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

Background The Coronavirus disease-19 (COVID-19) infection of severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) has emerged as a recent pandemic, increasing the need for epidemiological studies and studies on public health. Only some studies have evaluated the awareness of medical undergraduates in India and other countries, leading to a lack of literature. Methods This study is a descriptive cross-sectional questionnaire-based study conducted in Kasturba Medical College, Mangalore, India, between June to August 2020. An online survey using Google Forms was circulated among undergraduate medical students in India by a convenient sampling method for data collection. Descriptive analysis was derived based on frequencies and percentages, and the association with age, gender, and year of undergraduate training medical course was derived using the chi-square test. Results Altogether, 630 students from India responded to the survey, with a maximum response from students studying in the second year (38.7%). Nearly 63.85% of responders identified themselves as females. Knowledge regarding the human-to-human transmission of the virus, symptoms, complications, definition of “close contact, quarantine, and its indications was adequate among the students, with more than 70% correct responses. However, one-fourth of the students needed to gain more knowledge about masks. Respiratory hygiene was poor among 24.8%. Nearly 40% of students were unaware of the management of patients with COVID-19. Conclusion There is a need for regular quality training and institutional programs on infection control of COVID-19 and other infectious diseases across all Indian medical colleges to educate undergraduate medical students, who are future healthcare professionals, thus minimizing the risk of transmission and providing standardized care for patients.


Utsav Raj
, All India Institute of Medical Sciences, Raipur, India 2.
Any reports and responses or comments on the article can be found at the end of the article.

Results
Altogether, 630 students from India responded to the survey, with a maximum response from students studying in the second year (38.7%).Nearly 63.85% of responders identified themselves as females.Knowledge regarding the human-to-human transmission of the virus, symptoms, complications, definition of "close contact, quarantine, and its indications was adequate among the students, with more than 70% correct responses.However, one-fourth of the students needed to gain more knowledge about masks.Respiratory hygiene was poor among 24.8%.Nearly 40% of students were unaware of the management of patients with COVID-19.

Conclusion
There is a need for regular quality training and institutional programs on infection control of COVID-19 and other infectious diseases across all Indian medical colleges to educate undergraduate medical students, who are future healthcare professionals, thus minimizing the risk of transmission and providing standardized care for patients.

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. 1The 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.4][5] It has drastically declined the number of new cases. 6However, 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. 6,7Under the worst-case scenario, voluntary recruitment of medical undergraduates as a potential solution for lacking human resources may be beneficial. 2The student's and patient's safety is of significant concern in such emergent circumstances. 8,95][16][17][18][19][20][21][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. 2,8,9The 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.

Ethics
We obtained online written informed consent from all participants and approval from the Institutional Ethics Committee.This study is a descriptive cross-sectional study.An online survey using Google Forms was circulated among 630 medical undergraduate students in India.With an assumption of 50% of the Indian Medical undergraduates having adequate awareness and 10% relative precision, for a 95% confidence interval, the sample size was calculated to be 384.Adding 20% non-response rate, the final sample size came to be 460.A self-administered questionnaire was developed which consisted of socio-demographic questions, 20 questions based on knowledge, 7 questions based on attitude, and 12 questions on practices related to COVID-19 disease. 45The questionnaire underwent content validation and was crafted by drawing from the latest interim guidance and information provided by the World Health Organization (WHO), as of June 12th, 2020.4][25][26][27][28][29][30][31][32][33] The authors approached their colleagues from other institutions throughout the country through whom the medical undergraduates were identified.Social media platforms like Facebook, WhatsApp, Twitter were also used to identify common groups containing medical undergraduates from the country.The survey was circulated through social media by creating a link to the questionnaire.Non-random (convenience and snowball) sampling was done.Undergraduates who were studying in India and willing to participate in the survey irrespective of their age, sex, gender or institution were included in the study.The gender and age of the students were considered based on the responses given by them in the online forms.The online responses were collected over a period of two months duration from 16th June to 15 th August 2020.

REVISED Amendments from Version 1
The validity of the questionnaire is mentioned in the method section with reference.The questionnaire with the option of responses is shared as underlying data on a data repository and the reference for the same is mentioned in the main text as well.Results are presented in Tables and summarized to increase the readability of the article.The discussion has been improvised with a reduction in the number of paragraphs and adequate comparison with similar studies from other countries with appropriate references.The conclusion is given under a separate heading.
We analyzed the collected data using the Statistical Package for the Social Sciences, version 25.Only complete responses were considered for data analysis.Descriptive analysis using frequencies and percentages was done.At the same time, the chi-square test was done for association between KAP concerning age, gender, and year of undergraduate training medical course.

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. 14eyond 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. 344][5][6][7] Therefore, a deeper understanding of medical students' attitudes and practices is necessary to further transmission and potential subsequent waves.5][16][17][18][19][20][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. 19,20Misconceptions 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. 15,16The understanding of "close contact" and home quarantine and its indication was satisfactory among students. 33There 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. 19,38,39e 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. 40Despite 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.
17][18][19][20][21][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. 8Which 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.

Moawia Gameraddin
Taibah University, Al-Madinah, Saudi Arabia I did not find Tables and figures.The results section did not cite the tables and figures.I recommend revising the manuscript to provide the tables and figures, and the citation of them in the results section.

Utsav Raj
Department of Community and Family Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India Methods: Strengths: The methodology and statistical analysis are intricately detailed, bolstering the study's reliability. 1.
The inclusion of references for questionnaire preparation and data availability, elucidating question details and choices, enhances its credibility and ensures its value for future reference. 2.
Results: Weakness (minor): Presenting the results in paragraphs rather than in tabular format diminishes readability for the audience. 1.

Discussion and Conclusion: Strengths:
The discussion adeptly compares and analyses findings in relation to other studies, enriching its depth. 1.
The conclusion underscores the imperative of comprehensive training for healthcare professionals worldwide to tackle unforeseen challenges effectively, advocating for the development of safer and better strategies.

2.
The study holds relevance for a broad spectrum of reader's 3.

Bodrun Naher Siddiquea
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Methods
Please mention about the validity of the questionnaire (tested or not) in the method section.1.
Please clearly mention about options of responses and scoring or of the questionnaire in the method section.

Results
Results presented in Tables and short summary will increase the readability of the article.1.

Discussion and conclusion
Please compare your results with published literature from other countries.1.

Too many paragraphs. 2.
Please write the conclusion under separate heading.

3.
Generally the paper needs proof reading to improve the grammatical errors.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?Partly Are all the source data underlying the results available to ensure full reproducibility?Yes Are the conclusions drawn adequately supported by the results?
Are all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesCompeting Interests: No competing interests were disclosed.Reviewer Expertise: Public heath I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Reviewer Report 07 August 2023 https://doi.org/10.5256/f1000research.143880.r181439© 2023 Siddiquea B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 1 .
Table showing the percentage of student responses for various categories under knowledge, attitude, and practices.
4,41Misinformation 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 Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).Advice on the use of masks in the context of covid-19.Interim uidance; 2020.[Accessed 18 June 2020].
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.Maheshwari S, Gupta PK, Sinha R, et al.: Knowledge, attitude, and practice towards coronavirus disease 2019 (COVID-19) among medical students: A cross-sectional study.J Acute Dis.2020; 9(3): 100-104.[Accessed 16 June 2020].Publisher Full Text 10.World Health Organization: Surveillance protocol for SARS-CoV-2 infection among health workers.WHO; 2020.[Accessed 16 June 2020].Reference Source 41.Lahariya C: Third wave of the COVID-19 pandemic in India: What lies ahead?DownToEarth; 2022.[Accessed 19 January 2022].Reference Source 42.Banarjee C: India world's biggest Covid misinformation source: Study.The Times of India; 2021.[Accessed 19 January 2022].Reference Source 43.Nayak R, Rai S, Jain A: Data table.Epub ahead of print 27 February 2023.