Knowledge, Attitude on Health Practices of University Students and Staffs During the COVID-19 Pandemic in Malaysia

A novel coronavirus; COVID-19 is posing a great threat to mankind worldwide. The World Health Organization (WHO) has declared the deadly pathogen as a pandemic in view of its alarming spread. Literature affirms that universities have a higher potential to be centres of a pandemic outbreak. The infectious disease could easily transmit from one person to many others within a university vicinity, thus creating a cluster if not properly contained. The Malaysian government has imposed the movement control order (MCO) to flatten the curve of infection. All economic sectors were closed during the MCO period. This study was conducted to explore the knowledge, attitude and health practices towards COVID-19 among internal stakeholders of a public university in Malaysia. An online survey was carried out on the first week of MCO. A total of 340 respondentsD comprised of students and staffs took part in the survey. The regression analysis found knowledge and attitude were significant predictors for adopting appropriate health practices among the internal stakeholders during the new coronavirus outbreak. This present study extends the existing literature on health crisis focusing on internal stakeholders of an institute of higher learning particularly during an early phase of MCO in Malaysia.


INTRODUCTION
The world is struggling to combat a life-threatening disease that has claimed thousands of lives. A novel coronavirus that was officially named COVID-19 has placed many countries on lockdown, thus suspending all human activities. The scarcity of information about its spread, symptoms, how the human body reacts to the virus and the absence of a vaccine for the disease have made preventive measures more challenging and problematic. This new strain of coronavirus causes an acute respiratory disease leading to fatality. The first few novel coronavirus cases were traced at the end of December 2019, when the World Health Organization (WHO) China Country Office was informed of pneumonia cases in Wuhan City of Hubei province (World Health Organization 2020). Similar cases have been detected outside China since then. By the end of January 2020, WHO had declared the outbreak a Public Health Emergency of International Concern (PHEIC) (World Health Organization 2020). In the sixth month, the virus has affected more than 7 million people in 187 countries and the death toll has exceeded 400,000 lives (CPRC, 14 June 2020).
Malaysia has not been spared from this health calamity. The first wave of the pandemic in Malaysia began in January 2020 until 26 February 2020 with 22 confirmed positive cases of COVID-19 (Anon 2020). The country braced for the second wave when the number of infected cases increased exponentially. In less than three months, Malaysia has become the hardest-hit nation in Southeast Asia with the highest number of infected cases. The total number of confirmed cases in the country as of March 15, 2020, was 428. This number has surpassed Singapore (226 cases) and the Philippines (140 cases) (Ong 2020). COVID-19 disease imposes a lethal threat to anyone and that includes the internal stakeholders in a university (Fauzi, Harianto, and Affandi 2020).
Literature affirms that universities have great potential to become explosive outbreak centres due to their large number of populations, high level of social contact and permeable boundaries (Van et al. 2010). Students and staffs are sharing basic facilities and amenities on campus. Besides, most public university students live in the university's accommodation on campus. In addition, academic and co-curricular activities normally involved close social contacts that could increase the likelihood of the COVID-19 transmission (Fauzi, Diarti, and Rohmawati 2019).
A h m a d : K n o w l e d g e , A t t i t u d e o n H e a l t h P r a c t i c e s o f U n i v e r s i t y S t u d e n t s a n d S t a f f s D u r i n g t h e C O V I D -1 9 P a n d e m i c i n M a l a y s i a | 369 In this study, the internal stakeholders refer to the students and staffs of the institute of higher learning in Malaysia. Both students and staffs are the primary stakeholders of a university. Drawing from Freeman (1984) stakeholders are individuals whose actions affected the organization and vice versa (Rawlins 2006

The Scenario of COVID-19 pandemic in Malaysia
The arrival of the year 2020 has been tainted with the outbreak of a novel coronavirus; a new strain of the virus that has never before been identified in humans (Lim 2020  Asia. The surge in the number of cases was associated with a cluster of religious gathering at Sri Petaling mosque that was claimed to have been attended by more than 16,000 people (Ong 2020

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The pandemic could affect anyone who has been exposed to the virus and this includes the students and staffs at the institute of higher learning in the country.

The response of campus community towards COVID-19 pandemic
The first wave of the pandemic coincided with the resumption of the new semester in public universities in Malaysia. The Deputy Education Minister stated that public universities have the autonomy to make postponement of classes in view of the outbreak (Anon 2020). In response to the pandemic situation, several universities postponed registration for the semester while a few conducted online teaching to replace face-to-face lectures, i.e., UPM, UM, UUM. Among early preemptive measures implemented involved temperature screening and 14-day home surveillance for those who travelled to or from China. The implementation of these pre-emptive measures was not without criticism. One reputable public university had received a backlash for using student volunteers instead of trained medical personnel to do the health screening for students returning from China.
The student union also protested over the issue of using one of the residential areas as isolation place for students returning from abroad during the outbreak (Chung 2020   April to 28 April 2020) the government had given the green light to students who were stranded on campus to go home in stages, effective 27 April 2020 onwards (CPRC, 12 May 2020). A standard operating procedure (SOP) was imposed and strictly monitored to minimize the risks of transmission in the process of sending them back to their hometowns. It has been estimated that 53,000 (85%) of the students had applied to go back home while another 15% decided to remain on campus (Muhamad 2020).

Research on past pandemic studies
This study argues that students and staffs knowledge and attitude towards the pandemic would have a profound effect on their health practices. Health practices in this context, refers to adopting the guidelines as recommended by the public health experts that would protect them from COVID-19 infection. This includes to observe physical distance at least 1 meter with others, frequently washing hands with water and soap, wear a face mask in the public area, avoid social contact including shaking hands, observe cough etiquette and alike.
The extant of literature has generated mixed results of students' and staffs' knowledge, attitude and behaviour change during a pandemic situation. A previous study on the influenza AH1N1 pandemic at the University of New South Wales found that most students and staff had not adopted any behaviour change during the pandemic ( Van et al. 2010). A cross-sectional study in Yeditepe University, Turkey found that students had sufficient knowledge about H1N1 pandemic but showed negative attitude towards the H1N1 vaccination (Akan et al. 2010). On the other hand, Seale, Mak, Razee and MacIntyre (2012) found that students' origin could be a factor that influences behaviour change during the H1N1 pandemic. Their study found that students of Asian origin were more likely to perceive high risk of a pandemic and adopt behavioural change. In contrast, a study on pandemic influenza AH1N1 in Malaysia found that people had overestimated the severity of the pandemic. However, the study also reported a high confidence in preventing the infection of AH1N1 and low perceived susceptibility of infection (Wong and Sam 2011). This may discourage Malaysians from practicing preventive measures during the pandemic. The present study is conducted to examine the knowledge, attitude and health practices among students and staff in the institute of higher education in Malaysia during the MCO.

METHOD
This study has adopted a quantitative approach. An online survey using a Google form survey had been distributed within the first week of the movement control order (MCO) that was from 18 to 24 March, 2020. A total of 340 respondents completed the questionnaires.

Instrument
The questionnaires were adapted from a previous study related to past pandemic (Almutairi et al. 2015). The survey was pilot tested a week before the actual survey with 30 respondents. The reliability analyses of the pilot study Cronbach's alpha ranged between from 0.725 to 0.814. The actual study's Cronbach's alpha was also above 0.7 are further elaborated in Table 1.

RESULT AND DISCUSSION
The results of this study consist of the demographic and psychographic data of the respondents. They are followed by the explanation of the findings, continue with the correlation and regression analyses.

Demographic
More than half of the respondents' age ranged between 18-25 years old (62%) followed by 26-40 years old (22%). Only 16% of the respondents were 40 years old and above. The majority of the respondents were females (72%) with only 28% of males. This is due to the campus community ratio in numbers where there are usually more females than males. In terms of education, slightly more

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than half (55%) of the respondents' level of education were bachelor's degrees with 22% doing their master's and 10% with PhD. Respondents of this study belonged to the campus community of IIUM that includes both students, staff and contractors. More than three quarters of the respondents were students (82 percent) with 8 percent staff and 10 percent contractors. This corresponds with the ratio in community as there are more students than staffs on campus. In terms of nationality, more than half of the respondents were Malaysian (68 percent) while international respondents encompassed 32 percent of the population. Even though the majority of the respondents were Malaysian, the number of international respondents was

A h m a d : K n o w l e d g e , A t t i t u d e o n H e a l t h P r a c t i c e s o f U n i v e r s i t y S t u d e n t s a n d S t a f f s D u r i n g t h e C O V I D -1 9 P a n d e m i c i n M a l a y s i a | 377
relatively big hence, the findings not only represent the knowledge, attitudes and health practices from the Malaysians' perspective, but also the international community's in IIUM.

Correlation Analysis
Correlation analysis was performed to measure the relationship between knowledge, attitude and health practices of the campus community during the COVID-19 pandemic. In general, all of the variables were significant but the strength of their relationship was moderate. However, the relationship between the variables still exist and valid. Table 3 Correlation analysis between knowledge, attitude and practice .427 ** .000 **. Correlation is significant at the 0.01 level (2-tailed). Table 3 shows the relationship between attitude, knowledge and health practices. The result indicates a moderate and significant correlation between knowledge and attitude (r=.482; p=.000). Similarly, knowledge and practice also show a moderate and significant relationship (r=.477; p=.000). Hence, knowledge was found to have an association with practice and practice and attitude (r=.427; p=.000) is also found to have a positive correlation.

Regression Analysis
Regression analysis was conducted to predict the health practices adopted by the respondents during a severe pandemic based on their knowledge and attitude (Table 4)  The results indicate that the respondents adoption of health practices increased when they have more knowledge about how to protect themselves from the COVID-19 virus. Moreover, the analysis also found that health practices increased when the respondents' attitude was positive towards shielding p=.000) and attitude (β=.257; t=4.843; p=.000) were found to be significant with knowledge as the strongest predictor for adopting appropriate health practices.   pandemic inside the university is critical. Having one infected case could create a cluster within a university campus. The university may not be able to prevent the novel coronavirus infection if students and staffs themselves are not practising the preventive measures and guidelines provided by the authority. Unlike other strains of coronavirus, COVID-19 has greater devastating effects in view of its rapid and intense widespread. In this case, the Ministry of Higher Education's decision to restrict the students' and staffs' movements on campus was commendable. As a preventive measure to curb the virus transmission on campus, students who stayed in hostels were not allowed to leave the university's premise.
Similarly, students and staffs who stayed outside campus were not permitted to enter the university without prior permission during the MCO period. The findings of this study among others showed that the relationship between knowledge and attitude in influencing health practices among students and staffs were just moderate. It is worth noting that the study was carried out during the first week of the initial phase of MCO (approximately three months after the first case of COVID-19 was reported in the country). The total number of confirmed COVID-19 cases at the time the survey was carried out stood at 673 with two fatalities (Choong 2020). The number of cases and fatality were relatively low in comparison to a much higher number among most affected nations such as China, Italy and Iran (Anon 2020). By end of May, the number of COVID-19 cases in the country has increased to 7,417 cases with 115 deaths (Anon 2020). Thus, future research should consider examining attitude, knowledge and adoption of health practices among the internal campus community as the pandemic progresses or at the different phases of MCO. This could provide useful insight for the institutes of higher learning to understand to what extend knowledge, attitude, and adoption of health practices among students and staffs changed as the pandemic unfold. Such information would be useful prior to design an effective communication strategy or campaign on campus during a severe pandemic outbreak such as COVID-19.