A cross-sectional survey of knowledge and practices toward COVID-19 among medical students in Northern Sri Lanka

The COVID-19 pandemic has created a significant threat to global health, economy and psycho-social life. It is a highly contagious disease transmitted mainly via human to human interactions. As such, control of the pandemic mainly depends on preventive strategies and safe practices. This study is aimed at assessing the knowledge and practices of medical students of the Faculty of Medicine, University of Jaffna, towards the COVID-19 pandemic. A cross sectional study was conducted among the medical students using a self-administered questionnaire to assess knowledge and practices. Analysis was done using SPSS 26. Of 431 students, the majority (81.4%:95%CI:77.6-84.8%) answered more than 80% of the questions correctly. The most popular source for information on COVID-19 was social media (86.3%) followed by news media (63.8%). The majority of the participants (85.4%) reported they adhered to more than 80% of correct practices assessed in this study. However, only35.5% of students attended any of the lectures/discussions on the COVID-19 pandemic held at the university and only 37.1% reported they had infection control training during their career. Organized usage of resources and infection control training, specific to COVID-19 pandemic could be used to fill the gaps in knowledge and practices further.


Introduction
"Corona virus disease 2019" (COVID-19) is a respiratory illness caused by a novel corona virus (SARS-CoV-2), which was first identified as an outbreak of respiratory illness in Wuhan City in China. 1 It quickly spread in China, followed by increasing number of cases in other countries throughout the world. The World Health Organization (WHO) declared this outbreak as a public health emergency of international concern (PHEIC) on 30 th of January 2020 and a pandemic on the 11 th of March 2020. 1,2 In Sri Lanka, the first imported case of COVID-19 was identified on the 27 th of January 2020. On the 10 th of March 2021, a Sri Lankan national was confirmed with COVID-19 for the first time. 1 In spite of implementing different preventive measures, a second wave started from a cluster of cases in October 2020.
The dominant mode of transmission of this virus is through respiratory droplets and an infected person can spread the virus while coughing, sneezing, or talking. The incubation period of COVID-19 is 2-14 days, with 80% of infected persons developing mild or no symptoms. The main symptoms are cough, fever, shortness of breathing, tiredness, body ache, loss of taste and smell, and loose bowel movements. More adversely, infection leads to respiratory failure, sepsis, and kidney failure. 3,4 There is no proven antiviral treatment. However, since December 2020, newly developed vaccines were introduced which many countries, including Sri Lanka started to provide to their population.
During the initial days of the pandemic, despite the closure of universities, many medical students actively volunteered in their communities to provide medical assistance and support to overcome the lockdown related crisis. With time, the Sri Lankan government opened the higher educational centres and clinical students were therefore expected to continue with their clinical clerkship programs with an almost equivalent risk to other healthcare staff. Medical students also participated in health education of the patients and were expected to have a clear understanding about the pandemic. Assessing the knowledge and practices among various subgroups, including medical students is needed. This study presents data on assessment of knowledge and practices regarding COVID-19 amongst medical students at the University of Jaffna, Sri Lanka.

Study design and setting
This is a descriptive cross-sectional study, conducted from August to September 2020, in the Faculty of Medicine, University of Jaffna. During the study period, the faculty had a total of 820 undergraduate students from six batches.

Sample size determination and procedure.
As there was no similar study on medical students in Sri Lanka, the sample size was calculated based on studies from other countries (60-86%) [5][6][7][8] and the minimum required sample size was 425. The latest enrolled students' name list was obtained from the Dean's office. Stratified random sampling was used to select 431 students from all batches using this list. From each batch name list every other student (820/425=1.93 ---2) was selected. The first student was selected randomly, either starting from the first or second name in the list. The students were informed about the study and the voluntary nature of participation. Informed written consent was obtained.

Study variables:
Knowledge and practices were assessed as independent variables. In addition, details such as gender, clinical stage year, religion, participation in any infection control programme or attendance at any COVID-19 lectures and the main source of information on COVID-19 were assessed.

Study instrument and techniques
A self-administered questionnaire, prepared by the investigators (created based on the WHO study materials and previous studies) 7-8 was used for data collection. Questions covered demographic data (6 questions), assessment of participants' knowledge (16 questions) and practices regarding COVID -19 pandemic (20 questions). Each question was given 3 options namely "Yes" "No" and "Do not know/No Opinion". The contents of the questionnaire were assessed by general physicians and public health personnel for consensual, face and content validity and improved using their feedback.

Data processing and Analysis
The data collected was entered in an EXCEL sheet, transferred to and analysed using SPSS 26. Descriptive analysis was mainly based on frequencies and percentages. Confidence Interval (CI) was calculated for percentages where appropriate. The knowledge level was compared between the students according to the different stages in their career (pre-clinical, para clinical and clinical). Pre-clinical was defined as students in the first two years who are not required to attend teaching hospitals and who follow basic medical science subjects such as anatomy, physiology, and biochemistry. Para clinical students do their clinical clerkship in hospital in the morning and follow para clinical subjects such as pathology, microbiology, parasitology, and community medicine in the afternoon. In addition, para clinical students have community-based field visits as part of the course in Community Medicine. Clinical students spend most of their time in the wards and clinics of the Teaching hospital Jaffna and have direct contact with patients. Comparison of those with correct knowledge (more than 80% of the time) and those without were analysed using the Chi square test to identify differences between students in the three clinical stages (Table 2).

Results
Background characteristics: For this survey, 431 medical students at different stages of training were interviewed. The basic characteristics of the students are summarized in Table  1.The majority of students were female (54.6%) and belonged to the Hindu religion (52.0%). There were 76 students (17.6%) in their first year of training and 15.1% in the final year of their career. Interestingly, 64.5% had not attended any lectures or discussions on the COVID-19 pandemic prior to the study period. Only 37.1% reported that they had received any kind of infection control training during their career. Knowledge towards the COVID-19 pandemic Most of the students (81.4%:95%CI:77.6-84.8%) answered more than 80% of the questions correctly. The response to key knowledge assessment questions according to the different clinical stage category of students are summarized in Table 2. The median number for correctly answered questions to assess knowledge was 14 (87.5%) of 16 questions (Range 3-16 questions).
Only 67.5% of students correctly identified the name of the virus causing COVID-19 as SARS-COV-2 and 62.2% stated that COVID-19 infection can be transmitted by eating or contact with animals. This proportion was less among para clinical students (51.5%) compared to pre-clinical students (71.0%) and increased again in the clinical years (66.9%) (P-0.002).

Source of information regarding COVID-19
Students were asked to name the main source of their information on COVID-19 infection including prevention and control. All four main sources, news media, social media, health professionals and health organization such as MOH and RDHS offices and family and friends were used by 120 students (27.8%). The most popular source was social media (86.3%) followed by news media (63.8%), family and friends (54.5%) and government health organizations website and relevant scientific article (52.2%).

Assessment of practices.
Of 20 practices assessed, the majority (85.4%: CI: 81.8-88.5) of participants reported they adhered to more than 80% of the correct practices aimed at preventing COVID-19. For example, 97% reported wearing face masks. Similarly, other practices such as washing hands regularly with soap and water (96.1%), respiratory etiquette practice (92.6%), staying at home when sick (94.8%) and social distancing 94.4% also were high among them (Table 3).

Discussion
Even after vaccination, continued adherence to correct practices are essential to prevent the spread of COVID-19. Assessment of knowledge, attitude and practices among the general public and health care personnel is therefore vital to improve the overall pandemic control.
The involvement of medical students in patient care and clinical activities causes significant risk of disease transmission among them. Clinical students have direct contact with patients and should have adequate knowledge to educate them. However according to our analysis, only 37.5% of the students attended COVID-19 education programs and only 37.1% had infection control training throughout their career at the time of the survey even though IPC (Infection Prevention Control) guidelines are part of their curriculum during the para clinical years.
In this study, more than 80% of the students correctly responded to the questions on mode of transmission and incubation period. However, only 67.5% of the study sample knew the name of the virus (SARS-CoV-2). Knowledge on clinical features, treatment and prevention was higher at 70-95%. These findings are similar to the study done in Iran 6 , which showed that almost 89.96% of candidates had positive knowledge on the COVID-19 pandemic. Similarly, high levels of basic knowledge were reported among university students in Japan, particularly on hand washing and mask wearing. Further, 96.4% of the Japanese University students showed positive knowledge regarding avoiding crowded places 9 similar to findings in the current study which showed that 96.1% of medical students avoided public gatherings to reduce the risk of infection. When comparing medical students at different stages of training, more clinical students (96.0%) answered correctly for availability of antiviral treatment compared to preclinical (87.5%) or para clinical students (95.5%) (P0.022). However, with regard to hand washing and wearing face masks, more pre-clinical students answered correctly compared to para-clinical and clinical students (P>0.05).
Student responses towards correct practices, were also very positive, with most students practicing appropriate measures to prevent the spread of infection. Similarly, a study done in Pakistan among 358 university students reported high level adherence to key preventive practices toward Covid-19 such as hand washing with soap and water (90.9%), avoiding crowded places (88.1%) and avoiding patients who exhibit symptoms (93.2%). 10 These findings are also consistent with studies done on medical students in Jordan, India and Afghanistan. 5,11,12 This understanding about safe practices by medical students provides additional benefit to the society as it can reflect directly on the general public.
The majority (86.3%) of students in the current study used social media as their main source of information on the pandemic. A study conducted among 422 MizanTepi University students in Ethiopia revealed that 57.2% used social media for COVID-19 information. 8 Similar findings were observed in a study done in Turkey in 2010 among University students during the Influenza A H1N1 pandemic which reported social media (72.1%), followed by the internet (19.9%) and (8.0%) from health personnel, as the main sources of information. 13 Similarly, among medical students and non-medical students in Jordan, the main source of information for COVID-19 was social media (34%), followed by the WHO (19.9%), television (17.6%), internet (13%), Ministry of Health (10.1%) and friends (5.4%). 14 Even though the majority of students reported overall positive knowledge, 273 students (62.2%) in the current study, responded that those who eat, or have contact with animals can contract COVID-19 infection. Similarly, in a study among 354 medical students in India, 44.4% showed the same kind of confusion. 11 In the current study, the proportion who believed this was significantly higher (P-0.002) among pre-clinical students (71.0%), compared with para-clinical students (51.5%), and clinical students (66.9%). This confusion could be due to confusing messages from social media. Social media users who post messages have a responsibility to communicate correct facts and regulators at country level as well as owners of social media platforms should ensure accuracy of such posts. It is also crucial that government responses should use the social media platform to counteract inaccurate information and to spread accurate and reliable facts. 15 Such belief and gaps in knowledge can be rectified through organized training or lectures regarding COVID-19, in addition to infection control training in the early stages of a pandemic, as our findings showed that two thirds of students had not attended any COVID-19 related training at the time of being interviewed.

Limitations
This study was conducted among medical students at the University of Jaffna. Generalising findings to other medical or non-medical students at other universities need caution as cultural background and their courses of study need to be taken into consideration. Further studies on assessment of attitude and practices of students would be useful, in particular as some practices such as avoiding public transport can be assessed only in a local setting.

Conclusion
This study showed that the majority of medical students had adequate knowledge and followed correct practices towards the COVID-19 pandemic. The most popular source for information in this cohort was social media. The majority of students had not attended any lectures or discussions on the COVID-19 pandemic at the time of survey. Only 37.1% reported they received any kind of infection control training during their career.
Correct information is a major requirement and is vital in the early phases of a public health emergency rather than reliance on social media. It is therefore important to ensure that students are guided to appropriate sources for information and given adequate training to reduce the gaps in knowledge.