COVID-19 Myth Busters: Comparing knowledge and perceptions amongst the dental workforce at an institution in the Eastern Province, Saudi Arabia

Background Currently, world is suffering from a respiratory disease names as COVID-19. This is a novel coronavirus (n-CoV), a new strain which has not been previously identified in humans and it has spread in more than 100 locations internationally due to which it is termed as “public health emergency of international concern” (PHEIC) by the World Health Organization So far, no study done as yet to assess whether the dental workforce is aware about the facts and myths related to Covid-19 awareness. Objective This study aims to analyze and compare the level of awareness about the facts and myths related to COVID-19 amongst faculty, dental students and prep year students of the College of Dentistry (COD) as part of an awareness campaign. Methods An awareness test about COVID-19 was designed using information from the World Health Organization’s (WHO) Myth Busters Awareness webpage. The questionnaire was administrated online to faculty and students, of the College of Dentistry and preparatory year students who had applied for the admission to the dental college using a secure enterprise online assessment platform (Blackboard). The tests were administered over a period of three months from March to June 2020. A written informed consent was obtained. Results The online COVID-19 awareness test was administered to 810 participants, out of which 325 (40%) were prep year students, 429(53%%) were dental students, and 56 (7%) were faculty members. Analysis of the results showed that 86% of the Faculty were able to correctly identify the facts and the myths related to COVID-19 followed by 81% of the prep year students and 74% of the dental students. Preparatory year student’s knowledge related to COVID-19 was found to be high when compared to dental students (26.47±4.27, 23.67±6.2). Student to faculty knowledge score did not differ significantly (p = 0.808). Conclusion This study reports about a successful pilot test conducted to assess the perceived knowledge about facts and myths related to corona virus amongst the dental workforce.


Introduction
The recent outbreak of Coronaviruses (CoV) named as COVID-19 in more than 100 locations internationally has been termed a "public health emergency of international concern" (PHEIC) by the World Health Organization [1]. This is a novel coronavirus (n-CoV), a new strain which has not been previously identified in humans. This virus belongs to the same family of corona viruses identified in the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS--CoV) [1].
Coronaviruses are transmitted between animals and people. Studies on SARS-CoV and MERS-CoV reported that civet cats and dromedary camels were the source for transmission from animal to humans. While n-CoV has been reported to be transmitted through the animal market in Wuhan, China, the epicenter of the outbreak [1].
Signs of n-CoV infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties which could worsen to cause pneumonia, severe acute respiratory syndrome, kidney failure and even death especially in elderly.
Standard recommendations to prevent infection spread include regular hand washing, covering mouth and nose when coughing and sneezing and avoiding close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing.
Possible routes of transmission of n-CoV have been identified as airborne, contact spread and spread via contaminated surfaces. Hence, a large number of countries have imposed travel bans, are suspending public gatherings and are screening populations to identify people at risk [2].
Healthcare professionals and staff in hospitals are particularly vulnerable to acquire the infection from the symptomatic as well as asymptomatic individuals due to the aerosols emitted in the air from invasive procedures, proximity to the patients during examinations and contact with contaminated instruments or surfaces [2].
Studies are in progress targeting the characteristics of the virus, factors promoting the spread of the virus, clinical trials to assess the most effective drugs and vaccines, knowledge attitude and practices in populations related to the n-CoV. Recent studies done to assess the awareness about COVID-19 amongst dental workforce focus on awareness about specific practices which help reduce the spread of infection [3][4][5][6][7][8][9]. However, we came across no study done as yet to assess whether the dental workforce is aware about the facts and myths related to Covid-19 awareness.
This study aims to analyze and compare the level of awareness about the facts and myths related to COVID 19 amongst faculty, dental students of COD and preparatory year students as part of an awareness campaign.

Test instrument
The covid-19 awareness test conducted at the College of Dentistry was designed using information from the World Health Organization's (WHO) Myth Busters Awareness webpage (March 2020) [10]. The main purpose of the test was to assess how well the respondents can differentiate between the facts and myths related to the Corona Virus. The online test consisted of 35 MCQ items and was administered to all Faculty, dental students and preparatory year students (prospective students taking admission at the College of Dentistry) using a secure enterprise online assessment platform (Blackboard).

Research question
What is the true level of awareness amongst faculty, prep year students and undergraduate dental students about the facts and myths related to corona virus?

Hypothesis
• Faculty are more knowledgeable and can correctly distinguish the facts and myths related to COVID 19.
• There is no difference in knowledge about the facts and myths related to COVID 19 amongst the prep year and dental students.

Setting
Faculty, dental students of the College of Dentistry and preparatory year students who had applied for the admission to the dental college.

Study period
The tests were administered over a period of three months from March to June 2020.

Consent
A Written informed Consent was obtained from all participants in the start regarding the usage of their responses for the publication purpose.

Ethical information
Ethical Approval was approved by the institutional review board at college of dentistry, IAU holding number EA: 202049.

Statistical analysis
The data was analyzed using descriptive statistics and summarized by frequency, percentages, mean and standard deviations. One-way ANOVA was used to determine the mean difference among the faculty, dental students and prep year student's knowledge score. Chi-square test was used to check the associations of myth and facts of the three groups. All the analysis was carried out on software Statistical Package for Social Science (SPSS, version 22 Inc, IBM). All tests were performed at a significance level of α = 0.05.

Results
The online COVID-19 awareness test was administered to 810 participants, out of which 325 (40%) were prep year students, 429 (53%%) were dental students, and 56 (7%) were faculty members. The average time spent filling the questionnaire was 12.8 mins (range: 1 to 45 mins) by each participant. Out of 810 participants, 86% of the Faculty were able to correctly identify the facts and the myths related to COVID-19 followed by 81% of the prep year students and 74% of the dental students. Table 1 shows the overall participant's mean knowledge score out of maximum 35. Preparatory year student's knowledge related to COVID-19 was found to be high as compared to dental students (26.47±4.247) and most senior dental students of the college also have higher knowledge score of (25.82±4.317).
Overall knowledge score comparison was performed to check the differences among the three groups, and it was found significant (P<0.001). Multiple comparison showed that prep year students' knowledge score was significantly higher than dental student (26.47±4.27, 23.67 ±6.2 respectively) (P<0.001) and even faculty members (23.30±7.34) (P<0.001). however, the knowledge score of dental students was almost same as faculty members and difference was not statistically significant (p-0.808). Table 2 represents the overall item wise comparison of fact and myth between the Faculty; dental students and preparatory year students. All items in related to facts showed the significant proportional difference between the groups except items 10, 11, 12 and 15 showed the same level of knowledge between three groups (faculty, prep year and dental students). All three groups showed almost the same ability in recognizing the myth stating that 'COVID-19 is old disease and effective vaccine of COVID in available.

Fact versus Myth-Comparison among the participants
Overall, the knowledge of faculty about the facts is higher than the undergraduate students. Faculty was more likely to be aware about the facts than students, but the difference is not significant (86%, 74%, respectively). Figs 1 and 2 showing the overall facts and myths comparison between dental and prep years students. Dental student's awareness to the facts was little lower as compared to the prep year students whereas the difference was negligible about the myths between both groups.

PLOS ONE
Comparing knowledge and perceptions amongst the dental workforce: Myths Vs. Facts Table 2. Overall item wise comparison of fact and myth between faculty members, dental students and preparatory year students. Myths that were considered facts and vice versa by dental students Table 3 presents the list of top five Myths that were considered as facts by the dental students. Thirty one percent (31%) of the dental students thought that ultraviolet light can help to kill COVID-19 virus, this was significantly higher as compared to the faculty among whom only 17% considered it as a fact. Wearing a mask generally is recommended to protect you from COVID-19 was considered as fact by majority of dental students (59%). Whereas around 30% dental students wrongly marked the facts that COVID-19 virus can be transmitted in hot and humidity and smoking is ineffective against COVID-19 (29%), as myths and these proportions were significantly different than faculty's response.

Myths that were considered facts and vice versa by faculty members
Similarly, like dental students' majority of the faculty 55% incorrectly marked that wearing a mask is recommended to protect against COVID-19. Nineteen percent (19%) of them thought the fact spraying alcohol chlorine can kill the virus is a myth, but this percentage was significantly lesser than dental students among whom 37% considered it a myth.
Creating stigma because of COVID-19 hurts everyone more this fact was considered as myth by 23% of the faculty and using diluted bleach as surface disinfection was also marked wrongly by the 13% faculty. Only two items were marked significantly lesser than dental students were 22 and 27 see Table 4.

PLOS ONE
Comparing knowledge and perceptions amongst the dental workforce: Myths Vs. Facts

Myths that were considered facts and vice versa by prep year students
The myth that COVID-19 is an old disease cause by an old coronavirus was incorrectly recognized by 40% preparatory year students as a fact (Table 5). Another large number of preparatory year student (24%) thought spraying alcohol or chlorine on your body can kill virus but this number was still significantly less than dental students (34%). Another big difference was observed about myth that was considered as fact by preparatory year and dental students (14%, 25% respectively) that hand dryers are effective in killing virus. Top facts which were marked as myth by the preparatory year students were "Creating stigma because of COVID-19 hurts everyone (31% considered it a myth)", diluted "bleach as surface disinfector (28% considered it a myth)" and "COVID-19 virus can be transmitted in hot and humidity area 22% considered it a myth" and these incorrect responses were significantly different from the responses of faculty and dental students.

Discussion
Very few studies have tried to assess whether the healthcare workforce is clear and vigilant about the facts and myths related to the corona virus. Most of the studies focus on the knowledge, attitude and practice related to awareness about specific practices in reducing the spread of infection [3][4][5][6][7][8][9]. It is imperative for healthcare professionals to be able to discern between the facts and myths related to the transmission of corona virus. Since things are not black and white or

PLOS ONE
Comparing knowledge and perceptions amongst the dental workforce: Myths Vs. Facts "clear cut" when dealing with a new infectious disease, it becomes the responsibility of the healthcare provider to follow the facts and be the myth busters.
This study used the "COVID-19 Advice for Public: MythBusters" shared by WHO [10] to prepare the 35 items test to assess whether the faculty and students at the College of Dentistry could correctly differentiate between the facts and myths related to COVID -19, as part of the awareness campaign.
Results of the test showed that 86% of the faculty, 74% dental students and 81% of the prep year students were able to correctly differentiate between the facts and the myths. Faculty members were the first group to be administered the test and the preparatory year students the last group during the three-month study period from April to June. The reason for the low percentage of correct answers from the faculty and high percentage of correct answers from the preparatory year students could be because of the timing of the tests where the preparatory year students benefitted from the updated information shared on a regular basis by the Ministry of Health and WHO leading to increased awareness towards the end of the study period.
Generally, there was significantly higher awareness about the facts related to the COVID-19 symptoms, spread of the disease, use of face mask and appropriate quarantine by the majority of the respondents in all groups. These findings concur with other studies focusing on knowledge, attitudes and practices related to COVID-19 pandemic [3][4][5][6][7][8][9].
The results showed that facts were easier than myths to be perceived among different groups as more than 70% of participants answered the facts correctly. On the other hand, most myths were challenging, especially those related to prevention and treatment.  Table 3. Top five Myths that were considered facts and vice versa by dental students.

Question
No.

Questions
Percentage of Dental students who considered myth as fact 9 Wearing a face mask generally is recommended to protect you from COVID-19.

PLOS ONE
Comparing knowledge and perceptions amongst the dental workforce: Myths Vs. Facts "Wearing a face mask generally is recommended to protect you from COVID-19" was a Myth according to the WHO Myth Busters webpage. In our study, this myth was one of the top 5 myths considered as a fact by 60% of the dental students and 55% of the faculty. WHO website is also updating the MythBusters regularly and this particular myth has now been updated as a "Fact" with additional information regarding wearing a mask during exercise and for prolonged time, also the difference between various types of available masks. Recent study highlights the importance of use of face masks with social distancing of 1 m or more as a potential barrier against the rapid spread of COVID-19 infection [11][12][13].
Outbreak of COVID-19 pandemic led to increased social stigmatization at various levels, from those who got infected and recovered to the Chinese community from where the disease is believed to have spread [14]. The statement that "Creating stigma because of COVID-19 hurts everyone by creating more fear or anger" was a "Fact" according to the WHO Myth Buster webpage, however it was wrongly identified as one of the top five "Myths" by 31% of the preparatory year students, 28% of the dental students and 22% of the faculty members. As part of the healthcare workforce, increased awareness should be directed towards the negative side of creating stigma [14], emphasizing that 96% of people have recovered till date from the COVID-19 infection [15] and that this is not a life-long disease like Acquired Immunodeficiency Disease (AIDS). WHO has also recently introduced a portal for reporting any misleading information related to COVID-19 as part of its awareness campaign to minimize spread of false or misleading information related to .
Similarly, the statement "COVID-19 is the same as SARS" identified as a "Myth" according to the WHO Myth Buster webpage was wrongly identified as a "Fact" by 40% of the dental students; 25% of the faculty members and 19% of the preparatory year students. Another common myth that there are specific validated medicines for treatment, was found to be prevalent among the dental students (55%%) and faculty (51%) followed by preparatory year students (53%). This brings us to the importance of awareness about the process for validating medicines. Health care workers should be aware that there are several ongoing drug trials and that there is currently no proof that hydroxychloroquine or any other drug can cure or prevent COVID-19. Misuse of medicine can cause serious side effects and illness and even lead to death [17]. However, those infected with the virus should receive appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care.
The myth that pneumococcal vaccine can be used to provide protection against COVID-19 was found to be prevalent among the dental students and preparatory year students (39%, 34% respectively) with 51% of the faculty also believing it while the fact is that there is no validated vaccine for COVID-19 till now.

Conclusion
This study reports about a successful pilot test conducted to assess the perceived knowledge about facts and myths related to corona virus amongst the dental workforce. Results from the study guide the administrators to focus on the facts in the multiple awareness sessions and processes and emphasizes the role of the healthcare provider as myth-busters.

Recommendations
Information should be acquired from International organizations, such as WHO, CDC or Government Health Ministry instead of following the news spread through multiple news channels or social media.
Regular awareness campaigns should be conducted and followed by pre and post test of knowledge attitude and practices, Signage and posters related to important facts and the busting of the most prevalent myths should be put up in all public places, workplaces, and institutions as a constant reminder.