COVID-19 Pandemic: Knowledge, Attitude, and Perception of Medical Students Toward the Novel Coronavirus Disease

Background: Medical students are vulnerable to infection by the coronavirus. Their awareness of the disease is crucial for their safety and for the management of the epidemic by spreading supportive information in their communities. The aim of this study was to assess coronavirus disease 2019 (COVID-19)-related knowledge, attitude, and preventive practices among Egyptian medical students. Methods: We conducted a cross-sectional study from the beginning of April to June 2020; a total of 439 undergraduate medical students (1st to 6th academic years) were assessed using an online questionnaire. The questionnaire consisted of 33 questions, including 5 items regarding socio-demographic features, 23 items concerning COVID-19 related knowledge, 2 items regarding attitude, and 3 items related to preventive measures. Results: We observed an acceptable level of knowledge (74.3%) among the sample studied. Preclinical and female students were significantly more optimistic as 69.1% expected successful control of COVID-19, and 48.9% predicted that Egypt will win the fight against COVID-19. The majority of participants reported wearing a facemask in public places as a preventive measure (56.7%). Conclusions: Egyptian medical students had an acceptable level of knowledge, positive attitude, and good practices of preventive measures regarding the COVID-19 virus. There is no significant difference in almost all items of knowledge, attitude, and practices in relation to gender or academic grade.

Coronavirus disease 2019 (COVID- 19) is an evolving contagious respiratory disease caused by a new coronavirus. China first identified the virus, in December 2019, and infection started to spread rapidly in China and many other countries to represent a global health crisis. 1 The main clinical symptoms of COVID-19 include fever, fatigue, dry cough, myalgia, and shortness of breath. The International Committee on Taxonomy of Viruses (ICTV) named the virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 2 Egypt identified its first COVID-19 case on February 14, 2020. According to daily reported statistics of the Ministry of Health and Population in Egypt, the total confirmed cases have reached 100,557 by September 10, 2020, with total deaths of 5590 in Egypt. 3,4 The World Health Organization (WHO) declared the novel coronavirus a public health emergency in response to the alarming situation and rapidly increasing number of cases all over the world. The WHO warned all countries to undertake emergency preparedness measures to face the current situation through many means, including active surveillance, early detection, and isolation. 5 Although medical education has been affected because of the wide spread of the COVID-19 pandemic, opinions differ regarding the convenient participation of medical students in clinical care among different institutions. 6 However, medical students had a salient role in care of patients during the Spanish flu pandemic in 1918 and the polio epidemic in 1952 in Denmark. 7,8 The Egyptian government adopted preventive measures to control COVID-19 spread in all governorates. These measures included self-isolation at home; closure of public places, such as shopping centers, restaurants, sport clubs; and isolation of suspected cases and infected patients. In addition, schools and universities were closed. 9 Moreover, despite suspending medical education in Egypt for many weeks, authorities advocated streamed online lectures to keep students on track with teaching. 10 We conducted the current study to assess knowledge, attitudes, and practices regarding COVID-19 among medical students at Tanta University, Faculty of Medicine, and to detect any gender and academic grade difference among participants.

Study Design and Settings
A cross-sectional study was conducted at the Faculty of Medicine, Tanta University, during the period from April 1 to June 30, 2020.

Participants
The study population was undergraduate medical students (1st to 6th academic years). The total number of the study population was 5340. We calculated the sample size using Epi Info 7 software. We assumed the probability of having good knowledge and a positive attitude toward preventive measures against coronavirus disease at 50.0 %, 11 with 97% confidence interval and 5% precision. The calculated sample size was 434 participants. We recruited a convenient sample of 439 students.

Study Tool
The authors designed a self-structured questionnaire sheet to collect data based on the survey instrument developed in a study on Chinese residents' knowledge, attitudes, and practices (KAP) toward COVID-19 in China. 12 The questionnaire was comprised of 3 sections with 33 questions as follows: Section I This section included 5 items centered on students' characteristics: age, gender, year of study, residence, and last year's achievement grade.
Section II This section measured knowledge regarding COVID-19. Thirteen questions were adapted from previous research, and authors added another 10 questions. The 23 items assessing knowledge were answered by "true," "false," or "do not know" options. Other questions had different response options (items 14,18,23). We scored right answers by a 1 point, whereas a wrong/ not sure answer was assigned 0 points. Thus, a total score ≥ 70% (16 points and more) was designated as acceptable, 50% to <70% (12-15 points) as moderate, and less than 50% (11 points and less) as low level of knowledge.
Section III This section measured attitudes and practices toward COVID-19, including 5 questions. Two questions regarding the students' attitude: if they expected successful control of the current pandemic, and their trust in the Egyptian authorities to win the fight against COVID-19. Students had to answer with agree, disagree, or not sure. Three questions measured practices with yes/no answers: if participants tried to avoid going to overcrowded places, wore a mask when going outside the home, and if they cleaned their houses with disinfectants.

Validity of the Tool
Two consultants of infectious diseases and 3 Egyptian professors from the epidemiology department assessed validity of the questionnaire. The panel of experts reviewed both the website and the questionnaire. For the website, experts provided helpful techniques about general use by participants. For the questionnaire, reviewers recommended shortening of some questions and proposed minor changes in 4 knowledge section questions (questions (2, 5, 8, and 9). Regarding the time required to finish the questionnaire by participants, experts stated that all questions were understandable and participants can fill it out in 7 to 10 min.
We tested the questionnaire in a pilot study to assess its reliability by recruiting 20 medical students not included in current study. We used data to assess internal consistency using alpha Cronbach and test-retest reliability by using the intra-class correlation coefficient, (with Cronbach's alpha = 0.82 and the intra-class correlation coefficient was 0.91), which represented adequate internal consistency and reliability.

Data Collection
We collected data online through Google Forms posted on the Internet platforms. We posted the questionnaire on social media platforms, and shared it on Facebook groups of Tanta medical students. Responders were 439 students who shared in the study voluntary and anonymously. Data were stored on a network-attached storage solution, the cloud, which made them available through a network connection.
Once the data were collected, researchers developed a data-sharing scheme with a secure password to guarantee confidentiality of data owners and the security of the outsourced cloud data, and securely destroying the data after completing the research.

Statistical Analysis
We used SPSS version 20 (Statistical Package for Social Studies) created by IBM, Chicago, Illinois, to organize and tabulate the collected data. We used descriptive statistical methods to calculate numbers and percentages for each variable. The chi-squared test was used to assess potential statistical relationships between socio-demographic and knowledge, attitudes, and precautionary measures. If chi-squared was inappropriate, we used the Fisher exact test. We adopted the value of P < 0.05 for statistical significance.

Ethical Considerations
The Ethical Committee of Scientific Research in Tanta Faculty of Medicine approved the research before starting the study. For participant consent, we inserted a written consent in the introductory part of the online survey; all participants consented before answering the questions.

Demographic Characteristics
The total number of participants was 439. Table 1 shows demographic characteristics of participants; females represented 52.6%. Approximately half of the participants were 22 to 23 y old (47.4%), one-third of them were between 18 and 19 y (29.8%), whereas only 8.2% were 24 y and older and 14.6% were 20 and 21 y. Most of the participants (43.1%) were 5th year medical students, and one-quarter of them were 1st year students (24.8%). Nearly half of the participants (47.2%) had excellent grades in their last year of university. More than half of the students (55.4%) lived in urban areas.

Assessment of Knowledge
The average knowledge score for students was 17.1 ± 1.9 (range = 0-23). The overall correct answer rate of the knowledge questionnaire was 74.3%, and the ranges of correct answer rates for all students were 31.9% to 94.8%. Undergraduates who had scores above 17 were 57.2% (n = 251), indicating an acceptable level of knowledge on COVID-19.
Knowledge of infection of COVID-19 virus by droplets from infected patients was reported by 98.6%; prevention of COVID-19 infection requires people to avoid visiting overcrowded places and avoiding taking public transportation was reported by 97.5%. The majority of participants had an awareness of the major clinical symptoms of COVID-19 (76.6%). Only 47.2% of participants gave a correct answer when asked if eating or contacting wild animals may cause infection by the COVID-19 virus. Among participants, 11.8% believed that it is not necessary for juniors and youngsters to follow the preventive measures against being infected by COVID-19 virus ( Table 2).

Assessment of Attitudes
Regarding a successful control of the COVID-19 pandemic, a majority of participants confirmed that it would be controlled (64.2%). Less than half of participants trusted that Egypt could win the fight against COVID-19 (43.7%), while almost one-third of the participants did not have a belief that Egypt can win the battle against the COVID-19 virus (33.3%). Almost a quarter of the participants did not know whether Egypt could win the battle or not (23%).w

Assessment of Practices
Among all participants, 76.8% stated that they have not visited any crowded places recently. The majority of participants said that they were keen to wear facemasks whenever they were in public places (56.7%). Last, the majority of the participants reported cleaning their houses with disinfectants (94.8%). Table 3 illustrates that females significantly have more confidence that Egypt will overcome the problem of COVID-19 (48.9%) than males (38.0%) (P = 0.005), and Table 4 shows the differences in knowledge in relation to academic grade were almost all not significant except for identification of fever as one of the symptoms and the fact that flu vaccine is not protective for COVID-19 which were reported significantly more by students of clinical grades (P = 0.014 and 0.03, respectively). Table 5 explains attitude of pre-clinical students towards successful control of the disease was significantly more positive (69.1%) compared to clinical students (60.4%) (P = 0.040).

Disaster Medicine and Public Health Preparedness
Other items related to attitude and practices showed no significant difference in relation to academic grade of participants.

Discussion
COVID-19 has postponed training of medical students in different universities due to the closure of campused during lockdown.
During pandemics, such as COVID-19, the health-care system is put under great pressure, so much so that it forces authorities to recruit medical undergraduates to provide medical care to patients, exposing the students to the risk of infection. 13 Moreover, medical students represent common references for health-care advice for family members and friends, 14,15 particularly senior students (clinical stages). 16 Thus, it is crucial to assess medical students' knowledge, attitudes, and practices toward the novel coronavirus.
In the current study, the majority of undergraduates had an acceptable level of knowledge related to COVID-19. This coincides with Çalışkan et al., who assessed senior medical undergraduates' knowledge regarding the COVID-19 pandemic in a Turkish university, and found that they had a moderate level of knowledge. 17 Therefore, medical students need to be updated with medical information related to COVID-19 not only from research articles, but also from academic media and webinars.
Among the participants studied, female students were more knowledgeable about COVID-19 infection regarding main clinical symptoms (fever, fatigue) and high-risk groups (pregnant females, chronic patients). It coincides with Gao et al., who conducted a Web-based cross-sectional study among 588 medical and nonmedical students in China and found that female students had a better conception regarding portals of transmitting the disease and how to prevent the spread of coronavirus than male students. 18 Female students were more interested in following the updated information presented in well-trusted platforms. In addition, the issue of pregnancy can be of more concern for females than males. Moreover, medical students in the clinical stages had more knowledge regarding coronavirus than those in the preclinical stages. This is in accordance with a study among Iranian medical students reporting that intern students were significantly more knowledgeable than younger students. 19 This difference can be illustrated by the fact that senior students have more confidence and skills that enable them to interrelate with different scientific research and give more better interpretation of information.
The majority of preclinical students had the belief that the current pandemic will be controlled. This confidence was low regarding the ability of Egypt to control the disease. Moreover, female students were more optimistic regarding Egypt' success in controlling the current situation than males. This was contrary to the results of a Turkish study reporting that one-third of Turkish final year medical undergraduates trusted that the current pandemic could not be controlled. 17 Despite the wide sharing of epidemic situation statistics by the Ministry of Health and professional and public communities, confidence of students in the ability of Egypt to control the disease was less than half of them. This refers to the lack of confidence of students in available regulations and resources needed to control the epidemic in Egypt. Decisionmakers and medical authorities in Egypt should exert more efforts and show more transparency in sharing information with medical professionals to gain their confidence and cooperation in dealing with this crisis.
In the current study, most of the participants adopted precautionary measures such as using disinfectants in cleaning issues, avoiding crowded places, and wearing a facemask. On the contrary, a study among students in 6 medical schools in Jordan, 61% of undergraduates never used the face-masks. 13 Only 30.3% of medical students and university staff in a Kazakhstani university reported that it was difficult to maintain social distance isolation. 20 This could be due to differences in rules issued by governments and previous experiences in dealing with other pandemics. Also, it emphasizes the necessity of raising awareness of students about face-mask practices as advised by health authority all over the world. The Egyptian Ministry of Health announced from May 2020 the necessity of wearing a facemask as a preventive measure through different channels. In a study among Egyptians in March 2020, results showed that three-quarters of the participants believed that protection of infection could be achieved through putting on facemasks. 21 It indicates that Egyptians are aware of necessary precautions but their commitment to use protective measures is not as strong. Hence, more health education regarding the need for using protective measures and wearing a face-mask is essential, especially among medical students.

Conclusions
Egyptian medical students had an acceptable level of knowledge, positive attitude, and good practices of preventive measures regarding the COVID-19 virus. There is no significant difference in almost all items of knowledge, attitude, and practices in relation to gender or academic grade.

Recommendations
It is crucial to design strategies to raise the awareness and knowledge of medical students about public health disasters and medical emergencies. Assessing knowledge and different precautionary measures to contain the disease represents pivotal steps in determining the future efforts toward the educational process.

Limitations of Study
There are several limitations regarding the current study. First, the attitude and practice sections consisted of only 5 items and can be modified in future studies. Second, the current study included only students from a governmental medical institution. Future researchers should consider recruiting an equal number of students from both government and private institutions for better understanding of their knowledge and perceptions. In addition, recall bias could result as collection of data depended on students' memory abilities. Moreover, we used a Web-based survey method in the study, so we expected selection bias. Finally, the participants had access to the Internet for their computers and cellphones; thus, participants may have higher income or better educational access than those who did not have similar facilities.

Future Work
These findings shed more light on the importance of public health preparedness by implementing awareness educational programs for medical students about the current pandemic. This will promote their knowledge and inculcate positive perception. In addition, medical students act as role models for all people in the community. Hence, such surveys will be instrumental in quantifying the gaps in knowledge. Therefore, it is crucial to target improving orientation of students as the rest of the world prepares to resume medical training, an essential intervention for the continuity of essential medical services, especially in low resource settings.