To the Editor—The advent of the coronavirus disease 2019 (COVID-19) pandemic has greatly impacted the learning environment in schools. Many primary schools worldwide have switched to online learning, and most private schools have opened with numerous infection prevention measures.^{Reference Lobo, Del Ser, Bifet and Kasabov1} Uncertainty in the natural history of COVID-19 includes the infectivity of asymptomatic and presymptomatic children in school as well as the frequency of within school transmission of COVID-19. ^{Reference Li, Li, He and Cao2,Reference Zimmerman, Akinboyo and Brookhart3} Thus uncertainty has resulted in strict infection prevention measures taken at schools to ensure the safest environment for both students and teachers. Previous studies have shown that COVID-19 has an impact on anxiety and fear levels of healthcare personnel and patients. ^{Reference Apisarnthanarak, Apisarnthanarak, Siripraparat, Saengaram, Leeprechanon and Weber4,Reference Apisarnthanarak, Siripraparat and Apisarnthanarak5} Nevertheless, the impacts of COVID-19 on emotional well-being on students and teachers in schools has not been well studied. ^{Reference Cullen, Gulati and Kelly6} In this study, we evaluated the emotional health of students and teachers as well as infection prevention practices at an international school during the COVID-19 outbreak in Thailand.

We performed an online survey of students and teachers attending Ruamrudee International School, Bangkok, Thailand, from February 1, 2021, to April 30, 2021, to evaluate their emotional health, infection prevention practices regarding COVID-19, and the school’s preparedness plan. The online survey was distributed to students and teachers (grades 6–12) for participation. Data collected included student and teacher demographics; school infection prevention measures; confidence levels in the school’s infection prevention measures, and changes in infection prevention behaviors in both school and community settings, knowledge of COVID-19 transmission, and emotional health inclusive of anxiety, worriness, and stress. Respondents rated their confidence level on knowledge and school preparedness plan on a Likert scale from 1 to 5 (1, no confidence to 5, very confident) also changes in their infection prevention behaviors on a Likert scale from 1 to 5 (1, never use to 5, always use). Infection prevention behavior changes (eg, hand hygiene, wearing a mask, and physical distancing) were defined as a rating of 4 (almost always) or 5 (always). We used the Generalized Anxiety Disorder 7-item (GAD-7) scale to categorize anxiety following the original scale: 0–4, minimal anxiety; 5–9, mild anxiety; 10–14, moderate anxiety; and >14, severe anxiety. ^{Reference Apisarnthanarak, Apisarnthanarak, Siripraparat, Saengaram, Leeprechanon and Weber4} Self-rated worry about acquiring COVID-19 and its negative impacts were rated on a Likert scale of 1 to 10 (1, not worried to 10, extremely worried). Analyses were performed using SPSS version 15 software (IBM, Amronk, NY). Categorical data were compared using a 2-tailed χ² or Fisher exact test, as appropriate. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were computed; a significant statistical difference was defined as P < .05.

Overall, 274 participants consented to study participation; 218 (79.6%) were students, 56 (20.4%) were teachers, and 192 participants (70.1%) were in high school. The infection prevention policies include temperature checks, hand hygiene, wearing masks, and physical distancing (≥1 m). The overall confidence toward school measures to prevent COVID-19 transmission was 72.6% for temperature checks, 73.0% for wearing masks and hand hygiene, and 50.7% physical distancing (Table 1). Furthermore, 64 participants (23.4%) were worried about acquiring COVID-19 and potentially spreading it to their friends and families; 101 participants (36.9%) felt stress about it, and 207 participants (75.5%) felt at least minimal anxiety about it. Notably, 228 participants (83.2%) reported wearing a mask in the community; 154 participants (56.2%) reported physical distancing in the community; and 133 participants (48.5%) reported washing their hands more frequently in both school and community settings. There were no statistically significant differences in practices between students and teachers.

Table 1. Student and Teacher Characteristics, Emotions, and Infection Control Practices

Note. GAD-7, Generalized Anxiety Disorder 7-item.

^a Several social media platforms including Line, Facebook, Instagram.

^b Official news sources, which includes academic sources from the medical community, news sources from news agency, and news sources from the government.

By multivariate analysis, receiving accurate information from academic sources was associated with changing behavior in hand washing (aOR, 1.44; 95% CI, 1.15–1.8), wearing a mask (aOR, 1.37; 95% CI, 1.05–1.8), and physical distancing (aOR, 1.9; 95% CI, 1.3–3.29) in the community. Similarly, receiving education on infection prevention measures at school led to changing behaviors regarding hand hygiene (aOR, 1.26; 95% CI, 1.1–4.9), wearing a mask (aOR, 1.3; 95% CI, 1.2–2.2), and physical distancing (aOR, 2.3; 95% CI, 1.3–4.1) in the community, while having regular workshop discussions on COVID-19 prevention in school was associated with improved hand washing (aOR, 1.2; 95% CI, 1.1–3.6) and wearing a mask (aOR, 2.1; 95% CI, 1.9–4.7) in the community. Notably, participants who did not report anxiety were less likely to wear a mask (aOR, 0.46; 95% CI, 0.27–0.77) and to practice physical distancing (aOR, 0.72; 95% CI, 0.75–0.95) in the community.

This study has several limitations. The study design was a self-reported online survey. It was conducted at a single center, and sample size was small. Despite these limitations, participants were overwhelmed with emotions, especially anxiety toward COVID-19. However, most of the participants remained confident in the school’s policies to prevent COVID-19. Notably, several infection prevention measures continued to be practiced at suboptimal levels at both school and community settings, whereas changes in several infection prevention behaviors were practiced in the community. Having continuous education particularly focusing on hand washing and physical distancing in school remains critical to improving adherence to both school and community infection prevention measures. Accurate and reliable academic information as well as receiving education on infection prevention measures at school led to changes in 3 new normal behaviors (ie, hand hygiene, wearing mask, and physical distancing). This change likely was due to the increasing awareness by students and teachers towards COVID-19 prevention. Additional studies to evaluate strategies to improve infection prevention practices at schools are needed.