Knowledge toward COVID‐19 in children among undergraduate students at the beginning of COVID‐19 era

Abstract Aims To describe the level of knowledge of undergraduate students in Jordan toward COVID‐19 in children in respect of the clinical signs of the disease, modes of transmission, protection measures against the disease and satisfaction with governmental measures. Design A cross‐section was utilized in this study. Methods An online survey questionnaire was utilized in this research study. All undergraduate students in Jordan were able to take part. The size of the sample was 799. Knowledge toward COVID‐19 among children was used to assess the participants' knowledge about COVID‐19. Results The findings indicate that the students had a good understanding of the clinical signs, mode of transmission and protection measures and were satisfied with governmental measures. According to the students' responses, the resource they used the most was social media followed by news channels. Our study also found that medical specialty students had more knowledge toward COVID‐19 than non‐medical.

analysed in a conventional manner; there is a clinical diagnosis in two-thirds of the cases, without virology confirmation. Besides, it has also been found that there is a greater likelihood of children without virological symptoms being ill as compared to those with detected COVID-19, probably because other pathogens have caused their symptoms (Ogimi et al., 2019;Wei et al., 2020). Third, children may play a significant role in the transmission of viruses within the community (Cruz & Zeichner, 2020). Jordan is no exception, there is an increase in coronavirus cases worldwide and Jordan is no exception, where the virus is transmitted through contact between individuals (Abuhammad, Khabour & Alzoubi., 2020).
In Jordan, the current batch of university students will soon serve society in various professional capacities. Therefore, understanding the knowledge of undergraduate students about COVID-19 in children will allow their tutors to prepare them to manage the increasing incidence of COVID-19. Thus, it is essential to understand the currents among these future parents and providers of healthcare

| Design
A cross-sectional design was employed to collect data from the participants.

| Sample and setting
All undergraduate students from all government and private universities in Jordan were eligible to participate in the study so long as they met the following inclusion criteria: (1) able to read and write in the Arabic language and (2) aged more than 18 years old.
Students were excluded if they are not able to write and read the Arabic language. The quota sampling strategy used was based on the participant's age and gender to ensure that the sample was a broad representation of the general population in Jordan. The sample size of the study was calculated using G-Power 3.1., Universitat Kiel, Germany (RRID:SCR_013726), based on convenience/quota sample method, small effect size, alpha of 0.05 and power of 0.95.
The required minimum number of subjects was 750 More than 1000 questionnaires were sent out electronically to undergraduate students from all universities in Jordan. The authors used STROBE checklist to ensure meeting all the requirements for a cross-sectional study (Ghaferi et al., 2021).

| Measures
The following demographic characteristics were obtained through the self-reported online survey: age, gender, living conditions, income, nationality, specialization, level of education and education of parents. The second part of the survey (Knowledge toward COVID-19 among children) was used to assess the participants' knowledge about COVID-19. This instrument was adopted from another study that used the instrument to measure the knowledge of parents about COVID-19 in children (Abuhammad, 2021). The components of this instrument are the signs and symptoms of the disease (nine signs), modes of transmission (three questions), protection measures against the disease (11 statements) and satisfaction with government decisions for children (three questions). However, it should be noted that there is yet no standard measure of student knowledge about COVID-19 in children. The Cronbach alpha for the instrument was .89. The permission to use the instrument was approved by the original authors.

| Data collection
The researcher utilized an online questionnaire to obtain the data for this research study. Before interacting with human subjects, the researcher obtained permission from the Institutional Review Board (IRB) of Jordan University of Science and Technology (JUST) to conduct the study. Following receipt of IRB permission, the participants were recruited via online advertisement distributed on social media such as Facebook and Twitter. Anyone interested contacted the researchers to let them know they wanted to participate. The researcher sent them the consent form and the survey online via social media such as Facebook, Messenger, WhatsApp and other social media applications for people who sent that they met the inclusion criteria. To avoid bias, the link of the study was mentioned in the cover letter of the electronic survey that people who did not meet the inclusion criteria, and they should not participate in the study. More than 1000 questionnaires were sent to undergraduate students in public and private universities in Jordan.

| Ethical consideration
Jordan University of Science and Technology IRB approved this study. The researcher approached eligible participants and issued them with detailed information regarding the objective of the study.
This information included the following statements: "The researcher will utilize the information in assisting the community and the university; the researcher will keep the student information private; the researcher will not use any information in presentations or publications in a manner that will result in your [the student's] exposure to the Principal Investigator and the Office for Human Research Protection at (243/2020)".

| Data analysis
The Statistical Package for the Social Sciences version 25 was used for all statistical analyses (IBM, Armonk, NY, USA). The results of the descriptive and bivariate analyses were deemed significant based on an alpha level of less than .05. The Kolmogorov-Smirnov test was used to evaluate the normality of all continuous variables.
Any discrepant variables were transformed into more distributed scores. The subjects' responses were evaluated for each variable (measure). If each variable had 40% or more missing data, then the participants' responses for that measure were deleted listwise (10). Where the amount of missing data was below 40% this imputed from the mean of the responses to the items for each variable. Descriptive statistics were used to describe the research subjects' demographics and the total scores for each of the variables. Outliers were determined and eliminated prior to the data analysis.

| Demographic data
A total of 1000 questionnaires were distributed, and 799 undergraduates filled in and returned the questionnaire. Therefore, the response rate was 79.9%. Out of the 799 participants, 528 were female (66.3%) and 263 were male (37.3%). The mean age of the participants was 21 years. See Table 1

| Sources of information
There are many resources from which to gain information regarding COVID-19. According to the students' responses, the resource they used the most was social media (n = 520, 65%) followed by news channels (n = 532, 66.5%). The least used source was other sources such as newspapers (n = 50, 6.2%). See Table 2.

| Clinical signs and modes of transmission
Information was collected regarding the students' knowledge about the signs and symptoms of COVID-19 in children. Many correctly stated that fever (n = 720, 90.1%) was a clinical sign, followed by cough (n = 582, 72.8%). Only a few reported that red eyes (n = 102, 12.7%) constituted a clinical sign. As regards transmission, the three main modes that were recognized by the students were touching surfaces such as door handles and tables (n = 700, 87.6%), coughing and sneezing (n = 686, 85.8%), and shaking hands (604, 75.5%). See Table 3.

| Measures to protect against COVID-19 in children
Many measures can be taken to prevent the spread of COVID-19.
Students were asked to choose from multiple options for possible ways to prevent COVID-19 in children. Almost all the students answered that "Quarantine for all family members (stay at home) to protect children" (n = 792, 99.9%) and that "Educating people about coronavirus in children is important to prevent the spread of the disease" (n = 780, 97.7%). However, very few students answered "know how to apply social separation with family children" as an effective way to reduce the incidence of the disease (n = 22, 2.8%).
See Our results also showed that the undergraduate students had adequate knowledge about the clinical signs of COVID-19 that include fever, exhaustion, production of sputum, breathlessness, cough, headache and sore throat. This is congruent with the literature, which indicates that the most frequent clinical signs are fever, exhaustion, production of sputum, breathlessness, cough, headache and sore throat (Chen et al., 2020). Besides, there can be a manifestation of gastrointestinal symptoms in some patients, such as diarrhoea and vomiting. Three studies were conducted in 41 and 138 children's patient investigations in Hubei province (Chen et al., 2020;Huang et al., 2020). In the first study of them, fever and cough were found to be the dominant manifestations and rarely upper respiratory and gastrointestinal signs, which indicates that there may be the differences in viral tropism in comparison to other previous respiratory outbreaks such as influenza (Wang et al., 2016).
One probable reason children seem less prone to contracting COVID-19 in the beginning of the outbreak is that they perform minimal outdoor activities and undertake minimal travel to international destinations, thus lowering their probability of getting the virus. However, there may still be a future increase in the number of paediatric patients. It remains a mystery why children are relatively resistant to some infectious ailments (Sinha et al., 2020).
However, it has been suggested that developmental changes in the axonal transport system may give the answer to the greater immunity in baby mice to paralysis triggered by the polio vaccine. Some other possible reasons may be the innate immune system in children has a continually active response and that children have a healthier respiratory system because they have not been in as much contact with pollutants as compared to older individuals and have minimal hidden complications due to their early age (Sinha et al., 2020). However, a more robust immune system in adults may explain the disadvantageous immunity that is linked to acute respiratory distress syndrome. Differences in the distribution, development and functioning of virus receptors are often linked with the level of incidence that is associated with differences in age (Ludvigsson, 2020;Sinha et al., 2020).

TA B L E 2 Sources of information on COVID-19 in children
Our study found that many undergraduate students think that COVID-19 affects children to the same degree as adults and many think coronavirus poses a threat to children's lives. Previous research has shown that there is a more common adult COVID-19 infection compared with children (Lee et al., 2019;Lu et al., 2020), this outcome indicates that children may indeed be quite resistant to SARS-CoV-2. It has been determined that the expression of ACE2 in the lungs of rats significantly reduces with age. This result may be different from the relative susceptibility of children to COVID-19.
Therefore, it is essential to discuss the principal factors that may assist in caring for child patients who have COVID-19 infection (Thompson & Rasmussen, 2020).
As for modes of transmission, our study found that most of the i.e. encountering sneezing or coughing aerosols or encountering fluids from infected persons (Shen et al., 2020;Sinha et al., 2020). The function of faecal-oral transmission has not yet been determined in COVID-19. However, it was found to occur during the SARS outbreak (Sinha et al., 2020).
In our study, many students reported that "Quarantine for all family members (stay at home) to protect children" and "Educating people about COVID-19 in children is important to prevent the spread of the disease." On the contrary, only a few students answered that "Applying social separation with family children" is an effective way to combat the disease. Methods of lowering COVID-19 transmission include personal and environmental actions, determining and separating incidences, tracing contacts and quarantining, implementing measures on social and physical distancing including the banning of mass gatherings, setting rules for international travel (Adalja et al., 2020;Chinazzi et al., 2020), providing relevant treatments and conducting vaccinations.
In our study, many students supported the government measure that requires that children should stay at home all the time to tackle the coronavirus epidemic. The WHO (2020) has provided many steps to ensure the safety and prevent COVID-19 in children. These steps include the physical separation of individuals (at least 1 m) and reduced contact in infected areas as well as promoting and maintaining virtual contact with relatives and communities (Abuhammad, 2020;Anderson et al., 2020). There are also general measures that can be taken to ensure the safety of everyone, especially children. These include implementing flexible methods of working such as teleworking, offering distance learning to students, minimizing and preventing gatherings, as well as closing non-essential facilities and services Adalja et al., 2020;Muflih et al., 2021), protecting and securing vulnerable populations, restricting the local or national movements of individuals, implementing or enforcing measures to stay at home (Cauchemez et al., 2009) Keeling et al., 2020). These measures are enacted together with personal protective actions against COVID-19 such as frequent washing of hands and good hygiene manners when coughing (Chinazzi et al., 2020;Fisher & Heymann, 2020;Thompson & Rasmussen, 2020).
Our findings contradict the results of previous literature, an assumption can be made that nonpharmacological strategies are useful from an individual perspective, for instance, fluid support, oxygen and ventilation support (Ali & Gatiti, 2020;Wu & McGoogan., 2020). Non-pharmaceutical measures remain important in managing COVID-19 because of the absence of official vaccines or antivirals for coronavirus (Abuhammad et al., 2022;Shen et al., 2020).

| Strengths and limitations
One of the strengths of this study is using many students and recruiting them over social media to reach the highest number of students. The limitations of the study include using a cross-sectional design, which limits the cause-and-effect relationship. Another limitation is using this study in Jordan, which limits the generalizability to other countries.

| CON CLUS ION
In summary, the students showed satisfactory-level knowledge of COVID-19 in children. The students had knowledge about the signs and symptoms of disease, ways of transmission, protection measures and satisfaction with measures to combat COVID-19 in children, considering the importance of possessing knowledge about this ongoing global public health emergency.

AUTH O R CO NTR I B UTI O N S
All authors participated in all steps of this study.

FU N D I N G I N FO R M ATI O N
This research did not receive a grant.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to disclose.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data will be avaliable upon request.