key: cord-0312294-8pdufaoa authors: Adli, I.; Widyahening, I. S.; Lazarus, G.; Phowira, J.; Azzahra, L.; Ariffandi, B.; Putera, A. M.; Nugraha, D.; Gamalliel, N.; Findyartini, A. title: Knowledge, attitude, and practice related to the COVID-19 pandemic among undergraduate medical students in Indonesia: a nationwide cross-sectional study date: 2021-07-06 journal: nan DOI: 10.1101/2021.07.05.21260021 sha: 671204465b8fa594eb8669d82282d38a9a57a9e2 doc_id: 312294 cord_uid: 8pdufaoa Introduction. The potential role of medical students in raising awareness during public health emergencies has been acknowledged. To further explore their potentials as public educators and role models for the communities during the coronavirus disease 2019 (COVID-19) pandemic, a study is conducted to assess the knowledge, attitude, and practice of these students toward COVID-19. Methods. An online cross-sectional survey was conducted among undergraduate medical students in Indonesia. Socio-demographical characteristics, social interaction history, information-seeking behavior, as well as knowledge, attitude, and practice toward COVID-19 were collected through a self-reported questionnaire. A p-value of <0.05 indicated statistical significance. Results. Out of 4870 respondents, 64.9% and 51.5% had positive attitude and practice toward COVID-19 while only 29.8% had adequate knowledge. Knowledge was slightly positively correlated with attitude and practice (rho=0.074 and rho=0.054, respectively; both p<0.001), while attitude was weakly correlated with practice (rho=0.234, p<0.001). Several factors including age, sex, place of residence, institution type, academic level, family income, history of chronic illness, prior volunteering experience, and perceptual awareness on COVID-19 were significantly associated with either knowledge, attitude, and/or practice toward COVID-19. Furthermore, health institution's and the government's press releases, as well as health expert opinions were deemed as the most reliable sources of COVID-19-related information - yet trivially none of these sources were associated with knowledge, attitude, and practice in the study population. Conclusion. Many undergraduate medical students in Indonesia had positive attitude and practice against COVID-19, yet only a few had adequate knowledge. This warrants further interventions to keep them updated with COVID-19 evidence to maximize their potentials in raising public awareness on COVID-19. Since the declaration of the coronavirus disease 2019 (COVID-19) as a pandemic in early 54 2020[1], global communities have strived to implement various strategies in mitigating the 55 devastating disease burden caused by the virus. In Indonesia, the government has prompted 56 several unprecedented measures to control the spread of the disease[2], including implementing 57 large-scale social distancing, increasing the capacity of COVID-19 diagnostic tests, and 58 launching a national research consortium to accelerate innovations to combat the disease. [3, 4] 59 Despite these, the COVID-19 disease spread remains concerning as the number of cases and 60 deaths resulting from the disease has perpetually surged -rendering Indonesia as the hardest-hit 61 country in the region. [2] This may partly be attributable to the fact that COVID-19 literacy 62 among Indonesian population is still poor.[5,6] Although a previous study revealed that 63 Indonesian population has had positive behaviors toward COVID-19 prevention, some of the 64 essential preventive measures were still lacking, especially in terms of social distancing, self-65 isolation, maintenance of healthy lifestyle, and health-seeking behavior. [5] This indicated that 66 further strategies to increase the public's awareness and preventive behaviors on COVID-19 are 67 imperative, in which medical students may provide unyielding support by taking part in raising 68 awareness on COVID-19. 69 The role of medical students in raising awareness during public health emergencies have 70 long been established. A systematic review by Martin et al revealed that medical students have 71 been involved in public health campaigns during previous viral outbreaks, including human 72 immunodeficiency virus, influenza, severe acute respiratory syndrome, and Ebola. [7] Being 73 perceived as having a higher level of health literacy, medical students may serve as role models 74 for the public to adopt COVID-19 preventive health behaviors. During the COVID-19 pandemic, 75 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint Indonesian medical students have also taken part in disseminating health information to the 76 public, mainly through the use of social media and news outlets. [8] However, as the disease 77 burden of COVID-19 in Indonesia persists despite rigorous efforts, comprehensive assessments 78 of medical students' knowledge, attitude, and practice are imperative to further enhance their 79 potentials in educating the public. Specifically, this may provide crucial information for 80 stakeholders to identify field gaps and devise strategies to further encourage communities to 81 follow health standards. Furthermore, this information may also be utilized by medical 82 institutions to improve the medical curricula to prepare for future outbreaks. Therefore, this 83 study aims to assess the knowledge, attitude, and practice of Indonesian undergraduate medical 84 students toward the COVID-19 disease. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint diagnosis, treatment, and prevention. Each correct answer accounts for one point with a 121 maximum score of 10 points. In contrast, attitude and practice were measured using two 12 five-122 point Likert scales with a maximum score of 55 points each. Higher knowledge, attitudinal, and 123 behavioral scores indicated favorable perceptions. Lastly, the reliability of the questionnaire was 124 appraised using Cronbach's alpha, with a coefficient for knowledge, attitude, and practice of 125 0.655, 0.726, 0.807, respectively, indicating satisfactory internal reliability [15] . 143 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 6, 2021. resided in Java (86.9%), followed by Eastern Indonesia (6.0%), Sumatra (4.9%), and Central 148 Indonesia (2.1%). Further details on the characteristics of the included participants can be seen 149 on S1 Table. 150 151 Knowledge, attitude, and practice toward COVID-19 152 We discovered that about 64.9% and 51.5% respondents yielded positive attitude and Table) . 159 Furthermore, only 16.1% of the participants correctly answered the incubation period of SARS-160 CoV-2. In addition, a considerable number of participants believed that the communities' 161 awareness on COVID-19 were still lacking (37.0%) and disagreed that COVID-19 patients could 162 be treated at home (22.5%). Item-specific responses of the attitude and practice of Indonesian 163 medical students toward COVID-19 can be seen on S3 Table and S4 Table, respectively. 164 In this study, we found that the correlation between knowledge with attitude and practice 165 was negligible (ρ=0.074 and ρ =0.054, respectively; both p<0.001). Attitude was also weakly 166 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. Table 3 ). In addition, 199 we also found that students whose family members had been infected by COVID-19 had a more CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. 220 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint In addition to the knowledge, attitude, and practice toward COVID-19, we also explored 221 the study population's levels of trust toward COVID-19-related national health information 222 sources. We discovered that most of the participants considered that health information released 223 by health institutions (89.3%), health experts (78.0%), and the government (70.8%) to be 224 reliable. In contrast, only 26.0% and 12.7% of the participants deemed online news and media 225 social to be trustworthy (Fig 2) . Nearly half of the participants also trusted the health information 226 broadcasted by television and newspaper outlets (45.8% and 44.3%, respectively). No robust 227 correlations could be established between trust in specific health information sources and the 228 students' knowledge, attitude, or practice. Although the negative association between trust in 229 social media and the students' knowledge was statistically significant, the magnitude of the 230 correlation was clinically negligible (ρ= -0.0439; p=0.006; S5 Table) . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint medical students had a positive attitude and practice against COVID-19. However, this number 244 was not accompanied by a proportionate number of students with adequate knowledge, 245 indicating the urgent need to take active measures to keep these students updated with COVID-246 19-related evidence. 247 In the present study, female medical students were superior to males in terms of knowledge 248 and practice. This finding is further validated by a meta-analysis demonstrating that women were sources was significantly associated with the levels of knowledge, attitude, or practice toward 300 COVID-19 in the study population may also indicate that some more influential resources such 301 as scientific articles or medical textbooks, which were unexplored in this study, may impact the 302 overall trend. 303 Overall, the gaps in knowledge relating to COVID-19 persisted although most respondents 304 in the study demonstrated a high level of attitude and a fair level of practice. These results 305 showed that positive attitude and appropriate practices regarding COVID-19 documented among 306 medical students might suggest their valuable role as role models for the general population. 307 However, as future health professionals, demonstration of high standards of attitude and practice 308 has to be aptly supported by excellence in clinical knowledge and understanding, especially if 309 they are to be involved in global health emergencies. Addressing this knowledge gap will 310 warrant not only a more effective public education but also a safer and more efficient 311 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 6, 2021. One's level of knowledge is substantially influenced by an effective and efficient education 314 system that plays a key role in ensuring high-quality teaching and learning. The low level of 315 knowledge reported might be justified by the rapidly evolving COVID-19 evidence [26] , which 316 represents an enormous challenge to medical education and thus may subsequently hinder the CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint only the current pandemic but also future unforeseeable global health crises. A key priority 335 should therefore be to plan these dedicated programs to strengthen students' disaster and 336 pandemic preparedness against similar global health calamities. [29] 337 The relatively large sample size and our geographical reach contributed to the strength of 338 the study. Furthermore, the questionnaire had previously been validated and yielded a fair 339 reliability, thus further ascertaining the validity of our findings. However, the study was limited 340 by the unbalanced distribution of pre-clinical and clinical medical students, which could have 341 potentially limited the generalizability of the study results. Moreover, due to the cross-sectional 342 nature of the survey, we were not able to disentangle the directionality of the relationships 343 observed. An additional uncontrolled factor was the possibility that possible confounding 344 variables, which were not scrutinized in this study, might affect our results. To the best of our 345 knowledge, this is the first reported study assessing the levels of knowledge, attitude, and 346 practice toward the COVID-19 disease among Indonesian medical students, thus providing key 347 parameters for policymakers and institutions in formulating effective strategies and tools to 348 enhance the medical students' potentials in raising public awareness and protective practices in 349 the current COVID-19 pandemic and prospective potential public health emergencies. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 6, 2021. ; https://doi.org/10.1101/2021.07.05.21260021 doi: medRxiv preprint educators and role models for communities, while also equipping them with appropriate 358 knowledge and skills to prepare for future public health emergencies. In turn, this approach may 359 create a positive feedback loop enhancing the students' knowledge, attitude, and practice, which 360 were positively intercorrelated in this study. 361 362 WHO declares COVID-19 a pandemic COVID-19 and Indonesia Review 382 and analysis of current responses to COVID-19 in Indonesia: Period of Knowledge, attitudes, practices and information needs during the COVID-19 386 pandemic in Indonesia COVID-19-related knowledge, attitude, and practices among indonesian undergraduate 390 students A rapid systematic 392 review exploring the involvement of medical students in pandemics and other global 393 health emergencies Medical students in Indonesia: An invaluable 396 living gemstone during coronavirus disease 2019 pandemic Knowledge, attitudes, and 403 practices towards COVID-19 among chinese residents during the rapid rise COVID-19 outbreak: A quick online cross-sectional survey 407 attitude and practice toward the novel coronavirus (COVID-19) outbreak: A population-408 based survey in Iran. Bull World Health Organ Willingness 413 to volunteer and readiness to practice of undergraduate medical students during the 414 COVID-19 pandemic: a cross-sectional survey in Indonesia Analisis konsumsi rumah tangga miskin di Kelurahan Kebonsari Kulon 417 University of Muhammadiyah Malang The use of Cronbach's alpha when developing and reporting research 419 instruments in science education R: A language and environment for statistical computing Knowledge and attitude towards antimicrobial resistance among 424 final year undergraduate paramedical students at University of Gondar, Ethiopia. BMC 425 Infect Dis Communications in public health emergency preparedness: 427 A systematic review of the literature A meta-analysis of the association between gender and 430 protective behaviors in response to respiratory epidemics and pandemics Involvement of medical students during the 433 coronavirus disease 2019 pandemic: A cross-sectional survey study Perceptions of and reflections on volunteering: The impact of community service 436 on citizenship in students Learning 438 through service: Student perceptions on volunteering at interprofessional hepatitis B 439 student-run clinics COVID-19 risk 441 assessment tool: Dual application of risk communication and risk governance 100109 media platforms on public health protection against the COVID-19 pandemic via the 445 mediating effects of public health awareness and behavioral changes: Integrated model Fighting fake news in the COVID-19 era: Policy insights from an 448 equilibrium model SARS-CoV-2/COVID-19: Evolving reality, global response, knowledge 451 gaps, and opportunities Idle medical students review emerging COVID-19 research Developments in 455 medical education in response to the COVID-19 pandemic: A rapid BEME systematic 456 review: BEME Guide No. 63 Preparing medical students 459 for a pandemic: A systematic review of student disaster training programmes