ABSTRACT.
This study aimed to compare bachelor nursing students’ knowledge, attitudes, and practices (KAP) regarding tropical diseases. This cross-sectional study was conducted with 128 participants who were recruited using stratified random sampling and completed a sociodemographics questionnaire and KAP questionnaire concerning tropical diseases. Descriptive statistics were used to present the data, and inferential statistics, including one-way analysis of variance and Mann–Whitney U tests, were calculated to identify potential differences between variables. The study found nursing students who took the tropical nursing courses had better knowledge and attitudes regarding preventing tropical diseases than those who did not. Participants who took the tropical nursing courses had a significantly higher median knowledge score of 22 with an interquartile range (IQR) of 2 (P <0.001) and a median attitude score of 31 (IQR: 6, P = 0.02) compared with those who did not take it. However, there were no significant differences between the two groups in practice regarding tropical diseases (P = 0.20). In conclusion, students who take tropical nursing courses may improve their knowledge and attitudes toward tropical diseases, but the two groups in this study did not significantly differ in practice, possibly because of self-reported practices rather than direct observation. This study highlights the potential of accurate digital information to provide credible resources in enhancing nursing students’ KAP concerning tropical diseases.
INTRODUCTION
Tropical diseases are a significant global health problem, especially in developing or low- and middle-income countries.1,2 In these areas of the world, low health knowledge, poor sanitation and limited access to health services contribute significantly to the etiology and pathogenesis of these tropical diseases.3,4 It is estimated that as many as one-sixth of the world’s population is infected with one or more tropical diseases. Millions of people die annually due to tropical parasitic and infectious diseases.5–7 The most common tropical diseases include malaria, dengue fever, and measles, but many other neglected tropical diseases (NTDs) are currently on the rise, such as chikungunya, leishmaniasis, and scabies.8,9
In addition to severely affecting health, tropical diseases can also negatively affect the welfare of individuals, families, and countries.10 Tropical diseases cause social stigma and discrimination, which can result in disability, mental illness, malnutrition, and cognitive development disorders. Cumulatively, these diseases are ultimately considered a significant social burden and can dramatically harm the country’s economy.6,11–13 Nurses at the forefront of the health system are essential in the fight against these tropical diseases.14 Nurses play a central role not only as caregivers but also as health educators and motivators for patients, families, and communities.15 Accordingly, they are required to have adequate knowledge about diseases, recognize signs and symptoms of tropical diseases, and be able to provide appropriate care.14,16,17
Efforts to prevent and control tropical diseases must also be balanced with increased knowledge, attitudes, and practices (KAP) that can be started from the educational period by including them in the education curriculum.2,18 Nursing students who will later become nurses must thoroughly understand tropical diseases, their signs and symptoms, and their prevention and control.19 Having sufficient knowledge about the various tropical diseases and NTDs can foster student confidence and their ability to provide quality patient care.20 Also, increased knowledge about the wide range of tropical and infectious diseases can develop positive attitudes toward good and effective prevention and management practices.21
Several recent studies were conducted to assess students’ KAP toward tropical diseases. The review study conducted by Yusuf et al. in 2021 regarding students’ KAP regarding tuberculosis in Indonesia stated that eight of the 12 reviewed studies reported a poor level of knowledge, in two of six studies, students had negative attitudes, and one study reported students’ poor practices concerning tuberculosis.22 Another study conducted in 2011 by Van Damme-Ostapowicz et al. on nursing students at the Medical University in Białystok, Poland, determined the knowledge possessed by nursing student participants regarding tropical infectious diseases needed to be improved, and most participants (90%) had never been involved in educating patients about tropical diseases. However, the study’s results also revealed that 64% of participants believed in the importance of educating nurses about tropical diseases for sharing accurate health and hygiene knowledge with patients.23 Meanwhile, a 2014 study by Jain et al. in a tertiary care hospital in India found that 57.2% of nursing students knew about the symptoms, management, and transmission of dengue fever, and 68.7% of the participants had good attitudes toward its treatment. However, the practice aspect was still poor.24
Nursing students play a crucial role in disease prevention and control, so it is essential for them to understand the pathogenesis of infectious and tropical diseases. This study compared KAP related to tropical diseases among nursing students at the Bachelor Nursing Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia. The results of this study can help evaluate KAP and education programs related to tropical diseases and provide recommendations for improved efforts to provide quality care.
MATERIALS AND METHODS
Study design and settings.
This comparative cross-sectional study was conducted from November to December 2022 in the nursing study program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
Sample and participants.
Respondents were nursing students in a bachelor of nursing study program. The tropical nursing course was first offered as an elective course to students in 2021 and has since been taken by four groups of students through 2022. The course covers a total of 68 hours of study per semester (3 credits). The material is delivered through lectures, tutorial discussions, and evidence-based seminars. Individual and group assignments include raising awareness of tropical diseases in the form of promotional media and visits to the Yogyakarta World Mosquito Program. We also use a learning management system. Each cohort of students receives equal exposure to the course material, enabling accurate data collection from across cohorts to obtain a more comprehensive picture of their KAP concerning tropical infectious diseases. The inclusion criteria in this study were enrolled students in the classes of 2018 to 2021 who either took or did not take tropical nursing courses and who expressed a willingness to participate in the study. Nursing students who were unable to provide informed consent or had incomplete responses in the questionnaires were excluded.
The sample size was calculated using Slovin’s formula: n = N/(1 + N(e2)), with a margin of error (e) =10% for each group. According to the calculations, 60 samples were obtained from a total of 136 students who took the tropical nursing courses. Meanwhile, 72 samples were obtained from 249 students who did not take tropical nursing courses. Thus, the total number of eligible samples was 132 students, but four samples from students who took the tropical nursing courses were unwilling to participate, resulting in 128 respondents divided between the two groups (Figure 1). The sampling technique utilized was stratified random sampling, in which the students were classified by academic year within each group (Table 1).
Figure 1.
CONSORT flow diagram of the cross-sectional study.
Table 1.
Number of samples
| Academic Year | No. of Students Who Took Tropical Nursing Course | Sample (willing to participate) | No. of Students Who Did Not Take Tropical Nursing Course | Sample (willing to participate) |
|---|---|---|---|---|
| 2021 (Second) | 52 | 22 | 55 | 16 |
| 2020 (Third) | 30 | 13 | 66 | 18 |
| 2019 (Fourth) | 31 | 11 | 62 | 20 |
| 2018 (Fifth) | 23 | 10 | 66 | 18 |
| Total | 136 | 56 | 249 | 72 |
Data collection.
The authors distributed broadcast messages via the WhatsApp application to each year’s batch of nursing students through the class leader. Respondents who were willing to fill out the questionnaire were given a Google link containing an informed consent form, general study information, instructions on how to complete the forms, and the contact person for the authors.
Instruments.
In this study, two questionnaires were used to collect participant data. The first demographic questionnaire gathered information about the respondents’ age, gender, academic year, participation in tropical nursing courses, and grade point average (GPA). The second questionnaire was a KAP questionnaire that used a 4-point Likert scale and included 22 items on measured knowledge (six items), attitudes (six items), and practices of tropical diseases (10 items). The researchers developed the KAP questionnaire following WHO guidelines to translate, validate, and test the reliability of the questionnaires based on previous studies related to tropical diseases among nursing students. For this study, it was translated into Indonesian (Bahasa).19,25–27 The questionnaire’s construct validity and internal consistency were assessed using Pearson product–moment and Cronbach’s alpha coefficient, respectively. A pilot test was conducted with 30 nursing students from the class of 2022, and the Cronbach’s alpha result was 0.868. The item validity test showed that r count >r table 0.349 with a significance of 5%.
Ethical considerations.
This study received ethical approval from the Medical and Health Research Ethics Committee of the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia (ref. no: KE/1222/09/2022).
Data analysis.
The Kolmogorov–Smirnov normality test was performed on the KAP scores. Demographic variables used frequency and percentage. The KAP scores were compared between groups using independent one-way analysis of variance tests based on demographic comparisons, but we omitted gender because the sample contained too few men for accurate analysis. In addition, Mann–Whitney tests were conducted if the data were not normally distributed. The analysis was performed at a significant level of P <0.05 with 95% CI. In addition, the researchers used the descriptive study to identify the results of open-ended and multiple-choice questions.
RESULTS
Demographics.
Table 2 presents the distribution of demographic variables among students who took the tropical nursing course (n = 56) compared with those who did not (n = 72). Female students constituted the majority in both groups, with 91% who took the course and 96% who did not take it. Most students were aged 18 to 21 (77% versus 66.07%). Meanwhile, the GPA variable’s majority was 3.51 to 4.00 (87% versus 82%). Furthermore, Table 2 compares the scores associated with KAP between the two sets of participants. The results of the analysis show that most P-values were >0.05, indicating that many of the observed differences did not have statistical significance when grouped by gender, age range, academic level and cumulative achievement index (GPA).
Table 2.
Comparison of knowledge, attitudes, and practices scores according to different variables
| Variables | Students Who Took Tropical Nursing Course (n = 56) | Students Who DIid Not Take Tropical Nursing Course (n = 72) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n (%) | Knowledge | Attitudes | Practices | n (%) | Knowledge | Attitudes | Practices | ||||||||
| M (SD) | 95% CI for Mean | M (SD) | 95% CI for Mean | M (SD) | 95% CI for Mean | M (SD) | 95% CI for Mean | M (SD) | 95% CI for Mean | M (SD) | 95% CI for Mean | ||||
| Sex | M | 5 (9%) | 3 (4%) | ||||||||||||
| F | 51 (91%) | 69 (96%) | |||||||||||||
| Age | 18–21 | 43 (77%) | 13.46 (1.29) | 13.06–13.86 | 18.95 (1.74) | 18.41–19.49 | 30.46 (3.40) | 29.41–31.51 | 48 (66,07%) | 20.50 (2.00) | 19.91–21.09 | 18.16 (1.66) | 17.68–18.65 | 29.06 (2.86) | 28.23–29.89 |
| 22–25 | 13 (23%) | 13.38 (1.44) | 12.51–14.25 | 19.07 (2.36) | 17.64–20.50 | 31.00 (3.55) | 28.84–33.15 | 24 (33%) | 21.00 (1.91) | 20.19–21.80 | 18.87 (1.56) | 18.21–19.53 | 29.70 (3.23) | 28.34–31.07 | |
| P-value* | 0.84 | 0.83 | 0.62 | 0.31 | 0.08 | 0.39 | |||||||||
| Academic level (year) | 2nd | 22 (39%) | 13.40 (1.25) | 12.85–13.96 | 19.09 (1.71) | 18.33–19.85 | 30.77 (3.23) | 29.33–32.20 | 16 (22,02%) | 19.87 (1.78) | 18.92–20.82 | 17.87 (2.02) | 16.79–18.95 | 29.00 (3.18) | 27.30–30.69 |
| 3rd | 13 (23%) | 13.23 (1.30) | 12.44–14.01 | 18.61 (1.93) | 17.44–19.78 | 30.00 (3.74) | 27.73–32.26 | 18 (25%) | 20.66 (2.30) | 19.52–21.81 | 18.22 (1.76) | 17.34–19.10 | 29.38 (2.87) | 27.96–30.81 | |
| 4th | 10 (18%) | 14.10 (1.44) | 13.06–15.13 | 19.50 (2.17) | 17.94–21.05 | 30.70 (3.43) | 28.24–33.15 | 20 (27%) | 20.80 (1.67) | 20.01–21.58 | 18.55 (1.46) | 17.86–19.23 | 28.70 (2.92) | 27.33–30.06 | |
| 5th | 11 (10%) | 13.18 (1.32) | 12.28–14.07 | 18.72 (2.00) | 17.38–20.07 | 30.81 (3.76) | 28.28–33.34 | 18 (25%) | 21.22 (2.01) | 20.21–22.22 | 18.40 (1.65) | 18.01–18.79 | 30.05 (3.05) | 28.53–31.57 | |
| P-value* | 0.36 | 0.68 | 0.92 | 0.25 | 0.32 | 0.55 | |||||||||
| GPA | 2.75–3.50 | 7 (12.05%) | 13.28 (1.38) | 12.00–14.56 | 19.71 (2.36) | 17.53–21.89 | 30.71 (2.28) | 28.59–32.83 | 13 (18%) | 20.00 (1.89) | 18.72–21.27 | 18.27 (1.79) | 17.06–19.47 | 29.45 (3.35) | 27.19–31.71 |
| 3.51–4.00 | 49 (87.05%) | 13.46 (1.32) | 13.08–13.84 | 18.87 (1.81) | 18.35–19.39 | 30.57 (3.56) | 29.54–31.59 | 59 (82%) | 20.78 (1.97) | 20.28–21.29 | 18.42 (1.64) | 18.00–18.84 | 29.24 (2.94) | 28.49–29.99 | |
| P-value* | 0.73 | 0.27 | 0.91 | 0.22 | 0.78 | 0.83 | |||||||||
F = female; GPA = grade point average; M = male.
One-way analysis of variance test performed.
Respondents’ KAP of respondents about tropical diseases and NTDs.
Students who took the tropical nursing course reported slightly higher confidence in their knowledge regarding tropical diseases, with a percentage of agreement (>75%) (Table 3). There was an advantage, especially in understanding NTDs, with higher percentage of agree (82.1%) and strongly agree (12.5%) compared with those who did not take the course, with agree (61.1%) and strongly agree (4.2%).
Table 3.
Knowledge, attitude, and practice of respondents concerning tropical diseases and neglected tropical diseases
| Item | Questions | Students Who Took Tropical Nursing Course (n = 56) | Students Who Did Not Take Tropical Nursing Course (n = 56) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| f (%) | (M ± SD) | f (%) | (M ± SD) | ||||||||
| Strongly Disagree | Disagree | Agree | Strongly Agree | Strongly Disagree | Disagree | Agree | Strongly Agree | ||||
| K1 | 1. I know the meaning of tropical disease. | 0 | 0 | 42 (75.0) | 14 (25.0) | 3.25 ± 0.437 | 0 | 4 (5.60) | 63 (87.5) | 5 (6.90) | 3.01 ± 0.356 |
| K2 | 2. I have heard about tropical diseases in Indonesia. | 0 | 0 | 31 (55.4) | 25 (44.6) | 3.45 ± 0.502 | 0 | 1 (1.40) | 56 (77.8) | 15 (20.8) | 3.19 ± 0.432 |
| K3 | 3. I believe tropical diseases are an important public health problem in Indonesia. | 0 | 0 | 21 (37.5) | 35 (62.5) | 3.63 ± 0.489 | 0 | 1 (1.40) | 39 (54.2) | 32 (44.4) | 3.43 ± 0.529 |
| K4 | 4. I have seen someone with a tropical disease. | 0 | 6 (10.7) | 37 (66.1) | 13 (23.2) | 3.13 ± 0.574 | 0 | 16 (22.2) | 45 (62.5) | 11 (15.3) | 2.93 ± 0.613 |
| K5 | 5. I know the meaning of neglected tropical disease. | 1 (1.80) | 2 (3.60) | 46 (82.1) | 7 (12.5) | 3.05 ± 0.483 | 3 (4.20) | 22 (30.6) | 44 (61.1) | 3 (4.20) | 2.65 ± 0.632 |
| K6 | 6. I believe neglected tropical diseases are an important public health problem in Indonesia. | 0 | 0 | 42 (75.0) | 14 (25.0) | 3.25 ± 0.437 | 0 | 2 (2.80) | 54 (75.0) | 16 (22.2) | 3.19 ± 0.464 |
| K7 | 7. I have seen someone with a neglected tropical disease. | 1 (1.80) | 33 (58.9) | 20 (35.7) | 2 (3.60) | 2.41 ± 0.569 | 4 (5.60) | 47 (65.3) | 20 (27.8) | 1 (1.40) | 2.25 ± 0.575 |
| A1 | 1. I am aware of the control methods for certain tropical diseases. | 0 | 0 | 50 (89.3) | 6 (10.7) | 3.11 ± 0.312 | 0 | 15 (20.8) | 55 (76.4) | 2 (2.80) | 2.82 ± 0.454 |
| A2 | 2. I will participate in tropical disease prevention/control activities. | 0 | 0 | 40 (71.4) | 16 (28.6) | 3.29 ± 0.456 | 0 | 0 | 50 (69.4) | 22 (30.6) | 3.31 ± 0.464 |
| A3 | 3. I think awareness of tropical diseases is still poor in Indonesia. | 0 | 3 (5.40) | 44 (78.6) | 9 (16.1) | 3.11 ± 0.454 | 0 | 4 (5.60) | 59 (81.9) | 9 (12.5) | 3.07 ± 0.422 |
| A4 | 4. I am aware of the control methods for certain neglected tropical diseases. | 0 | 3 (5.40) | 48 (85.7) | 5 (8.90) | 3.04 ± 0.380 | 0 | 27 (37.5) | 45 (62.5) | 0 | 2.63 ± 0.488 |
| A5 | 5. I am willing to participate in the prevention/control activities of neglected tropical diseases. | 0 | 0 | 39 (69.6) | 17 (30.4) | 3.30 ± 0.464 | 0 | 1 (1.40) | 54 (75.0) | 17 (23.6) | 3.22 ± 0.451 |
| A6 | 6. I think awareness of neglected tropical diseases is still poor in Indonesia. | 0 | 2 (3.60) | 44 (78.6) | 10 (17.9) | 3.14 ± 0.444 | 0 | 2 (2.80) | 60 (83.3) | 10 (13.9) | 3.11 ± 0.396 |
| P1 | 1. I would remove stagnant water around the house to prevent mosquitoes from breeding. | 0 | 2 (3.60) | 27 (48.2) | 27 (48.2) | 3.45 ± 0.570 | 2 (2.80) | 4 (5.60) | 45 (62.5) | 21 (29.2) | 3.18 ± 0.657 |
| P2 | 2. I would use insecticides to combat mosquitoes. | 1 (1.80) | 15 (26.8) | 33 (58.9) | 7 (12.5) | 2.82 ± 0.664 | 1 (1.40) | 27 (37.5) | 36 (50.0) | 8 (11.1) | 2.71 ± 0.680 |
| P3 | 3. I would clean up trash around the house. | 0 | 0 | 27 (48.2) | 29 (51.8) | 3.52 ± 0.504 | 0 | 0 | 46 (63.9) | 26 (36.1) | 3.36 ± 0.484 |
| P4 | 4. I would ensure the use of clean water for each activity. | 0 | 0 | 23 (41.1) | 33 (58.9) | 3.59 ± 0.496 | 0 | 0 | 33 (45.8) | 39 (54.2) | 3.54 ± 0.502 |
| P5 | 5. I would wash my hands or clean them with hand sanitizer. | 0 | 0 | 25 (44.6) | 31 (55.4) | 3.55 ± 0.502 | 0 | 4 (5.60) | 37 (51.4) | 31 (43.1) | 3.38 ± 0.592 |
| P6 | 6. I would conduct health education, including health promotion and prevention of tropical diseases. | 0 | 8 (14.3) | 42 (75.0) | 6 (10.7) | 2.96 ± 0.503 | 0 | 27 (37.5) | 38 (52.8) | 7 (9.70) | 2.72 ± 0.633 |
| P7 | 7. I would wear footwear like sandals or shoes. | 0 | 0 | 21 (37.5) | 35 (62.5) | 3.63 ± 0.489 | 0 | 0 | 29 (40.3) | 43 (59.7) | 3.60 ± 0.494 |
| P8 | 8. I would cook meat thoroughly. | 0 | 0 | 30 (35.7) | 36 (64.3) | 3.64 ± 0.483 | 0 | 0 | 31 (43.1) | 41 (56.9) | 3.57 ± 0.499 |
| P9 | 9. I would follow travel guides when traveling to tropical and subtropical regions. | s0 | 2 (3.60) | 28 (50.0) | 26 (46.4) | 3.43 ± 0.568 | 0 | 6 (8.30) | 44 (61.1) | 22 (30.6) | 3.22 ± 0.587 |
A = attitudes; K = knowledge; P = practices.
Most students from both groups reported positive attitudes regarding tropical disease control methods. However, those who took the course showed slightly more awareness, with agree (89.3%) and strongly agree (10.7%) versus agree (76.4%) and strongly agree (2.8%). However, all students (100%) from both groups were committed to participating in disease prevention efforts. Regarding practical steps, most survey participants indicated their intention to participate in activities such as tidying up the area of their residences (48.2%) and avoiding accumulation of still (stagnant) water, which can become a mosquito breeding site, with agree (48.2%). Nevertheless, tropical nursing students reported being more proactive in health promotion efforts. They reported their intent to use insecticides for mosquito control, with agree (58.9%) and strongly agree (12.5%). They stated they would undertake health education efforts focused on advocating for control and prevention measures against tropical diseases, with 42 responding agree (75%) and six strongly agree (10.7%).
Table 4 presents the outcomes of responses in open-ended questions concerning knowledge, attitudes, and intention to practices related to tropical diseases and NTDs. Students who took the tropical nursing course indicated a higher tendency to acquire information from the courses themselves (38.2%) and research articles (23.6%), whereas students who did not take it tended to learn more by obtaining information from social media (30%), and research articles (19.4%). As many as 66% of students who took the tropical nursing course gave the correct answer regarding identifying a minimum of three tropical diseases prevalent in Indonesia, whereas only 54.2% could among the group who did not take the course.
Table 4.
Open-ended questions and answer choices for knowledge, attitudes, and practices of tropical diseases and neglected tropical diseases
| Response Choice | Students Who Took Tropical Nursing Course (n = 56) | Students Who Did Not Take Tropical Nursing Course (n = 72) | Students Who Took Tropical Nursing Course (n = 56) | Students Who Did Not Take Tropical Nursing Course (n = 72) | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Where did you hear about tropical diseases?* | Where did you hear about neglected tropical diseases?* | |||||||
| Research articles | 34 | 23.61 | 31 | 19.38 | 23 | 22.12 | 17 | 19.10 |
| Social media | 30 | 20.83 | 48 | 30.00 | 22 | 21.15 | 46 | 51.69 |
| Courses/blocks | 55 | 38.19 | 43 | 26.88 | 49 | 47.12 | 16 | 17.98 |
| Conference/seminar | 9 | 6.25 | 13 | 8.13 | 5 | 4.81 | 4 | 4.49 |
| TV/radio | 7 | 4.86 | 12 | 7.50 | 1 | 0.96 | 4 | 4.49 |
| Pamphlets/banners | 9 | 6.25 | 13 | 8.13 | 4 | 3.846 | 2 | 2.25 |
| I believe the following are tropical diseases in Indonesia (at least three types of conditions can be mentioned). | I believe the following are neglected tropical diseases in Indonesia (at least three types of conditions can be mentioned). | |||||||
| Correct | 37 | 66.07 | 39 | 54.17 | 20 | 35.71 | 10 | 13.89 |
| Incorrect | 19 | 33.93 | 33 | 45.83 | 36 | 64.29 | 62 | 86.11 |
| In my opinion, the following is the prevention of tropical diseases* | In my opinion, the following is the prevention of neglected tropical diseases* | |||||||
| Correct | 42 | 75 | 51 | 70.83 | 46 | 82.14 | 50 | 69.44 |
| Incorrect | 14 | 25 | 21 | 29.17 | 10 | 17.86 | 22 | 30.56 |
| In my opinion, the following is the role that I will play in the prevention/control of tropical infectious diseases | In my opinion, the following is the role that I will play in the prevention/control of neglected tropical diseases | |||||||
| Correct | 41 | 73.21 | 52 | 72.22 | 46 | 82.14 | 48 | 66.67 |
| Incorrect | 15 | 26.79 | 20 | 27.78 | 10 | 17.86 | 24 | 33.33 |
| In my opinion, the following showed that awareness of tropical infectious diseases is still poor in Indonesia | In my opinion, the following showed that awareness of neglected tropical infectious diseases is still poor in Indonesia | |||||||
| Correct | 45 | 80.36 | 33 | 45.83 | 40 | 71.43 | 34 | 47.22 |
| Incorrect | 11 | 19.64 | 39 | 54.17 | 16 | 28.57 | 38 | 52.78 |
Regarding tropical disease prevention, 75% of students who took the course identified the correct preventive measures, compared with 70.8% could from those who did not take the course. Both groups expressed a desire to be involved in preventing and managing tropical diseases. In comparison, slightly more students who took the tropical nursing course (73.2%) answered correctly than those who did not take the course (72.2%).
The most striking difference between the two groups was evident in their perception of awareness levels in Indonesia. A significant percentage (80.4%) of the students who took the course believed that the awareness of tropical infectious diseases was poor in Indonesia. In contrast, only 45.8% of those who did not take the course shared this sentiment. Although both groups demonstrated an understanding of tropical diseases and their prevention, students taking tropical nursing courses demonstrated a better awareness of Indonesia’s current conditions.
Comparison of students who took tropical nursing courses with those who did not on KAP variables related to tropical diseases.
Table 5 displays the outcomes of a median comparison analysis between students who took the tropical nursing course and those who did not, focusing on KAP related to tropical diseases. The Mann–Whitney U test was applied to accommodate the nonnormal data distribution because the Kolmogorov–Smirnov test revealed a P-value of 0.02 (P <0.05). The findings indicated that students who took the tropical nursing course showcased improved knowledge, with a median of 22 and interquartile range (IQR) of 2 and P <0.001, as well as improved attitudes, with a median of 31.00 (IQR: 6.00) and P = 0.02, compared with students who did not take the course. However, no significant discrepancy was observed between the two groups concerning their intention to engage in practices relevant to tropical diseases, as indicated by P = 0.20.
Table 5.
Differences in knowledge, attitudes, and practices between students who took the tropical nursing course and those who did not
| Variable | Who Took Tropical Nursing Course (n = 56) | Students Who Did Not Take Tropical Nursing Course (n = 72) | Z Statistic | P-Value* |
|---|---|---|---|---|
| Median (interquartile range) | ||||
| Knowledge | 22.00 (2.00) | 21.00 (3.00) | 1,210.50 | <0.001* |
| Attitudes | 31.00 (6.00) | 29.00 (4.75) | 1,540.50 | 0.02* |
| Practices | 18.00 (2.00) | 18.00 (2.00) | 1,765.50 | 0.20 |
Mann-Whitney U test was performed.
Significant at P <0.05.
DISCUSSION
We present the findings concerning the KAP of students who took a tropical disease nursing course and those who did not. The comparative results related to the demographics of KAP regarding tropical diseases in each group and the sources of information were obtained from questionnaires completed by the participating students.
Students’ knowledge, attitudes, and behaviors concerning tropical diseases are essential determinants of their willingness to determine the quality of care related to the prevention and control of these diseases.20 From the data presented in Table 2, the analysis of KAP demographics related to tropical diseases and NTDs showed that there were no significant differences in KAP scores between the two groups based on gender, age group, academic level, or GPA. This study’s results align with several studies conducted in different regions.28,29 However, other studies in Bangladesh and Ghana30,31 have reported a significant relationship between demographic characteristics such as gender, academic level, and academic achievement with students’ knowledge, attitudes, and behaviors toward tropical infectious diseases.
This study revealed that students who participated in a tropical nursing course reported a slight improvement in knowledge and a more positive attitude toward treating tropical diseases compared with those who did not take the course. However, there was no difference in their intentions to practice. These findings represent self-reported knowledge, attitudes, and intentions and might not necessarily mirror actual practices. Accordingly, it is essential to recognize the disparity between KAP outcomes and real-world actions. In the broader context of KAP concerning tropical diseases, our findings can be compared with other research. For instance, a 2022 study by Riccò concerning KAP related to NTDs, specifically monkeypox, underscored unsatisfactory knowledge and inconsistent risk perceptions among Italian doctors. However, there was a significant awareness in their attitudes. Similarly, research by Aggarwal et al. in 2012, which focused on dental and nursing students in India,20 discovered that most participants had a sound understanding of HIV/AIDS. Their attitudes toward patients with HIV/AIDS were predominantly positive, with ∼95% indicating their attitudes would remain unchanged after learning a friend was diagnosed with HIV/AIDS.
The study results support the premise that the better the respondents’ knowledge, the better will be their attitudes. In a 2021 study by Yusuf et al. on students’ KAP toward tuberculosis, eight of 12 reviewed studies reported poor knowledge among respondents, two of six studies found participants had negative attitudes, and one study reported poor practices toward tuberculosis.22 These findings further emphasize the importance of good knowledge compared with poor knowledge because usually, better knowledge will be followed by the person’s improved attitudes.
Entwistle and Peterson32 revealed that a robust learning environment, often provided by formal education, significantly influences student engagement and learning behaviors, which are molded by various methods, settings, and strategies. Education serves as a tool for enhancing knowledge, skills, and cross-contextual reasoning.33 However, the pursuit of knowledge is not confined to formal educational systems. Nonformal education is praised for its effective development of critical and innovative pedagogical approaches, prioritizing “learning to know,” whereas formal education typically emphasizes “learning to become.”34
This study findings indicate a positive effect on students’ knowledge and attitudes but no significant difference in their practices regarding tropical infectious diseases among students. This could be because practice in this context is merely an intention to act, self-reported, and not corroborated by observational documentation. In a related study conducted in Pakistan, the average scores for good, medium, and poor knowledge were 50.2%, 42.8%, and 7.0%, respectively. Meanwhile, for attitudes, 65.4% of individuals had a positive attitude; for practice, only 36.5% of participants had good prevention practices.35 In this study, despite the overall good knowledge and attitudes, it was worrisome that preventive practices related to COVID-19 were far from satisfactory. This finding could be attributed to limited access to online health information sources. Vulnerable community groups, such as those with illiteracy or low literacy; the elderly; and rural, marginalized populations, tend to have inadequate knowledge, attitudes, and preventive practices.
In our study results, only a few students reported that they would consider using insecticides to combat mosquitoes. In a separate study from New Orleans, LA, more than 42% of survey participants indicated that they believed spraying chemicals is not the most effective method to eliminate mosquitoes.36 More than one-third (35%) of the respondents reported that they would empty potentially stagnant water containers to reduce the possible presence of adult mosquitoes on their property. Meanwhile, 20% reported that they would apply pesticides to combat mosquitoes on their premises. The most common preventive measure against mosquito bites chosen by participants was the use of repellents (16.7%). The second most common was removing or emptying containers filled with water (15.3%). Only a minimal number of participants (3.5%) reported that they would use pesticides as a preventive measure against mosquito bites. In a 2023 study conducted by Rahman et al., a significant majority of students (76.4%) reported participating in NTDs control activities in Bangladesh, such as efforts to raise public health and hygiene awareness through seminars or school campaigns.29
Our study findings from the open-ended questions revealed that participants who took a tropical nursing course had better awareness of best practices toward infectious diseases. They argued that awareness of tropical disease prevention practices is still low in Indonesia. A similar study conducted by Elfar et al. in 2020 also showed that almost half of the study participants agreed that awareness of tropical diseases, especially NTDs, is still low in Egypt.19 Accordingly, planning strategies are needed to overcome this low awareness through teaching and training as well as the involvement of key stakeholders, namely the government.
In our study, respondents’ results from Table 4 indicate they seek information from a variety of sources concerning tropical infectious diseases. Participants from the tropical disease nursing course more frequently obtained information from the course/module, whereas noncourse participants primarily sourced their information from social media. Moreover, both groups could essentially identify the correct ways to prevent tropical diseases, even though they accessed different information sources. Elfar et al.’s research in 2020 also showed similar results indicating most student participants used social media as the main source of information about tropical diseases.19
In today’s digital era, knowledge is increasingly accessible. Both students who take courses regarding tropical diseases and those who do not can still seek knowledge obtained from the Internet, social media, and online newspapers that can be accessed through computers or smartphones. In Indonesia, where Internet saturation is high, almost everyone, especially students, has a smartphone and can access various sources of information anytime and anywhere.37 It becomes a challenge in this digital era if we do not leverage advancements in technology. This potential deficit in accurate information sharing can hinder our level of knowledge about the information available to us. However, another challenge to address is the availability of credible and evidence-based information. This is supported by the WHO, which advocates for digital health literacy by integrating the “digital” element that ensures broader access while emphasizing trustworthy and high-quality health data.38
Limitations.
This KAP study has some methodological limitations. Although the questionnaires used to measure KAP have been properly developed and appropriately validated, they may not fully capture the complexity of nursing students’ behavior and attitudes. For example, this study does not include direct observations of student behavior. However, this study offers some initial insights into the comparison of students’ KAP who took the tropical nursing courses with those who did not.
CONCLUSION
The findings indicated that students who took the tropical nursing course reported better knowledge and attitudes compared with those who did not. Although there was no significant difference in the intention to practice between the two groups, the group that took the tropical nursing course seemed more proactive in their health promotion efforts. This study also highlights that information can be obtained from nonformal sources such as social media. These findings emphasize the importance of educational institutions to provide education concerning how to obtain credible sources of information. Apart from that, formal education remains important in increasing student’s understanding of tropical diseases. Further studies can be conducted by directly observing student behavior regarding how their knowledge and attitudes were applied in infectious disease control and prevention. Future studies can aim to assess the students’ knowledge in relation to the credibility and effectiveness of various sources of health-related information.
Supplemental Materials
ACKNOWLEDGMENTS
We thank everyone involved with this study, both the educational institution of the Bachelor of Nursing Study Program and the nursing students at Universitas Gadjah Mada as participants, who are not individually identified but who have contributed to this study. The American Society of Tropical Medicine and Hygiene (ASTMH) assisted with publication expenses.
Note: Supplemental materials appear at www.ajtmh.org.
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