Abstract

Background

After two years of the COVID-19 pandemic, Malaysia began the transition to the endemic phase. students at higher education institutes are among those who were affected by the COVID-19 outbreak and deserve further attention. Hence, this study aimed to assess the knowledge, attitude, and practice (KAP) associated with COVID-19 among public university undergraduate students in Malaysia during the endemic phase. This study would be able to provide valuable insights that can enhance public health strategies, improve educational efforts, and prepare better for future health challenges.

Methods

An online cross-sectional study was conducted among undergraduate students at public universities in Malaysia. KAP towards COVID-19 were measured using a structured Malay and English version questionnaire consisting of (i) sociodemographic characteristics, (ii) knowledge of COVID-19 (10 items), attitudes associated with COVID-19 (five items) and practice on COVID-19 preventive measures (six items). Validity and reliability tests were conducted to assess the level of consistency of KAP content with Cronbach alpha values of 0.617, 0.616 and 0.722 for each section, respectively. Descriptive statistics, independent t-tests, one-way analysis of variance (ANOVA), Mann-Whitney test, Kruskal Wallis test and Pearson correlation were conducted.

Results

Around 73% of the respondents had good knowledge of COVID-19, 58.6% possessed positive attitudes, and 54.6% were classified as having good practices in COVID-19 prevention. There was no significant difference in knowledge scores among sociodemographic data. A significant difference in attitude scores was observed among race, zones of the public university and household incomes. Besides that, a significant difference in practice scores was also observed among gender, race and student accommodation. A weak positive and significant correlation existed between knowledge and practices (r鈥�=鈥�0.220 and p鈥�=鈥�0.001). Meanwhile, there was no correlation between knowledge and attitude (r鈥�=鈥�0.039 and p鈥�=鈥�0.517).

Conclusion

Undergraduate students from Malaysian public universities had good KAP associated with COVID-19. Still, appropriate health promotion activities are needed to provide the students with adequate knowledge, positive attitudes and good practice of COVID-19 prevention measures in the future.

Background

By early 2020, the outbreak of an infectious disease known as Coronavirus disease 2019 (COVID-19) has become the main attention of the entire world. COVID-19 affects the human respiratory system caused by a strain of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, previously known as 2019-novel-coronavirus (2019-nCoV) [1]. Most individuals infected with the COVID-19 virus experience symptoms such as fever, cough, mild to moderate shortness of breath, fatigue, headache, diarrhoea, sore throat and vomiting [2]. After the first case of the COVID-19 disease reported in Wuhan, Hubei Province, China, the SARS-CoV-2 virus spread rapidly around the world by the end of December 2019 [3]. The COVID-19 outbreak forced the World Health Organization (WHO) to declare it a global pandemic on March 11, 2020 [4]. Based on statistics released by the WHO as of 11th January 2024, there were more than 701听million cases detected and 6.96听million people died due to COVID-19 worldwide [5].

Malaysia recorded its first case of COVID-19 on January 25, 2020, and began to spread throughout Malaysia. In order to curb the spread of COVID-19, the Movement Control Order (MCO) was declared with the empowerment of strict standard operating procedures (SOP) of COVID-19 on March 18, 2020 [6]. The public health implementation protocols such as movement control, social distancing, MySejahtera QR code scanning and wearing face masks were an effort to reduce the increase in COVID-19 cases. The Malaysian government was also actively channelling information related to COVID-19 through the mass media to the public [7]. As of June 1st, 2024, Malaysia has recorded 5.2听million cases of COVID-19 with a death toll of 37, 350 people reported through the website of the Ministry of Health Malaysia [6].

On April 1, 2022, Malaysia moved to the transition phase of the endemic COVID-19 [6]. The National Recovery Plan (NRP), which is the roadmap to control the pandemic implementation, has paved the way to end the COVID-19 pandemic in our country. The rapid development of vaccines including the COVID-19 booster vaccine has also led to better management of COVID-19 and vaccination programs [8]. The endemic phase had given relaxation in COVID-19 SOP and some liberty to the people. However, the government consistently reminds all Malaysians to keep practising and adhere to the latest COVID-19 SOPs and strive to spread information about COVID-19.

Information related to COVID-19 given by the Malaysian government affects the knowledge, thinking, practice and level of compliance towards SOP during the MCO [9]. On the other hand, the Centers for Disease Control and Prevention (CDC) stated that adherence to the control and prevention measures of COVID-19 can contain the outbreak of COVID-19 [10]. However, people鈥檚 compliance with the measures to prevent COVID-19 recommended by the government depends on the public鈥檚 knowledge, attitudes and practices (KAP). Sazali et al. (2021) stated that people鈥檚 awareness of COVID-19 led to a change in attitude and behaviour towards the prevention of COVID-19 [11].

The KAP survey aimed to assess a certain population鈥檚 KAP toward COVID-19. KAP research can assess what is known, believed and practised by a certain population to control the spread of COVID-19. According to Teng et al. (2021), the assessment of KAP levels can help to provide a better understanding of the development of COVID-19 prevention strategies and health promotion programs in the future [12].

Students of higher education institutes are among the groups that are also affected by the wave of the COVID-19 pandemic and deserve attention. In Malaysia, the role of undergraduate students in public universities is critical as they are a large, active, and influential segment of the population. However, there is limited understanding of their KAP related to COVID-19. Identifying gaps and misconceptions will provide valuable insights for developing targeted interventions and improving public health strategies during the endemic phase of COVID including (i) transmission risk management as the students often reside in shared accommodations, frequent communal areas, and engage in social activities, increasing COVID-19 spread; (ii) vulnerability and impact, where young adults generally exhibit lower COVID-19 severity and unknowingly contribute to community transmission, risking vulnerable populations; (iii) healthcare resource allocation where understanding undergraduates behaviours and attitudes towards COVID-19 preventive measures can aid effective allocation of healthcare resources; (iv) psychological well-being has brought about significant disruptions to the academic, social, and emotional well-being of undergraduates and (v) effective communication strategies are essential for promoting behavioural change and fostering community-wide adherence to public health guidelines.

Although Malaysia has become stable with the endemic phase transition and the tertiary education sectors are fully operated as before, online options are still being considered when the students or lecturers are unwell. Therefore, this study aims to address the gap by evaluating the level of KAP associated with COVID-19 among public university undergraduate students in Malaysia. The results of this study can help the government to improve a more effective public awareness plan for COVID-19 during the endemic phase. Identifying gaps in knowledge, misconceptions, or attitudes towards COVID-19 may hinder compliance with public health measures, and may facilitate targeted interventions to address challenges, enhance resilience, and promote positive coping strategies among students navigating the uncertainties of the endemic phase or preparation for future pandemics.

Methods

Ethics approval and consent to participate

The institutional Research Ethics Secretariat, Universiti Kebangsaan Malaysia (JEP UKM), reviewed and approved the study protocol, procedures, information sheet and consent statement (JEP-2022-179). The respondents were given the link to the online Google form and required to read the explanation about the purpose of the research before answering the questionnaire. A written informed consent form was included in the Google form and was obtained from all the participant before answering the questionnaire and their personal information and responses are kept confidential.

Study design, population and sampling

An online cross-sectional study was carried out among undergraduate students from public universities in Malaysia. The study was conducted during the transitional phase of the endemic in Malaysia and the data collection was performed online from May to June 2022. Respondents were recruited through multistage sampling. A total of 20 public universities throughout Malaysia were divided according to five geographical zones; (i) north, (ii) central, (iii) south, (iv) east and (v) Borneo. One public university was selected randomly by using simple random sampling from each zone to represent the undergraduate public university students in that particular zone. The public universities that were selected were the University of Malaysia Terengganu (UMT) (east), University of Malaysia Perlis (UniMAP) (north), University of Malaya (UM) (central), Technical University Malaysia Melaka (UTeM) (south) and the University of Malaysia Sabah (UMS) (Borneo). The second stage of purposive sampling was used to select the respondents from each public university. The target sample size was calculated as 220 respondents using G power analysis version 3.1.9.6 and with a 20% dropout rate, the total number of respondents was 264. A total of 52 respondents from each selected university are required to reach 260 respondents for this study. Google forms were spread online through WhatsApp, Telegram, and email to the respective universities. The target samples were full-time undergraduate students registered for 2021/2022 academic sessions, in the age range of 19 to 28 years old from the selected public universities.

Study instruments

The questionnaire was adapted from the KAP study of COVID-19 by Azlan et al. (2020) [9] and Peng et al. (2020) [13]. Slight modifications were made according to the suitability of the study and the endemic status of COVID-19 in Malaysia to allow a better understanding. A content validation test was conducted with six experts in related fields (virologist, epidemiologist, medical microbiologist and medical doctor). The final value of the content validity index (CVI) was 0.895, which exceeds the acceptable CVI cut-off score for six experts [14]. Then after, to test the suitability of the questionnaire, a pilot study was conducted using a face validation test aimed at testing the appropriateness of the research instrument in the questionnaire to be used in the study (Fig.听1). Subject comprehension, appropriateness of items and instructions contained in the questionnaire were tested and analysed using Cronbach鈥檚 alpha. A preliminary study was conducted on 30 fourth-year Biomedical Science students from Universiti Kebnagsaan Malaysia (UKM) [11]. The reliability of the variables was tested by using the Cronbach alpha coefficient. The results showed that Cronbach鈥檚 alpha was 0.607, 0.616 and 0.722 for knowledge, attitudes and practices, respectively. Overall, the alpha value achieved was good and acceptable [15].

Fig. 1

Phases description for the questionnaire development

Procedure

The questionnaire was in the form of a Google form and distributed online in Malay and English (back translation was conducted by a professional translator and confirmed by the experts). To avoid multiple entries by the participants, email address login and fill-in once with the personalised link was selected as an option. There were four sections in this questionnaire which were (i) sociodemographic characteristics, (ii) knowledge about COVID-19, attitudes towards COVID-19 and iv) practices of COVID-19 prevention. To measure the knowledge about COVID-19, 10 questions related to the disease of COVID-19, symptoms, groups at risk, mode of transmission, incubation period and the prevention control of COVID-19 were enquired. This section was closed-ended questions with a three-level Likert scale, namely 鈥渃orrect鈥�, 鈥渋ncorrect鈥� and 鈥渘ot sure鈥�. One point was given for a correct response, while incorrect and not-sure responses were given zero points. The total score was 10 (0鈥�5: poor; 6鈥�7: moderate; 8鈥�10: good) [9].

Five questions were stated to assess the respondents鈥� views in the attitude section towards COVID-19 such as the effectiveness of SOP to control COVID-19, the effectiveness of the COVID-19 vaccines, the ability of the Malaysian government to deal with the COVID-19 crisis, the reopening of campus and Malaysia鈥檚 readiness to move to the endemic phase. This section was closed-ended with a Likert scale format of five, namely 鈥渟trongly disagree鈥�, 鈥渄isagree鈥�, 鈥渘eutral鈥�, 鈥渁gree鈥� and 鈥渟trongly agree鈥�. Five points were awarded for a strongly agreed answer and one point was reduced for each subsequent level of answer. The total score was 25 (total scores were divided by 2.5 to determine the score; 0鈥�5: poor; 6鈥�7: moderate; 8鈥�10: good) [9].

To determine the level of practice of COVID-19 prevention measures, six practical questions including hand hygiene, wearing a face mask, scanning the MySejahtera application, physical distancing, visiting crowded areas and efforts to encourage the people to comply with the latest SOP were questioned in this section. The questions referred to the enforcement of the COVID-19 SOP before May 1, 2022. This section used a closed Likert scale format with four rating levels, namely 鈥渘ever鈥�, 鈥渟ometimes鈥�, 鈥渙ften鈥� and 鈥渁lways鈥�. Four points were given for always, three points for often, two points for sometimes and one point for never. Scoring was reversed for negative statements. The total score was 24 (total scores were divided by 2.4 to determine the score; 0鈥�5: poor; 6鈥�7: moderate; 8鈥�10: good) [9].

Statistical analysis

The collected data were analysed using the Statistical Package for the Social Sciences (SPSS), version 26. All statistical tests were performed under a鈥壜扁��5% margin of error and a confidence level and confidence interval levels of 95% and 99%, respectively. The significance level for this study was p鈥�<鈥�0.05. Frequencies and percentages were determined using descriptive analysis. The dependent variables were KAP behaviour towards COVID-19 infection. The scores of responses were equalled and categorised into three categories; poor, moderate and good levels.

Normality testing was conducted by skewness ratio and boxplot and showed that knowledge and practice were normally distributed, whilst attitude was not normally distributed. To compare the scores of KAP towards COVID-19 among different sociodemographic, parametric and non-parametric tests were used. Independent t-tests and one-way ANOVA tests were used to compare differences in knowledge and practice scores, while the Mann-Whitney and Kruskal-Wallis tests were used to compare attitude scores. Tukey鈥檚 test was used for post hoc analysis of the one-way ANOVA test, while Dunn鈥檚 procedure with Bonferroni adjustment was used for the Kruskal鈥揥allis test. Pearson correlation test was used to assess the relationship between knowledge versus practices whilst Spearman鈥檚 Rho correlation test was used to assess the relationship between knowledge versus attitudes.

Results

Sociodemographic characteristics of respondents

A total of 273 undergraduate students completed the survey (Supplementary Table 1). The majority of the respondents were females (n鈥�=鈥�144; 52.7%) aged beteen 19 to 28 years old. The participants were commonly Malays (n鈥�=鈥�204; 74.7%) and the highest participation was of Year 1 undergraduate students (n鈥�=鈥�88; 32.2). Most of the participants were not living with their family members (n鈥�=鈥�220; 80.6%), around 200 (73.3%) participants were from the B40 category and 166 (60.8%) had experienced COVID-19 disease (Table听1).

Table 1 Demographic characteristics of the participants (n鈥�=鈥�273)

The level of knowledge, attitudes and practices associated with COVID-19

The KAP level of Malaysian public university undergraduate students was assessed by taking the distribution of the knowledge score, attitude score and practice score of the respondents. According to Bloom鈥檚 taxonomy cut-off, the total score was categorized into good, moderate and poor. Table听2 shows the level of KAP of Malaysian public university undergraduate students regarding COVID-19.

Assessment of knowledge

A total of 199 (72.9%) respondents have a good level of knowledge. A total of 71 (26.0%) respondents belong to a moderate level of knowledge about COVID-19. Three (1.1%) respondents were categorized with a weak level of knowledge.

Assessment of attitudes

The majority of respondents (n鈥�=鈥�160; 58.6%) were categorized as having a good attitude towards COVID-19. A total of 90 (33.0%) respondents were categorized with a moderate level of attitude with a total attitude score between 16 and 19 marks. However, 23 (8.4%) respondents have a poor level of attitude with a total attitude score of less than 15.

Assessment of practices

A total of 149 (54.6%) respondents were classified as having good prevention practices with a score of 19 to 24 points. A total of 106 (38.8%) people were categorized at a moderate level of practice by reaching a total score of 15 to 18, while 18 (6.6%) respondents fell into the category of a weak level of practice.

Table 2 The distribution of the total knowledge, attitude and practice score for the assessment of the attitude level associated with COVID-19

COVID-19 knowledge, attitudes and practices scores associated with sociodemographic data

Assessment of knowledge

Overall, it was found that there was no significant difference in knowledge scores between different sociodemographics (Table听3). The results of the study showed that there was no significant difference between genders (p-value鈥�=鈥�0.354), and different ethnic groups (p-value鈥�=鈥�0.382). Similarly, the knowledge score between the university zones, academic programs and the years of study did not show a significant value with p-value鈥�=鈥�0.209, 0.209 and 0.711, respectively. Additionally, there was no significant difference between students鈥� current accommodations (p-value鈥�=鈥�0.897), and household income of B40, M40 and T20 status did not show a significant difference in knowledge scores (p-value鈥�=鈥�0.243). Students who have experience with COVID-19 and students with no experience with COVID-19 also did not show significant knowledge scores (p鈥�=鈥�0.500).

Table 3 The knowledge scores comparison among different sociodemographic

Assessment of attitudes

As shown in Table听4, there was a significant score difference between race, zone of the university and household income concerning attitude with a p-value of p鈥�<鈥�0.05, respectively. The median of Indian students was the lowest (17.5) compared to Malay students (20.0), students from Sabah Sarawak (22.0) and Chinese undergraduates (19.0).

The post hoc analysis showed a significant difference in scores between the east and north zones and the central zones only while the rest did not. Additionally, the post hoc analysis showed that students with B40 status with a mean rank of 145.93 had a significant attitude score with students with M40 status with a mean rank of 116.25. Students with B40 status also showed a significant attitude score with students with T20 status with a mean rank of 102.70. Overall, there was no significant difference in attitude scores that was seen between gender, academic program, year of study, current student accommodation and experience with COVID-19.

Table 4 The attitude scores comparison among different sociodemographic

Assessment of practices

There were significant differences in practice scores between gender, race and current accommodation of students (Table听5). Gender shows a significant difference in practice scores with p鈥�=鈥�0.001. Female students have a higher mean practice score (19.61) compared to male students (18.40). The race also showed significant practice score differences. A post hoc test showed that Chinese students (mean score of 20.79) had a significant attitude score compared to Malay students (mean score of 18.78). Chinese students also showed a significant difference in practice scores from Indian students with a mean score of 18.50. There was no significant difference in practice scores between Chinese and students from Sabah/Sarawak. In addition, there was a significant difference in practice scores between students鈥� current accommodations (p鈥�=鈥�0.001). Students who live with family members (mean score of 20.23) showed a significant score difference from students who live apart from family members (mean score of 18.75).

However, university zone, academic program, year of study, household income and experience with COVID-19 do not show significant practice scores.

Table 5 The practice scores comparison among different sociodemographic

The correlation between knowledge about COVID-19 with attitudes and practices among undergraduate students in Malaysia

The correlation between knowledge versus attitudes and knowledge versus practices toward COVID-19 among public university undergraduate students in Malaysia. The results showed that knowledge has a weak positive correlation with practice with a value of r鈥�=鈥�0.220, p鈥�=鈥�0.001. However, knowledge does not show a significant relationship to attitude with a value of r= -0.039, p鈥�=鈥�0.517 (Table听6).

Table 6 The correlation between knowledge versus attitude and practice

Discussion

Overall, we observed that undergraduate students at public universities in Malaysia have good levels of KAP associated with COVID-19. Our results are shown to be similar to the KAP study done in North Asia involving undergraduate students in China and Japan [13, 16]. Good KAP levels were also observed in a study involving 438 medical students at the International Islamic University of Malaysia (IIUM) [17].

In general, undergraduate students of public universities in Malaysia have a basic knowledge of COVID-19. This proved that Malaysian undergraduate students actively read news and current information related to COVID-19 [18]. This led to an increase in public knowledge and awareness of the disease. According to Hazirah et al. (2021), a high level of knowledge on COVID-19 is due to good access to information related to COVID-19 [19]. Omar et al. (2021) conducted a study that examines the effectiveness of spreading information on COVID-19 in Malaysia and found that the Malaysian government has succeeded in disseminating information related to the COVID-19 outbreak in order to spread knowledge and educate a high self-awareness among the public [20]. The effective medium used by the government to deliver the COVID-19 disease information has given wide exposure and increased the knowledge of undergraduate students across Malaysia.

However, there were still a number of students who had moderate and weak knowledge of COVID-19. This was believed to be caused by the dumping of information from inauthentic sources and fake news regarding COVID-19 [17]. Information on COVID-19 can be obtained from various sources such as magazines, government official websites, articles, journals or as simple as messages shared on social media. There was also information about COVID-19 that was not based on reliable sources such as scientific studies and based on the author鈥檚 opinion. This caused misunderstanding, confusion and difficulty for the students to determine the correct information about COVID-19 [9]. Hence, this could be the reason for some students to have low or moderate KAP levels. However, these gaps can be improved by enhancing the education programs, promoting positive attitudes and encouraging practical application.

Based on our study, the attitude of Malaysian public university undergraduate students was at a good level. Similar results were also obtained by a KAP study among medical students on the East Coast of Peninsular Malaysia, medical students at IIUM and undergraduates from University Science Islam Malaysia (USIM) [17, 21, 22]. The positive attitude shown by Malaysian undergraduate students proves that they are getting comfortable with the new norm [9]. During the beginning of the COVID-19 pandemic, students might have worried about COVID-19 because it was their first pandemic experience [23]. Therefore, their attitude was affected by panic and nervousness. Social media also creates anxiety about COVID-19 disease [24]. However, the speed of the authorities in dealing with the COVID-19 crisis has caused the students to put high trust in all government efforts [21].

The students鈥� attitude toward COVID-19 could also influenced by psychological factors such as personality [25]. Hatabu et al. (2021) argued that students鈥� personality affects their attitudes toward COVID-19 [16]. Students with an optimistic personality are more likely to have an open view of the impact of COVID-19 than students with a pessimistic mindset, who tend to think negatively and are not confident about the government鈥檚 actions in controlling the spread of the COVID-19 disease. However, according to Abd Rahim et al. (2021) differences in attitude instruments, cut-off scores to categorise attitude levels and sociocultural differences make the attitude assessment difficult to compare with the previous studies [17].

Additionally, our study also showed that Malaysian public university undergraduate students have good COVID-19 prevention practices. Good COVID-19 prevention practices prove that public university undergraduate students in Malaysia practice proactive basic COVID-19 prevention measures and adhere to the SOP issued by the government [9, 26]. Our study is similar to the KAP study on Malaysians by Hazirah et al. (2021) which showed that 76.4% of undergraduate students had a proactive level of practice against COVID-19 [19]. Peng et al. (2020) also support our findings, that students tend to display good practices because they feel the responsibility in the efforts to deal with the COVID-19 crisis [13]. Chai et al. (2021) reported that the higher the level of education, the better the prevention practices [27]. This was triggered because students have a deeper understanding of the COVID-19 disease and its outcome. The lack of understanding about the disease of COVID-19 leads to a lack of efforts to prevent COVID-19 in an individual [28]. The efforts of the Malaysian government to spread awareness of COVID-19 through media platforms led to increased efforts to prevent COVID-19 [19]. A high level of awareness of the risks of COVID-19 leads to students鈥� willingness to change their behaviour in the face of COVID-19 [9]. The lack of awareness about COVID-19 has a negative impact on an individual鈥檚 practice in preventing the disease of COVID-19 [28].

We also observed no difference in knowledge scores between sociodemographics among public university undergraduate students in Malaysia. At the same time, the basic knowledge of undergraduate students regarding the COVID-19 disease is not influenced by sociodemographic differences. Similarly, a KAP study on COVID-19 involving 951 university students in Palestine showed no significant difference in knowledge scores between sociodemographics [29]. Besides that, the results of the study showed differences in attitude scores between race, university zones and household income, which proves that student attitudes are influenced by these factors.

In this study, we perceived a significant difference in attitude scores between the races of the participants. The results of this study support the study of Hazirah et al. (2021) which states that attitudes depend on the race or ethnicity of the respondents [19]. On the contrary, Bachok et al. (2020) stated that Malay and Chinese have a negative attitude towards COVID-19 compared to other races [18]. However, our study shows that Indian students have the lowest mean score and this could be due to a smaller number of respondents involved. Similarly, Aidid et al. (2022) also concur this could be because of a small number of Indian and Bumiputera respondents from Borneo to represent the entire population [21]. Therefore, it can be said that the data distribution was unbalanced due to the sampling method used.

We also noticed that the public university zone in the study also affects the attitude scores. In support, a study by Azlan et al. (2020) stated that regions in Malaysia influence attitudes towards COVID-19 [9]. A KAP study during the end of the pandemic involving the Malaysian public found that respondents from the Eastern region of Malaysia were more optimistic because the number of cases of COVID-19 in that area was low compared to other areas [27]. This could be the reason undergraduate students studying at public universities in the East Zone show a positive attitude and are less worried about the COVID-19 disease.

Household income also affects the students鈥� attitudes towards COVID-19. Students with B40 status have higher attitude scores compared to those under M40 and T20 status. This finding was different from studies by Azlan et al. (2020) [9] and Chai et al. (2022) [27] and this difference in attitude scores is probably due to psychological factors. According to a study by Hatabu et al. (2021), Japanese university students鈥� attitudes towards COVID-19 were influenced by psychological factors such as self-awareness and personality [16]. According to researchers, individual behaviour patterns differ depending on their personality. Additionally, students from higher-income households typically have better access to access to accurate information and healthcare services, including testing, treatment, and vaccination. This can influence their attitudes towards the severity and management of COVID-19 [30].

Based on scores associated with COVID-19 practices, we found that gender, race and current accommodation of undergraduate students showed significant differences. This proves the practice of preventing COVID-19 was influenced by these factors. We observed female students have higher COVID-19 prevention practices and awareness than male students. Several studies also stated that compliance with COVID-19 prevention measures was influenced by gender, as female students took less risk against COVID-19 [13, 16, 19, 31]. Similarly, a study on the daily behaviour of people of different genders found that women have better behaviour than men because they take less risk [32]. In our study, students鈥� race also showed significant practice score differences. Chinese students have a significant practice score compared to Malay and Indian students. In contradiction, a KAP study among IIUM medical students showed no significant correlation between attitudes and race [17]. This could be because of the uneven distribution of respondents of various races.

Finally, we also found that students鈥� current residence influences their COVID-19 prevention practices. Students who live with family have a higher mean score than students who live apart from family members. Students who live with family members are more alert to the disease of COVID-19 and concerned about the safety of their family members. Parents are also pessimistic and overprotective of family members causing their COVID-19 prevention practices to be more proactive [21]. Because of that, students who live with families advise each other and take care of each other鈥檚 welfare. The results of this study differ from the study by Rahman et al. (2021) who think that university students who live without their families show better health practice behaviour because they are aware of the importance of self-protection against COVID-19 [33]. Even so, the results of this study support the study by Chai et al. (2022) who stated that individuals who live alone were less likely to practice COVID-19 prevention measures because they do not have the responsibility to protect close family members from being infected with COVID-19 [27].

Additionally, there was an association between knowledge and practice, but no significant correlation was observed between knowledge and attitude towards COVID-19. This proves that knowledge of COVID-19 disease among public university undergraduate students in Malaysia influenced their practice of COVID-19 prevention, but knowledge does not influence their attitude towards COVID-19. In such a situation, good knowledge would indirectly increase the intention and motivation to practice and comply with the preventive measures for COVID-19. Our findings differ from a study by Zubir et al. (2021) which showed no relationship between KAP among university students in Malaysia [23].

KAP survey theory states that knowledge is the basis for behaviour change [34]. An individual with a good knowledge of COVID-19 has an optimistic attitude and practices strict preventive measures [35]. The weak positive relationship between knowledge and practice was similar to the KAP study on COVID-19 by Chai et al. (2021) during the end of the pandemic in Malaysia [27]. The results of this study support the opinion of Lee et al. (2021) regarding knowledge being enough to change students鈥� health behaviour [36].

However, good knowledge does not affect the attitude of undergraduate students. Students鈥� attitudes depend on their ideas and acceptance of something. For example, even though students know about the SARS-CoV-2 virus infection and the COVID-19 disease, it does not change their view on the effectiveness of the vaccine in controlling the spread of COVID-19. This resulted in a group of students agreeing that the vaccine effectively controlled the spread of COVID-19 while the rest disagreed. Similarly, Zhang et al. (2021) also suggested that having good knowledge about COVID-19 does not necessarily lead to a positive attitude as the undergraduate students in China exhibited good knowledge of COVID-19, but this did not uniformly translate into a positive attitude towards the disease and its prevention measures [37]. Overall, human response to a situation is different according to their opinions and beliefs.

Study limitation

Despite the importance of understanding undergraduate students鈥� responses to the pandemic, existing research may have certain limitation, gaps or challenges that need to be addressed including (i) limited and uneven representation where the existing studies may not adequately capture the diversity of undergraduate student populations, and more inclusive sampling strategies needed to ensure representative insights into the knowledge, attitudes, and practices of all undergraduate students, including those from marginalised or underrepresented groups; (ii) longitudinal perspectives where many studies may offer cross-sectional snapshots of undergraduate students鈥� responses to COVID-19, overlooking progressive changes, evolving attitudes, and the impact of interventions over time and providing a more comprehensive understanding of students鈥� responses to the pandemic across different phases and contexts; and (iii) contextual factors, where effectiveness of public health interventions among undergraduate students may be influenced by various contextual factors, including institutional policies, socio-cultural norms, and peer influences.

Conclusion

In general, public university undergraduate students in Malaysia have a good level of knowledge, attitude and practice associated with COVID-19. The majority of respondents have a high level of knowledge, showed a positive attitude towards COVID-19 and practice proactive COVID-19 prevention measures. There was no difference in knowledge scores between sociodemographic characteristics. Attitude scores differ between race, public university zone and household income. Next, practice scores are different for students based on gender, race, and current place of residence. There was a weak positive correlation between knowledge and practice against COVID-19 while there was no correlation between knowledge and attitude.

Although our study shows that the majority of public university undergraduate students in Malaysia have a good level of KAP associated with COVID-19, attention needs to be given to the students who belong to the weak category. Public awareness programs against COVID-19 targeting that student group need to be carried out. In addition, health promotion and education should be carried out to empower the knowledge about COVID-19 and ensure students practice the correct COVID-19 SOP. The Malaysian government and public higher education institutes can advise students on the importance of continuous compliance with COVID-19 SOP through various information dissemination platforms. This was because Malaysia has just moved into the endemic phase and cases of COVID-19 infection are still prevalent in Malaysia. The findings of this study are useful for the guidance of the KAP study of COVID-19 in Malaysia during the next endemic transition phase. We believe that addressing the challenges and gaps in existing research can strengthen the problem statement and enhance the relevance and impact of public health policymaking and intervention planning for undergraduate students in Malaysia during the endemic phase of COVID-19.