Evaluation of knowledge, attitude and practice towards corona virus disease 2019 (COVID-19) among second year medical students in post lockdown period: A quick online questionnaire based study

1 Post Graduate Student in Pharmacology, MGIMS, SEVAGRAM 2 Associate Professor, Department of Pharmacology, MGIMS, SEVAGRAM 3 Director Professor and head, Department of Pharmacology, MGIMS, SEVAGRAM Conflicts of Interest: Nil Corresponding author: Ashishkumar Baheti DOI: https://doi.org/10.32553/ijmsdr.v4i12.722 Abstract: Background: The year 2019–2020 has seen a worldwide pandemic resulting from corona virus disease 2019 (COVID‐19), which can result in illnesses ranging from the common cold to severe acute respiratory syndrome (SARS). Hence, this global health crisis of COVID‐19 pandemic offers a unique opportunity to evaluate knowledge, attitude, and practice among medical students. Methods: This prospective, web‐based, cross‐sectional study was conducted among 100 undergraduate medical students after obtaining informed consent during first week of August 2020 using a 37-items structured questionnaire based on the Ministry of Health and Family welfare course materials and was distributed using Google forms. All the tests were performed at a significance level of 5%. Results: Overall, the study participants’ knowledge regarding COVID‐19 was satisfactory they have positive attitude and they followed healthy preventive practices also. There was no significant difference found among male and females in knowledge and practice however attitude score was affected by gender. Conclusions: Most medical students had satisfactory knowledge levels, and discrepancies in the perceptions of COVID‐19, thus, with adequate training and counseling undergraduate medical students via structured teaching program, most medical students can act as a potential reservoir to fill the gaps in health‐care services in the hour of need.


Introduction:
COVID-19 also known as coronavirus disease 2019 is an infectious disease caused by a new, recently discovered novel Coronavirus(1). This new virus and the disease were unknown before the outbreak began in Wuhan, China, in December 2019. It was responsible for serious illness and numerous deaths in china. The scope of this outbreak is unclear at present and the situation is rapidly evolving still now (2). COVID-19 causes respiratory illness with main clinical symptoms such as a dry cough, fever and in more severe cases, difficulty in breathing. In the past, multiple epidemic outbreaks occurred like SARS in 2002 resulting in 800 deaths and Middle East respiratory syndrome (MERS)-CoV in 2012 resulting in 860 deaths. (3)(4) COVID-19 is a highly contagious disease and has spread very quickly. In China only there were 50,054 laboratoryconfirmed cases and 1524 deaths by 15 February 2020 and had reached 25 countries. (5) China has taken firm infection control measures by isolating the exposed and suspected cases according to international standards. China is also constantly updating the diagnosis, treatment process and carrying out public education (6). On 11 March 2020, WHO changed the status of the COVID-19 emergency from public health international emergency (30th January 2020) to a pandemic. The fatality rate of the current pandemic is on the rise (2%-4%), relatively lower than the previous SARS-CoV (2002) and MERS-CoV (2012) outbreaks (7).
The first case of COVID-19 in India, which originated from China, was reported on 30 January 2020. As of 8 June 2020, the MoH & FW has confirmed a total of 256,611 cases, 124,430 recoveries (including 1 migration) and 7,200 deaths in the country.(8) After a 14hour voluntary public curfew named as 'Janta Curfew' on 22 nd March, India immediately announced the implementation of a nation-wide complete lockdown for 21 days (i.e. from 25th March to 14th April 2020), which only allowed essential services to operate over the entire 130 million population of India (8). Further centre extended the lockdown till 31 May(9)(10). This pandemic has increased workload on the healthcare system in all over the world. Following preventive measures is the most important step in order to prevent the spread of disease as no specific vaccine or drug found still now. (11) Guidelines for the prevention and control of COVID-19 for health-care workers were published by the WHO and Ministry of Health and Family welfare and they have also initiated several online training sessions and materials on COVID-19 in various languages.
Thus this COVID-19 pandemic offers an unique opportunity to evaluate knowledge, attitudes, and practices (KAP) towards COVID-19 among medical students.
Several studies have shown that the KAP level in individuals is associated with effective prevention and management of illness and promotion of one's own health. On the contrary, deficiencies in KAP are linked to poor health and maladaptive disease preventive behavior.(12)(13)(14) Therefore, we conducted a survey to investigate the Knowledge, Attitude and Practice towards COVID-19 among the second year medical students of a government medical college during the post lockdown period of the COVID-19 outbreak in Maharashtra.

Study setting and design:
This online, Cross sectional study was carried out at Mahatma Gandhi Institute of Medical Sciences, Sevagram in Wardha district of Maharashtra, India during the 1 st week of August 2020.

Study population and sample size:
The study participants included 100 Second year MBBS students of 2017 batch. The study participants were informed about the details of the study objectives for filling the questionnaire and confidentiality and informed consent was obtained from each participant and and anonymity and confidentiality of the participants was maintained.

Study tool:
A self-designed questionnaire was prepared. The questions established on the basis of some published literature (15) (16) (17) and from the MoHFW i.e. Ministry of Health and Family Welfare website (18) and the authors' experience of KAP.
The study questionnaire comprised four sections containing 37 items. Section 1 had two items that explored the demographic information of respondents like age and gender. Section 2 comprised 17 questions and aimed to gather students' in depth knowledge about COVID-19 including symptoms, route of transmission, high risk groups, treatment, vaccination, preventive measures for COVID-19. Section 3 comprised 6 questions and aimed to evaluate students' attitudes about COVID-19. Section 4 comprised of 12 questions and aimed at evaluation of students' practices for prevention of COVID-19 including washing hands, using personal protective equipments, carrying hand sanitizer, social distancing and travelling. These questions were responded on a true/false basis with an additional "I don't know" option. The true answer was assigned with 1 point and false/I don't know answers were assigned with 0 point. Higher scores represented a better knowledge of COVID-19. Similar options were assigned for the questions related to attitude while only two options namely 'Yes' and 'No' were assigned for the questions related to practice towards COVID- 19. After the preparation of the questionnaire, it was sent to some experts to consult their opinions regarding the validity of the questionnaire followed by a small pilot study to test its simplicity and difficulty. The questionnaire was distributed using Google Forms.

Data collection:
The data was collected using Google form platform as an online survey. Participation in this survey was voluntary and was not compensated. Informed consent was obtained from each participant prior to participation. students were approached and recruited through social networking websites (Gmail, WhatsApp), and the survey links were posted on the same. The study participants were informed about the details of the study objectives for filling the questionnaire and confidentiality at the beginning of the survey, and informed consent was obtained from each participant. It has been disclosed to all the participants that their identity will keep confidential and the results will be used only for research purposes. The participants were given a week's time to voluntarily complete the questionnaire and those does not respond back to the questionnaire within defined time and reminders were declared as dropouts and were not included in the data analysis.

Data analysis:
The collected data were tabulated and analysed using Microsoft excel worksheet. Measurement data were expressed as mean±SD and categorical data were expressed as frequency and percentage. Parametric tests (t and ANOVA) were used for comparison between different subgroups of the participants pre-intervention. Comparisons of KAP scores among the students with respect to gender and age-category are done using independent samples t-test and one-way analysis of variance (ANOVA), as appropriate. The statistical significance level of the test was expressed as α=0.05.

Demographic characteristics:
Frequency and percentage of all the demographic characteristics like gender and age are represented in Table  1. Out of the 100 participants, 60% were males while the rest were female (40%); 53% of them were between 18-20 years old while 47% were > 20 years old. Females were relatively younger than males though there was no significant difference in age of males and females (P > 0.05) The results of the knowledge survey are presented in    Practice:  Analysis of KAP scores with respect to demographic characteristics Table 5 describes the scores of knowledge, attitude, and practices towards COVID-19 with respect to demographic variables such as gender and age. The knowledge scores of both males and females were equal and there was no significant difference (P>0.05).
Higher scores of females were observed in the attitude as compared with that of males. In addition, the difference in attitude score was significant (P<0.05). Practice score was slightly higher in males as compared to females but the difference was not significant (P>0.05).
Secondly, the Knowledge score among different agecategories was almost equal. While attitude score was higher among <20 age group than the other category, with no significant difference among groups (P>0.05). Practice score was higher among >20 age group though the difference was not significant (P>0.05). In the present study no significant difference was found in mean knowledge scores with respect to all demographic variables i.e. age and gender. But gender played a significant role in mean attitude scores. Practice score was higher in males which shows that practice is affected by gender and this result is similar to the studies conducted in China, which also reported that practice scores were affected by gender (17)(22). It is worth mentioning that sufficient COVID-19 knowledge scores, positive attitude, and adequate practice were found among the students.
Considering that the present study assessed only two demographic variables, so it is recommended that more demographic factors should be included in further studies.
Our study shows that the results are very positive towards KAP. But this study was performed among medical students and not general population so we still have some suggestions for both the government and residents of India as well: (1) The importance of frequently washing hands with sanitizershould be emphasized more; (2) Avoiding crowded places and unnecessary travelling and outing (3) wearing masks regularly.
Consequently, health promotion activities are vital in improving KAP towards COVID-19. Positively, In the near future, India will be able to tackle COVID-19 through joint efforts of the Indian governments and all Indian residents.
The major limitation of the present study is that the sample sizes are limited to the students of a government medical college, and hence the results based on the used sample sizes could not be generalized to all the populations of Maharashtra and India as well, although it can certainly help the state and the country to enhance the awareness regarding KAP in the general population. Due to the questionnaire being self-answered by the participants, there is also a high chance of errors or misrepresentation of information. Less demographic variables is also a limitations. In view of these, more studies should be conducted in the near future to investigate the KAP for COVID-19 at various states and countries.

Conclusion:
Most medical students had satisfactory knowledge levels, positive attitude towards COVID-19 and they had adequate practices also. Though there are some discrepancies in the perceptions of COVID-19, thus, with adequate training and counseling medical students via structured teaching program, most medical students can act as a potential reservoir to fill the gaps in health-care services in the hour of need.