Dental students and COVID 19: An online multinational survey on perception and knowledge.

Background: Coronavirus is an emerging respiratory pathogen that causes coronavirus disease-2019 (COVID-19), as per the Chinese Center for Disease Control and Prevention. Objective: This study aimed to assess the state of awareness and extent of knowledge about COVID-19 among dental students from India, Pakistan, and Saudi Arabia. Materials and
Methods: The present descriptive cross-sectional study was conducted on 872 participants from December 2020 to January 2021. Random sampling was performed using an electronic questionnaire. One-way analysis of variance and independent sample t-test were performed to assess and compare the mean knowledge score between different demographic data.
Results: Approximately 60% (n = 520) of the responders were women and 40% responders were men (n = 352). The responders were from Saudi Arabia (36.9%; n = 322), India (34.2%; n = 298), and Pakistan (28.8%; n = 252). The difference within the subgroups was statistically nonsignificant (P > 0.05), indicating that dental students of all subparameters possessed equal knowledge on COVID-19. Conclusions: Dental students possess sufficient knowledge about COVID-19, qualifying them at least to work in a medical ward. However, more emphasis must be placed on infection prevention and control policies such as hand hygiene, personal protective equipment, and pre- and postexposure prophylaxis.

INTRODUCTION

According to the Chinese Center for Disease Control and Prevention, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is an emerging respiratory pathogen that is responsible for coronavirus disease-2019 (COVID-19).[1] The currently rampant and global occurrence of novel coronavirus was first reported in Wuhan City, Hubei Province, China. This incidence was documented as a pandemic by the World Health Organization (WHO) on March 11, 2020. The virus is believed to be of zoonotic origin.[234] As of April 13, 2021, more than 137,694,031 confirmed cases and more than 2,973,053 deaths have been reported across 222 countries.[5] According to the WHO, the virus spreads mainly through respiratory droplets that patients cough out or exhale.[6] Although patients with symptomatic COVID-19 have been the vital source of virus spread, current observations recommend that asymptomatic patients in the incubation period could also act as probable carriers of SARS-CoV-2.[78]

To date, only a few antiviral treatments or vaccines for COVID-19 have been suggested. Consequently, the application of preventive measures such as regular, thorough handwashing, maintaining social distancing, and practicing respiratory hygiene to control COVID-19 infection is deemed as the most critical. Owing to the characteristics of hospital settings, the risk of cross-infection is expected to be high among medical practitioners and patients. To help medical practitioners protect themselves, the WHO initiated several online training sessions on COVID-19 in the English, French, Chinese, Spanish, and Russian languages to reinforce awareness and preventive approaches.[9]

Dental students are expected to possess an adequate level of knowledge and sensitivities for the COVID-19 pandemic. Thus, the present study assessed the awareness and knowledge regarding COVID-19 among some dental students in their clinical years from India, the Kingdom of Saudi Arabia, and Pakistan.

MATERIALS AND METHODS

Participants and methods

Design and sampling

A descriptive cross-sectional study was conducted from December 2020 to January 2021 on 872 dental students from Saudi Arabia, India, and Pakistan. Random sampling in the form of an electronic questionnaire was performed. The estimation of the sample size was performed using the formula, n = P (1 − P) Z2/d2, assuming an unknown prevalence of 50%, Z = 1.96, d = 0.05, confidence level (5% margin of error) =95%, and power = 80%. The calculated sample size for this study was hence 872.

Inclusion and exclusion criteria

The consecutive samples of all male and female students were sourced from Saudi Arabia, India, and Pakistan. The age of the students ranged from 18 to 40 years. The study population consisted of dental students pursuing a bachelor's degree in dental surgery from different universities across the three countries. Participants who did not answer all these questions were excluded from the study.

Data collection and measures

A closed ended questionnaire comprising multiple-choice questions in the English language was employed for data collection. Sociodemographic data (including name, age, sex, nationality, educational level, region, and income) and disease knowledge (including the mode of infection, clinical picture, methods of control, and sources of information) were evaluated through the questionnaire. The possible responses regarding disease knowledge were classified as “correct,” “incorrect,” and “I do not know.” For a “correct” response, 1 point was assigned, whereas for both “incorrect” and “I do not know” responses, 0 point was assigned. High scores of the respondents denoted their greater knowledge. The questionnaire was reviewed and validated by three experts in the fields of microbiology, internal medicine, and biostatistics.

A pilot study was conducted on a group of 115 people to ensure the applicability of the questionnaire as well as to estimate the time frame required to complete the questionnaire. The questionnaires were distributed electronically through social media applications, such as Facebook, Twitter, Instagram, and WhatsApp. All the questionnaires were attached with a greeting letter that detailed the purpose of the study and informed the participants that their participation was optional and that they had the right to withdraw from the study at any stage.

Ethical approval

The study was conducted after institutional ethics clearance (REC12/2020).

Statistical analyses

Data entry and analysis were performed using SPSS version 21 (SPSS Inc. Armonk, NY, USA). Descriptive statistics were used to describe all the variables. The mean and standard deviation were employed to identify the mean scores of the different studied domains. The Chi-square test was applied to measure differences between the groups. P < 0.05 was considered to be statistically significant. One-way analysis of variance and independent sample t-test were applied to compare the mean knowledge score between different sets of demographic data.

RESULTS

A total of 872 health-care dental students studying in Saudi Arabia (36.9%; n = 322), India (34.2%; n = 298), and Pakistan (28.8%; n = 252) responded to the survey. The majority of the responders belonged to the age group of 24–26 years (n = 294), with nearly 80% of the students pursuing virology or clinical microbiology as one of the subjects. Approximately 60% (n = 520) of the respondents were women and 40% of the respondents were men (n = 352). Most of the students acquired information on COVID-19 through the respective official government websites (43.6%) and social media applications (42%). Among the various subgroups of educational status, 55.9% (n = 448) of fourth- and fifth-year students, 25.6% (n = 224) of the internship students, and 18.3% (n = 160) of the first-, second-, and third-year students completed the survey [Table 1].

Table 1

Distribution of subject (n=872) demographics and comparison of the knowledge status about coronavirus disease-2019 related to different subparameters of the student population

Demographics	Frequency (%)	Mean	SD	SE	P
Sex#
Female	520 (60)	71.3	19.6	5.1	0.805
Male	352 (40)	69.6	17.5	4.5
Age groups (years)
18-21	150 (17)	64.9	22.3	5.8	0.317
21-23	262 (30)	65.7	19.3	5.0
24-26	294 (33)	76.4	16.2	4.2
27-29	166 (19)	71.8	18.5	4.8
Educational status
First to third year	160 (18.3)	66.35	22.4	5.8	0.85
Fourth to fifth year	488 (55.9)	69.8	20.1	5.2
Internship	224 (25.6)	73.8	15.9	4.1
Study of virology or clinical microbiology#
No	160 (18)	65.3	24.2	6.3	0.392
Yes	712 (80)	71.9	16.4	4.2
Source of information on COVID-19
News channel	112 (12.7)	74.8	12.9	3.3	0.173
Government websites	384 (43.6)	70.0	19.2	5.0
Social media	376 (42)	70.2	18.9	4.9
Country of origin
Saudi Arabia	322 (36.9)	66.3	23.7	6.1	0.372
India	298 (34.1)	67.8	19.1	4.9
Pakistan	252 (28.8)	73.3	28.7	7.4

*Statistical significance set at 0.05, #Independent sample t-test. COVID-19=Coronavirus disease-2019, SD=Standard deviation, SE=Standard error

The overall observation suggested that the students possessed moderate knowledge (69.8%) on the general information, prevention, complications, diagnosis, transmission, and treatment aspects of COVID-19. The students were found to possess adequate information on the high-risk groups (93.8%), incubation period (92.9%), lethal complications (92%), and suspected animal carriers of COVID-19 (83.9%), while they displayed poor knowledge in the field of Ro (R Knot) of the disease (41.1%), effective medication (42%), and disease distribution in the world (48.2%) [Table 2].

Table 2

Percent of correct responses by the students on the awareness about coronavirus disease-2019

Question number	Questionnaire	Percentage
Q1	What type of a virus is COVID 19?	67.9
Q2	What is the most likely route of spread/transmission for the COVID-19 virus?	70.5
Q3	As of December 3, 2020, which country has the highest number of COVID-19 cases?	48.2
Q4	Which one of the following is a potentially effective medication that is currently under trial for the treatment of COVID-19?	42
Q5	Which one of the following tests is currently being used for the laboratory diagnosis of COVID-19?	65.2
Q6	Which one of the following is the most effective way to protect oneself from COVID-19?	75
Q7	Which one of the following is the best sample type for the lab diagnosis of COVID-19?	72.3
Q8	Which one of the following group is at an increased risk of developing medical complications caused by COVID-19?	93.8
Q9	Which number accurately reflects the case fatality rate of COVID-19?	75
Q10	What is the known incubation period of the COVID-19 virus?	92.9
Q11	Which one of the following is the most common and lethal complication of COVID-19?	92
Q12	COVID-19 is suspected to be carried and transmitted by one of the following animals:	83.9
Q13	People in which one of the following occupations are at a higher risk for getting infected by COVID-19?	56.3
Q14	What does the Ro (R knot) of disease indicate?	41.1
Q15	Genetically, the COVID-19 virus is closely related to which of the following viruses?	71.4
	Overall knowledge	69.8

COVID-19=Coronavirus disease-2019

The male participants possessed better overall knowledge about COVID-19 than the female participants; however, the female participants displayed better knowledge in the fields of medication use (Q4), prevention (Q6), sampling for diagnosis (Q7), high-risk populations (Q8), and incubation period (Q10). The participants in the age group of 24–26 years displayed higher overall knowledge about COVID-19, whereas those in the age group of 27–29 years displayed better knowledge on the sampling for lab diagnosis (Q7), incubation period (Q10), lethal complication (Q11), and resemblance of the virus (Q15). The participants in the age group of 18–20 years displayed greater knowledge related to disease severity (or the case fatality rate) (Q9). Pakistani students exhibited 100% knowledge regarding the diagnostic tests used (Q5), high-risk population (Q8), disease severity (the case fatality rate) (Q9), incubation period (Q10), lethal complications (Q11), suspected animal carriers (Q12), and high-risk occupations (Q13) of COVID-19. The Indian students expressed better knowledge concerning the mode of transmission (Q2) [Table 3 and Graphs 1-3].

Table 3

Percent of correct responses by students of different sex, age groups, and nationalities

Question number	Percent with the correct answer
	Sex		Age group (years)				Nationality
	Female	Male	18-21	21-23	24-26	27-29	Saudi Arabia	India	Pakistan
Q1	68.2	68.2	63.2	60.6	75.7	71.4	64.1	66.7	33.3
Q2	65.2	79.5	84.2	57.6	86.5	52.4	64.1	77.8	33.3
Q3	45.5	52.3	42.1	42.4	54.1	52.4	48.7	47.2	66.7
Q4	47	36.4	31.6	36.4	51.4	47.6	25.6	44.4	66.7
Q5	65.2	65.9	52.6	60.6	73	71.4	51.3	63.9	100
Q6	81.8	65.9	73.7	60.6	86.5	81	82.1	52.8	66.7
Q7	81.8	59.1	68.4	57.6	78.4	90.5	53.8	77.8	66.7
Q8	95.5	93.2	89.5	97	97.3	90.5	94.9	94.4	100
Q9	65.2	90.9	84.2	78.8	78.4	57.1	87.2	66.7	100
Q10	93.9	93.2	94.7	90.9	91.9	100	100	88.9	100
Q11	90.9	95.5	84.2	93.9	94.6	95.2	94.9	94.4	100
Q12	78.8	93.2	78.9	84.8	89.2	81	89.7	77.8	100
Q13	50	65.9	26.3	54.5	70.3	61.9	56.4	38.9	100
Q14	43.9	38.6	36.8	42.4	43.2	42.9	33.3	41.7	33.3
Q15	71.2	71.7	63.2	66.7	75.7	81	48.7	83.3	33.3
Overall knowledge	69.6	71.3	64.9	65.7	76.4	71.8	66.3	67.8	73.3

Graph 1

Distribution of overall knowledge on coronavirus disease-2019 among students of different nationality

Graph 3

Distribution of overall knowledge on coronavirus disease-2019 among students of different age groups

Distribution of overall knowledge on coronavirus disease-2019 among students of different sex

The internship students showed greater overall knowledge about COVID-19, whereas the first- to third-year students displayed greater knowledge about the disease distribution status across the world (Q3). Of the 872 students, 39.4% of students were aware of the medications under trial (Q4), and the fourth- and fifth-year students displayed greater knowledge related to the disease severity (or the case fatality rate) (Q9). Moreover, news channels were found to deliver a more correct answer to the global disease distribution situation across the world (Q3), and Ro (R Knot) of a disease (Q14) was compared with official government websites and social media. The students pursuing study on virology or clinical microbiology exhibited greater knowledge about COVID-19, whereas those who did not study virology or clinical microbiology displayed greater knowledge related to the sample types used for diagnosis (Q7), incubation period (Q10), lethal complication (Q11), suspected animal carriers (Q12), and high-risk occupations (Q13) for COVID-19 [Table 4 and Graph 4].

Table 4

Distribution of the correct responses by students with different education levels, source of information, and differences in having studied virology

Question number	Percentage with the correct answer
	Education level			Source of Information			Study of virology
	First to third year	Fourth and fifth year	Internship	News channel	Official government websites	Social media	No	Yes
Q1	59.6	65.5	78.6	57.1	66.7	72.3	65	68.5
Q2	76.25	72.2	64.3	85.7	75	63.8	60	74.2
Q3	68.7	35.95	60.7	57.1	54.2	42.6	25	53.9
Q4	39.4	42.45	46.4	64.3	33.3	44.7	25	47.2
Q5	42.9	68.7	71.4	78.6	60.4	66	55	67.4
Q6	70.7	68.75	92.9	85.7	79.2	68.1	70	76.4
Q7	58.55	68.75	89.3	78.6	77.1	66	75	71.9
Q8	94.45	96.75	89.3	92.9	95.8	95.7	95	95.5
Q9	69.7	81.95	67.9	71.4	72.9	80.9	75	76.4
Q10	100	93.5	89.3	85.7	95.8	95.7	95	94.4
Q11	89.9	93.5	92.9	85.7	91.7	97.9	95	93.3
Q12	84.35	83.6	85.7	85.7	83.3	87.2	90	84.3
Q13	30.3	63.75	57.1	57.1	47.9	66	70	53.9
Q14	44.95	37.85	50	57.1	41.7	38.3	30	44.9
Q15	65.15	73.6	71.4	78.6	75	68.1	55	76.4
Overall knowledge	66.3	69.7	73.8	74.8	70.0	70.2	65.3	71.9

Graph 4

Distribution of overall knowledge on coronavirus disease-2019 among students of different education levels, different sources of information, and study of virology

The difference between the subgroups was found to be statistically nonsignificant (P > 0.05), indicating that dental students possessed equal knowledge of different subparameters related to COVID-19.

DISCUSSION

A few studies conducted over the recent past have attempted to determine the awareness status regarding coronavirus among dental and medical students. Nevertheless, our literature search did not reveal any study on the comparative assessment of the level of awareness regarding COVID-19 in medical students across the Asian and Middle Eastern countries simultaneously.

The present study focused on the awareness status regarding COVID-19 across different countries, with a major focus on India, Saudi Arabia, and Pakistan. The average incubation period determined through research has been estimated to be approximately 14 days.[1011] Health-care professionals must ideally be aware of the incubation period considering its vital role in the control of the source of infections. The present study indicated that a majority of the dental students had a high level of understanding regarding the incubation period of the COVID-19 virus [Table 3]. Furthermore, the students displayed knowledge regarding the signs and symptoms of COVID-19 as well as the complications related to the disease that could lead to mortality. Most of the dental students also possessed knowledge regarding the transmission and population who are at a high risk of infection and mortality [Table 4]. However, Indian and Pakistani dental students were found to possess a slightly greater amount of knowledge regarding the aforementioned areas of COVID-19 than the students from Saudi Arabia; however, this difference was found to be statistically nonsignificant. The students from Pakistan exhibited a lower amount of knowledge regarding the available treatment options and diagnosis of COVID-19 than the students from Saudi Arabia and India. This difference could be attributed to the fact that several antivirals are currently under trial. However, to the best of our knowledge, no high-quality randomized controlled trial with a low bias definitively supporting an established antiviral or immunomodulation therapy has been recently published.[121314] Another area where most of the students showed a lack of knowledge was the transmissibility of the COVID-19 disease, and only 41% of the students displayed better knowledge regarding the R knot of the disease. Recent studies conducted by Quadri et al.,[15] Al Jasser et al.,[16] and Kanaparthi et al.[17] have concluded that the awareness status of dental students about COVID-19 is satisfactory.

Although the situation of the pandemic is difficult, several countries have resorted to setting up special hotlines and dedicated websites to disseminate accurate information about the pandemic.[1819] It was identified that many students still need to resort to social media to obtain information regarding COVID-19. Social media platforms such as Facebook, Instagram, Snapchat, and YouTube have contributed to the abundant misinformation and myths regarding the virus. The present study showed that a significant proportion of students (42%) used social media to obtain information related to COVID-19,[2021] which could be one of the main reasons for the low level of knowledge related to COVID-19 in certain areas. Overall, both the male and female students showed an almost equal level of knowledge regarding COVID-19. The knowledge level was satisfactory in both the gender and age groups. The level of knowledge displayed by the participants in the present study was similar to that reported in a study conducted in India by Modi et al., who demonstrated that medical students had satisfactory knowledge about COVID-19.[22]

CONCLUSIONS

Dental students and interns have sufficient knowledge about COVID-19, qualifying them at least to work in a medical ward. However, special emphasis must be placed on awareness regarding viral infections in the academic and clinical curriculum of dental students to further raise the level of their awareness toward the threats faced by public health infrastructure due to the presence of different viral infectious diseases with a higher rate of morbidity, mortality, and virulence. In the current situation, more emphasis must be placed on infection prevention and control policies such as maintaining hand hygiene, use of personal protective equipment, and pre- and postexposure prophylaxis. Newer interventions such as the use of antivirals should be rapidly utilized as soon as these medications prove to have a strong efficacy against COVID-19-positive patients. We believe that further studies with larger samples and involving dental students from different academic years and countries can further strengthen the findings of the present study.

Financial support and sponsorship

This project is funded by the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA.

Conflicts of interest

There are no conflicts of interest.