A survey was conducted among the preparatory year students attending Aden University, Yemen. The program aimed to prepare the students by teaching them the basic knowledge needed to attend a university and to select the students eligible for each field based on their performance during the year. Aden University’s preparatory program has 4 colleges: the Medicine Faculty, Administration Science Faculty, Languages Faculty and Engineering Faculty.

The protocol of the study was approved by the Research and Ethics Committee of the Faculty of Medicine of the University of Aden (Research Code: REC-25-2018). All respondents were fully notified that their participation was voluntary and that it was possible to withdraw from the study without notice. Those who wished to participate were required to sign a consent form.

Of a total population of 1500 students, a sample size of 212 students was needed. The required sample size was calculated based on a margin of error of 5%, a 95% confidence level and an 80% response distribution (Raosoft® (http://www.raosoft.com/samplesize.html)). Three of these colleges (Medicine Faculty, Administration Science Faculty and Languages Faculty) were chosen by simple random sampling. Representative samples of students at each faculty were chosen randomly through the class list.

Inclusion criteria: The study included preparatory year students who were: (1) healthy, willing to participate and willing to sign the informed consent form; and (2) available at the time of data collection.

Exclusion criteria: The study excluded the students who: (1) reported previous residence in another country; (2) were not present during data collection; or (3) were not willing to participate.

A structured questionnaire was designed to gather information regarding sociodemographics and KAP related to rubella. The questionnaire was first developed in English and then translated into Arabic language. The questionnaire consisted of three sections. The first section included sociodemographic data such as sex, age, marital status, educational level and residence. Section two included questions used to assess the respondent’s KAP level such as questions about the signs and symptoms and modes of transmission of rubella. Questions related to the respondent’s history of rubella were included. Section three included questions about the respondent’s history of MMR vaccination, and the attitude of the respondent towards the vaccine.

The questionnaire was validated by the following process: (1) The questionnaire was designed in English by the principal researchers; (2) Forward translation from English to Arabic was performed by a specialist; (3) Pretesting of the questionnaire was conducted. Face to face interviews were conducted with 20 students who did not participate in the main study; (4) Retesting of the questionnaire was also performed with the same people who participated in the pretesting two weeks later. It was observed that most of the respondents gave the same or very similar answers on the pretest and retest; (5) A statistical analysis was performed to test the internal consistency (Cronbach’s alpha); (6) Validity was evaluated by the face validity test, and the final draft of the questionnaire was sent to two researchers from the Faculty of Medicine, Aden University. The Cronbach’s alpha was 0.83, indicating good consistency and high test reliability.

Data were entered into the Microsoft Office Excel version 2013; then, analysed with SPSS software version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). The demographic characteristics of the respondents are presented as percentages and frequencies. The associations of the knowledge of rubella with the sociodemographic factors of the respondents were assessed using the chi-square test. A p-value of 0.05 or less was considered significant.

The questionnaires were administered to 250 students, and 220 were received back, yielding a response rate of 88%. Of the 220 returned surveys, 30 were incomplete, giving a final total of 190 (76%) of usable questionnaires.

The general sociodemographic characteristics of the respondents in this study are shown in [Table/Fig-1]. Out of the 190 respondents, 96 (50.5%) were males, with a mean age of 20.31±1.96 years; most of them were 19-year-old (n=66, 35%) and 122 (64.2%) were urban residents. More than half of the respondents, 128 (67.4%), were from Aden governorate.

Eighty-one (42.6%), or approximately half, of the fathers of the respondents had a college education, followed by 66 (34.7%) had a secondary level education. On the other hand, most of the mothers had a secondary level education (n=60, 31.6%). A majority of the respondents (n=182, 95.8%) were not married [Table/Fig-1].

The results showed that 120 (63.2%) of the participants had heard about rubella [Table/Fig-2]. Out of these 120 participants, 46 (38.3%) indicated that the main source of their information about rubella was other people (friends and neighbours), followed by social media (n=31, 25.8%), then school (n=12, 10.0%).

Among the participants who had heard about rubella, approximately half of them (61, 50.8%) knew that rubella was caused by a virus. Fifty-seven (47.5%) of the participants knew that close contact with a patient, sneezing, coughing, and transfer across the placenta are modes of transmission of the disease. In total, 57 (47.5%) of the participants stated that the main symptoms of rubella are fever, skin rash, headache, malaise and redness of the eye, while 31 (25.8%) admitted that they did not know any symptoms of rubella.

Out of the participants who reported their history of rubella, 18 (15%) students stated they had rubella [Table/Fig-3].

More than two-thirds of the respondents (n=85, 70.8%) were aware of the rubella vaccine, while 35 (29.2%) were not aware of the rubella vaccine. Almost all (n=82, 96.5%) respondents who had previous knowledge of the rubella vaccine stated that they did not know the timing of the administration of the rubella vaccine.

The results regarding the respondents’ attitude towards rubella are presented in [Table/Fig-4]. Among those who indicated that they had heard about rubella, the majority (n=75, 62.5%) stated that rubella is harmful to people’s health. When asked about their intention to immunise any future children with the MMR vaccine, more than half (n=99, 82.5%) of the students reported that they intended to immunise any future children with the MMR vaccine. Moreover, the majority of students (n=76, 63.3%) agreed that any future children should be vaccinated, regardless of the opinions of others.

Fifteen (12.5%) respondents who reported having prior knowledge of rubella had received the vaccine, and approximately one-third (30, 25.0%) of them had not received the vaccine, while 75 (62.5%) individuals did not know whether they had received it or not.

Differences in the KAP scores among different subgroups of respondents were determined using the chi-square test [Table/Fig-5]. The results showed that only gender was significantly associated with KAP. The female respondents had a superior knowledge of rubella compared to male respondents (p=0.004).

In brief, the findings from this survey on preparatory year students attending Aden University demonstrated that there was inadequate KAP regarding rubella among preparatory year students attending Aden University.

Overall, the present results show that the participants’ knowledge of rubella was generally poor, with low levels of awareness of the symptoms, modes of transmission, and sources of infection. The current study showed that although 63.2% of the respondents stated that they had heard about rubella, their actual knowledge of the disease was limited. This is in agreement with the previous findings from studies performed in various countries such as Egypt [13], with reports of a lack of awareness regarding rubella among studied women, and Brazil [14], where more than half of the respondents (69.9%) indicated that Brazilian adults were aware of rubella but their knowledge of the disease was poor. A study in India [15] found that the majority of the non-medical students (78%) were unaware of rubella.

Regarding the source of information about rubella, most of those who had prior knowledge mentioned that they had gained information about rubella from different sources such as friends, neighbour, social media, TV, and newspapers. A study in India observed that two-fifth of the participants who had heard of rubella obtained the information from books and television [16]. Only one-tenth of respondents had heard about rubella from school. This finding deserves more attention, as the school is considered one of the best places to enact positive changes in any community, and it can be a suitable environment for health education because students spend most of their time in school and interacting with their colleagues and teachers. Furthermore, students in school are more vulnerable to infection. In addition, school age is the age at which new information is most easily acquired, and students are able to transfer this information to the surrounding community. A study concluded that students are important stakeholders in future public health campaigns [17].

Despite the literacy of the participants, the knowledge of rubella was low. Health education in schools might not be adequate. Previous findings from Italy [18] and Nigeria [19,20], found that, although the level of literacy observed among the respondents was high, there was still a low level of knowledge of rubella. In another study, it was found during health screening campaigns administered by the Ministry of Health personnel that no respondents had heard about rubella [21]. The spread of the rubella virus from one person to another occurs through contact with nose or throat secretions, often in the form of airborne droplets, and it is also passed from pregnant women to the fetus through the placenta [19]. In the present study, the level of the participants’ knowledge of rubella transmission was low, with close to half of them know about the method of transmission of the disease. This is in accordance with the findings of the study by Olajide OM et al., who reported that only a minority of respondents knew about rubella and how it could be transmitted; in the same study [20], they found around two-fifth of the students recognised breathing as a mode of transmission. Contrary to finding of this study, another study reported that less than one-fifth of their respondents knew about the modes of transmission [22]. The finding of the present study showed that approximately half of the respondents knew that a virus was responsible for causing the disease. However, these findings are contrary to those of a previous study in which they reported that all respondents knew that rubella is caused by a virus [23].

Moreover, the findings from this study showed that around half of the respondents recognised the common signs and symptoms associated with rubella infection. The present results are in contrast with the findings from Brazil [14], where less than one-third of the respondents were able to answer affirmatively when asked if they would recognise the symptoms of rubella infection. In this study, female participants were more knowledgeable about rubella than male participants, and this is similar to the findings from Brazil [14]. Contrary, there were no significant differences observed between female and male participants in India [23]. Additionally, there were no significant associations between knowledge and other sociodemographic factors such as age, residence, and education; similar observations were found in Egypt [13]. With regard to vaccine awareness, however, to the best of authors’ knowledge, there is no data available pertaining to the general population in Yemen. In the present study, more than two-third of the participants had heard about the rubella vaccine. Sharma P et al., stated that the knowledge of the vaccine among respondents was adequate [23]. However, the present findings are in contrast with those of a previous study in which it was reported that only 13.0% of the participants knew about the rubella vaccine [16].

Concerning the history of rubella infection, the current study reported that 15% of students had a history of rubella infection, and this is in accordance with previous studies [13,24], in which the majority of respondents stated that they had not had rubella or they did not remember having had rubella.

The attitudes of the respondents towards rubella showed that close to two-third of the respondents viewed rubella as a problematic disease. However, in India, it is reported that about four-fifth of adolescent girls believed rubella was not an infectious disease [16]. In the present study, the majority of the students did not know about the complications of rubella during pregnancy. Kumari S et al., observed that more than four-fifth of respondents did not know the adverse effect of rubella on pregnancy and the fetus [16]. Contrary to finding of the present study, Gupta H et al., reported that 92.1% of respondents were aware of the potential damage to the fetus caused by rubella contracted during pregnancy [15]. In the present study, none of the respondents knew the appropriate timing for receiving the rubella vaccine, although the majority of the respondents expressed a willingness to be vaccinated. Despite the lack of knowledge of rubella, their attitude towards the vaccine was overall positive. Vieira JC et al. and Kumari S et al., reported similar observations [14,16]. Gadallah M et al., reported that medical student respondents state that they will not be vaccinated in the future [24].

With respect to the vaccination status, the present study showed that slightly more than one-tenth of respondents had received the vaccine. However, the present findings contradict other reports [15,25], which showed that 42.1% and 46.9% of respondents were reported to be vaccinated against rubella, respectively. Taneja DK and Sharma P supported the idea to have the goal to eliminate rubella [26]. The initiative of Yemen Ministry of Public Health and Population, World Bank, WHO and UNICEF on the nationwide awareness and vaccination campaign, should continue to be among the top public health priorities and need to be supported [27].

The results are limited to only preparatory year students, and there was a small sample size. In the preparatory year; all students entered from high schools; all would have the same level of knowledge/exposure. Thus, the findings of this study may not reflect the perspective of the whole community. Therefore, the findings need to be interpreted within the context of this study limitation. The authors are planning to expand the study in Yemen (i.e., sample size and geographical areas) to provide findings that could be used to inform educational programs and improvements in practices and health policies in the country.

In summary, the results of the present study showed that the majority of the preparatory year students attending Aden University have inadequate knowledge, insufficiently positive attitudes and a lack of proper practices pertaining to rubella.