INTRODUCTION:

COVID-19 was declared a global pandemic by the World Health organization (WHO) on 11^th of March, 2020. The gravity of the pandemic is unfathomable and the presence of the COVID-19 virus in 213 countries leading to the presence of 57,882,183 cases worldwide, and 1,377,395deaths as of November 22^rd, 2020¹, this has led to challenges in medical treatment delivery across the globe.²

Currently, there are large number of COVID-19 vaccines which has been recommended by the World Health Organization (WHO) and the Center for disease control (CDC). The modus operandito reduce the transmission has been behavioral such as social distancing, hand sanitization, regular washing of Hands, and wearing of masks. Reported COVID-19 symptoms includes fever, dry cough, runny nose, and sore throat tiredness.^3,4 Severe COVID-19 cases may develop difficulty breathing, organ failure, and consequently requiring critical care respiratory ventilation with specialized management at intensive care units (ICU), and the most severe complication death.^3,5-8

Researchers are expanding their understanding to assess the group at greatest risk of infection, serious illness, or death. It is evident that most COVID-19 patients may suffer mild or moderate respiratory illness or may recover from the infection while the elderly and immunocompromised patients are at greatest risk to develop serious disease.⁹It was reported that one-fifth of hospitalized infected cases were between the age group 20 to 44 years, this included 2 to 4% of the most severe cases and those who required ICU treatment, with the highest rates of death being among the elderly.¹⁰

Factors which may contribute to the success in control of the disease and saving severe and critical patients, include the improved and optimized diagnosis and treatment strategies^11-13, However, globally the number of newly confirmed cases showed a steep rise for all age groups, this is in part may be explained by the drastic measures taken by various countries in providing testing services to all suspected cases. Interestingly, the rate of the recovered cases also showed significant improvement especially among the younger patients.¹⁴

The knowledge and behavior assessment among the healthcare professionals, service providers and medical students toward COVID-19 outbreaks is essential and are important predictors of whether they engage in disease-specific preventive behaviors. Adequate knowledge about infectious diseases was reported to be positively associated with appropriate protective behavior during an outbreak.^15-21 Moreover, previous reports indicated that adequate knowledge can also impact on the individual perceptions of the disease due to past experiences.^22-24However, only limited number of studies focused on exploring the knowledge, attitude and practices to deal with COVID-19 pandemic. For example,among the healthcare professionals^25-32and medical students in China^33-35, Uganda³⁶, India^37-38, Turkey³⁹, Bangladesh⁴⁰, Ecuador⁴¹, Spain⁴², Pakistan⁴³,

Iran⁴⁴, Saudi Arabia⁴⁵, Sudan⁴⁶, Latin America⁴⁷, Afghanistan⁴⁸, Western India⁴⁹, Vietnam⁵⁰ and Indonesia⁵¹(Table 1). However, no such study has been carried out to explore UAE medical students' opinions about COVID-19 outbreaks. Therefore, the aim of this study is to study the COVID-19 related knowledge, attitudes, perceptions, and precautionary measures amongst medical students (MS) of Ajman University (AU). Inadequate knowledge of the COVID-19 infection by MS may lead to poor recognition of cases and implementation of infection control measures to protect health care worker.

MATERIALS AND METHODS:

A descriptive cross-sectional study was conducted at the Medical College, Ajman University (AU), during April and May 2020. Ajman University is in the City of Ajman, United Arab Emirates (UAE). AU is the 3^rd largest institution of higher education in the UAE. The study was introduced after obtaining approval from Ethical committee of the AU. All the participants were informed about the objectives of the study and an informed consent was obtained from each student before enrollment in the study.

Inclusion criteria include:

All male and female students, currently registered with the college of medicine, Ajman University (AU), and be able to understand English or Arabic languages to fill the online questionnaire.

Exclusion criteria include:

Students that are not currently registered with AU or unable to read and understand English or Arabic languages, as well as students from colleges other than college of medicine.

Table 1: Summary of the studies which investigated medical student’s level of knowledge, attitudes and practices related to COVID-19

Author/ Year	Country	Sample size	Knowledge scores Symptoms Transmission Overall			Attitude scores Isolation Positive Overall				Practice scores		Study outcomes
Author/ Year	Country	Sample size	Knowledge scores Symptoms Transmission Overall			Attitude scores Isolation Positive Overall			Wear mask	Hand hygiene	overall
Ronald Olum, et al/May 2020	Uganda	741 Medical students	649(88%)	718 (97%)	671 (90.55%)	673 (91%)	699 (94%)	550 (74%)	170 (23%)	359 (48%)	426 (57%)	medical students showed sufficient knowledge and attitude while moderately good practice
BurkayYakara, et al/May 2020	Turkey	530 medical students	331 (62.45%)	345 (65.09%)	456 (86.04%)	Not Stated	479 (90.36%)	479 (90.36%)	424 (80%)	498 (93.96%)	373 (70.38%)	Medical students had sufficient knowledge and attitude towards COVID-19.
Haojun Yang, et al/May 2020	China	889 all (728 for knowledge)	725 (99.59%)	719 (98.76%)	Not Stated	711 (97.66%)	827 (93.03%)	824 (92.7%)	726(99.72%)	696 (95.60%)	Not stated	Medical students showed good knowledge, positive attitude and sufficient practices.
Lincango-Naranjo, et al/June 2020	Ecuador	309 medical students	303 (98.1%)	284 (91.9%)	274 (88.7%)	304 (98.4%)	130 (42.1%)	179 (57.9%)	174 (56.3%)	279 (90.3%)	174 (56.3%)	The study showed high level of students’ knowledge, with coexisting negative attitudes and insufficient practices.
Cervera-Gasch, et al/May 2020	Spain	102 students (44 medical students)	56 (54.9%)	90 (88.2%)	70 (68.6%)	Not Stated	35 (34.3%)	76 (74.5%)	Not Stated	Not Stated	Not Stated	level of knowledge can be considered adequate, but they need to obtain higher scores in knowledge and attitude.
Azal Ikhlaq, et al/April 2020	Pakistan	384 medical students	353 (91.9%)	374 (97.4%)	307 (79.9%)	347 (90.4%)	346 (90.1%)	353 (91.3%)	Not Stated	326 (84.9%)	Not Stated	The medical students of CMH LMC showed a satisfactory level of awareness and attitudestowards COVID-19
Sonam Maheshwari, et al/May 2020	India	354 medical students	307 (86.7%)	328 (92.7%)	298 (84.18%)	342 (96.6%)	259 (73.2%)	284 (80.25%)	322 (91.0%)	342 (96.6%)	322 (90.96%)	The majority of the participants in Indian medical school had good knowledge, positive attitude, and sufficient practice.
Mohammad Hossein, et al/April 2020	Iran	240 medical students	216 (90%)	223 (92.9%)	208 (86.67%)	177 (73.8%)	225 (93.8%)	209 (87.08%)	205 (85.4%)	232 (96.7%)	227 (94.46%)	Iranian medical students had a high level of related knowledge and high performance in preventive behaviors (practices), but a moderate risk perception (Attitude).
Sultan Fahad, et al/July 2020	Saudi Arabia	250 medical intern students	240 (96%)	153 (61.2%)	95 (38%)	230 (92%)	153 (61.2%)	138 (55.2%)	83 (33.2%)	228 (91.2%)	50 (24%)	these findings reveal gaps in Knowledge, Attitude and Practice among medical interns.
Md. Abdul Wadood, et al/April 2020	Bangladesh	305 Students	106 (34.75%)	211 (69.18%)	248 (81.31%)	182 (59.7%)	175 (57.38%)	175 (57.38%)	164 (53.8%)	273 (89.5%)	240 (78.69%)	General knowledge, attitude, practice and perception of the university students regarding COVID-19 were not satisfactory.
RadiTofahaAlhusseini et al, 2020	Sudan	2603 students (19 Universities)	1351 (51.9%)	2444 (93.9%)	2314 (88.9%)	2527 (97.1%)	1325 (50.9%)	1325 (50.9%)	1567 (60.2%)	1687 (64.81%)	2046 (78.6%)	This study has found that medical students in Sudan demonstrated good knowledge and good practice toward Covid19.
Eddy Lincango-Naranjo et al, 2021	Latin America	309 medical Students	303 (98.1%)	284 (91.9%)	272 (88%)	304 (98.4%)	90 (29.1%)	130 (42.1%)	55 (17.8%)	306 (99%)	174 (56.3%)	large number of students displayed negative attitudes, high knowledge score and optimal practice level.
ArashNemat et al, 2021	Afghanistan	1169 Students	1036 (88.6%)	960 (82.1%)	1089 (93.15%)	1021 (87.3%)	1064 (91%)	1099 (94%)	1112 (95.2%)	1144 (97.9%)	1025 (87.6%)	Overall, the students had acceptable knowledge, attitude and practice regarding COVID-19.
Anjali Govind et al, 2021	Western India	342 Medical Students	337 (98.54%)	331 (96.78%)	Not stated	304 (88.89%)	302 (88.3%)	Not stated	318 (92.98%)	334 (97.66%)	Not stated	Students need to be made more knowledgeable aboutcomplications about disease. Attitude and Practice were acceptable
Pham Le An et al, 2021	Vietnam	2351 Healthcare Students	2299 (97.8%)	2287 (97.3%)	2036 (86.6%)	2260 (96.1%)	2029 (86.3%)	1617 (68.8%)	2119 (90.1%)	2218 (94.3%)	2182 (92.8%)	The findings practice towards COVID-19;however, sufficient knowledge and positive attitude were low
Imam Adli et al, 2022	Indonesia	4870 medical students	2781 (57.1%)	4695 (96.4%)	1451 (29.8%)	2083 (42.8%)	3160 (64.9%)	2325 (47.7%)	4728 (97.08%)	4216 (86.57%)	2508 (51.5%)	considerably positive attitude and practice against COVID-19. But inadequate knowledge.

Study Instrument:

The self-administered questionnaire was used and consisted of four basic domains (demographic details, Knowledge, Attitude and Practice). In the knowledge domain, students understanding of COVID-19 definition, transmission, symptoms, incubation period, characteristics of the disease, treatment and vaccination of COVID-19 were assessed using 8 relevant questions. Knowledge scores ranged from 0 to 8 (total scoring was calculated for each participant) in which a value of 5 was consider as cutoff level, accordingly a level of <5 were set for poor knowledge and ≥5 for good knowledge.

Risk Perception (Attitude) evaluation was achieved through 6 questions using five‑point Likert scale. Positive responses with a score of 1 was assigned to strongly agree and agree answers, whereas strongly disagree, and disagree answers were scored zero, therefore, total score of ≥3 was considered as positive attitude while score of lower than 3 was considered for negative attitude.

Preventive behavior section evaluated using 11 related questions, and the scores ranged from 0 to 11 in which a score of 7 and higher were considered positive preventive measures by the participant. Furthermore, practice domains were assessed by given the students three hypothetical situations in relation to COVID-19, and students response was ranged from 0-3 according to each scenario. Finally, students were asked question on the sources of information about Novel coronavirus and their opinion on the reliability of these sources where identified. The content of the questionnaire was evaluated by two senior faculty. The validity of questionnaire was tested among ten MSs with Cronbach’s alpha 0.8. The questionnaire then was revised and finalized based on feedback from MS.

Statistical analysis:

The statistical analyses were performed using SPSS 26.0 (SPSS, Inc, Chicago, Illinois, United States). The questionnaire was validated using factor analysis. Internal reliability of all four domains (knowledge, attitude, behaviour and practice) of the questionnaire was assessed by calculating Cronbach’s alpha. Non-parametric tests were used to estimate the difference between the selected variables (gender and year of study) in relation to different parameters (Knowledge, Attitude, Behaviour, Practice and source of information) while Independent t-test and ANOVA were used to estimate the difference between the independent parameters in relation to the total scoring. The mean of total score and standard deviation were tabulated for each of the measures under the current research. Statistical analysis was done after dividing the questionnaire into 4 categories: 8 knowledge related items, 6-items in relation to attitude, 11 behaviour related items and 3 items for practical situations.

In order to assess the relation between the variables, Spearman’s correlation and multiple linear regression analysis - beta coefficient (β) - were calculated. The statistical significance (p-value) was set at p < 0.05 and at a confidence interval of 95%.

RESULTS:

Out of 108 students in the college of medicine, 82 students filled the questionnaire (response rate of 76.0%). Study questionnaires were internally consistent as assessed by Cronbach’s alpha coefficient test, (α = 0.701 for knowledge, 0.879 for attitude, α = 0.787 for behavior, 0.599 and 0.751 for source of information).

More than half of the participants were females (64.6%), aged between 18-20 years. Most of the participants in the current analysis were aware of the UAE government COVID19 task force (UAE National Emergency Crisis and Disaster Management (82.9%) and they follow the UAE press conferences to some extend as well (85.4%) (Table 2).

Table 2: Sociodemographic characteristics of Medical Students (N=82 students)

	Variables	Frequency	Percentage
Gender	Male	29	35.4%
Gender	Female	53	64.6%
Age	18-20 Years old	70	85.4%
Age	21-23 Years old	12	14.6%
Year of Study	First Year	41	50.0%
Year of Study	Second Year	41	50.0%
Awareness about government COVID-19 task Force (UAE)	YES	68	82.9%
Awareness about government COVID-19 task Force (UAE)	NO	14	17.1%
Following UAE press Conferences	Always	31	37.8%
	Sometimes	35	42.7%
	Never	12	14.6%
	More often	4	4.9%

Knowledge of medical Students on COVID-19:

Roughly half of the participants (43.9%) rate their knowledge level as good in a Likert scale of 5, while the other half distributed between very good (24.4%) and average Knowledge (25.6%), comparing to only 6.1% collectively scored themselves as poor or very poor knowledge scores. Mann-Whitney test reveals no significant difference age wise (p=0.143) and year of study (p=0.178).

Assessment of knowledge related questions towards COVID-19 among medical students revealed that a total of 82.9% demonstrate a good knowledge of definition of COVID-19, other knowledge related questions that showed a good level of knowledge was related to the route of transmission of the disease, symptoms and the current available treatment or vaccination for COVID -19 (79.3%, 96.3% and 80.5%, respectively). Conversely, poor knowledge was clearer in questions related to close contact and characteristics of COVID-19 (46.3% and 40.2%, respectively). Gender wise all of the knowledge related questions revealed no significant difference except for the questions related to the definition of COVID-19 (p<0.000) and Treatment of COVID-19 (p<0.011) in which females exhibit more knowledge than males (Table 3).

The relation of the independent variables and the overall mean of the total knowledge score displayed an overall acceptable score (5.30±1.53) out of 8, precisely, females (5.60±1.31) had more knowledge than males (4.76±1.77) and first year students (5.51±1.53) were more aware about COVID-19 than second year Students (5.10±1.51) (Table 4).

Attitude Section (Risk Perception) of Medical Students on COVID-19:

The inclusive responses regarding the attitude perception of the participants towards COVID-19 pandemic was displayed in Table 3. Two-third of the students had positive attitude towards the transmission of COVID-19 by direct contact (76.8%), and they do believe that COVID-19 will inflict serious damage to the community (72%), on contrast, only 37.8% and 29.3% believe that COVID-19 causes a serious damage to the human health and the disease is more severe than any other respiratory diseases, respectively. The conflict between the students raised when exact attitude where asked about contracting COVID-19 even if no contact with suspected patient and going to the hospital for any other medical condition in which almost half of them they disagree (62.2%) and believe that they won’t get COVID-19 if no direct contact with COVID-19 patients (59.8%).

The overall mean of the total attitude was acceptable (3.38±1.32) out of 6 with neither significant difference between males and females (p<0.079) nor the year of study (p=0.361), yet males had more positive attitude score (3.72±1.28) comparing to females (3.19±1.32) and first year (3.51±1.16) had more positive attitude score (3.24±1.46) (Table 4).

Table 3: Medical students correct responses to knowledge, attitude and preventive measures to control spread of COVID-19 virus in relation to gender and study level

Knowledge	Gender				Study Level				Overall
Knowledge	Male	Female	X²	p-value	1^st Year	2^nd Year	X²	p-value	Overall
Which of the following is correct about the definition of COVID-19?	18(62.1%)	50(94.3%)	13.787	0.000	33(80.5%)	35(85.4%)	0.345	0.557	68(82.9%)
Which of the following is correct about transmission route of COVID-19?	22(75.9%)	43(81.1%)	0.317	0.574	33(80.5%)	32(78.0%)	0.074	0.785	65(79.3%)
Which of the following is NOT correct about “close contact” of COVID-19?	11(37.9%)	27(50.9%)	1.276	0.259	22(53.7%)	16(39.0%)	1.766	0.184	38(46.3%)
Which of the following is correct about symptom of COVID-19?	27(93.1%)	52(98.1%)	1.335	0.248	41(100%)	38(92.7%)	3.114	0.078	79(96.3%)
Which of the following is correct about the incubation period of COVID-19?	14(48.3%)	30(56.6%)	0.523	0.470	19(46.3%)	25(61.0%)	1.766	0.184	44(53.7%)
Which of the following explanations is NOT correct about the characteristics of COVID-19?	13(44.8%)	20(37.7%)	0.392	0.531	19(46.3%)	14(34.1%)	1.268	0.260	33(40.2%)
Which one is incorrect about self-isolation of COVID-19?	14(48.3%)	28(52.8%)	0.156	0.693	26(63.4%)	16(39.0%)	4.881	0.027	42(51.2%)
Which one is correct about vaccine of COVID-19?	19(65.5%)	47(88.7%)	6.403	0.011	33(80.5%)	33(80.5%)	0.000	1.000	66(80.5%)
Attitude
I think that I will contract COVID-19 if I come into contact with a COVID-19 patient.	21(72.4%)	42(79.2%)	0.491	0.483	35(85.4%)	28(68.3%)	3.357	0.067	63(76.8%)
I think that I might contract COVID-19 even if I do not come into contact with a COVID-19 patient.	21(72.4%)	28(52.8%)	2.989	0.084	27(65.9%)	22(53.7%)	1.268	0.260	49(59.8%)
My health will be severely damaged if I contract COVID-19.	10(34.5%)	21(39.6%)	0.211	0.646	13(31.7%)	18(43.9%)	1.297	0.255	31(37.8%)
I think COVID-19 is more severe than any other respiratory diseases.	10(34.5%)	14(26.4%)	0.589	0.443	13(31.7%)	11(26.8%)	0.236	0.627	24(29.3%)
Even if I fall ill with another disease, I will not go to hospital because of COVID-19.	19(65.5%)	32(60.4%)	0.211	0.646	27(65.9%)	24(58.5%)	0.467	0.494	51(62.2%)
COVID-19 will inflict serious damage to my community.	27(93.1%)	32(60.4%)	9.947	0.002	29(70.7%)	30(73.2%)	0.060	0.806	59(72.0%)
Preventive measures
If possible, I did not leave home.	29(100.0%)	51(96.2%)	1.122	0.290	40(97.6%)	40(97.6%)	0.000	1.000	80(97.6%)
I washed my hands with water and soap before and after I left home.	28(96.6%)	51(96.2%)	0.006	0.940	40(97.6%)	39(95.1%)	0.346	0.556	79(96.3%)
I didn’t touch my eyes, nose, with hands I had not washed.	27(93.1%)	42(79.2%)	2.698	0.100	40(97.6%)	29(70.7%)	11.061	0.001	69(84.1%)
I washed my hands with hand sanitizers when I was outside.	29(100.0%)	53(100%)	-	1.000	41(100.0%)	41(100.0%)	-	1.000	82(100.0%)
I wore a mask when I go outside.	29(100.0%)	52(98.1%)	0.554	0.457	40(97.6%)	41(100.0%)	1.012	0.314	81(98.8%)
I ate food that strengthen my immune system.	22(75.9%)	34(64.2%)	1.187	0.276	24(58.5%)	32(78.0%)	3.604	0.058	56(68.3%)
I exercised to strengthen my immune system.	20(69.0%)	22(41.5%)	5.655	0.017	23(56.1%)	19(46.3%)	0.781	0.377	42(51.2%)

Table 4: Average of the Total Score in respect to Knowledge, Attitude, Behavior and Practice

	Overall Mean ±SD	Gender				Year of Study
	Overall Mean ±SD	Male	Female	t- value	P-value	1^st Year	2^nd Year	t- value	P-value
Knowledge	5.30±1.53	4.76±1.77	5.60±1.31	-2.467	0.016	5.51±1.53	5.10±1.51	1.232	0.222
Attitude	3.38±1.32	3.72±1.28	3.19±1.32	1.779	0.079	3.51±1.16	3.24±1.46	0.919	0.361
Behavior	9.88±1.17	10.31±0.81	9.64±1.27	2.559	0.012	10.00±1.14	9.76±1.20	0.944	0.348
Practice	2.26±0.56	2.24±0.63	2.26±0.52	-0.174	0.862	2.44±0.50	2.07±0.56	3.098	0.003

In order to establish the relationship between the attitude, behavior and practice in relation to different parameters multiple binary logistic regression analysis was chosen, in addition to the pervious analysis more codes were given to attitude, behavior and practice as positive and negative with respect to the pervious criteria of the scoring methods, multiple binary logistic regression analysis verified that Gender and study level were not considered as a significant predictors of the probability of the behavior score (p>0.05).on the other hand, binary regression analysis also showed that knowledge scores (b= 0.882, p<0.010) is a positive and significant predictor of the probability of the practice score and there is a strong association with the Odds Ratio (OR) indicating that for every unit increase in the knowledge predictors the OR of the positive practice increases by 2.416. The remaining predictors had no significant association with the attitude, behavior or practice (Table 5).

DISCUSSION:

Adequate understanding of COVID-19 among healthcare workers including medical students is crucial to properly face the COVID-19 outbreak. Only with adequate levels of knowledge can health care workers comprehensively identify, diagnose, manage the cases and prevent the transmission of COVID-19. In this first study which assess the nature and extent of knowledge, attitude and practice by medical students from UAE towards COVID-19 during the pandemic period, we found that 44% of the surveyed MSs had a good knowledge of COVID-19, these findings together with the previous reviews which focused on understanding of the extent of preparedness of medical students towards disaster training programs⁵²and efficacy of face mask in preventing respiratory virus^53-54provided evidence of effectiveness of prevention of transmission of COVID-19 virus by following preventive measures such as handwashing, wearing masks, and practicing social distancing. The knowledge and perception of MS will play an important role as to how these students will be emergency prepared in unprecedented times such as these. Gathering information related to both these factors among the students will help in raising awareness and also augment better clinical judgement and address risk perception. Furthermore, knowledge and perception studies provide data that can help overcome poor knowledge about the disease and also institute COVID-19 awareness programs.⁵⁵ Further analysis of knowledge related questions towards COVID-19 among medical students revealed that 83% of MS demonstrate a good knowledge of COVID-19 definition, route of transmission of the virus, symptoms and the current available treatment or vaccination for COVID-19. Likewise, poor knowledge was clearer in questions related to spread of the disease and characteristics of COVID-19. Similar findings were reported from Lahore MS.⁴³The rapid spread of the COVID-19 pandemic has critically impacted on health care systems and also restricted the training of medical students as a result of the closure of medical schools during the lockdown period.^54-56

Our results are similar to the findings of Lincango-Naranjo’s report from Ecuador⁴¹, but in contrast to studies from Spain⁴²and Turkey³⁹in which participants had poor knowledge of the symptom of COVID-19. It can thus be suggested that the positive influence of the educational program on the MS. Additionally, the results of the knowledge survey done in Uganda showed that most of the MS (88.0%) had correct knowledge of COVID-19 symptoms and 92.4% of them aware that supportive treatment can help most of the patients to recover from the infection.⁴² Likewise, the majority of the MS from Iran⁴⁴were able to identify the main clinical symptoms of COVID-19. Furthermore, 91% of MS from Jordan were sure that the virus is likely to be transmitted through inhalation of infected droplets.⁵⁷ And 41.8% believe that the infection with COVID-19 is air born. WHO adapted two modes of transmission of COVID-19 virus which refers to particles >5–10µm in diameter as respiratory droplets, while airborne transmission occurs in droplet nuclei which are particles.^58-60There is no significant difference in the knowledge level between male and female MS, except for the questions related to the definition of COVID-19 (p<0.000) and available treatment of COVID-19 (p<0.011) in which females exhibit more knowledge than males. This is in concordance with findings from government medical college in Uttarakhand, India.³⁸

The findings of the current study showed that social Media (69.5%) and Governmental websites (54.9%) were the main source of Knowledge about COVID-19 but more than half of the participants believe that Governments websites (76.8%) is the most reliable source of information, followed by TV broadcasting (63.4%) in comparing to the social media (23.2%). Similar findings also reported from Lahore medical college which confirm that social media is the major sources of information for MS followed by Television (18%).⁴³ Additionally, MS from Jordan relied heavily on online resources for information about COVID-19 pandemic.⁵⁷

Is encouraging that more than 63% of MS used official government websites as source of information about COVID-19. This indicates that the COVID-19-related updates released by official government health authorities online have had a significant effect on improving the level of MS awareness. The use of authentic sources for COVID-19 information and notifications is a key factor in providing students with transparent information and is important for MS preparedness and response. Furthermore, using authentic sources for information and updates about COVID-19 is crucial factor in delivering transparent information to students and is essential for MS preparedness and response. It was reported that the type and quality of information about COVID-19 in the social media is a cause of concern as highlighted by many authorities.^58-60

Among social media, Instagram, Twitter and WhatsApp are the top three sources. However, they are not considered very much reliable, furthermore, more than half of the participants believe that TV broadcasting and Governments websites is the most reliable source of information. Similar findings also reported from different centers.^43-45It was reported that social media as a source of information is cost-effective and easily accessible, but also, it might spread fake information that can have devastating effects on the society.

In this study, 76.8% of Ajman MS showed positive attitude towards COVID-19 pandemic which is similar to the findings reported by medical students from India (73.2%)³⁸, but less than the 94% response reported by Ugandan MS and 93.8% by Iranian MS.In the current study, nearly all of the MS responded positively about the preventive measures to control spread of the virus such as home quarantine (97.6%), washing hands before and after any task (96.3%), wearing mask (98.8%), avoiding people with fever (95.1%) and avoid using public transportation (98.8%), further analysis revealed that most of the preventive behavior related questions showed no significant difference between MS gender or study level (p>0.05). A similar observation also reported among the participants in government medical college in India, in which 96.9% of students were aware that COVID-19 can be prevented by avoiding crowded places and avoiding public transportation.³⁸Conversely, Jordanian MS indicated that personal hygiene, and home quarantine to be the most important strategies for protection from COVID-19 infection.^57,61-66

In this study, most of MS reacted positively to the practice-based questions (96.3% to 97.6%) and comprehensive evaluation of the practical situations revealed a higher score of females than males with no significant difference in relation to gender (p=0.862), higher scores in the attitude and practice among females were also reported by MS in India³⁸and China.^61-63

The main limitation of the present study is that the sample sizes are limited to the medical students studying at AU, and hence the results could not be generalized to all MS of UAE, other limitation of the current study related to the cross sectional study design, the data presented are dependent on the integrity and recall ability of the students, so there is a risk of misrepresentation of information or some of the students could overestimate or underestimate while presenting results as they relied on their memories in answering the questions. Furthermore, Online surveys and Web-based research, can be subject to considerable bias.

CONCLUSION:

Ajman University medical students have sufficient knowledge of COVID-19 pandemic and implemented proper strategies to prevent COVID-19 spread. It is obligation of academic institutions to promote effective infection control training to protect patients, health care workers and students by encouraging safer working practices in the clinics sitting.

REFERENCES:

1. World Health Organization- Geneva, Switzerland; WHO Director-General's opening remarks at the media briefing on COVID-19-11 March 2020.Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 [Accessed 2020 October 15]

2. World Health Organization-Geneva, Switzerland; Coronavirus disease 2019 (COVID-19) situation report 169. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200707-covid-19-sitrep-169.pdf[Accessed 23 November, 2020]

3. Adhikari SP, Meng S, Wu Y-J, Mao Y-P, Ye R-X, Wang Q-Z, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infect Dis Poverty 2020;9(1);1-2. https://doi.org/10.1186/s40249-020-00646-x.

4. Centers for Disease Control and Prevention. 2020. Coronavirus (COVID-19) URL: https://www.cdc.gov/coronavirus/2019-ncov/index.html [accessed 27-5-2020]

5. Zhu N, Zhang D, Wang W, et al (2020) A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 382:727–733. https://doi.org/10.1056/NEJMoa2001017

6. Chan JF-W, Yuan S, Kok K-H, To KK-W, 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. The Lancet 2020;395(10223):514–23. https://doi.org/10.1016/s0140-6736(20)30154-9.

7. 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. The Lancet 2020;395(10223):507–13. https://doi.org/10.1016/s0140-6736(20)30211-7.

8. Bastola A, Sah R, Rodriguez-Morales AJ, Lal BK, Jha R, Ojha HC, et al. The first 2019 novel coronavirus case in Nepal. The Lancet Infectious Diseases 2020;20(3):279–80. https://doi.org/10.1016/s1473-3099(20)30067-0.

9. CDC Weekly C. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China CDC Weekly 2020;2(8):113–22. https://doi.org/10.46234/ccdcw2020.032.

10. Eurosurveillance Editorial Team. Updated rapid risk assessment from ECDC on the novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK. Eurosurveillance. 2020 Mar 12;25(10):2003121.https://doi.org/10.2807/1560-7917.ES.2020.25.10.2003121

11. Zhang Z, Yao W, Wang Y, Long C, Fu X. Wuhan and Hubei COVID-19 mortality analysis reveals the critical role of timely supply of medical resources. Journal of Infection. 2020 Jul 1;81(1):147-78.https://doi.org/10.1016/j.jinf.2020.03.018.

12. The National Health Commission of China, Coronavirus Disease 2019 (COVID-19) diagnosis and treatment plan (in Chinese, 7th version). http://www.nhc.gov.cn/yzygj/s7653p/202003/ 46c9294a7dfe4cef80dc7f5912eb1989.

13. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-repor t.pdf. 2020.

14. Ludvigsson JF. Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults. Acta Paediatrica. 2020 Jun;109(6):1088-95.https://doi.org/10.1111/apa.15270.

15. Prue CE, Roth Jr JN, Garcia-Williams A, Yoos A, Camperlengo L, DeWilde L, Lamtahri M, Prosper A, Harrison C, Witbart L, Guendel I. Awareness, beliefs, and actions concerning Zika virus among pregnant women and community members—US Virgin Islands, November–December 2016. Morbidity and Mortality Weekly Report. 2017 Sep 9;66(34):909.https://doi.org/10.15585/mmwr.mm6634a4.

16. Lunn, P., C. Belton, C. Lavin, F. McGowan, S. Timmons and D. Robertson. Using behavioural science to help fight the coronavirus, 2020 ESRI Working Paper 656, Dublin: ESRI, https://www.esri.ie/publications/using-behavioural-science-to-help-fight-the-coronavirus

17. Toppenberg-Pejcic D, Noyes J, Allen T, Alexander N, Vanderford M, Gamhewage G. Emergency risk communication: lessons learned from a rapid review of recent gray literature on Ebola, Zika, and yellow fever. Health Communication. 2019 Mar 21;34(4):437-55.https://doi.org/10.1080/10410236.2017.1405488

18. Naresh BV. A review of the 2019 novel coronavirus (covid-19) pandemic. Asian J. Pharm. Res. 2020 Jul;10(3):233-8. Retrieved from https://www.proquest.com/scholarly-journals/review-2019-novel-coronavirus-covid-19-pandemic/docview/2450902514/se-2

19. Rokade M, Khandagale P. A Review of a New Threat to Public Health. Asian Journal of Pharmaceutical Research. 2020 Sep 1;10(3).https://doi.org/10.5958/2231-5691.2020.00042.8.

20. Angela Braver, ShivrajKhaire. Knowledge, Attitude and Practices towards Covid-19 Outbreak in Maharashtra State. Int. J. of Advances in Nur. Management. 2021; 9(2):162-168.https://doi.org/10.5958/2454-2652.2021.00037.8

21. Gentili D, Bardin A, Ros E, Piovesan C, Ramigni M, Dalmanzio M, Dettori M, Filia A, Cinquetti S. Impact of communication measures implemented during a school tuberculosis outbreak on risk perception among parents and school staff, Italy, 2019. International Journal of Environmental Research and Public Health. 2020 Feb;17(3):911.https://doi.org/10.3390/ijerph17030911.

22. Hogg R, Nkala B, Dietrich J, Collins A, Closson K, Cui Z, Kanters S, Chia J, Barhafuma B, Palmer A, Kaida A. Conspiracy beliefs and knowledge about HIV origins among adolescents in Soweto, South Africa. PLoS One. 2017 Feb 2;12(2):e0165087.https://doi.org/10.1371/journal.pone.0165087

23. Oppenheim B, Lidow N, Ayscue P, et al. Knowledge and beliefs about Ebola virus in a conflict-affected area: early evidence from the North Kivu outbreak. J Glob Health. 2019;9(2):020311. https://doi.org/10.7189/jogh.09.020311.

24. Vinck P, Pham PN, Bindu KK, Bedford J, Nilles EJ. Institutional trust and misinformation in the response to the 2018–19 Ebola outbreak in North Kivu, DR Congo: a population-based survey. The Lancet Infectious Diseases. 2019 May 1;19(5):529-36.http://dx.doi.org/10.1016/S1473-3099(19)30063-5

25. Alfahan A, Alhabib S, Abdulmajeed I, Rahman S, Bamuhair S. In the era of corona virus: health care professionals’ knowledge, attitudes, and practice of hand hygiene in Saudi primary care centers: a cross-sectional study. Journal of Community Hospital Internal Medicine Perspectives. 2016 Jan 1;6(4):32151.https://doi.org/10.3402/jchimp.v6.32151

26. Olaimat AN, Aolymat I, Shahbaz HM, Holley RA. Knowledge and information sources about COVID-19 among university students in Jordan: a cross-sectional study. Frontiers in Public Health. 2020 May 29;8:254.https://doi.org/10.3389/fpubh.2020.00254.

27. Alzoubi H, Alnawaiseh N, Al-Mnayyis AA, Abu-Lubad M, Aqel A, Al-Shagahin H. COVID-19-knowledge, attitude and practice among medical and non-medical University Students in Jordan. J Pure Appl Microbiol. 2020 Mar 31;14(1):17-24.https://doi.org/10.22207/JPAM.14.1.04

28. Taghrir MH, Borazjani R, Shiraly R. COVID-19 and Iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception. Archives of Iranian Medicine. 2020 Apr 1;23(4):249-54.https://doi.org/10.34172/aim.2020.06.

29. Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: cross-sectional study. JMIR Public Health and Surveillance. 2020 Apr 30;6(2):e19160.https://doi.org/10.2196/19160.

30. Debnath S, Saha J. Asian Journal of Pharmacy and Technology. Asian J. Pharm. Tech. 2022;12(1):63-9.https://doi.org/10.52711/2231-5713.2022.00011.

31. Fernandes M, Thakur JR, Gavanje MS. A Study to assess knowledge regarding covid-19 among Nursing students. Asian Journal of Nursing Education and Research. 2021;11(1):65-7.https://doi.org/10.5958/2349-2996.2021.00017.3.

32. Grace PC, George D, Jose S, Maria JC, Naveena CM, Tomy AT, Mathew JT, Thomas JP, Francis D, Poulose T, Joseph M. Knowledge and anxiety regarding COVID 19 pandemic among parents and students. Asian Journal of Nursing Education and Research. 2022;12(1):98-101.https://doi.org/10.52711/2349-2996.2022.00020.

33. Haojun Yang1,Yue Zheng, Fang YU, Bohao Cheng, Ziqing Zhu, Sheng Liao, Yu Chen. Fang Wang. Knowledge, attitudes, social responsibilities and career plans toward Corona Virus Disease 2019 (Covid-19) among Chinese clinical medical students. Res Square 2020.https://doi.org/10.21203/rs.3.rs-27032/v1

34. Peng Y, Pei C, Zheng Y, Wang J, Zhang K, Zheng Z, Zhu P. A cross-sectional survey of knowledge, attitude and practice associated with COVID-19 among undergraduate students in China. BMC Public Health. 2020 Dec;20(1):1-8.https://doi.org/10.1186/s12889-020-09392-z

35. Gao Z, Ying S, Liu J, Zhang H, Li J, Ma C. A cross-sectional study: Comparing the attitude and knowledge of medical and non-medical students toward 2019 novel coronavirus. Journal of Infection and Public Health. 2020 Oct 1;13(10):1419-23.https://doi.org/10.1016/j.jiph.2020.06.031.

36. Olum R, Kajjimu J, Kanyike A, Chekwech G, Wekha G, Nassozi D, et al. Perspective of Medical Students on the COVID-19 Pandemic: Survey of Nine Medical Schools in Uganda. JMIR Public Health Surveill. 2020;6:e19847:1-10.https://doi.org/10.2196/19847.

37. Gupta L, Agarwal V, Davalbhakta S, Agarwal V, Misra D. A survey-based study on the knowledge, attitude, and the practices pertaining to the 2019 novel Corona Virus infection amongst undergraduate medical students in India. medRxiv. 2020.. https://www.medrxiv.org/content/10.1101/2020.04.11.20061333v1.

38. Maheshwari S, Gupta PK, Sinha R, Rawat P. Knowledge, attitude, and practice towards coronavirus disease 2019 (COVID-19) among medical students: A cross-sectional study. Journal of Acute Disease. 2020 May 1;9(3):100.https://doi.org/10.4103/2221-6189.283886.

39. Yakar B, Kaygusuz TÖ, Pirinçci E, Önalan E, Ertekin YH. Knowledge, attitude and anxiety of medical students about the current COVID-19 outbreak in Turkey. Family Practice and Palliative Care. 2020 May 22;5(2):36-44.https://doi.org/10.22391/fppc.737469

40. Wadood MA, Mamun AS, Rafi MA, Kamrul Islam M, Mohd S, Lee LL, Hossain MG. Knowledge, attitude, practice and perception regarding COVID-19 among students in Bangladesh: Survey in Rajshahi University. Medrxiv. 2020 Jan 1.https://doi.org/10.1101/2020.04.21.20074757

41. Ortega-Paredes D, Larrea-Álvarez CM, Jijón SI, Loaiza K, Šefcová MA, Molina-Cuasapaz G, Barba P, Vinueza-Burgos C, Fernandez-Moreira E, Ramírez H, Larrea-Álvarez M. A cross-sectional study to assess knowledge of COVID-19 among undergraduate students in North-Central Ecuador. International Journal of Environmental Research and Public Health. 2021 Aug 18;18(16):8706.https://doi.org/10.3390/ijerph18168706

42. Cervera-Gasch Á, González-Chordá VM, Mena-Tudela D. COVID-19: Are Spanish medicine and nursing students prepared?. Nurse Education Today. 2020 Sep;92:104473.https://doi.org/10.1016/j.nedt.2020.104473

43. Ikhlaq A, Hunniya BE, Bashir I, Ijaz F. Awareness and attitude of undergraduate medical students towards 2019-novel corona virus. Pakistan Journal of Medical Sciences. 2020 May;36(COVID19-S4):S32.https://doi.org/10.12669/pjms.36.covid19-s4.2636.

44. Canti, N. A. N., Mohd Zain, N. ., &Embong, H. Knowledge on Coronavirus Disease (COVID-19) and Practice of COVID-19 Prevention Among Students in the Health Campus. International Journal of Care Scholars. 2022, 5(2), 75–86. https://doi.org/10.31436/ijcs.v5i2.238

45. ALNohair SF, Mahmud I, ALShehri F, ALShuqayran R, ALBatanouni M. Knowledge, attitudes, and practices of medical interns toward COVID-19 in Saudi Arabia: a cross-sectional survey, April-May 2020.https://doi.org/10.21203/rs.3.rs-48682/v1

46. Alfatih M, Mohamed Ahmed KAH, Alhusseini RT, et al. Knowledge, attitude and practice of medical students towards COVID19 in Sudan: A cross sectional study among 19 universities. Ann Med Surg (Lond). 2022;84:104874. https://doi.org/10.1016/j.amsu.2022.104874

47. Lincango-Naranjo E, Espinoza-Suarez N, Solis-Pazmino P, Vinueza-Moreano P, Rodriguez-Villafuerte S, Lincango-Naranjo J, Barberis-Barcia G, Ruiz-Sosa C, Rojas-Velasco G, Gravholt D, Golembiewski E. Paradigms about the COVID-19 pandemic: knowledge, attitudes and practices from medical students. BMC Medical Education. 2021 Dec;21(1):1-0.https://doi.org/10.1186/s12909-021-02559-1

48. Nemat A, Raufi N, Sediqi MF, Rasib AR, Asady A. Knowledge, attitudes, and practices of medical students regarding COVID-19 in Afghanistan: a cross-sectional study. Risk Management and Healthcare Policy. 2021;14:1491. https://doi.org/10.2147/RMHP.S308039

49. Patel AG, Rokade VK, Modi GS. Knowledge, Attitude and Practice Regarding SARS CoV-19 Among Medical Students of a Medical College in Western India. National Journal of Community Medicine. 2021 Jul 31;12(07):199-203. https://doi.org/10.5455/njcm.20210728105000.

50. Le An P, Huynh G, Nguyen HT, Pham BD, Nguyen TV, Tran TT, Tran TD. Knowledge, attitude, and practice towards COVID-19 among healthcare students in Vietnam. Infection and Drug Resistance. 2021;14:3405.https://doi.org/10.2147/idr.s328677.

51. Adli I, Widyahening IS, Lazarus G, Phowira J, Baihaqi LA, Ariffandi B, Putera AM, Nugraha D, Gamalliel N, Findyartini A. Knowledge, attitude, and practice related to the COVID-19 pandemic among undergraduate medical students in Indonesia: A Nationwide Cross-sectional Study. PloS one. 2022 Jan 21;17(1):e0262827. https://doi.org/10.1371/journal.pone.0262827.

52. Ashcroft J, Byrne MH, Brennan PA, Davies RJ. Preparing medical students for a pandemic: a systematic review of student disaster training programmes. Postgraduate Medical Journal. 2021 Jun 1;97(1148):368-79.https://doi.org/10.1136/postgradmedj-2020-137906.

53. Liang M, Gao L, Cheng C, Zhou Q, Uy JP, Heiner K, Sun C. Efficacy of face mask in preventing respiratory virus transmission: A systematic review and meta-analysis. Travel Medicine and Infectious Disease. 2020 Jul 1;36:101751.https://doi.org/10.1016/j.tmaid.2020.101751.

54. Kamate SK, Sharma S, Thakar S, Srivastava D, Sengupta K, Hadi AJ, Chaudhary A, Joshi R, Dhanker K. Assessing Knowledge, Attitudes and Practices of dental practitioners regarding the COVID-19 pandemic: A multinational study. Dental and Medical Problems. 2020 Jan 1;57(1):11-7.https://doi.org/10.17219/dmp/119743.

55. Belingheri M, Paladino ME, Riva MA. Beyond the assistance: additional exposure situations to COVID-19 for healthcare workers. Journal of Hospital Infection. 2020 Jun 1;105(2):353.https://doi.org/10.1016/j.jhin.2020.03.033.

56. Whelan A, Prescott J, Young G, et al. Interim guidance on medical students' participation in direct patient contact activities: principles and guidelines. Association of American Medical Colleges. 30 March 2020. https://lcme.org/wp-content/uploads/filebase/March-30-2020-Interim-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdf on 31 March 2020.

57. Khasawneh AI, Humeidan AA, Alsulaiman JW, Bloukh S, Ramadan M, Al-Shatanawi TN, Awad HH, Hijazi WY, Al-Kammash KR, Obeidat N, Saleh T. Medical students and COVID-19: knowledge, attitudes, and precautionary measures. A descriptive study from Jordan. Frontiers in Public Health. 2020 May 29;8:253.https://doi.org/10.3389/fpubh.2020.00253.

58. Akan H, Gurol Y, Izbirak G, Ozdatlı S, Yilmaz G, Vitrinel A, Hayran O. Knowledge and attitudes of university students toward pandemic influenza: a cross-sectional study from Turkey. BMC Public health. 2010 Dec;10(1):1-8.https://doi.org/10.1186/1471-2458-10-413

59. Shu K, Sliva A, Wang S, Tang J, Liu H. Fake news detection on social media: A data mining perspective. ACM SIGKDD explorations newsletter. 2017 Sep 1;19(1):22-36.https://doi.org/10.1145/3137597.3137600

60. World Health Organization. (‎2020)‎. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance, 21 March 2020. World Health Organization. https://apps.who.int/iris/handle/10665/331508. License: CC BY-NC-SA 3.0 IGO

61. Salman M, Mustafa ZU, Asif N, Zaidi HA, Hussain K, Shehzadi N, Khan TM, Saleem Z. Knowledge, attitude and preventive practices related to COVID-19: a cross-sectional study in two Pakistani University Populations. Drugs & Therapy Perspectives. 2020 Jul;36(7):319-25.https://doi.org/10.1007/s40267-020-00737-7.

62. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, Li Y. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. International Journal of Biological Sciences. 2020;16(10):1745.https://doi.org/10.7150/ijbs.45221.

63. Nair B, Mathew J. Mental health and psychosocial wellbeing during Covid-19. International Journal of Nursing Education and Research. 2021 Dec 1;9(4):488-90.https://doi.org/10.52711/2454-2660.2021.00114.

64. Thomas A, Anagha KV, Irshad F, Chinnu K, Jessan P, Shajan S, Sreelakshmi T, Nair B, Mathew J. A study to Assess the Psychosocial Issues Associated with Covid-19 Pandemic among the Family Members of Third year B. Sc. Nursing Students in selected Colleges of Pathanamthitta District. International Journal of Nursing Education and Research. 2021 Dec 1;9(4):417-9.https://doi.org/10.52711/2454-2660.2021.00096.

65. Choudhary M, Gopichandran L. Post Covid-19 Complications: A New Dimension of Awareness for Healthcare Workers. Asian Journal of Nursing Education and Research. 2021 Oct 1;11(4):455-8.https://doi.org/10.52711/2349-2996.2021.00110.

66. Vijayashree L, Srinivasa S. Covid 19 and stress among students. Asian Journal of Management. 2021 Nov 25;12(4):477-82.https://doi.org/10.52711/2321-5763.2021.00074.

Received on 06.11.2022 Modified on 10.12.2022

Research J. Pharm. and Tech 2023; 16(7):3228-3238.

DOI: 10.52711/0974-360X.2023.00531

	Attitude			Behavior			Practice
Variable	B	Odds Ratio (95% CI)	p-value	B	Odds Ratio (95% CI)	p-value	B	Odds Ratio (95% CI)	p-value
Gender (Male vs. Female)	-0.688	0.502 (0.137 - 1.83)	0.298	-18.046	0.000	0.998	1.789	5.982 (0.819 - 43.67)	0.078
Study Level (1^st vs. 2^nd year students)	-0.868	0.420 (0.138 - 1.27)	0.126	0.357	1.429 (0.085 – 24.14)	0.805	-19.718	0.000	0.997
Knowledge Score	0.081	1.085 (0.778 – 1.51)	0.631	-0.733	0.480 (0.130 – 1.76)	0.270	0.882	2.416 (1.239 – 4.71)	0.010