Knowledge, attitude and practice of medical students towards COVID19 in Sudan: A cross sectional study among 19 universities

Background Since December 2019, an outbreak of severe respiratory infection (COVID-19) emerged in the city of Wuhan in China. The knowledge, awareness and practice of medical students toward COVID-19 pandemic is of most importance as it demonstrates their preparedness to deal with this pandemic. The objective of this study is to assess the knowledge, awareness and practice of medical students in Sudan universities about COVID 19. Methodogy This is a cross-sectional study conducted on 19 universities that have medical schools in Sudan. Data from at least 100 medical students from each university were included in the study. Data were collected using an online questionnaire in April 2020. Statistical analysis was conducted using the Statistical Package for Social Science software, version 25. Results About 2603 medical students from 19 universities were included. Overall good knowledge and practice were demonstrated by the medical students (88.9%) and (78.6%), respectively. Respondents who answered that the most common clinical symptoms of COVID-19 were the main combination of dry cough, fatigue and fever were (27.7%), and the first initial symptom was headache were (48.3%.). (60.2%) Wear medical masks, (95%) said that avoiding crowded places protects against the spread of COVID-19, and (50.7%) have confidence that Sudan can win the battle against the COVID-19. Finally, (68.8%) agreed that COVID-19 will finally be successfully controlled. Conclusion This study has found that medical students in Sudan demonstrated good knowledge and good practice toward Covid19.


Introduction
On the January 7, 2020, the Chinese Centre for Disease Control and Prevention (CCDC) isolated the causative agent from throat swab samples, and the name Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was given to this virus. The World Health Organization (WHO) then renamed it Coronavirus disease-19 (COVID-19) [1]. Coronaviruses are a large family of enveloped RNA viruses that can infect a broad range of animals; including camels, cattle, cats, and bats. In relatively rare events, vectors can transmit coronaviruses to humans, and continued circulation results in human-to-human exposure [2]. COVID-2019 is the third coronavirus emerging in the human population in the past two decades; as preceded by the severe acute respiratory syndrome (SARS) outbreak in 2002 and the Middle East Respiratory Syndrome (MERS) outbreak in 2012 [3,4]. All these coronaviruses have originated in bats [2]. In January 2020, the WHO described the COVID-19 outbreak as an international public health emergency. Thereafter, in March 2020, the WHO announced the disease as a pandemic [5,6].
This pandemic has captured the attention of the world due to severe political, social, psychological, and economic influences, necessitating a strong international concern and collaborative efforts from all countries to prevent the serious spread of COVID-19 [1]. More than 8 million cases were reported in Africa until September 17, 2021, with more than 226 million cases reported worldwide. Since the first occurrence of COVID-19 in Sudan on March 13, 2020, more than 38 000 cases have been confirmed and recorded, with a sum of 2833 lives lost and 31 590 cases recovered, with studies indicating a case fatality rate of 7.7% [2,3]. The firing of case numbers compelled Sudan's government to implement immediate health measures such as isolating infected individuals and implementing personal protective measures. People are advised to avoid overcrowding and maintain proper social distancing. Hand hygiene should also be maintained through frequent hand washing and the use of hand sanitizers. Wearing facemasks and avoiding touching one's face with one's hands have also been shown to effectively prevent the spread of COVID-19 [7][8][9].
While community perception of these measures remains a source of contention. Only a few studies have been conducted in this area, demonstrating that the potency of government interventional policies was highly reliant on people's adherence to these control measures, which was heavily influenced by their knowledge, attitude, and practice toward COVID-19 [10].
With students returning to their institutions to resume their postponed educational schedules, the seriousness of applying preventive measures can fall back on the overall population as a single case may affect entire students and thus the rest of the community; however, despite this, only a few studies have been conducted in Sudanese medical students to assess their knowledge, attitude, and practice towards Covid-19. We intend to assess medical students' knowledge, attitudes, and practices regarding COVID-19 in 19 Sudanese universities in this cross-sectional study.

Study setting
This cross-sectional study was conducted on universities that have medical schools in Sudan. The included medical schools were chosen according to their willingness to participate. A minimum of 100 medical students from each university were randomly included in this study. Out of 24 medical schools in Sudan, only 19 medical schools met our criteria to be included in this study.

Study participants
Medical students on the selected medical schools constituted our targeted participants. These students were approached by a member of the study team from their own university. The students were asked for their consent to participate, and those who agreed were given a link to the study questionnaire on a Google form. The students were approached on the social media platforms that are widely used amongst students in Sudan (Facebook and WhatsApp). This approach was complemented by telephone calls to stress the importance of our study in some instances. Additionally, the messages on the social media platforms were repeated if the response rate slowed down. Respondents were required to sign in to fill the Google form using their Google account to ensure only one response per participant. During the period from the 7th to the April 18, 2020, all the required responses were collected.
This a cross-sectional study in is fully compliant with the STROCSS 2021 criteria [11].

Data collection method
The study instrument was an online well-structured non-shuffled questionnaire developed by the authors. The questionnaire was initially self-tested by the authors before implementation and a pilot study was done on 40 participants. Our questionnaire was delivered through Google forms questionnaire timed for 3 min and consisted of two parts: Part one: Demographic data, which had six variables (age, gender, academic year, university name, marital status, and nationality).
Part two: Knowledge, attitudes, and practice, which had 35 questions. Following the guidelines for clinical and community management of COVID-19 by the National Health Commission of the People's Republic of China (24), the COVID-19 knowledge questionnaire was developed by the authors. Further questions about the attitudes and practices towards COVID-19 were added to this questionnaire. This part had 23 questions regarding knowledge of COVID-19. A correct answer was assigned 1 point and an incorrect/unknown answer was assigned 0 points. Making the knowledge score ranges from zero to 23 points, with a higher score denoting a better knowledge of COVID-19. Attitudes towards COVID-19 were measured by two questions and respondents' practice was assessed by 10 questions.

Statistical analysis
Statistical analysis was performed using the using R software version 4.0.2. Data were presented as number (percentages). Chi-square test and fisher exact test were used to find the difference in knowledge attitude and practice of COVID-19 between males and females. A p-value of less than 0.05 was used to determine the level of significance.

Sociodemographic characteristics
About 2603 medical students from 19 universities responded to the survey ( Table 1). As expected, 90.9% were between 18 and 24 years of age with 90.4% of them being between the first and fifth year of medical school, and almost equally distributed through the first to fifth academic years, while those in the sixth year being less represented; this later fact was because 12 out of the 19 medical schools had a 5-year program only. There is only equal representation for the 19 universities. More details could be found on Table 2.

Knowledge
Of all the respondents 74.7% take their covid-19 information from social media, and 29.3% from medical journals. Almost 86.9% Participants responded that the most common clinical symptoms of COVID 19  is dry cough, and 87.2% said it's fever, and about 27.7% indicated dry cough, fatigue and fever as the main combination of clinical symptoms for COVID-19. Also, Respiratory droplets had been identified as the main route of spread of COVID-19 by 94.1% and it was highly associated with the academic year of the medical students with a P value of (< .6), and 86.3% identified that asymptomatic persons cannot spread the virus. 97.2% said that people who contacted someone infected with the COVID-19 virus should be immediately isolated for an observation period of 14 days. (50.9%) have confidence that Sudan can win the battle against the COVID-19. More details about medical students' knowledge could be obtained from Table 3.

Practice
A total of 72.2% do not go to crowded places most of them were females 78.2%. Females were also more likely to wear masks when leaving home (58.6%) with a P value = <.0001 (significant). Regarding the use of hand sanitizer, (38.1%) said that they always use hand sanitizer after touching foreign surfaces outside their house and 9.3% answered never. Near 93.1% said that they wash their hands with soap first thing when they get back home with females (95.2%) being slightly better. Only 6.5% never used tissue after sneezing, with females being significantly better at using tissues (P value < .001). About 43,1% of females do not shake hands during this COVID-19 pandemic and when asked about frequency of hand shaking it was less among females with most of them answering sometime 70.31% which was significantly different from males with a p-value < 001). In addition, only 27.5% of medical students said that they still hug people. Refer to (Table 4) to explore more.

Discussion
With the emergence of COVID-19 from the city of Wuhan, China in 2019 [1,2] and its rapid spread around the globe with more than 23 000 cases in Sudan, more than 2.5 million cases in Africa and more than 80 million cases around the globe until the end of December 2020 [9,12], knowledge, awareness and practice (KAP) about COVID-19 among medical students is highly crucial. This study set out with the aim of assessing the knowledge and awareness and knowledge of medical students in Sudan concerning the novel corona virus COVID-19.
In this cross-sectional study, we provided an insight of knowledge and practice towards COVID-19 among medical students during the first wave of the pandemic. This study showed that the knowledge score among medical students in Sudan, was an overall good knowledge of (88.9%), in addition about (78.6%) of the participants had good practice. These findings are similar with that of Sonam Maheshwari (2019) in their study among medical students in the government medical college in Uttarakhan, India, which demonstrated good knowledge (92.7%) and about (80%) in the practice of the respondents [13], We attribute this good level to the source of information that medical students get  their information from, with social media being the most common source (74.7%), news and TV (60.7%), WHO updates (61.4%), medical journals (29.3%) and ministry of health updates (11%.2). These sources are somehow similar to the results of phan LT et al. which found that social media was the commonest source (34%) [14].
Overall, there was no significant difference in Knowledge score between gender males and females. In the practice aspect females demonstrated better practice in using hands sanitizers, masks and not going to crowed places. Finally, all medical students think that Sudan can win the battle against COVID-19.
The limitations of the study hopefully have no or minimal impact on the study results. As its a cross-sectional study it doesn't assess cause, change overtime, and relationship. Moreover, data collection was in the form of self-administered questionnaires so there is a risk of information bias. On the other hand, the study included 19 universities so reflecting the overall knowledge of Sudanese medical students with generalizable findings and up-to date information that improve preventive measures for COVID-19.

Conclusion
This study has found that medical students in Sudan demonstrated good knowledge and good practice toward COVID-19. Although the results were very positive, further education and awareness should be carried out to increase the preparedness of medical students toward such pandemics and public health modules should focus more on the importance of the knowledge of newly emerging diseases and the practices towards them.

Ethical approval
Ethical clearance was obtained from the National Health Research Ethics Committee, Federal Ministry of Health of Sudan (Ethical number: 4-5-20) before conducting data collection.

Ethical declaration
Ethical clearance was obtained from the National Health Research Ethics Committee, Federal Ministry of Health of Sudan (Ethical number: 4-5-20) before conducting data collection. At the time of data collection written consent was obtained from the study participants, each participant was asked to check a question asking about his free will to participate in the study, the obtained information was confidentially handled and processed through all the research period. All the costs of doing this study were borne by the authors who had no conflict of interest.