (20).
There were no significant differences among students' knowledge score and their province of residence. This could suggest that the information origin of the popular media was the same, led by the national audiovisual media. Although the gender of the students was not a determinant of their level of knowledge, there are studies where women were more knowledgeable about COVID-19 (7,11). No significant differences were found in the knowledge scores of students of various ethnicities. On the contrary, a study in the United States reported significant differences between white people and other ethnicities (21). Most students believed that nations would finally defeat the disease, which is higher than a study among senior pharmacy students in Egypt (10) and similar to a study among the public in Malaysia (22). The majority of children expected that the pandemic would be controlled within a year, highlighting their hopes and belief in the scientific community and healthcare authorities. In the meantime, most students believed that people need to follow safe practices as suggested by healthcare authorities.
The pandemic unlocks some potentials of currently available technology and thus transforms people's behavior (23). Consumers are adapting to movement restrictions and are adopting newer technologies to facilitate work. More and more people are choosing online shopping to avoid unnecessary transport and contact with others. In our study, 94% of students reported that they would rather shop online instead of shopping in person.
Some 36% of students said they did not leave their houses during the preceding week, which is significant, especially considering that the early days of movement restrictions coincided with the holidays for the Persian new year, Nowruz, which are at least 2 weeks. Iranians have rituals before and during Nowruz. Before Nowruz, they go shopping for new clothes, shoes, sweets, and nuts, which are crucial for children and young adolescents. They also visit graveyards for deceased beloved ones on the last Thursday before Nowruz. During the holidays, Iranians visit family and friends or go on trips. However, some 90% of students reported that they did not go to the Bazaar before Nowruz and did not go on trips during the holidays. Students had a relatively safe hygiene practice. Only 11% of students said they did not wear masks while going outside, which is much lower than the 50% among senior pharmacy students in a study in Egypt (10) or the public in Malaysia (22). Nevertheless, some students followed traditional methods to prevent the disease. This could raise concerns, as the use of unapproved medications could result in unknown consequences (24).

STRENGTHS AND LIMITATIONS
This is a rapid online survey to assess the knowledge, attitudes, and safety practices of high school students in Iran about COVID-19. Although in the recent infectious outbreaks, some concerns about Iranian students' knowledge, attitudes, and safety practices were raised (25), a study that specifically considers high school students has not been conducted in previous infectious outbreaks in Iran. The strengths are its rather large sample and data gathering in the early days of the outbreak in Iran. Findings could empower education and public health authorities better to understand the current educational needs of high school students to be addressed. We realize the limitations of the study. Due to the complexity of some questions in the questionnaire of the present study, only high school students were included in the study. Nevertheless, the knowledge, attitudes, and safety practices of primary school students need to be investigated, considering that they are also quite influenced by social media (26). The administration of the study questionnaire via parents of the students could result in some impairments in the reflection of truths. Although we had explicitly asked parents not to change their children's answers, such voluntary measures are not guaranteed. Since there was no representative online platform to connect researchers to people in Iran, we decided to conduct this study in the Google Forms platform. The penetration rate of the Internet in Iran is high. However, some groups, especially those in rural areas, might not have access to the platform.

CONCLUSIONS
High school students' knowledge and safety practices about COVID-19 were somewhat satisfactory, and their attitudes toward the disease were mainly positive. Nevertheless, some witnessed knowledge gaps, negative attitudes, and unsafe practices in the study highlighted the need for targeted education on the pandemic. The significant role and potential of social and mass media could be utilized to battle misinformation and deliver proper knowledge to young adolescents.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Shahid Beheshti University of Medical Sciences, Tehran, Iran.

ETHICS STATEMENT
This study was approved by the Ethical Committee of Shahid Beheshti University of Medical Sciences under code IR.SBMU.RETECH.REC.1399.412. Participation was anonymous and upon the participant's own decision and parental consent. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

AUTHOR CONTRIBUTIONS
A-AK, HH, and MA-K: conceptualization. A-AK, MA-K, and M-RM: data collection. MA-K and M-RM: data analysis. HH and MA-K: writing-original draft. A-AK, MA-K, and HH: writing-review and editing. A-AK: resources and supervision. All authors have read and approved the manuscript prior to submission.

FUNDING
This study was supported by Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences under code 22975. The funding body was not in any ways involved in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.