The coronavirus disease (COVID-19) is an emerging respiratory infection that causes illnesses ranging from the common cold to severe acute respiratory syndrome. It spreads from human to human through droplets and direct contact (1–5). A person infected with the COVID-19 virus might be asymptomatic (i.e., while spreading the virus) or develop flu-like symptoms, such as fever, runny nose, sneezing, or sore throat, vomiting, diarrhea, nausea, chest tightness, palpitations, dry cough, tiredness, and shortness of breath, immediate medical attention is advised when severe symptoms, such as persistent chest pain or pressure, difficulty breathing, confusion, and bluish face or lips, arise (1–4). For instance, about 80% of reported cases in China had mild-to-moderate diseases, 13.8% had severe diseases, and 6.1% were critical (4–6). Estimates suggest that the median incubation period of the disease ranges from 5 to 6 days, with a range from 1 to 14 days (5, 6).

The World Health Organization (WHO) declared it a global pandemic disease on 11 March 2020. In response, countries around the world have adopted different prevention methods (2, 5, 7), and the public has been instructed to seek information about the disease solely from well-trusted sources and practice protective measures, such as physical distancing, hand hygiene, avoiding touching the eyes, nose, and mouth with unwashed hands (7), and uptake vaccination (8). Similarly, Ethiopia has swiftly implemented several public health measures to stop transmission and prevent the spread of the virus, including partial lockdown, school/university closure, virtual working policy in some sectors, closing borders, mandatory 14 days quarantine for international travelers, declaration of a state of emergency, and others preventive practices (9–11).

The pandemic has become a challenging global burden for all continents affecting humanity's healthcare systems and social, economic, and psychological wellbeing. Low- and middle-income countries are profoundly affected because of deficient medical equipment and fundamental supplies for victims resulting in a disastrous loss of life (12, 13). As of 19 December 2021, COVID-19 has affected over 222 countries and territories, with over 274,583,552 confirmed cases and over 5,368,198 deaths. In Ethiopia, there were 375,810 COVID-19 cases and 6,861 deaths till 19 December 2021 (14).

In addition, it greatly impacts countries' wellbeing and results in increased healthcare costs, unemployment, reduction in remittances, food insecurity, loss of income, school absenteeism, and so on (13). Schools were closed in different countries as safety measures to prevent and stop the spread of the virus (5, 11, 14). As a result, more than 26 million students were affected in Ethiopia, and feeding programs in schools for ~1 million children across multiple regions of the country stopped (15).

However, through gradual assessment, as the impact of COVID-19 is likely to stay over an extended period, the government decided to re-open schools by ensuring safety protocols, such as maintaining physical distance both inside and outside of the classroom; reducing student size per class; consistent use of face masks and frequent hand washing with soap and water; regular screening for symptoms of COVID-19; provision of regular health education, cleaning and disinfection, adequate ventilation, and spacing of desks or grouping of children if required; and availability of necessary resources (5, 11, 14, 15).

The school community, including students, could be a potential amplifier for the transmission of infectious diseases within communities. This is because schools are an important part of the infrastructure where the highest segment of the population spends time. Therefore, maintaining good health in school settings is essential to prevent or reduce the transmission or spread of infectious diseases, such as COVID-19. Existing evidence indicates that young children are often asymptomatic carriers, so they can spread the coronavirus to family and community members without manifesting clinical symptoms. This sustains the invisible transmission of the virus in the community, indicating that COVID-19 transmission in schools is associated with community transmission (5, 6, 15). Moreover, young people and those who spent their time in the school environment are relevant for COVID-19 prevention and control (5, 11, 15). Thus, empowering their knowledge about the disease, access to prevention resources and self-care practices are essential (11, 14, 15).

Although several actions have been implemented to combat the spread of the virus in school settings, little is known about students' practice of COVID-19 prevention measures, especially in the context of Ethiopia. Moreover, evidence was lacking about students' perceptions of COVID-19 and its preventive practices (16). For better implementation of COVID-19 prevention measures in schools, it is critical to assess students' self-protective practices and the determinant factors. Thus, this study assessed COVID-19 self-protective practices and associated factors among secondary school students. Moreover, the findings of the study might be important to review the actions and requirements taken and put in place to prevent the further spread of COVID-19 in schools and in the community and to ensure the safety of children and school staff while at school.

The study was guided by the Health Belief Model (HBM), which is one of the most commonly used behavioral models. It proposes that preventive health behavior is influenced by the following five factors: perceived barriers to making the recommended response, perceived benefits of making the response, perceived susceptibility to the health threat, perceived severity of the threat, and cues to action (17). Accordingly, people take action if they believe that they are susceptible to a disease condition, that it has potentially serious consequences, that the recommended action would reduce the severity of the condition or their susceptibility to it, and that the barriers to taking action are outweighed by benefits. Within the HBM, cues to action can trigger or activate a person's readiness to change health-related behaviors, and self-efficacy is a person's confidence in their ability to change those behaviors (17, 18).

The HBM was selected as the conceptual framework for several reasons. First, the constructs of the model are highly relevant for risk communication and conceptualization of perceptions of severity and vulnerability, which are important motivators for behavioral change or adoption of risk-protective behaviors. Second, given that the coronavirus is an emerging outbreak, public education efforts mostly focus on increasing perceptions of vulnerability to the disease, severity, or consequences due to the disease along with perceptions of self-efficacy and benefits of taking action (17, 18).

In addition to the main constructs of the HBM model, other factors, such as awareness of the knowledge of diseases and preventive measures, exposure to information, and several support factors, can affect people's response to take action (15, 17, 18). Thus, perceived school support was included in the tool to assess the level of school environment support and adherence to preventive practices. This is because schools were reopened considering the school environment needs to be supportive of the school community to prevent COVID-19 preventive practices. Also, schools are infrastructures where large segments of the population, especially the youth and adolescents, spend more of their time and interact with each other. Therefore, there is a need to include this context-based dimension as it contributes to preventing or disseminating COVID-19 infection (10, 12, 13). Similarly, self-efficacy (i.e., an individual's belief in their capacity to execute behaviors necessary to produce specific performance attainments) was added to the additional construct of HBM to assess students' confidence to adhere to COVID-19 preventive practices.

The study found that the cumulative mean score of self-protective practice was 28.38 (SD ±11.04). Accordingly, the age of the respondent, the mother's education (no formal education), and perceived vulnerability were negatively associated with self-protective practices. However, perceived benefits, perceived school support, and perceived self-efficacy were positively associated with it.

The study found that the user adoption of COVID-19 safety and preventive practices among secondary school students was not satisfactory (mean = 28.38). This indicates that strict practice of preventive packages, especially on the use of face masks in the classroom, seating alone (one person per chair), maintaining physical distancing, and hand washing practices were quite low. These might suggest that the school did not pay adequate attention to ensuring COVID-19 school safety protocol, or those young people might be reluctant to use preventive measures. The finding is inconsistent with the expectation that enforcement of school COVID-19 protocol is in place (15). Those young people should practice possible preventive strategies to protect themselves and others from infection (1–7). To combat the pandemic, the school programs and COVID-19 task forces should seriously promote appropriate self-protective behaviors among school students. This finding is slightly higher than the findings of studies conducted elsewhere (15, 16).

The age of the respondent was also negatively associated with COVID-19 self-protective practices. This might imply that, as age increases, they would feel as if they are not at risk of COVID-19 infection or not harmed by it. This underscores that there is a need to conduct risk communications and behavioral change communication interventions about the nature of COVID-19. Similarly, a study conducted in the Egyptian community indicated that people of younger age had good preventive practices (25). In contrast, a study conducted in Iran indicated that age is strongly associated with good preventive practices (26). The difference might happen from geographical or cultural variations.

It was also found that there was a disparity in practicing COVID-19 self-protective measures with respect to maternal education. Students whose mother's education level not attended formal education had decreased self-care practices. This would be because they might not have adequate knowledge about the disease or could not perceive its risk and consequences. Mothers who have higher educational levels have a better understanding of COVID-19 protective methods, and they might be teaching their students about protective measures for COVID-19 and vice versa. This issue also needs greater attention and research on how parents influence and shape COVID-19 behaviors among school students. This is because existing evidence indicates that the more frequent parent–adolescent conversations early in the pandemic predicted increased adherence to HPBs throughout the pandemic (27).

According to the HBM, for an individual to actively perform the behavior, one should hold a belief that they are vulnerable to the disease (17, 18). In the present study, the perceived vulnerability had an adjusted mean score of 26.37 and was negatively associated with self-protective practices. This might imply that those school students did not perceive as they were at risk of COVID-19 infection. Some early studies in Ethiopia also reflected that perceptions of threat (vulnerability and severity) to COVID-19 were low (28, 29). This issue needs further research to investigate why and how the higher perceived vulnerability was associated with decreased self-care practices. Furthermore, there is a need to develop health education programs and conduct risk communication interventions. Similarly, this finding is similar to the findings of studies conducted elsewhere (27).

The study also found that perceived benefit was relatively high (mean = 43.13) and positively associated with self-protective practices. This indicates that those school children correctly appreciated or recognized the effectiveness of COVID-19 preventive measures. Therefore, this underscores the need to strengthen COVID-19 education to enhance perceptions of benefits which is crucial to promoting self-protective behaviors. Similarly, the findings were consistent with other study findings done elsewhere (27, 30).

Similarly, self-efficacy, the personal confidence to take the recommended actions, does not look optimal (mean = 33.38) and is positively associated with self-protective practices. This might imply that self-efficacy is important in practicing preventive measures against COVID-19 disease. Therefore, this underscores the need to strengthen COVID-19 education to enhance perceptions of benefits and build higher self-efficacy crucial to promoting self-protective behaviors. Similarly, the findings were consistent with other study findings done elsewhere (27, 30).

From a practical point of view, school-related public health measures to prevent and minimize calls for addressing the conditions and risk factors that could contribute to the transmission of COVID-19 in school settings and families (15, 31, 32). This requires ensuring access to preventive resources, educational aids, continuous education, and monitoring the adherence to school COVID-19 protocol, and the school should be supportive of students. In this study, we found that the mean score of perceived school support was 25.45 and positively associated with self-protective practices. However, this shows a huge gap in ensuring access to adequate resources needed for COVID-19 prevention, such as water, educational reminder, visual aids, and ensuring classroom facilities that could be COVID-19-sensitive. This is an important finding and the implications for policy and practices, calling for strengthening access to facilities, services, and COVID-19 support infrastructure to establish a safe and supportive environment in the school. Existing evidence also highly recommended it (31, 32).

In principle, knowledge about COVID-19 disease, symptoms of the disease, methods of prevention, and the transmission of COVID-19 infection will increase prevention practices of individuals, and they might be implementing the key messages of the guideline, such as wearing a face mask and proper hand washing practices (5, 7, 12). Inconsistent with this reality, the present study did not find significant associations between knowledge of the diseases and self-protective behaviors. This confirms the notion that knowledge is not a sufficient condition for behavioral change. This calls for the need to go beyond information dissemination and build a knowledge base to influence and address other factors that could affect the practice of self-protective measures.

This study assessed secondary school students' perceptions and COVID-19 self-protective behaviors based on a theoretical framework (health belief model) and additional constructs, such as school support dimensions, and self-efficacy. The findings might complement other study findings to contribute their own impute for policymakers and for other researchers on controlling the distribution of this pandemic. As a limitation, a three-scale measurement was used, rather than using five-point Likert scale measurements, and respondents specified their level of agreement or disagreement on a symmetric agree–disagree scale for a series of statements, especially for perceived severity and vulnerability items. In addition, there might be limitations, such as social desirability bias (respondents might be made socially acceptable answers, rather than trustful), exaggeration of the answers, or being too embarrassed to reveal private details as the study used a self-administered questionnaire.

In this study, COVID-19 self-protective practice was unsatisfactory. Perceived benefit, self-efficacy, and perceived school support were positively associated with self-protective measures. However, the age of the respondent, maternal educational status, and perceived vulnerability were negatively associated with it. This underscores the need to strengthen COVID-19 education to enhance perceptions of benefits and build higher self-efficacy along with establishing a safe and supportive school environment to promote self-protective behaviors among school students. Similarly, the findings are for policies and practices, calling for strengthening access to facilities, services, and COVID-19 support infrastructure in the school. Students would benefit from social and behavioral change communication interventions, including risk communication interventions, irrespective of their age, as all people are susceptible to COVID-19 infection. Similarly, awareness creation intervention programs that target maternal educational status should be carried out. Moreover, further research would be important to investigate why and how these variables were associated with decreased self-care practices.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by Jimma University Ethical Review Committee. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

ZB: conceptualization. ZB, GT, and KGT: data curation, formal analysis, methodology, project administration, validation, visualization, and writing—review and editing. KGT: writing—original draft. All authors have read the manuscript and approved the final version of the manuscript.