Knowledge and Attitudes
A majority of studies indicated that students possessed moderate to high levels of overall knowledge regarding H1N1 that ranged from 75% in Mexico (Wilson and Huttlinger, 2010) to 99.6% in Australia (Van et al., 2010). However, this was not always the case; for example, one study conducted in the United Kingdom reported low levels of H1N1-related knowledge with 37.4% of students failing to identify any causes of the infection (Williams et al., 2012). Similar to H1N1, knowledge about MERS was variable, however it was considerably lower, ranging from 43.2% in Saudi Arabia (Al-Mohaissen, 2016) to 53.5% in South Korea (Yang and Cho, 2017). In contrast, 93.2% of students in one study from Iran expressed awareness of EVD and was thus, indicative of high levels of overall knowledge about the disease (Holakouie-Naieni et al., 2015).
Knowledge regarding the means of transmission of various pandemics was generally high. A total of six studies reported that a majority of participants were knowledgeable about the modes of transmission (Akan et al., 2010; Al-Mohaissen, 2016; Hasan et al., 2018; Holakouie-Naieni et al., 2015; Hussain et al., 2012; Seale et al., 2012). Human-to-human transmission of H1N1 was identified by a range of 52% of students in Pakistan (Hussain et al., 2012) to 84.4% in Turkey (Akan et al., 2010). In Iran, 56.2% of undergraduate and 88.9% of graduate students were aware of Ebola transmission (Holakouie-Naieni et al., 2015). 60.5% of students from Saudi Arabia could identify different routes of MERS transmission including animal to human transmission, as well as transmission from infected family members, patients, and health care professionals (Al-Mohaissen, 2016).
Multiple studies noted high levels of knowledge about the signs and symptoms of H1N1, MERS, and EVD (Al-Mohaissen, 2016; Hasan et al., 2018; Holakouie-Naieni et al., 2015; Hussain et al., 2012). For example, a study conducted in Iran suggested that 77.7% of the students were aware of the signs and symptoms of EVD (Holakouie-Naieni et al., 2015). Moreover, fever, cough, difficulty in respiration and occasional diarrhea were recognized as symptoms of MERS by 78.9% of students in Saudi Arabia (Al-Mohaissen, 2016). Knowledge regarding the symptoms of H1N1 was more variable; while cough was identified as a common symptom of H1N1 by 72% (Hasan et al., 2018) to 83% (Hussain et al., 2012) of students in Pakistan, diarrhea and vomiting were identified by only 15.5% and 32.2% of students, respectively (Hasan et al., 2018).
We also identified several gaps in knowledge among students, pertaining to the nature of pandemics, transmission modes, antiviral drugs and high-risk populations (Akan et al., 2010; Hasan et al., 2018; Holakouie-Naieni et al., 2015; Seale et al., 2012; Serino et al., 2011). For example, university students from Australia were unable to accurately define what ‘pandemic influenza’ meant despite being knowledgeable about its transmission (Seale et al., 2012). Furthermore, a study conducted in Turkey indicated a lack of knowledge about antiviral drugs and antiviral treatment in nearly one-third of the students (Akan et al., 2010). Another study reported that 37.1% of students from Iran had no knowledge regarding populations that were at the greatest risk of EVD (Holakouie-Naieni et al., 2015). Similarly, 45% of students in one study conducted in Pakistan were unaware that touching an infected person was a mode of H1N1 transmission (Hasan et al., 2018).
Information Sources
Students derived information about the pandemic from various sources such as social media, newspapers, university resources and health care workers (Akan et al., 2010; Al-Mohaissen, 2016; Mitchell et al., 2011; Seale et al., 2011; Serino et al., 2011; Wilson and Huttlinger, 2010). Sources of information about pandemics and outbreaks such as health care workers, social media, community leaders, and the government each play an important role in disseminating information related to the infection and disease. A study conducted in the United States found 96.8% of students received information from the university about the H1N1 pandemic via email, 82.6% via telephone messages, and 80.7% via text messages (Mitchell et al., 2011). For example, in one study conducted in Australia, students expressed doubt towards the impact that the disease had on communities (Seale et al., 2012). The university sent out an email to staff and students educating them about the disease, but only 53.6% of students who received it found that it was useful (Seale et al., 2012). Another study found students seldom accessed reputable information sources such as medical search engines, the Centers for Disease Control and Prevention, and health care workers (Akan et al., 2010). For example, only 8% of students in Turkey accessed health care workers as their primary source of information (Akan et al., 2010). A study conducted in Spain found students associated the emergence of EVD with government mismanagement and misinformation from mass media (Mondragon et al., 2017).
Social media was the most widely used source of information amongst students. Three studies from Italy, Turkey, and the United States reported that students used social media as their primary source of information (Akan et al., 2010; Serino et al., 2011; Wilson and Huttlinger, 2010). In Turkey, 72.1% of students reported using mass media as an information source, and 19.9% of students relied on the internet (Akan et al., 2010). In New Mexico University, a rural based community, students relied on electronic social networking through talking to individuals online or using electronic media (Wilson and Huttlinger, 2010). In Italy, 81% of students were informed about H1N1 through mass media, and often multiple information sources were also used (Serino et al., 2011). These findings emphasize the significance of social media use during pandemics which played a vital role in information dissemination to students. Social media is not only a tool for dissemination, distribution and seeking of health information, but it may also act as an outlet for the students’ emotions and sharing of personal experiences and opinions, which makes controlling the acquisition of information more difficult (Yang and Cho, 2017). These emotions may lead to expressions of skepticism about scientific topics and participation in decision-making within social media where misinformation may be widespread (Yang and Cho, 2017).
Risk Perception
Risk Perception and Attitude
Eight studies identified a “casual attitude” or low risk perception among students in response to pandemic infection or disease (Akan et al., 2010; Mitchell et al., 2011; Park et al., 2010; Seale et al., 2012; Serino et al., 2011; Van et al., 2010; Williams et al., 2012; Wilson and Huttlinger, 2010). A study conducted in Australia found that although 60.4% of university students believed that the H1N1 pandemic was serious, 40.4% reported that they were “not anxious” (Van et al., 2010). Students in this study believed they were not susceptible to H1N1, despite being the age group with the higher number of cases (Van et al., 2010). In a separate study conducted in Australia, students believed they were capable of fighting off any illness because they were young and led a healthy lifestyle (Seale et al., 2012). Similar sentiments were also found in students residing in the United States (Mitchell et al., 2011; Wilson and Huttlinger, 2010). For example, a study conducted in the United States found that 60% of students did not perceive dormitory residences to be a source of infection despite there being evidence that shared bathrooms and sleeping quarters were high risk areas for disease spread (Wilson and Huttlinger, 2010).
Influence of Mass Media on Risk Perception
The influence of mass media on student perception of the infection varied throughout the pandemic. For example, a study conducted in Australia found that the resurgence of H1N1 media coverage caused a significant increase in anxiety, perceived susceptibility, and seriousness of disease spread (Van et al., 2010). However, media coverage of the infection declined in accordance with a decrease in laboratory confirmed cases of H1N1 in Australia (Van et al., 2010). Similarly, another study conducted in Pakistan reported 32% of medical students believed themselves to be at a risk of contracting H1N1 (Hussain et al., 2012). This finding reflected the relationship between low-risk perception due to the low number of laboratory-confirmed outbreaks reported in the newspaper and media (Hussain et al., 2012). Furthermore, one study conducted in South Korea reported a positive correlation between trust in the media, risk perception and overreaction (Yang and Cho, 2017). The study supported the claim that the mass media may increase perceptions of disease risks due to the frequent reporting of community spread of disease (Yang and Cho, 2017).
Health Behaviors
Studies reported that a significant portion of students did not wear masks. Two studies found that the use of a face mask was met with the most resistance among undergraduate and graduate students (Hasan et al., 2018; Van et al., 2010). University students from Australia dismissed the use of masks as they were considered uncomfortable, inconvenient, and unnecessary (Seale et al., 2012). Furthermore, students believed that wearing a mask would contribute to embarrassment and social stigma (Seale et al., 2012). The percentage of students who did not wear face masks in crowded areas ranged from 16.8% in Australia (Van et al., 2010) to 84.5% in Pakistan (Hasan et al., 2018). Interestingly, the majority of the students agreed that the use of a facemask was an effective preventative measure, but only a 11.5% wore one when having fever, cough or a runny nose (Hasan et al., 2018).
Students in eight studies reported regular hand washing and sanitizing to prevent the spread of infection (Akan et al., 2010; Hasan et al., 2018; Mitchell et al., 2011; Park et al., 2010; Seale et al., 2012; Serino et al., 2011; Van et al., 2010; Zottarelli et al., 2012). The percentage of students who practiced regular handwashing ranged from 20.8% in Australia (Van et al., 2010) to 96% in the United States (Mitchell et al., 2011). Students in two studies conducted in South Korea and Italy reported an increase in handwashing frequency during the peak of the H1N1 influenza pandemic (Park et al., 2010; Serino et al., 2011). The proportion of students who reported an increase in this behavior ranged from 30.3% (Park et al., 2010) to 38% (Serino et al., 2011). A study conducted in Australia found students perceived hand washing as the most feasible and acceptable preventive measure compared to physical distancing and mask use (Seale et al., 2012).
Students in four studies reported avoiding close contact with their family and friends (Akan et al., 2010; Hasan et al., 2018; Mitchell et al., 2011; Van et al., 2010). The proportion of university students who reported this behavior ranged from 5% in Turkey (Akan et al., 2010) to 80.5% in Pakistan (Hasan et al., 2018). Furthermore, university students in two studies reported covering their mouth and nose while coughing or sneezing (Hasan et al., 2018; Mitchell et al., 2011). The proportion of students who reported this behaviour ranged from 77.7% in Pakistan (Hasan et al., 2018) to 80.6% in the United States (Mitchell et al., 2011). University students from three studies avoided crowded places (Hasan et al., 2018; Serino et al., 2011; Van et al., 2010). A study conducted in Australia reported approximately half of university student participants were willing to avoid large class sizes and resort to online learning instead (Van et al., 2010).
The Relationship between Risk Perception and Health Behavior
Students’ low perception of infection risk plays a vital role in encouraging the uptake of hygiene and social distancing behaviours. Six studies demonstrated a relationship between greater levels of concern and compliance to recommended health behaviors (Hasan et al., 2018; Hussain et al., 2012; Mitchell et al., 2011; Seale et al., 2012; Serino et al., 2011; Van et al., 2010). Students with high levels of concern complied with behaviours such as avoiding crowded places (Serino et al., 2011), cancelling their travel plans (Serino et al., 2011), handwashing (Seale et al., 2012), avoiding people who appeared to be ill (Mitchell et al., 2011), and displaying appropriate cough etiquette (Seale et al., 2012). Furthermore, a study conducted in Italy found that 67% of the ‘very worried’ students adopted a number of health behaviors, which contrasts with only 18% of ‘not worried’ students who adopted at least one health behavior (Serino et al., 2011). Furthermore, 32% of ‘very worried’ students from Italy reported that they would cancel their travel plans to the United States to avoid the risk of infection compared to only 5% of students who did not express worry (Serino et al., 2011). Consequently, 59% of students reported not modifying their behavior to reduce their risk of infection (Serino et al., 2011). One study reported that risk perception was directly associated with overreaction to the behavior of oneself and others. However, risk perception was not correlated with compliance with self-quarantine (Yang and Cho, 2017). This study found that risk perception motivates self-protective behaviour rather than behaviors that protect others such as quarantining (Yang and Cho, 2017).
Misconceptions
Three studies identified a lack of clarity about the different clinical manifestations of seasonal influenza, swine flu and the common cold among university students (Akan et al., 2010; Park et al., 2010; Serino et al., 2011). For example, 13% of university students from Italy and 50.5% of those from Turkey indicated that swine influenza was less serious than seasonal influenza (Akan et al., 2010; Serino et al., 2011). A similar pattern was also noted in another study conducted in South Korea which reported that 56.1% of university students believed that H1N1 caused symptoms that resembled those of the common cold but were milder in nature (Park et al., 2010).
Misconceptions regarding the transmission of disease were also prevalent. While 39% of medical and dental students thought that H1N1 can be contracted through contaminated food and water, 35.2% believed that eating cooked pork was a potential means of transmission (Hasan et al., 2018). The same study also reported that approximately a tenth of university students inaccurately identified sexual intercourse and mosquitoes as modes of transmission of the disease (Hasan et al., 2018). Similarly, 70.9% of students from Saudi Arabia were found to falsely believe that the consumption of raw or insufficiently cooked animal products, including dairy products and meat, was unsafe in the context of the MERS outbreak (Al-Mohaissen, 2016).
Students across various studies also demonstrated confusion regarding the origin of infection, classification of pandemics, and their support for conspiracy theories. For example, in one study, some university students from Iran suggested that EVD had been produced in the West to be tested in Africa (Holakouie-Naieni et al., 2015). Moreover, some university students in a study conducted in Pakistan incorrectly indicated that H1N1 was caused by a bacterium or that it was a heritable condition (Hasan et al., 2018). Students were also misled about the severity of disease with over half of those from a university in Turkey suggesting that H1N1 infection would result in death (Akan et al., 2010).
Vaccination
University students in three studies reported their willingness to vaccinate against H1N1 (Akan et al., 2010; Serino et al., 2011; Van et al., 2010). The proportion of students ranged from 7.2% in Turkey (Akan et al., 2010) to 60% of students in Australia (Van et al., 2010). Despite the low willingness to vaccinate in some regions, 54% of university students believed that the vaccine could curb the spread of H1N1 (Akan et al., 2010). Students in two studies conducted in Turkey and Italy reported that the low willingness to vaccinate was attributed to a lack of trust in the vaccine, and uncertainty of its efficacy and potential side-effects (Akan et al., 2010; Serino et al., 2011). Furthermore, the low willingness to undergo vaccination may be due to the 59.6% of students who believed that insufficient information had been provided regarding the H1N1 vaccine (Akan et al., 2010). Furthermore, a study in Pakistan found that only 1.7% of medical students were vaccinated against H1N1 (Hasan et al., 2018). Two studies conducted in Australia and the United States reported variables that influenced seasonal flu vaccination (Van et al., 2010; Zottarelli et al., 2012). Van et al. (2010) reported that students who had received seasonal influenza vaccinations in the past were significantly more likely to accept the H1N1 vaccine compared to their non-vaccinated counterparts. Finally, a study conducted in the United States reported a positive correlation between frequent hand sanitizing and seasonal flu vaccination (Zottarelli et al., 2012).