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

Background: Several public health strategic actions are required for effective avian influenza (AI) prevention and control, as well as the development of a communication plan to keep undergraduate students sufficiently informed on how to avoid or reduce exposure. The aim of the survey was to measure the level of knowledge, attitudes and practices (KAPs) toward AI among undergraduate university students in East Java, Indonesia, and observe the correlation between KAPs and the factors associated with the control and prevention of AI. Methods: A cross-sectional survey was conducted among undergraduate students to collect information about AI-related KAPs. Students were selected from three faculties of Universitas Airlangga Surabaya Indonesia (Faculty of Veterinary Medicine, Faculty of Fisheries and Marine, and Faculty of Science and Technology). Students voluntarily responded to a pre-designed questionnaire. Results: A total of 425 students (222 female; and 203 male), of ages ranging from 18 years (n=240) to 20-30 years (n=185), responded to the survey. This cohort consisted of 157 students from the Faculty of Fisheries and Marine, 149 from the Faculty of Veterinary Medicine, and 119 from the Faculty of Science and Technology. The results indicated that appropriate knowledge was obtained by 76.94% of students; significantly higher levels were seen in Faculty of Veterinary Medicine students as compared to the other two faculties (p<0.05). 72.89% of students documented positive attitudes; veterinary medicine students had significantly more positive attitudes than other faculties (p<0.05). Proactive behaviors were observed in 56.90% of students. The aggregate scores for KAPs were 6.93 ± 0.77 (range: 0-9) for knowledge, 7.6 ± 1.25 (range: 0-10) for attitude, and 9.1 ± 1.5 (range: 0-12) for practice.


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 worldwide 1 . 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 virus 3 . 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 poultry 4 .
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][6][7][8][9][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][12][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 poultry 17 . 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 orally 18 . 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 public 19 . 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 guidance 20 .
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".

Scoring and recording of response variables
The questionnaire contained four demographic characteristics (age, gender, hometown, and name of faculty); KAP parameters were a set of nine AI knowledge variables (avian influenza is a contagious infection, avian influenza is caused by highly pathogenic influenza A [H5N1] virus, avian influenza is similar to swine influenza regarding their signs and symptoms [transmission] animal-to-animal, animal-to-human, human-to-human (risk group) poultry workers, butchers, veterinarians); five AI attitude variables (washing hands before eating and after touching raw poultry meat, using gloves to touch raw poultry meat, preparing raw poultry and other foods using different knives, and cleaning the cutting boards after preparing raw poultry meat); and six AI practice variables (washing hands with soap before and after eating, covering nose when sneezing and coughing, wearing a surgical mask and consultation with the doctor promptly in case of suspected contamination). All questions were developed based on a published questionnaire from a study on Italian poultry workers 21 . For this KAP questionnaire, a standard scoring method was used encompassing all KAP sections. In the knowledge section, correct answers were scored 1 point and 0 points were given for incorrect responses, while in the attitude section positive options obtained 2 points, neutral options obtained one point, while negative options get zero points. Similarly, in the practice portion, 2 points were awarded for proactive actions, 1 point was given for neutral actions, and 0 points for passive actions.

Data processing and analysis
The data collected through a standard KAP questionnaire module were subjected to statistical analysis by using the SPSS 25.0 software package. Both descriptive and inferential statistical tests (Chi-square) were applied to compare categorical response variables and ratios, and to assess their statistical significance (p<0.05).

Respondent demographics
All undergraduate students (n=425) were selected from three different faculties of Universitas Airlangga Surabaya Indonesia. Among them, 52.2% (222 out of 425) were females and 47.8% (203 out of 425) were males. A total of 35.05% (149 out of 425) of the respondents were from the Faculty of Veterinay Medicine, 36.94% (157 out of 425) from the Faculty of Fisheries and Marine, and 28% (119 out of 425) students from the Faculty of Science and Technology. A 56.5% fraction (240 out of 425) of participants were <20 years old while 43.5% (185 out of 43.5%) were aged between 20-30 years.
Knowledge of AI AI-associated knowledge was assessed by five questions. Each question-and-answer is described with graded scores in Table 1. Among the total 3,825 answers, 2,943 (76.94%) were correct. Significantly higher scores were found in Faculty of Veterinary Medicine students for K1, K5, K6, and K8 as compared to those from the Faculty of Fisheries and Marine and the Faculty of Science and Technology (p<0.05), but no other statistical significance was found among the groups ( Table 2).
Attitude towards AI There were five categories of AI attitude questions. Each question-and-answer option is presented in detail with scores in Table 3. In total, 1,549 (72.89 %) of the 2,125 responses showed a positive attitude (Table 3). Faculty of Veterinary Medicine students' scores were significantly higher than other faculties for A4 and A5 (p<0.05), while no other variable showed statistically significant differences between faculties (Table 4).
Practice related to AI among the respondents Six questions were used to assess practices related to AI; each question-and-response option, along with their graded scores, are given in Table 5 and Table 6. Out of 2,550 responses, 1,451 (56.90%) had adopted proactive practices. For questions P1, P4, and P5, veterinary students scored significantly higher than Faculty of Fisheries and Marine students. Students from the Faculty of Science and Technology scored much higher on question P4 than Faculty of Fisheries and Marine students (p<0.05) ( Table 6).

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 pandemic 22 . 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 pandemic 23 . 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][25][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 emergency 27 . 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 environment 28 . 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 education 29 .
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.   Table 2 lists the questions and correct answers for each variable.

Faculty of Science and Technology
The percentage of correct information between different groups was compared using the Chi-square test. 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   Table 4 lists the questions and correct options for each variable.

Faculty of Science and Technology
The percentage of positive attitudes between different groups was compared using a Chi-square test.

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.   Table 6 lists the questions and proactive options for each variable.

Data availability
The percentage of proactive options in different groups was compared using the Chi-square test.

General comments:
The article was a questionnaire-based cross-sectional survey among undergraduate students (knowledge, attitude, and practices) in the mentioned study area on avian influenza. The report made it clear that the veterinary students learned more about this zoonotic disease than students of other faculties. The article preparation and structure are good, and they can be indexed. The manuscript has a clear layout, and the research findings fit the study objectives. Even though the author used clear English, there is enough scope to improvise sentence structures. Minor editing on references, tables, and English could improve the article.

Abstract:
The abstract seems highly well. Methods, results, and conclusions are correlated to the study and understandable.

Introduction:
Literature was clearly stated for publication, but some recent references would be good. A questionnaire-based survey and its importance should be a vital part of the introduction.

Methods:
Methods are comprehensive, and I do believe they cover the idea. The use of "Few" in the methodology is a little improper. How many students from the other faculty already knew about the disease would correlate with their response to the questionnaire.

Results:
The results could cover the objectives with the descriptive study, which could've done the regression analysis, but I think this could be enough for this report. However, the writing needs to be revised for more concise and precise. I would suggest one thing to consider -the author can make one pictorial presentation of the constructed tables.

Discussion:
Excellently written already, add some new references, particularly previous 2/3 years. This part needs to be revised mainly keeping in mind that results should not be repeated.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound? Yes

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes