Knowledge, attitude, and practices associated with avian influenza among undergraduate university students of East Java Indonesia: A cross-sectional survey

Introduction

Avian influenza (AI) is a highly contagious viral zoonotic disease, and has become a serious public health concern in the last two decades as a result of a significant increase in the interspecies transmission of AI viruses from diseased birds to humans^1,2. Since the first laboratory-confirmed case was reported in Hong Kong in 1997, there have been 860 confirmed human infections with the avian H5N1 virus, resulting in 454 deaths worldwide¹. To date, only the H5 and H7 AI subtypes have been associated with naturally occurring, highly pathogenic AI A (HPAI) viruses that cause acute clinical disease in chickens, ducks, turkeys, and other economically significant birds. The majority of AI viruses of the subtypes H5 and H7 identified from birds, have been found to be low-pathogenic to poultry. All H5 and H7 viruses have been categorized as Notifiable Avian Influenza (NAI) viruses, because there is a possibility for lentogenic H5 or H7 viruses to become velogenic through mutation. Humans, rats and mice, weasels and ferrets, pigs, cats, tigers, and dogs have all been found to be carriers of the virus³. In various countries, including Vietnam, Indonesia, Thailand, China, Cambodia, and, more recently, Turkey and Iraq, AI strains have been found in birds, including wild and commercial poultry⁴.

In Indonesia, the majority of human cases of HPAI H5N1 have occurred in the western part of the main Island of Java. Although minimal, non-sustained human-to-human transmission has undoubtedly occurred, and the transmission was linked to poultry exposure, such as direct or close contact with infected or dead birds or visiting a live poultry market^1,5–10. Late presentation to health care and hospitalization, delayed clinical detection of AI and delayed antiviral therapy have all been related to increased mortality from HPAI H5N1 virus infection in Indonesia^7,11–13. Knowledge, attitude, and practices (KAPs) are one of the most important factors in controlling and preventing the spread of certain diseases or infections to public health^14–16. In the past few years, infected countries like Thailand, China, Italy, Turkey, and Afghanistan have been studying KAPs towards AI. Workers in the poultry industry had the highest risk of contracting AI. A study of Italian poultry workers was undertaken to assess their KAPs toward AI, and it was discovered that workers' awareness of transmission and prevention measures might be enhanced because of their close contact with poultry¹⁷. A KAP questionnaire is a comprehensive survey conducted on a specific population to determine a population's knowledge (K), attitudes (A), and practices (P) on a particular topic. In most KAPs studies, an interviewer uses a standardized, structured questionnaire to obtain data orally¹⁸. An earlier survey was carried out in Thailand among the rural community on KAPs towards AI, revealing that a public education campaign was beneficial in promoting AI disease prevention methods to the public¹⁹. However, there is a paucity of research on the KAPs towards AI in Indonesia. Considering the pandemic classification of AI and its critical consequences in terms of economic losses to the poultry industry and serious deleterious effects on public health, a survey was undertaken among undergraduate university students at a public sector university, to explore the benefits of adopting a KAP strategic model in controlling and preventing AI in Indonesia. The aims of the survey was to measure the level of KAPs towards avian flu among the students, and observe the correlation between KAPs and the factors associated with control and prevention of AI. The findings will significantly help to understand the basic knowledge of AI, its clinical manifestation, pathogenesis, routes of transmission, broad range of hosts, and pandemic nature of the virus, acquired by undergraduate students in particular, and Indonesians in general.

Methods

The respondents of this survey were the undergraduate students (from the Faculty of Veterinary Medicine, Faculty of Fisheries and Marine, and Faculty of Science and Technology) of the University of Airlangga Surabaya Indonesia. The study was conducted from April 23 to May 20, 2021, during the peak of the COVID-19 pandemic. After obtaining ethical approval from the Faculty of Veterinary Medicine Research Ethics Committee, the respondents were interacted with through face-to-face meetings to respond to the study questionnaire. This measure was taken due to the practical nature of this study that required self-administration for rapid data collection. The advantage of this method includes handling missing values, consistency of data findings, transparency of personal interest and the study framework as per literature guidance²⁰.

We contacted 425 undergraduate students from three different faculties, of Universitas Airlangga of ages ranging between 18 to 30 years to get the questionnaire filled. Informed consent was obtained from participants and anonymity of personal information was also considered. The sample size was determined based on a 5% precision level of faculty population.

These faculties were chosen because most students from the Faculty of Veterinary Medicine carry out research related to zoonotic diseases; while few students from other faculty carry out research on zoonotic diseases, they are part of their curriculum, such as AI, salmonella, and klebsiella. All participants were informed about the survey before filling the questionnaire with the following statements “All participation in this study is completely voluntary, if you decide not to participate there will not be any negative consequences. Please be aware that if you decided to participate, you may stop participating any time and you may decide not to answer any specific question. The aim of the survey is to measure the level of KAPs toward avian flu among the students. You will receive no direct benefits from participating in this research study. However, your responses may help us learn more about KAPs of avian influenza”.

Results

Discussion

The goal of the study was to gather data on AI-related KAPs among undergraduate students from three different faculties of Universitas Airlangga, Indonesia. We found that all the participants were aware of AI. Additionally, public health education was identified as a useful method for preventing and controlling public health emergencies, as well as improving public preparedness in the case of any pandemic²². It encourages the public to gain adequate knowledge to reduce stress and anxiety, develop a positive attitude and keep desirable behaviors under the situation of pandemic²³. All of these KAP components have been deemed essential for efficient pandemic prevention and control. This cross-sectional study of 425 undergraduate students indicates that the majority of them were well-informed about AI knowledge, had a positive attitude, and engaged in proactive practices, showing that major public education efforts offered effective health awareness benefits. This finding reflects several previous studies reports on H1N1-related KAPs among university students in South Korea, the United Kingdom (UK), and Hong Kong^24–26. Our study revealed that Veterinary Medicine students scored much higher on knowledge than students from other faculties, which could be explained by their exposure to, and training in, clinical medicine and veterinary public health, the concept of One Health and zoonosis. Their obligations and responsibilities as future public veterinary health experts to combat any pandemic are assumed to motivate them to adopt more positive attitudes and proactive behaviors in the event of a public health emergency²⁷. In the attitude section, students from the Faculty of Veterinary Medicine showed a significantly greater positive attitude than the other two faculties, indicating that veterinary students were more aware of the zoonotic importance of AI. This could explain the importance of veterinary education in the current study regarding One Health approaches and the role of the veterinarian in an eco-friendly environment²⁸. Our findings are compatible with the results of previous studies on KAPs towards H1N1 among university students of Hong Kong, South Korea, and the UK^24–26.

In the practice section, students from the Faculty of Veterinary Medicine and Faculty of Science and Technology showed significantly higher scores (p<0.05) as compared to the Faculty of Fisheries and Marine students. These standard practices noted in the current study showed a positive correlation between science and technology and veterinary science courses with education on infectious diseases like AI. Similarly, a prior COVID-19-related KAP study are conducted among undergraduate students in China, revealed that medical and health science students have more proactive practices as compared to other students from different fields of education²⁹.

There are some limitations to our research that must be noted. First, the nature of the cross-sectional study design limits the ability to draw causal inferences from the observed relationships. Second, our participants were recruited from three faculties within a single university, and attended the university during a pandemic for their research activity, while the majority of students stayed at home at the time of the survey due to the COVID-19 pandemic lockdown.

To our knowledge, this is the first study of current KAPs related to AI among Indonesian undergraduate students at any university, and it provides useful information regarding public health education and preventative measures in Indonesian universities during any pandemic. Our findings revealed that most of the undergraduate students at the University of Airlangga have a baseline knowledge of AI, although their scores may vary depending on the Faculty. Attitude towards AI showed a discrepancy among the Faculty students. Overall, our findings showed that faculties other than Veterinary Medicine have an impact on students' reactions to AI-related KAPs. In the educational and health sectors, public health education and awareness initiatives are conducted regarding infectious diseases.

Conclusions

According to the findings of this study, the majority of undergraduate students grasped the basic information, had a positive attitude, and showed a proactive behavior toward AI, demonstrating the efficacy and success of current public health education initiatives. However, health and educational institutions should adopt public health trainings, prepare the global population and strengthen their prophylactic measures against any pandemic. The results suggest that the students from the Faculty of Fisheries and the Faculty of Science and Technology should be taken into consideration for future strategic studies of awareness campaigns, public health concerns preparedness, and proactiveness in case of any pandemic.

Data availability