Understanding of adolescents’ knowledge, attitudes, and prevention practices toward COVID-19 using a web-based cross-sectional study

Abstract

In Pakistan effective border control measures and school closures were implemented after declaration of COVID-19 pandemic. Public awareness campaigns were started to educate public including adolescents. This study aims to assess adolescent’s knowledge, attitudes and preventive practices during pandemic in Pakistan. A cross-sectional study was conducted among 328 individuals from October 2021 to February 2022 among school going adolescents aged 10–19 years in Pakistan. An online questionnaire was administered using online platforms. The questionnaire included sections on socio-demographic information, knowledge, attitudes, preventive practices, vaccine practice and information on new COVID-19 variants. Data was analyzed using multiple linear regression method. Among these individuals, mean knowledge scores were 9.64 (3.53), mean attitude score were 4.12 (1.77) and mean preventive practice score were 17 (6.83). Older adolescents exhibited better adherence to preventive measures and support to travel bans and adherence to SOPs during lock down. Multiple linear regression revealed that higher knowledge (β = 0.22, p = 0.03) and positive attitudes (β = 0.92, p < 0.001) were significantly associated with better preventive practices. This indicated that adolescents living in Pakistan have moderate knowledge about COVID-19 pandemic, with positive attitudes towards preventive measures taken by the government. However, there is a need for targeted educational interventions to enhance understanding and adherence to preventive measures among adolescents to better manage the pandemic in near future.

Introduction

In late 2019, speculations emerged of mysterious respiratory illness in Wuhan, China¹. As the number of cases rapidly increased, the alarming situation soon gathered international attention¹. The virus was identified as a novel coronavirus, subsequently named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)¹. The most important step taken was to understand and identify its modes of transmission. The primary modes of transmission for SARS-CoV-2 were through respiratory droplets formed when an infected individual coughs, sneezes, or talks². These droplets can be inhaled by nearby individuals, leading to infection. This virus can also spread by fomites and then touching particularly mouth nose and eyes². The appearance of the coronavirus disease (COVID-19) has undeniably transformed the global landscape, impacting societies, economies, and public health systems globally³. The World Health organization (WHO) declared COVID-19 declared in 2020, after that COVID-19 has captured the attention of individuals, governments, and medical communities across the globe³. During the surge of corona virus there was absence of availability of vaccine or any other therapy regimen to cope with the pandemic. The WHO stressed on the importance of being knowledgeable about COVID- 19, they recommended to be well aware about the disease including its symptoms modes and preventive measures such as practicing hand hygiene, maintaining social distance, following respiratory manners and wearing mask⁴.

The coronavirus was confirmed to have reached Pakistan on 26 February 2020⁵. Pakistan’s response to COVID was both fast and effective, and praised openly by the WHO⁶. In March 2020 the first set of responses by the government included border control, followed by restriction on international flights, closure of markets, businesses, educational institutions, and bans on large gatherings⁷. The government of Pakistan and digital media conducted advertising campaigns to educate the public about COVID-19. The goal of these efforts was to circulate information, raise awareness, and promote essential practices to prevent the spread of the virus among all age groups⁷.

Around 16% of world population consist of adolescents aged 10 to 19 years⁸. In Pakistan according to population statistics by UNICEF around 22.7% of total population consist of adolescents aged 10 to 19 years⁹. To assess the knowledge, attitude and preventive practices regarding COVID-19 among adolescents multiple studies have been conducted around the globe. A study in Jordanian adolescents exhibited notable health protective behaviors showing an increase level of knowledge and attitude in response to the pandemic. However, a significant minority shows poor knowledge, negative attitudes, and risky practices towards the pandemic³. Another study in rural Bangladesh exposed a concerning lack of COVID-19 knowledge and unsatisfactory preventive behaviors among adolescents, emphasizing the urgent need for tailored health education programs in such settings¹⁰. Similarly, parallel findings in India reveal approximately 25% of students in higher education institutions exhibiting limited knowledge, negative attitudes, and inadequate COVID-19 prevention practices, indicating the necessity for diverse strategies to improve KAP and curb the virus’s spread among this demographic¹¹.

The varying behaviors exhibited by adolescents in these different regional and global contexts highlighted the importance of a detailed study in Pakistan. Despite the reopening of many other sectors, educational institutes after pandemic, the management of schools have struggled to resume in person classes. Another reason is the huge number of students that use public transport or school vans for conveyance to and from schools which is a risk factor for exposure and spread⁶. Also, lack of compliance from children and adolescents to wear masks properly covering their nose, regular hand washing and maintaining a distance can result in spread of the virus¹². No such study is previously performed in Pakistan to measure this aspect. Very limited information is available on this topic in Pakistan. This approach enables a targeted and informed response to address adolescents’ knowledge, attitudes, and practices, a crucial consideration not only for COVID-19 but also for potential future pandemics.

The objectives of the study is to estimate the mean knowledge, attitude and preventive practice scores of adolescents regarding COVID-19. Moreover, we aim to explore the impact of the pandemic on adolescents’ mental health, social networks, and access to healthcare services. It is challenging to achieve compliance from school going adolescents to take proper infection control measures and prevention from engaging in risky health practices. By examining these aspects, we aim to find potential gaps in understanding, mistaken belief, or barriers to implementing recommended preventive measures.

Methods

Study design and setting

A cross-sectional study was conducted between October 1st, 2021, and February 28th, 2022, targeting adolescents attending public and private schools across various cities in Pakistan. An online questionnaire was distributed amongst these individuals using email and popular social media platforms such as WhatsApp, Facebook, Instagram, and Twitter.

Study Population, Sampling Technique, and Sample Size:

The study included adolescents aged 10 to 19 years, enrolled in grades 6 to 10 at any public or private school in Pakistan, who had internet access, used email or social networking sites (including Facebook, WhatsApp, Instagram, and Twitter), and were proficient in either Urdu or English. Conversely, participants below 10 years of age or above 19 years, overseas Pakistanis, those unwilling to participate, or whose parents did not provide informed consent were excluded from the study. Participants who did not follow the age requirement were excluded through the conditional logic flows based on their response that directly excluded these participants.

Participants were recruited by purposive sampling technique. The sample size was determined using NCSS PASS software, considering a 5% level of significance. The largest sample was considered, using the mean and SD of 11 ± 2 as reported in³, precision of 0.23, a sample size of 293 participants was determined. After considering an attrition rate of 10%, the final sample size calculated was at least 328 participants.

Participants recruitment and data collection

Data collection was performed through a structured questionnaire designed for google survey tool that was only accessible to adolescents living in Pakistan. The questionnaire link for the google form along with the brief introduction of the study, parental consent form and assent were shared randomly to the participants through social media groups (i.e. Facebook, WhatsApp, twitter and LinkedIn). The study materials, including consent forms and the questionnaire, were available in both English and Urdu languages. In order to gain access to the structured questionnaire, participants were required to provide consent and assent by clicking on the appropriate link provided. Only those individuals who responded positively were able to proceed with the study questionnaire, which encompassed six sections:

Sociodemographic characteristics

Socio demographic data of the participants were collected through close ended questions involving their age, gender, grade level, parental education, housing, number of family members, place of residence, and division.

Knowledge, attitude and preventive practice to COVID-19

Participant’s knowledge, attitude and preventive practices about COVID-19 was measured using a questionnaire adapted from a study in Jordan³. This study questionnaire was adapted from a study performed in China and modified by the Jordanian investigators according to the WHO (2020b) and Jordanian Ministry of Health guidelines. The questionnaire was forward translated as well as back translated. The Cronbach’s alpha for knowledge, attitude and practices components of the tool were determined to be 0.61, 0.64 and 0.81, respectively. The tool was modified according to the Pakistani population. The expert panelists including epidemiologists, biostatisticians and clinicians then performed content validity.

The knowledge section comprised 23 items that gauged participants’ understanding of various aspects related to COVID-19, including its causes, treatment, vaccination, and preventive measures. The responses to these items were categorized as true, false, or do not know, with each correct response assigned 1 point and each incorrect or uncertain response assigned 0 points.

The questionnaire also included attitude section, consisting of 14 items that captured participants’ attitudes and general viewpoints regarding COVID-19 and its preventive practices. Responses to these items were categorized as agree, do not agree, or I do not know.

Similarly, preventive practices were assessed using 17 items with categorical responses (2 = always, 1 = sometimes, and 0 = never). Higher scores in the knowledge, attitude, and preventive practices sections indicated greater knowledge, positive attitudes, and a higher level of commitment to preventive practices related to COVID-19. Additionally, vaccination practices and information about new variants of COVID-19 were evaluated through 7 and 5 items, respectively, employing categorical response options.

Vaccine and Information regarding new variants of COVID-19

Some questions were developed regarding awareness of Vaccine and information related to new COVID-19 variants. Content validity of these questions was performed by experts team.

Ethical clearance

An Ethical review was sought from the IRB: Ethics and Review Committee of Aga Khan University, Karachi. The ethical review board of The Aga Khan University Hospital approved the study (dated 13^th December 2021 with reference number: 2021-6921-19,907). The google forms were then shared using social media platforms. Those who met the criteria of inclusion and gave their consent, then were able to fill the structured questionnaire.

Statistical analysis

The collected data from the Google Forms platform was extracted using MS Excel 2019 for data cleaning and coding purposes. The cleaned data was subsequently transferred to STATA version 15.0 software for statistical analysis. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were computed to summarize the data. Later multiple linear regression analysis was performed following stepwise multiple linear regression with knowledge scores, attitude scores and preventive practices scores keeping significance level set at 5%.

Results

A total of 328 adolescents aged 10 to 19 (42.68% females) completed the online survey, predominantly in English (98%). Most resided in Sindh (96.95%, n = 318), in urban areas (98.17%), with an average of 4 rooms and 6 family members. Majority were in tenth grade (31.71%) and attended private schools (60.67%). TV (35.37%) and social media (33.84%) were primary COVID-19 information sources. Compliance with COVID-19 SOPs varied, with 66.17% always wearing masks, 46.65% using sanitizers, 49.7% practicing social distancing, and 49.39% handwashing. 22.26% reported previous COVID-19 history, and 21.65% a positive familial history. Table 1 shows the sociodemographic characteristics of the participant. Table 2 shows the comparative sociodemographic characteristics of all adolescents based on their Knowledge, Attitude and preventive practices. Table 3 shows the overall mean and standard deviation knowledge, attitudes, and generally followed healthy practices regarding COVID-19.

Table 1.

Socio-demographic status of preparatory school students in Pakistan, 2021 (n = 328).

Variables	Number	Percentage
Age*	15.00 ± 11.00 years
Gender
Male	188	57.32
Female	140	42.68
Language
English	324	98.78
Urdu	4	1.22
Province
Sindh	318	96.95
Other provinces	10	3.04
Type of residence
Village	6	1.68
City	322	98.17
Number of people living in the house*	6.00 ± 18.00
Number of rooms in the house*	4.00 ± 4.00
Grade
Sixth	49	14.94
Seventh	67	20.43
Eighth	60	18.29
Ninth	48	14.63
Tenth	104	31.71
Type of school
Public	118	35.98
Private	200	60.98
Semiprivate	10	3.05
History of any health problem
No	297	90.55
Yes	31	9.45
Source of information about COVID-19
TV	111	33.84
Newspaper/radio	19	5.79
Pak COVID 19 website	23	7.01
Social media	116	35.37
Family	15	4.57
Friends	26	7.93
School	18	5.49
SOPs followed during COVID 19-Wearing mask
Never	21	6.40
Rarely	26	7.93
Sometimes	64	19.51
Always	217	66.16
SOPs followed during COVID 19- Using a sanitizer
Never	15	4.57
Rarely	33	10.06
Sometimes	127	38.72
Always	153	46.65
SOPs followed during COVID 19- Social distancing
Never	17	5.18
Rarely	34	10.37
Sometimes	114	34.76
Always	163	49.70
SOPs followed during COVID 19-Visiting family members in lockdown
Never	26	7.93
Rarely	70	21.34
Sometimes	163	49.70
Always	69	21.04
SOPs followed during COVID 19-Hand washing during lockdown
Never	18	5.49
Rarely	26	7.93
Sometimes	122	37.20
Always	162	49.39
Previous history of COVID 19
No	255	77.74
Yes	73	22.26
Family history of COVID 19
No	257	78.35
Yes	71	21.65

*Mean ± Standard Deviation (SD).

Table 2.

Comparison of knowledge, attitude and practice scores among different demographic groups.

Variables	Knowledge	Attitude	Practice
Gender
Male	9.15±3.79	4.01±1.83	16.82±7.45
Female	10.3±3.04	4.27±1.68	17.25±5.92
Language
English	9.65±3.53	4.13±1.76	16.9±6.8
Urdu	8.75±3.65	3.5±2.38	18.5±8.3
Province
Sindh	9.62±3.56	4.10±1.78	16.9±6.88
Other provinces	10.4±2.22	4.9±1.37	20.2±3.91
Type of residence
Village	10±2.44	4.83±1.60	16.8±6.73
City	9.63±3.55	4.11±1.77	17.0±6.84
Grade
Sixth	7.24 ± 4.11	3.20 ± 2.03	14.69 ± 8.14
Seventh	8.94 ± 3.10	3.79 ± 1.88	16.82 ± 7.03
Eighth	9.60 ± 3.10	4.53 ± 1.67	14.93 ± 5.99
Ninth	10.16 ± 2.18	4.10 ± 1.85	16.77 ± 7.04
Tenth	11.01 ± 2.90	4.56 ± 1.37	19.53 ± 5.59
Type of school
Public	8.53 ± 4.05	3.61 ± 1.75	17.67 ± 7.49
Private	11.00 ± 2.11	4.50 ± 1.51	18.30 ± 4.14
Semiprivate	10.24 ± 3.08	4.42 ± 1.73	16.56 ± 6.52
History of any health problem
No	9.47 ± 3.54	4.11 ± 1.79	16.86 ± 6.76
Yes	11.35 ± 2.95	4.29 ± 1.62	18.48 ± 7.50
Source of information about COVID-19
TV	8.73 ± 3.60	8.73 ± 3.60	8.73 ± 3.60
Newspaper/radio	9.00 ± 3.81	9.00 ± 3.81	9.00 ± 3.81
Pak COVID 19 website	10.43 ± 4.07	10.43 ± 4.07	10.43 ± 4.07
Social media	10.23 ± 3.23	10.23 ± 3.23	10.23 ± 3.23
Family	11.00 ± 2.59	11.00 ± 2.59	11.00 ± 2.59
Friends	9.04 ± 4.16	9.04 ± 4.16	9.04 ± 4.16
School	11.22 ± 2.18	11.22 ± 2.18	11.22 ± 2.18
SOPs followed during COVID 19-Wearing mask
Never	7.46 ± 3.55	7.46 ± 3.55	7.46 ± 3.55
Rarely	7.67 ± 4.75	7.67 ± 4.75	7.67 ± 4.75
Sometimes	8.56 ± 4.13	8.56 ± 4.13	8.56 ± 4.13
Always	10.42 ± 2.91	10.42 ± 2.91	10.42 ± 2.91
SOPs followed during COVID 19- Using a sanitizer
Never	5.60 ± 4.08	5.60 ± 4.08	5.60 ± 4.08
Rarely	8.97 ± 3.92	8.97 ± 3.92	8.97 ± 3.92
Sometimes	9.54 ± 3.61	9.54 ± 3.61	9.54 ± 3.61
Always	10.27 ± 3.03	10.27 ± 3.03	10.27 ± 3.03
SOPs followed during COVID 19- Social distancing
Never	5.41 ± 5.00	5.41 ± 5.00	5.41 ± 5.00
Rarely	8.65 ± 4.00	8.65 ± 4.00	8.65 ± 4.00
Sometimes	9.96 ± 3.62	9.96 ± 3.62	9.96 ± 3.62
Always	10.08 ± 2.83	10.08 ± 2.83	10.08 ± 2.83
SOPs followed during COVID 19-Visiting family members in lockdown
Never	8.31 ± 5.01	8.31 ± 5.01	8.31 ± 5.01
Rarely	10.50 ± 3.34	10.50 ± 3.34	10.50 ± 3.34
Sometimes	9.48 ± 3.35	9.48 ± 3.35	9.48 ± 3.35
Always	9.68 ± 3.34	9.68 ± 3.34	9.68 ± 3.34
SOPs followed during COVID 19-Hand washing during lockdown
Never	10.61 ± 2.95	10.61 ± 2.95	10.61 ± 2.95
Rarely	9.07 ± 3.40	9.07 ± 3.40	9.07 ± 3.40
Sometimes	9.07 ± 3.40	9.07 ± 3.40	9.07 ± 3.40
Always	10.61 ± 2.95	10.61 ± 2.95	10.61 ± 2.95
Previous history of COVID 19
No	9.64 ± 3.58	9.64 ± 3.58	9.64 ± 3.58
Yes	9.67 ± 3.37	9.67 ± 3.37	9.67 ± 3.37
Family history of COVID 19
No	9.63 ± 3.58	9.63 ± 3.58	9.63 ± 3.58
Yes	9.70 ± 3.39	9.70 ± 3.39	9.70 ± 3.39

*Mean ± Standard Deviation (SD).

Table 3.

Descriptive Statistics for Knowledge, Attitude and Practices.

Variable	Mean	Standard deviation
Knowledge Score	9.64	3.53
Attitude Score	4.12	1.77
Practice Score	17.00	6.83

Determinants of adolescents’ knowledge on COVID 19.

The results revealed that grade level tenth significantly good knowledge as compared to other grade students. Knowledge was also influenced by inquiries about the pandemic, social distancing, travel bans, and information sources. However, Participants’ attitudes and practices, such as agreeing to follow SOPs even if vaccinated, were not significantly associated with higher knowledge scores. Respondents’ definitions of pandemic and social distancing affected their knowledge scores, as did their opinions on travel bans and the influence of celebrities and social media influencers. Table 4 shows the factors that influence the knowledge of participants significantly.

Table 4.

Multiple Linear Regression Analysis of Factors associated with overall Knowledge of Adolescents (n = 328) towards COVID 19.

Variable		95% CI	P value
Grade
Sixth	Reference	Reference
Seventh	0.04	− 1.21–1.31	0.94
Eighth	0.33	− 0.96–1.62	0.61
Ninth	0.84	− 0.53–2.22	0.22
Tenth	1.96	0.54–3.38	0.007
Can a person get infected by Covid-19 virus for the second time after being infected once?
No	Reference	Reference
Yes	1.45	0.46–2.44	0.004
Don’t know	− 0.26	− 1.37–0.85	0.64
What is Pandemic?
Spread of a disease over a whole world	Reference	Reference
Spread of a disease over a country	− 0.81	− 4.04–2.40	0.61
Don’t know	− 4.81	− 8.58—1.04	0.01
What is social distancing?
Maintaining a distance of at least 6 feet between yourself and others to reduce risk of infection	Reference	Reference
Practicing to keep a safe physical distance from other people	− 1.31	-2.28–0.35	< 0.001
Remaining out of crowded places	− 0.36	− 1.79–1.06	0.61
Staying indoor	− 2.76	− 5.90–0.36	0.08
All of the above	0.21	− 0.84–1.28	0.68
None of the above	4,20	1.38–7.03	0.004
Don’t know	− 0.88	− 3.22–1.45	0.45
Should traveling be banned to minimize spread of Covid-19 infection?
Agree	Reference	Reference
Disagree	− 0.72	− 1.53—0.09	0.08
Don’t know	− 2.19	− 3.20–− 1.17	< 0.001
The role of celebrities and social media influencers
Great deal	Reference	Reference
Very little	1.41	0.13–2.69	0.03
Little	0.03	-1.19–1.27	0.95
Some	0.68	-0.44–1.81	0.23
A lot	1.62	0.47–2.77	0.006
Don’t know	0.30	-0.73–1.33	0.56
Do you think that people who have been vaccinated still need to follow sops (wearing mask/follow social distancing)
Agree	Reference	Reference
Disagree	0.85	0.06–1.63	0.03

F = 7.73, Adj R2 = 0.35, p < 0.001.

The adjusted R2 of 0.35 indicates moderate amount of explanatory power. To determine the model goodness of fit, normal probability plot was made which shows that residuals are randomly distributed across the zero band (no homoscedasticity) (Fig. 1). In addition, the kolmogrov test was done to check normality of residuals which showed a p value of 0.41. Thus residuals are normally distributed, hence model is a good fit.

Fig. 1.

Normal probability plots of residuals for knowledge, attitude and practice scores.

Determinants of adolescents’ attitude toward COVID 19

Findings showed that adolescents’ knowledge and practices significantly predicted their attitudes toward COVID-19 protective measures. Factors such as residence type, SOP adherence (including handwashing), and knowledge about COVID-19 were significant determinants of attitudes. Attitudes were also influenced by opinions on testing when symptomatic and the need for further lockdowns. Living in a rented house, poor SOP adherence, incorrect pandemic definitions, and reluctance to get tested or impose lockdowns were associated with lower attitude scores. Conversely, higher knowledge and practice scores correlated with more positive attitudes. Table 5 shows the factors that influence the attitudes of participants.

Table 5.

Multiple Linear Regression Analysis of Factors associated with overall Attitude of Adolescents (n = 328) towards COVID 19.

Variable		95% CI	P value
Type of residence
Owned
Rented	0.06	-0.23–0.37	0.65
Don’t know	0.68	0.15–1.21	0.01
SOPs maintained during lockdown period [Hand washing]
Always	Reference	Reference
Sometimes	− 0.20	− 0.515—0.103	0.19
Rarely	− 0.83	− 1.375—-0.287	0.003
Never	− 0.42	− 1.069—0.224	0.20
What is pandemic?
Spread of a disease over a whole world	Reference	Reference
Spread of a disease over a country	− 0.82	− 2.28–0.64	0.27
Don’t know	− 1.76	− 3.39–0.12	0.03
If you feel symptoms like fever, cough, shortness of breath, would you get yourself tested for Covid-19?
Agree	Reference	Reference
Disagree	− 1.12	− 1.51–0.739	< 0.001
Do you think lockdown should be imposed further to minimize spread of Covid-19 infection?
Agree	Reference	Reference
Disagree	− 0.75	− 1.10–0.40	< 0.001
Knowledge	0.046	0.0009—0.0921	0.04
Practice	0.029	0.006—0.052	0.01

F = 26.94; p < 0.0001, Adjusted R2 = 0.507.

An adjusted R2 indicates a strong level of explanatory power. In addition, the normal probability plot indicates that residuals are normally distributed towards the zero band (Fig. 1). Indeed, the kolmogrov test indicates a p value of 0.20. Thus, the residuals are normally distributed and the model for attitude score is a good fit.

Determinants of adolescents’ practices towards COVID-19.

Findings indicate that adolescents’ positive attitudes and higher knowledge regarding COVID-19 were associated with better adherence to preventive practices. Support for travel bans and strict adherence to Standard Operating Procedures (SOPs), especially social distancing, were linked to higher practice scores. Older adolescents showed more robust adherence to preventive practices. However, preferences for online classes during COVID-19 suggested potentially lower engagement in recommended preventive behaviors. Table 6 shows the determinants that influence the overall practices of adolescents.

Table 6.

Multiple Linear Regression Analysis of Factors associated with overall practices of Adolescents (n = 328) towards COVID 19.

Variable			95% CI	P value
Age	0.40		0.08–0.72	0.01
Do you think travel ban should be imposed to minimize the spread of new variant
No	Reference		Reference
Yes	2.35		0.97–3.74	0.001
SOPs maintained during lock down (social distancing)
Always	Reference		Reference
Sometimes	2.163		− 1.15–5.48	0.13
Rarely	0.26		− 3.44–3.96	0.009
Never	− 3.43		− 6.67– − 0.18	0.03
Would you prefer online classes or on-site classes during Covid-19 pandemic?
Offline		Reference	Reference
Online		− 1.65	− 3.17–(− 0.129)	0.03
Attitude score		0.92	0.50–1.34	< 0.001
Knowledge score		0.22	0.01–0.43	0.03

F = 14.00 Adjusted R2 = 0.24 p < 0.001.

Model assumptions

The adjusted R-squared values for our models were 0.35 for Knowledge, 0.24 for Practice, and 0.50 for Attitude. The Knowledge and Attitude models demonstrate moderate to strong explanatory power, while the Practice model shows a weaker fit. To evaluate model fit, we assessed residuals for normality and homoscedasticity. Normal Probability Plots (NPPs) revealed that residuals are randomly distributed across the zero band, indicating no issues with homoscedasticity (Fig. 1). Additionally, Kolmogorov–Smirnov tests supported the normality of residuals, with p-values of 0.41 for Knowledge, 0.20 for Attitude, and 0.77 for Practice. These results confirm that residuals are normally distributed and support the validity of our models.

Discussion

The COVID-19 pandemic has presented significant challenges worldwide, affecting individuals physically, emotionally, financially, and socially⁸. It has led to the closure of schools, religious places, and recreational activities, and has strained healthcare organizations. Our study aimed to identify determinants influencing adolescents’ knowledge, attitudes, and practices (KAP) toward COVID-19 in Pakistan, providing insights for targeted interventions. We enrolled 328 adolescent students from secondary schools in Pakistan to assess their KAP regarding COVID-19.

In our study, adolescents displayed an average knowledge score of 9.64 out of 15, with 66.4% demonstrating good knowledge about COVID-19. This is notably lower than reported rates in India¹¹, China¹⁴, and Egypt¹⁵, possibly due to different sample sizes and population parameters, as well as delayed confirmation of the first case in Pakistan and delayed intervention implementation. Factors contributing to the adolescents’ knowledge included government and WHO awareness campaigns, TV, social media channels, community-based awareness campaigns, and the national Ministry of Health website¹³.

Despite these efforts, our findings suggest that adolescents’ knowledge levels were lower than those reported among adults and university students in Pakistan⁹. Social media and celebrities played a significant role in information dissemination, highlighting the need to utilize these platforms for health education^16,17. Only 5% of adolescents cited schools as their primary source of COVID-19 information, likely due to the sudden closure of schools during the pandemic and the focus on curriculum rather than raising awareness during online classes^18,19.

Regarding attitudes, participants’ type of residence and COVID-19 knowledge significantly influenced their attitudes toward the disease^2,20,21. Most participants expressed willingness to get tested for COVID-19 if symptomatic and agreed with imposing lockdowns to control the disease, similar to findings in Bangladesh¹¹. These results emphasize the importance of improving knowledge to enhance attitudes and promote preventive behaviours²⁰.

In terms of practices, adolescents scored an average of 17 out of 28, lower than reported in India. Adherence to preventive measures such as mask-wearing and social distancing was linked to better knowledge and positive attitudes. Support for government measures like travel bans was associated with higher practice scores, indicating compliance. Older adolescents tended to follow practices better, likely due to increased media exposure^22,23.

This study is the first to assess the knowledge, attitudes, and practices of school-going adolescents regarding COVID-19 in Pakistan, offering insights for future policy-making to enhance awareness through innovative tools like social media and celebrity endorsements²⁰. The findings highlight the interconnection between these aspects, suggesting that enhancing knowledge can lead to more favorable attitudes and improved practices²⁴. Leveraging social media and educational campaigns can effectively disseminate critical information and improve adherence to preventive measures, guiding targeted health interventions and awareness campaigns for this demographic²⁵. However, limitations include the cross-sectional survey design’s restriction in elucidating causal relationships, as well as the potential for response bias in anonymous online surveys. In addition, the validity of the tool was not checked for this study. Future research could benefit from mixed-methods approaches combining quantitative and qualitative data collection to gain a better understanding of knowledge, attitudes, and practices regarding COVID-19.

Conclusion

In conclusion, this study sheds light on the knowledge, attitudes, and practices of adolescents in Pakistan regarding COVID-19, highlighting the importance of targeted interventions to enhance awareness and promote adherence to preventive measures. The findings underscore the significant role of social media and educational campaigns in disseminating critical information and shaping adolescent behavior during pandemics. Addressing the identified limitations and further exploring the interplay between knowledge, attitudes, and practices can enhance future public health strategies aimed at this vulnerable population, ultimately contributing to effective pandemic control efforts.

Author contributions

Conception or design: SR, MAK, Execution of Project: SR, MAK, AP, WZJ, SI,HF, KJ, SL, FB, UAC, BU Data Collection: MH, NR Data Analysis and interpretation: MH, NR, MAK Drafting the Article: MH, NR, MAK, SQ Table formulations: MH, NR, SQ, MAK Critical review: MAK, SR, SQ Final approval: SR, MAK, SQ All authors read and approved the final manuscript SR: Shafquat Rozi, MAK: Mohiba Ali Khowaja, SQ: Sana Qamar, MH: Muzna Hashmi, NR: Noureen Rehman, AP: Aneela Pasha, WZJ: Wafa Zehra Jamal, SI: Shayan Imran, HF: Hareem Fatima, KJ: Kanza Jiwani, SL: Sohail Lakhani, FB: Fazila Bibi, AM: Asma Malik, and BU: Bilal Usmani,

Funding

This was a non- funded students project of MSc. Epidemiology and Biostatistics.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Ethical approval was obtained from Ethical Review Committee of the Aga Khan University Hospital, Karachi, Pakistan (Dated: 13th December 2021, Ref no. 2021–6921-19907). Written informed consent was obtained from all the study participants. All methods were performed in accordance with the Declaration of Helsinki.

Informed consent

Before data collection (access to electronic form), all participants were asked to sign a form of consent to be included in this study.

Consent for publication

Consent was obtained from the participants of the study to publish the study results, online in a scientific journal.