Knowledge, attitude and practices towards COVID-19 among Indian medical undergraduates: a questionnaire-based study

Introduction

The Coronavirus disease-19 (COVID-19), a recent pandemic due to severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) infection caused major health threats worldwide during the year 2020-2021.¹ The disease’s accelerated and extensive geographic spread during the pandemic posed significant challenges for administrative authorities and healthcare professionals.

All healthcare workers have a higher risk of infection due to patient exposure. Although undergraduate medical students are not actively involved in patient care, the possibility of them acquiring and transmitting the disease within healthcare centers and on medical college campuses is high.² Vaccinations like Covishield, Covaxin, Sputnik V, Corbevax, etc., are effectively used in India. Of these, Covishield is the most used, accounting for 81% of the total doses given.^3–5 It has drastically declined the number of new cases.⁶ However, due to new variants like omicron, emerging frequently, and the Peltzman effect in the country, several cities are still facing on-and-off spikes in incidence and mortality rate, which has caused a shortage of healthcare facilities and front-line doctors.^6,7 Under the worst-case scenario, voluntary recruitment of medical undergraduates as a potential solution for lacking human resources may be beneficial.² The student’s and patient’s safety is of significant concern in such emergent circumstances.^8,9

Awareness about the disease, its transmission, risk factors, prevention, infection control, guidelines, and practices during patient care among healthcare workers and students is fundamental to preventing healthcare-associated transmission and infection.^10–13 Studies have been done to assess the understanding of COVID-19 among healthcare workers and the general population in various countries.^14–22 But there are only few studies that have been done evaluating the awareness of medical undergraduates in India, leading to a need for more literature.^2,8,9 The objective of the study is to determine the Knowledge, Attitudes, and Practices (KAP) of Indian medical undergraduate students regarding the COVID-19 pandemic, which can help us to recognize faulty practices and attitudes of the students towards COVID-19. In addition, it can help us plan and review our policies to implement best practices for controlling the COVID-19 disease.

Methods

Results

Six hundred thirty students from various medical colleges in India belonging to different states like Karnataka, Kerala, Tamil Nadu, Hyderabad, Gujarat, Rajasthan, Maharashtra, Madhya Pradesh, West Bengal, Goa etc. responded to the survey. Out of these, we accepted only 618 responses and rejected 12 responses due to incomplete or incorrect answers. Most students were in the second year of their undergraduate training course (38.7%), with the maximum response from students aged 20 years (31.7%). Nearly 63.85% of responders identified themselves as females, and 36.2% identified themselves as males. Most responses were seen from different institutes of Karnataka state, followed by Kerala and Gujarat.

The study surveyed students’ knowledge, attitudes, and practices related to COVID-19 (Table 1). Findings showed that news media was the primary information source for 78.6% of students, with 73.5% receiving hand hygiene training in the past year. Knowledge about COVID-19 varied, with 68.4% correctly identifying the virus as SARS-CoV-2. While awareness of transmission routes was generally high, gaps existed, such as recognizing faeco-oral transmission (7.9%). Symptoms like fever (88.2%) were well-known, but less awareness of diarrhea (20.7%). Understanding of complications varied, with fewer students aware of cardiac (17.5%) and renal complications (12%). Overall, knowledge improved with academic progression and was statistically significant (p<0.05). Attitudes towards seeking medical care were positive, despite stigma concerns. Most students (94.8%) expressed willingness to take a COVID-19 vaccine if available. Additionally, many students (80.3%) were willing to volunteer as healthcare providers with confidence level increasing with academic progression (p<0.05). Practices like hand hygiene were generally followed, although some lapses existed, particularly in respiratory hygiene. Demographic differences were observed, with female students typically exhibiting more cautious behaviors and greater awareness (p<0.05).

Discussion

The emergence of COVID-19, originating in Wuhan, China, posed significant challenges globally in December 2019.¹⁴ Beyond frontline healthcare workers, individuals in healthcare facilities outside clinical settings, including medical students and clerical staff, face exposure risks and potential sources of further infection. Amid India’s pandemic response, medical colleges transitioned to online classes, reverting to on-site courses after the third wave in 2022. After the third wave in 2022, the students were recruited back to the campus for regular on-site courses.³⁴ Despite vaccinations like Covishield, Covaxin, Sputnik V, Corbevax etc. effectively bringing down the overall incidence of cases in the country, some high-alert cities like Delhi and Mumbai experienced sudden surges in patients, especially after re-opening of schools and colleges with a significant mortality rate.^3–7 Therefore, a deeper understanding of medical students’ attitudes and practices is necessary to prevent further transmission and potential subsequent waves. Comprehensive knowledge of COVID-19, including its transmission routes, prevention strategies, identification of high-risk groups, symptomatology, and early isolation of infected individuals is pivotal for effective disease control.^35–37

While students demonstrated awareness of respiratory transmission, other routes like airborne, contact, and faeco-oral transmission were less recognized.^14–21 Although respiratory symptoms were well-known, awareness of atypical manifestations like fatigue, reduced alertness, reduced mobility, diarrhoea, loss of appetite, delirium etc. and complications like, renal failure, shock etc. varied.^19,20 Misconceptions persisted regarding preventive measures, with a notable proportion endorsing ineffective strategies like antibiotics and other myths, like hand dryers, hot water baths, etc. Currently, no specific antiviral treatment is known to be effective in combating the disease.^15,16 The understanding of “close contact” and home quarantine and its indication was satisfactory among students.³³ There was adequate awareness about high-risk groups, such as those over 60, or with underlying comorbidities, smokers, pregnant women, malnourished and immune-compromised which was noteworthy as many resided with the vulnerable group during the pandemic.^19,38,39

The study underscored significant gaps in understanding standardized hand hygiene and respiratory etiquette, critical in curbing transmission. While measures like hand hygiene, mask-wearing, and social distancing were are effective in reducing transmission,²⁰ and widely practiced by the students, there were glaring misconceptions. For instance, many weren’t familiar with proper handwashing techniques for visibly soiled hands or the importance of respiratory hygiene, like using tissues when coughing or sneezing, and their proper disposal. Addressing these shortcomings requires careful attention. Moreover, there were misconceptions about mask types and reuse, potentially risking transmission in healthcare settings. Only half the responders knew respirators were the most effective mask for aerosol-generating procedures.⁴⁰ Despite commendable practices like social distancing during high-case alerts and a willingness among students to volunteer in healthcare, awareness of proper treatment protocols for COVID-19 patients was lacking.

Similar studies in other countries, especially among South Asian countries and India, reveal inadequate COVID-19 knowledge among medical students.^{2,8,9,16–22} Similarly, this study suggests that despite satisfactory awareness, attitude, and practices among the students, there is still scope for improvement. Moreover, in countries like India, where there is an acute shortage of front-line doctors, recruiting undergraduate medical students to serve in the voluntary front-line team against COVID-19 is a reasonable option.⁸ Which further demands effective planning and education to enable better adherence to good practices, including pre-exposure and post-exposure prophylaxis, to prevent the spread of COVID-19. Regular training in infection control, including theory and practical aspects, is imperative to prepare medical teams for unforeseen challenges.

The drawbacks of this study include the less-than-expected response from students and lack of proper representation from the entire country, probably due to selection bias as all the institutions and states couldn’t be approached due to the lack of contact details. Using social media to share the questionnaire and online survey, also limited the study as not all students had social media accounts and well-established internet is not widely available in remote areas of the country.

Conclusion

Three years since the initial outbreak in China, COVID-19’s key characteristics remain uncertain, prompting ongoing research. Vaccines and cures are still in trial phases, with implementation and acceptance requiring time.^4,41 Misinformation provided by spurious organizational bodies and shared on social media amplifies public anxiety,⁴² highlighting the vital role of healthcare workers in disseminating accurate information for infection control and prevention. Adequate knowledge about COVID-19 and updates on various guidelines among healthcare workers play a crucial role in infection control and transmission prevention. Medical students, as accessible sources of information, can bridge the gap between the medical community and society during health crises. But this demands comprehensive policies, educational initiatives, and interactive sessions, orchestrated by administrative authorities, to ensure preparedness for future emergencies.