|Year : 2021 | Volume
| Issue : 3 | Page : 182-187
A cross-sectional study on knowledge, attitude, and perception toward COVID-19 pandemic among dental students of India
Ichita Joshi1, Mamta Kaushik1, Akansha Rajawat1, Harshvardhan S Jois2, Neha Mehra1
1 Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, Telangana, India
2 Department of Oral Pathology, Army College of Dental Sciences, Secunderabad, Telangana, India
|Date of Submission||22-Mar-2021|
|Date of Decision||30-May-2021|
|Date of Acceptance||10-Jun-2021|
|Date of Web Publication||23-Aug-2021|
Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad - 500 087, Telangana
Source of Support: None, Conflict of Interest: None
Context: The rapid spread of COVID-19 globally continues to be a threat for healthcare professionals. Dental students and practitioners remain at the risk of having this disease. Aim: The aim of this survey was to assess the knowledge, attitude, and perception of dental students across India toward COVID-19. Settings and Design: A survey with 51 questions to obtain knowledge, attitude, and perception of dental students toward COVID-19 was formulated, pretested via a pilot study and then validated. Subjects and Methods: The final questionnaire was circulated through a link to Google forms, making participation voluntary. Statistical Analysis Used: Statistical analysis was carried out using one-way analysis of variance (ANOVA) test and independent t-test. Results: A total of 610 undergraduate dental students (3rd year, 4th year and students undergoing internship) from various dental colleges across the country responded. On intergroup comparison using One-way ANOVA test, between knowledge, attitude, and perception of dental undergraduate students, attitude toward COVID-19 was found be of statistical significance with P = 0.008. Conclusion: Knowledge, awareness, and perception toward COVID-19 will help contain the spread of this infectious disease that can be caused during dental procedures. There lies a strong call to conduct educational programs on COVID-19 regarding the infection control practices for all healthcare professions, especially dental school students.
Keywords: COVID-19, dental students, infection control, undergraduates
|How to cite this article:|
Joshi I, Kaushik M, Rajawat A, Jois HS, Mehra N. A cross-sectional study on knowledge, attitude, and perception toward COVID-19 pandemic among dental students of India. J Dent Res Rev 2021;8:182-7
|How to cite this URL:|
Joshi I, Kaushik M, Rajawat A, Jois HS, Mehra N. A cross-sectional study on knowledge, attitude, and perception toward COVID-19 pandemic among dental students of India. J Dent Res Rev [serial online] 2021 [cited 2022 Dec 1];8:182-7. Available from: https://www.jdrr.org/text.asp?2021/8/3/182/324416
| Introduction|| |
The first outbreak of COVID-19 occurred in Wuhan, China, in December 2019. The Chinese Center for Disease Control and Prevention announced a novel Coronavirus as the causative pathogen of COVID-19 on January 8, 2020. The rapid spread of this disease in such a short duration of time has become a major global health crisis worldwide., On January 30, 2020, the World Health Organization (WHO) announced this outbreak as a public health emergency of international concern. COVID-19 outburst first emerged with a single animal-to-human transmission; this later led to human-to-human spread., The primary mode of spread of COVID-19 is through respiratory droplets and contact transmission.,,,,, Typical symptoms of COVID-19 are fever, dry cough, shortness of breath, fatigue, and other atypical symptoms, such as muscle pain, confusion, headache, sore throat, diarrhea, and vomiting., Patients with chest computed tomography showed bilateral pneumonia with ground-glass opacity and the most observed pattern being-patchy bilateral shadows., However, not all infected patients present symptoms. Some infected, but asymptomatic people can transfer the virus, making it extremely difficult to identify the carriers of the virus.
Dentistry involves frequent exposure to saliva, blood, and other body fluids, aerosol production (high-speed handpiece, ultrasonic scalers), face-to-face communication with patients, and the handling of sharp instruments. Inhalation of airborne microbes that remain suspended in the air for long periods can be transferred in the dental setting. Thus, dental clinics/hospitals are a susceptible area for transmission of coronavirus not only to the service providers but also to the patients. American Dental Association, on March 16, 2020, recommended dentists nationwide in the USA to defer elective dental treatment for the next 3 weeks and focus on emergency care. At the same time, the Dental Council of India (DCI) suspended classes for all undergraduate students from 1st to 4th year in all the Dental Colleges across India from March 17 to March 31, which was further extended subsequently.,
As the virus is new and highly contagious, one of the critical strategies to tackle COVID-19 is through raising proper awareness regarding the infection. In this scenario, the dental students need to know the symptoms, spread, modes of transmission and preventive measures, and protocols indicated while handling COVID-positive or suspected patients. A survey was carried out to assess the knowledge, attitude, and perception of dental students across India toward COVID-19.
| Subjects and Methods|| |
The study was conducted by the Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, India. A cross-sectional survey was designed to assess the knowledge, attitude, and perception of dental students across the country toward COVID-19. The questionnaire designed to obtain this information consisted of 18 questions to assess knowledge [Figure 1], 15 questions to assess attitude [Figure 2], and 18 questions to judge the perception of respondents toward dental practice during the COVID-19 outbreak [Figure 3]. The questions were close-ended and responses were recorded on a 5-point Likert scale. The survey was exempted from the Institutional Review Board (IRB) with reference no. ACDS/IRB/01/Mar 2020.
A pilot study on 20 dental students was conducted to assess the validity and time required to understand, interpret and fill the responses to the questions. Based on the participant's feedback, the survey format was modified (correcting language and grammar mistakes, summarizing and shortening long questions, and omitting some questions because of repetition). The members of the pilot study did not participate in the main study.
An online survey was conducted from April 20, 2020 to May 15, 2020, using Google forms. At the end of 25 days, the link was deactivated. The link was circulated randomly through social media platforms, in groups where the undergraduate students and interns of various dental colleges across India had participated. Hence, the online link was shared via social media platforms where 824 dental students of various colleges participate. No personal data were collected and the decision of participation in the survey was completely voluntary. Data gathered were tabulated and subjected to statistical analysis.
Data obtained was entered into the Statistical Package for the Social Sciences (SPSS®) software for Windows® Version 20.0 (SPSS Inc, Chicago, Ill). Analysis of variance (ANOVA) test and independent t-test were applied. ANOVA compared the mean of data obtained about knowledge, attitude, and compliance scores, while independent t-test compared whether the two sample groups have different average values. The level of significance was set at P < 0.05 for both the statistical tests.
| Results|| |
The respondents for the present survey included undergraduate students of third and final-year BDS and interns. A total of 610 of 824 dental students responded to the survey at a response rate of 74.03%. These included undergraduates of 3rd year (181; 29.67%), 4th-year undergraduates (237; 38.85%) and interns (192; 31.48%) responded. The year-wise data of the participating students are depicted in [Figure 4]. As all dental colleges in India follow the curriculum prescribed by DCI further segregation of these participants based on states was not considered in this study.
A frequency analysis was performed to evaluate the responses. The dental students were aware of the infectious nature COVID-19, its spread, and the high probability of dental practitioners contracting this disease. Fifty-nine percent of 3rd-year students, 59.9% of final-year students and 74% of interns were aware that aerosol production by high-speed airotor handpieces and ultrasonic scalers would make dental practitioners more susceptible to acquiring COVID-19 infection. Results of this question were found to be statistically significant with P < 0.001. Hundred and one (55.8%) of 3rd year students, 123 (51.9%) of final-year students and 112 (57.3%) of interns strongly agreed that they were aware of the spread of COVID-19 via droplet and close contact with the infected person. From the different components assessed under the knowledge domain, 92 (50.8%) of 3rd years, 98 (41.35%) of 4th years, and 89 (46.35%) of interns were not aware whether coronavirus can spread from animals to human by contact. Awareness of the recommended treatment protocol for a confirmed COVID-19 infection was also low with 72 (30.4%) of final-year students and 58 (30.2%) of interns, aware of the same.
From the different questions assessed under the attitude section, 70 (38.7%) of 3rd-year students, 101 (42.6%) of final-year students and 74 (38.5%) of interns gave a neutral response on whether they felt threatened by COVID-19 pandemic 68 (28.7%) of final-year students and 52 (27.1%) of interns gave a neutral response whereas 56 (30.9%) of 3rd-year students disagreed, when asked whether they would avoid going to hospitals because of fear of isolation and quarantine. The rest of the questions [Figure 2], participants seemed to have a good attitude; they were cautious when treating patients with symptoms such as cough, cold, and fever, or patients who have had a recent history of travel. They were highly agreeable that online teaching methodologies such as online lectures, Webinars and online Continuing Dental Education programs should be adopted in institutions. Majority of students, 146 (80.6%) of 3rd year students, 187 (78.9%) of final-year students, and 159 (82.8%) of interns, agreed on the practice of wearing a mouth mask.
When the questions under the perception section were assessed and analyzed, 59 (32.6%) of 3rd-year students and 79 (33.3%) of final-year students gave a neutral response and 85 (44.27%) interns disagreed when asked whether N95 masks should be worn instead of the common surgical mask. Results of the same were found to be statistically significant with P < 0.001. Fifty-four (29.8%) of 3rd-year students and 81 (34.2%) of final-year students gave a neutral response and 50 (26%) interns disagreed with the question that the students will refrain from treating a suspected COVID-19 patient even when he/she needs emergency dental treatment. From the remaining questions [Figure 3], majority of students, 86 (47.5%) of 3rd year students, 110 (46.4%) of final-year students, and 97 (50.5%) interns were agreeable toward standard handwashing protocol and sincerely followed the same.
An intergroup comparison using one-way ANOVA test, between knowledge, attitude, and perception of dental undergraduate students suggested, that attitude was statistically significantly different among the groups [P = 0.008; [Table 1]]. Among all undergraduate students, students undergoing internships had better knowledge. However, this difference was not statistically significant. There was no difference in perception among groups.
| Discussion|| |
Due to the unknown and evolving nature of COVID-19, it becomes a challenge to treat patients with dental problems. The virus is highly contagious and is known to spread through droplets, contact, etc. Dental procedures include aerosol generation, close vicinity of the operator to the patient, verbal interaction with patients and relatives, and handling of sharps. This places dentistry at high risk of spread and dentists at high risk of exposure. In a dental school, students start attending to patients from 3rd year through internship. Thus a cross-sectional survey was designed to assess curiosity and awareness amongst the evaluated population.
Knowledge about COVID-19
An assessment of current knowledge among dental undergraduate students regarding COVID-19 will not only help in gaining new knowledge, but, it will also restrict the spread of disease, and will further overpass the gap between knowledge and application of information regarding COVID-19 in dental practice.
In the present study, all the undergraduate students (3rd year, 4th year, and interns) had good knowledge of COVID-19. The source of information could be through the internet and social media, especially messages forwarded through messenger applications. As Public Health Administrators across the globe are working toward contracting COVID-19 by circulating educational videos, social media updates and brochures from time to time not only for health care practitioners but also for the general population.,, Among all undergraduate students, students undergoing internship had better knowledge; this may be due to more comprehensive clinical experience and awareness of guidelines as issued by the WHO and DCI. All the students agreed to the fact that COVID-19 is a lethal infection with a high fatality rate. It has reported nearly 35 lakh death worldwide as on May 29, 2021. Most of the respondents disagreed when asked if COVID-19 is incurable (with a significant P = 0.002), which was partly correct as the majority of COVID-19 patients with mild to moderate symptoms are getting cured. The mortality rate was 4.2% for smaller percent of patients with symptoms similar to Severe Acute Respiratory Syndrome.
The results of the survey indicated that the respondents were aware of the etiology, mode of transmission, and symptoms of the disease. The responses were found to be statistically significant for the possibility of infected patients being symptomless and unaware off the disease (P = 0.001). The interns were more aware of asymptomatic patients and the common symptoms as compared to third and 4th-year undergraduate students (P = 0.002).
There was a difference in opinions (P < 0.001) regarding the susceptibility of dental practitioners to COVID-19 due to aerosol production by high-speed airotor handpieces and ultrasonic scalers, wherein 74% of interns agreed to this fact compared to third (59%) and 4th-year (60%) dental students. The reason could be more years of clinical knowledge, experience, and use of these treatment protocols in their dental practices compared to their junior counterparts. The majority of the students felt that they were not sure whether double-ply surgical masks are enough for their protection. The results for the above question were found to be statistically significant with P = 0.003. Although, double-ply surgical mask is sufficient in providing protection from COVID-19, in clinical settings use of N-95 mask is recommended. There was an overall disagreement seen amongst the dental students towards the zoonotic spread of the infection with a statistically significant result (P = 0.047). There was uncertainty regarding the spread from animals to humans, or vice versa, or by consumption of animals and animal products. A study stated that COVID-19 first emerged with a single animal-to-human transmission that was further followed by the sustained human-to-human spread., In the same context, healthcare providers should be encouraged to visit official websites, to seek knowledge on health-related issues, and the Ministry of Health website should also be updated regularly. The undergraduate dental students were well versed with standard infection control guidelines, as stated by the WHO.
Another issue highlighted was the lack of knowledge on the treatment protocol for COVID-19, where only 42.5% of 3rd-year students, 37.5% of 4th-year students, and 37% of interns were aware of the treatment modalities. This could be because the treatment protocol for COVID-19 is supportive. It was noted that only 54.7% of 3rd-year students, 47.7% of 4th-year students, and 47.4% of interns were aware of the investigations required and the centers for conducting these investigations/sample collections from a suspected patient of COVID-19 infection. The majority of students do not have adequate knowledge about the testing centers and investigations if they have to send a suspected patient for confirmation of themselves to get screened for the virus. This highlights the lack of awareness and educational programs for dental students regarding the management of an infected patient.
Attitude toward dental practice
Undergraduate students and interns gave a neutral response when asked whether they felt threatened by the COVID-19 pandemic. The dental students were aware of the high susceptibility of dentists towards COVID-19 due to the nature of the dental practice (P = 0.001) and exposure to aerosol-generating procedures. Majority of undergraduates agreed on the influence of social media platforms and mobile phone applications. The government should ensure that false information does not circulate, which could be misleading and life-threatening. The Indian government has been warning the public about the circulation of fake or uncertified messages regarding COVID-19 through such applications. Majority of students agreed that they would avoid patients with cold, cough, and fever (P < 0.05), as these are the most common symptoms of a suspected/confirmed COVID-19 patient, hence confining the OPD to emergency cases only (P < 0.001) and minimizing treatment for elective cases during the COVID-19 pandemic. Undergraduates (44.8% 3rd years, 47.3% 4th years, and interns 58.9%) were concerned about the global mouth mask shortage which was noticed in dental offices and institutions and this was found to be statistically significant (P < 0.001). Third-year students (48.6%), final-year students (44.3%) and interns (42.7%) preferred visiting a hospital as soon as they had mild common symptoms of cold, cough, sneezing, and fever (P value = 0.003). Forty-five percent 3rd year undergraduates and 39.6% of 4th-year undergraduates felt that the Indian government was able to control the pandemic, whereas 38.4% of interns gave a neutral response (P = 0.007).
Perception towards dental practice
Most of the interns (50.5%) strongly agreed and 3rd-year students (47.5%) and 45.6% of final-year students agreed that a suspected patient should be sent for COVID-19 screening (P = 0.023). If the patient is confirmed for COVID-19 disease, the patient goes into isolation and the spread of the disease can be controlled. Major number of undergraduates and interns agreed that flu suspected patients should be rescheduled for a later appointment (P < 0.01). Forty-nine percent 3rd-year students strongly agreed that they should wear mouth mask while going to hospitals, crowded/public places, compared to 40% of final-year students and 39.6% of interns with P = 0.002 (statistically significant). Many third and final-year students gave a neutral response on wear of N-95 mask instead of common surgical mask, whereas 34% of interns disagreed on wearing N-95 masks (P < 0.001). N-95 certified masks provide enough protection from COVID-19 instead of common surgical mask. Forty percent of 3rd-year undergraduates strongly agreed on disinfection of dental chairs and other exposed surfaces after treatment of every patient whereas 36.7% of 4th year students and 41% of interns agreed to the same and the result showed statistical significance (P = 0.040).
Cleaning and chemical disinfection of environmental surfaces can reduce the number of microorganisms. When asked if they will switch to hand scaling to avoid aerosol by ultrasonic scaling, 39% of 3rd-year students, 41% of final-year students, and 40.6% interns agreed on the same (P = 0.036). Ultrasonic scaling and aerosol-generating procedures tend to result in the generation of spatter and aerosols which may cause transmission of virus and spread of disease. To the question of whether the students will change the preprocedural mouthwash to betadine based after COVID-19, 40% of 3rd year, 43% of final year, and 39.6% of interns gave a neutral response instead of agreeing to the question (P = 0.002), as use of preprocedural mouth rinse like betadine based mouth rinse has shown to reduce the viral load. Majority of undergraduates and interns agreed that they coughed/sneezed into their sleeves (P = 0.004), this will prevent the aerosols and spatter to spread and remain suspended in the environment. When asked whether the students were vaccinated for flu virus, 30.4% of 3rd-year undergraduates, 36.3% of final-year undergraduates, and 34.4% of interns disagreed (P = 0.001).
The study had the following limitations. The questionnaire survey relied upon self-analysis of questions responded by undergraduate students, which relies on their honesty and their recall ability. The study design of this study was cross-sectional which has lesser quality of evidence when compared to longitudinal studies. Conducting a longitudinal study was not possible due to the current COVID-19 pandemic. Furthermore, students who were active on social media for this short period when the survey was circulated were the only ones that had participated. This may result in selection bias and sampling error, which makes it difficult to generalize the obtained results.
| Conclusion|| |
Dental students in the 3rd year and 4th year of undergraduate displayed adequate knowledge and awareness about COVID-19, interns on the other hand had better knowledge, attitude, and perception. In certain aspects of the disease, dental students had mixed perceptions. Awareness and knowledge about symptoms and the spread of COVID-19 are essential to prevent its spread and containment. As dental students and practitioners are more prone to this disease in clinical settings, one must be constantly aware of the latest infection control protocol as issued by the Centre for Disease Control from time to time.
Ethical clearance was obtained from Institutional Review Board (IRB) no. ACDS/IRB/01/ Mar 2020.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Phelan AL, Katz R, Gostin LO. The novel coronavirus originating in Wuhan, China: Challenges for global health governance. JAMA 2020;323:709-10.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al.
Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): Emerging and future challenges for dental and oral medicine. J Dent Res 2020;99:481-7.
Mahase E. China coronavirus: WHO declares international emergency as death toll exceeds 200. BMJ 2020;368:m408.
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al
. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.
del Rio C, Malani P. 2019 Novel coronavirus – Important information for clinicians. JAMA 2020;323:1039.
Liu J, Liao X, Qian S, Yuan J, Wang F, Liu Y, et al.
Community transmission of severe acute respiratory syndrome coronavirus 2, Shenzhen, China, 2020. Emerg Infect Dis 2020;26:1320-3.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al.
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Burke R, Midgley C, Dratch A, Fenstersheib M, Haupt T, Holshue M, et al.
Active monitoring of persons exposed to patients with confirmed COVID-19 – United States, January–February 2020. Morb Mortal Wkly Rep 2020;69:245-6.
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al.
Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
Guan W, Ni Z, Hu Y, Liang W. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020 N Engl J Med 2020;382:1708-20.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al.
Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al.
Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020;382:970-1.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.
Sarwar Shah SG, Farrow A. A commentary on World Health Organization declares globalemergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:128-9.
Purcell LN, Charles AG. An invited commentary on World Health Organizationdeclares global emergency: A review of the 2019 novel Coronavirus (COVID-19): Emergency or new reality? Int J Surg 2020;76:111.
Quadri MF, Jafer MA, Alqahtani AS, Al Mutahar SA, Odabi NI, Daghriri AA, et al.
Novel corona virus disease (COVID-19) awareness among the dental interns, dental auxiliaries and dental specialists in Saudi Arabia: A nationwide study. J Infect Public Health 2020;13:856-64.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]