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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 18-24 |
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Knowledge, attitudes, and behaviors of Indian medical students and health-care providers on COVID-19: An Online Cross-Sectional Survey
Bhagyajyoti Priyadarshini1, Shiba Sai Swarup2, Trupti Rekha Swain3, Joshil Kumar Behera4, Naresh Kumar5, Kumari Sandhya6, Himel Mondal7
1 MBBS Student, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha, India
2 Department of Community Medicine, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha, India
3 Department of Pharmacology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
4 Department of Physiology, Government Medical College and Hospital, Keonjhar, Odisha, India
5 Department of Physiology, Shaheed Hasan Khan Mewati Government Medical College, Nalhar, Haryana, India
6 Department of Anatomy, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
7 Department of Physiology, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha, India
| Date of Submission | 17-Apr-2022 |
| Date of Decision | 05-Jun-2022 |
| Date of Acceptance | 16-Jun-2022 |
| Date of Web Publication | 19-Oct-2022 |
Correspondence Address:
Dr. Himel Mondal
Department of Physiology, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jphpc.jphpc_19_22
Background: COVID-19 has created fear, misconception, and apprehensions among not just the public but also the present and future health-care providers. The COVID-19 pandemic has passed two waves, and currently, the third wave is waning. Aim: This study aimed to evaluate the knowledge, attitude, and practice toward COVID-19 among the health-care providers and medical students of India. Materials and Methods: This was a cross-sectional, observational study conducted with medical students, practicing doctors, nurses, ward attendants, and other health-care workers working all over India. The questionnaire used for the study was developed using the three-step modified Delphi method. It was prevalidated and standardized by conducting a pilot study. Then, the survey questionnaire was circulated via Google Forms. The collected responses were tested statistically by Kolmogorov–Smirnov test, Chi-square, and Spearman's rank correlation. Results: A total of 2211 (1137 medical students, 840 doctors, 126 nurses, 12 ward attendants, and 96 other health-care workers) respondents participated in the study. The mean score for knowledge was 5.93 ± 1.21, for attitude was 5.20 ± 0.84, and for practice was 2·38 ± 0·896. We found a significant positive correlation between knowledge and attitude, knowledge and practices, and attitude and practices. Conclusion: There is an average to a good level of knowledge, attitude, and practice toward COVID-19 among the medical students and health-care providers in India in the third wave of the COVID-19 pandemic. The positive correlation affirms that better knowledge can lead to a positive attitude. This ultimately helps build appropriate behavior.
Keywords: Attitude, COVID-19, health-care providers, India, knowledge, medical students, practice
How to cite this article:
Priyadarshini B, Swarup SS, Swain TR, Behera JK, Kumar N, Sandhya K, Mondal H. Knowledge, attitudes, and behaviors of Indian medical students and health-care providers on COVID-19: An Online Cross-Sectional Survey. J Public Health Prim Care 2023;4:18-24 |
How to cite this URL:
Priyadarshini B, Swarup SS, Swain TR, Behera JK, Kumar N, Sandhya K, Mondal H. Knowledge, attitudes, and behaviors of Indian medical students and health-care providers on COVID-19: An Online Cross-Sectional Survey. J Public Health Prim Care [serial online] 2023 [cited 2023 Jun 5];4:18-24. Available from: http://www.jphpc.org/text.asp?2023/4/1/18/358587 |
| Introduction | |  |
The alarming scenario of the novel coronavirus disease (COVID-19) has left millions infected and dead worldwide.[1],[2] The viral outbreak which can cause severe respiratory symptoms in humans has now been declared a pandemic after severe acute respiratory syndrome (SARS) of 2003 and Middle East respiratory syndrome (MERS) coronavirus of 2012.[3],[4] This demands the united action of the public, government authorities, and health-care providers to control its spread.[5],[6],[7]
With apprehensions and misinformation running high, considering the easy accessibility of information through various media, the health-care providers of today and future (who may be included as the health-care providers if the situation arises) need to have sufficient knowledge, a positive attitude, and good practices to be able to provide the correct treatment to the COVID-19 patients and influence society for better actions.[8],[9],[10] Strategies of the government to control the current situation of COVID-19 and any such future emergencies might be improved with better knowledge, attitudes, and practices among the present and future health-care workforce of the affected countries.[6] Two waves of the pandemic have ended, and currently, the third wave is relatively under control due to awareness programs and vaccinations.
With this background, with limited resources, we conducted this study to evaluate the knowledge, attitude, and practices among medical students and health-care providers in India during the third wave of the COVID-19 pandemic.
| Materials and Methods | | |
Ethical consideration
This study was approved by the institutional ethics committee. In the online survey, we used a paragraph of text for informed consent, and any targeted respondents agreeing to the informed consent were taken to the next section of the survey. We did not collect any personal identification like name or institution. The voluntary participation in this survey was not coupled with any monetary prize or any other benefits.
Study design and setting
This was an online survey-based cross-sectional study. The data were collected from January 16, 2022, to February 15, 2022 (30-day period was decided by the Delphi panelists). We used a predesigned (for this study) questionnaire in English with a good internal constancy (Cronbach's alpha = 0.8). The questionnaire was pretested on 30 participants. The data of the pretesting were omitted from the final analysis. The questionnaire was used to create a survey on a free platform (Google Forms). The link for the survey was circulated online (Facebook, WhatsApp, etc.) to reach out to the maximum number of medical students and health-care providers all over India.
Sampling and participants
We could not get the total number of health-care workers in India. Hence, we used the reference population of India about 1,366,400,000. Considering the 1:10000 doctor–population ratio, double the number of nurses and other health-care workers, and 336,090 (67218 × 5, each year intake multiplied by 5 years of study) medical students, we considered our target survey population to be approximately 746,010. With this number, 95% confidence interval, and 5% margin of error, the calculated sample size was 384.[11] However, we aimed to include a maximum number of participants as per our time and logistics capability.
We used a snowball sampling technique where the survey links are shared from one respondent to another respondent. It was ensured that there was no incomplete response in the questionnaire by marking all the questions as “required” in the Google Forms to get a 100% response rate. There could not be any submission with any questions unanswered.
While we circulated the questionnaire, we included a paragraph of text along with the link. This paragraph of text contained the inclusion criteria. We included medical students of any year of study, practicing doctors, nurses, ward attendants, and other health-care workers. This text also contained a section for the request to participate in the survey voluntarily. Participants from any other stream like dental and pharmacy were excluded from the study. We further did not collect data from any other countries.
Data collection tool and technique
Knowledge, attitude, and practices were assessed with a total of 18 questions randomly arranged (randomization of questions in Google Forms) without any indication of which domain they belong to avoid bias. The questionnaire was developed by a three-step modified Delphi method. We tested knowledge with 8 questions, attitude with 6 questions, and practices with 4 questions. The answers could be single or multiple choices (which were separately mentioned below the question). It was ensured with the Google Forms setting (limit to one response) that each participant gives a single response only. Scoring was done by scoring 1 mark for each correct answer and 0 for a wrong answer.
Statistical methods
The participant's demographic characteristics were analyzed by descriptive statistics. Kolmogorov–Smirnov test was applied to show the nature of data distribution. For inferential statistics, the Chi-square, and Spearman's rho correlation were used.[12],[13] P < 0.05 was considered statistically significant. All analyses were performed using SPSS 21.0 (IBM Inc.; NY, USA) and Microsoft Excel 2010 (Microsoft Inc., USA).
| Results | | |
A total of 2211 participants took part in this study. The demographics of the participants are presented in [Table 1]. The mean age of the respondents was 26.76 ± 9·51 years. State-wise distribution of the sample is shown in [Figure 1]. The highest numbers of participants were from the state of Odisha (25.1%), followed by West Bengal (16.7%), Haryana (10.6%), Telangana (9.3%), and Kerala (7.9%).
The knowledge of COVID-19 is presented in [Table 2]. Almost two-thirds (74.12%) of participants answered knowledge questions correctly.
The attitude toward COVID-19 is presented in [Table 3]. The majority of the participants (86.69%) showed a positive attitude.
More than half (59.45%) of the participants had recommended practices for COVID-19-related health issues as shown in [Table 4].
Significant correlations among knowledge, attitude, practice, age, profession, and residence are shown in [Table 5]. | Table 5: Correlation among knowledge, attitude, practice, age, and residence
Click here to view |
| Discussion | | |
The current descriptive study assessed the knowledge, attitude, and practices of medical students and health-care providers of India regarding COVID-19. The results of the study revealed that the participants possessed average to good knowledge, attitude, and practices with the percentage of correct answers for attitudes coming out to be highest and that of practices coming out to be lowest. Questions that tested the most essential knowledge that should be retained even by the common people were answered mostly correctly. Few questions were asked to test their knowledge as medical personnel. These questions on high-risk groups, similar previous outbreaks, and mitigation strategies to be followed in health-care systems were correctly answered by hardly half of the participants.
The total percentage of people giving correct answers for practice questions (59.45%) was lower than that for knowledge (74.12%) and attitude (86.69%) questions. This is a worrisome situation, especially in times of public health crisis, where health-care professionals are considered the most important reliable advisors, and thus, they are expected to practice before they preach.
Respondents possessed an average to good knowledge of COVID-19. Although the questions regarding nomenclature, symptoms, mode of infection, spread, and lockdown rules were mostly correctly answered, other questions regarding high-risk groups, similar previous outbreaks, and mitigation measures that should be followed in a health-care system were not correctly answered. A fair percentage (57.5%) of respondents failed to identify the high-risk group for the infection. This is even higher than the findings of Saqlain et al. who reported the percentage of wrong answer givers to be 21.01%.[14] We had expected the score for this particular question to be better because this information is shared in mass media and is known to the common people also. Not even half of the respondents (45.9%) knew that there existed a difference between COVID-19 and SARS. This implies that the rest were more or less confused that there had been a pandemic in the past, named SARS.[15] Only 50.8% of participants were sure that primordial and primary prevention, conducting screening/diagnostic tests, and increasing intensive care unit setup, all are important to our system of health care for mitigating the situation.[16],[17],[18] This implies that almost half of them were not aware of these public health strategies for containing the pandemic.
It is quite evident that novel infectious outbreaks are accompanied by fear and apprehensions among the people.[19] Our study subjects had a very good attitude toward COVID-19. It was pathetic to find that 62.5% of the respondents feel that the front-line warriors are discriminated against and often stigmatized in society. This finding is not very surprising because violence against doctors and other health-care workers has sadly become a common scene in our society.[20] Almost 96% of participants agreed that research and development deserve more attention. This might be because COVID-19 has acted as an eye-opener for the entire community. Now, that people are eagerly waiting for a more reliable and high-efficacy vaccine, all have realized the importance of research in the health sector. Almost all (97.4%) considered COVID-19 a serious issue and they were not in favor of keeping the potential cases of infection in their families undisclosed. This is a very positive attitude because studies conducted on previous outbreaks and infectious diseases such as MERS, SARS, acquired immunodeficiency syndrome, tuberculosis, and HIV suggest that stigmatization and fear may hamper or delay a patient's intention to seek medical assistance.[21],[22],[23]
Despite having good knowledge and attitude, health-care providers and medical students were barely putting it into action. Such strong disconnects between perception and practices intensify the need for awareness campaigns targeted to bridge the gap that eventually limits compliance.[24] Nearly two-thirds (75.4%) of individuals conformed to have not gone to crowded places during the lockdown period for no emergency. The majority (78.6%) of individuals followed preventive measures such as social distancing, hand washing, coughing, and sneezing etiquettes properly.[25] It was very shocking to learn that very few respondents (15.6%) solely relied on the Indian Council of Medical Research (ICMR) and World Health Organization (WHO) websites and government announcements for COVID-19-related information. The remaining 84.4% also trusted random posts on social media. Our finding is in line with the outcomes of surveys conducted on health-care workers of Pakistan and medical students of Jordan that have reported the dependence on social media to be 87.68% and 83.4%, respectively.[14],[26] Such social media posts are a major source of misinformation in times of crisis. Not just health-care professionals but also common people should consult reliable sources such as ICMR, WHO, Centers for Disease Control and Prevention, and government announcements. It is very essential because, at times of global pandemic, a pandemic of misinformation does exist, which might lead to xenophobia in the world.[27] Nearly 68% of participants did not follow any myth that claimed to protect individuals from the infection. This implies that the remaining proportion of medical students and health-care providers followed some of the other kinds of unscientific, perceived protective practices such as consuming alcohol, cutting-down meat (nonvegetarian) consumption, avoiding animals/pets, and taking hot baths/spraying alcohol or chlorine all over the body. In times of novel viral outbreaks, when nothing is certain, people tend to follow and promote several unapproved, unscientific practices, and blind beliefs to mitigate the situation by them. However, being a part of the scientific community, these types of activities should not be practiced by health-care personnel.
We found a significant positive linear association between knowledge and attitude, knowledge and practices, and attitude and practices. The reasoned action theory can be applied to explain this correlation. According to the theory of reasoned action, a person's intention to undertake a behavior is a function of the attitude toward that particular behavior.[28] The only profession had a significant correlation with knowledge, attitude, practice, and all three combined. The sequence of professions was as follows: doctors, medical students, other health-care workers, staff nurses, and ward attendants. In each of the four correlation tests, doctors scored the highest, followed by the medical students (future doctors). Similar to our results, a Chinese study on COVID-19 showed that doctors obtained higher knowledge scores as compared to nurses and paramedics.[29] Doctors and medical students keep on updating their knowledge with continuous medical education and vigorous training and they also keep a track of recent advances in the field of research and development through scientific journals. This proves that thorough scientific education and training is an important determinant of a person's overall behavior and perception. Age was significantly correlated with attitude and practice, but not knowledge. This asserts that age and experience matter a lot when it comes to one's attitude and practical application, but for acquiring knowledge, age does not stand as a barrier. It should be kept in mind that when there was a lack of evidence-based knowledge in the early parts of the COVID-19 outbreak, it was the experience of handling similar outbreaks that helped us sustain. People all across the nation follow similar sources of information, i.e., government announcements (same content for central and regional governments), national news channels, and social media, so they do not have many differences in the level of knowledge and perception. However, when it comes to action, the local (state) government and community play a vital role. Socioeconomic conditions, health-care facilities in the state, and the strictness with which the lockdown rules were implemented, all depend on the state government, which ultimately affects the practices of the regional residents. Moreover, some researchers have observed that knowledge, attitude, and practice are correlated with the incidences of many infectious diseases.[30]
Limitations and recommendation
This study has several limitations. We included only the Indian population. Hence, it cannot be generalized to health-care workers or medical students of any other country or region. This study depended on the recall ability of the participants. Hence, it might be subjected to recall bias. The sample size from each category (medical students, doctors, staff nurses, ward attendants, and other health-care workers) varied to a great extent. This is indicative of potential sample clustering. Hence, we suggest a global survey with a similar number of participants in each category for a more generalizable result.
| Conclusion | | |
There was an optimum level of knowledge about COVID-19 among Indian medical students and health-care workers. The majority of them have a positive attitude toward the management of the disease. However, the recommended practice is equivocal among the participants. The positive correlations among the knowledge, attitude, and practice score suggest that better knowledge can contribute to creating a positive attitude and subsequently that may result in the adaptation of good practices.
Acknowledgment
We thank all the participants who had responded voluntarily in this study. We are grateful to the colleagues and students who helped us to spread the survey invitations via social media. We thank https://indzara.com/for providing a free template of Excel for generating Indian heat map on their website.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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