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Knowledge and Attitude of Dental Students and Interns in Saudi Arabia (Riyadh Region) among Hepatitis C Virus Infection

Introduction: Hepatitis C virus (HCV) is considered one of the leading causes of chronic liver conditions in the world. The primary route of transmission of HCV can be by exposure of infected blood or sharing a contamination syringe during the injection of drugs. the purpose of this research to evaluate and assess the knowledge and attitude of HCV infection among dental students and interns in Saudi Arabia population specially Riyadh region. Materials and Methods: This is a cross sectional-based survey, using a questionnaire which was divided into two parts, first covering sociodemographic information of the participant regards gender, demographic variable, academic level of the participant and the University. Second part of the questionnaire was established based on the knowledge and attitude of the participant in regard to HCV. Original Research Article Alhedyan et al.; JPRI, 33(3): 13-26, 2021; Article no.JPRI.64842 14 Results: A total of 218 students participated in this study. The responses of participants differed in various academic levels with a statistically significant difference in only two questions; in question 10 when they were asked whether or not they knew that a vaccine for HCV exists (p = 0.02) and question 20, if they believed that dental staff would be afraid to treat a patient if they found out his/her positive HCV status (p = 0.02). Conclusions: The present study showed that knowledge, among the dental students and interns in the Riyadh region was not adequate in regard to HCV, and their attitude toward HCV patients was inequitable.


INTRODUCTION
Hepatitis can be defined as an inflammation of the liver that can cause a variety of health problems and can eventually cause death. Hepatitis mainly have different five types that include type A, B.C.D and E that have a distinct mode of transmission; however, all can lead to liver diseases [1]. Hepatitis C virus (HCV) is considered one of the leading causes of chronic liver conditions in the world [2]. The prevalence of HCV based on antibodies HCV positive test globally is estimated at 1.6%, which ranges between 90 -145 million individuals [3]. People infected by HCV can later develop severe form of liver diseases such as cirrhosis and cancer [4].
The primary route of transmission of HCV is through exposure of infected blood or sharing a contaminated syringe during the administration of drugs [2]. Another way of HCV transmission is either through sexual transmission or maternal HCV transmission, but it is considered to be less common compared to other modes of transmission [5,6]. Dentists have one of the highest risks of HCV transmission among health care workers [7]. Several researches examined the knowledge and attitude toward the infection control protocols with the student, lab technician and dentist. The outcome of those investigations revealed that dentists have poor knowledge of infection control that increases the risk of infection depending on use of protective aids [7,8].
For instance, Okasha et al. (2015) published a study that aimed to document the prevalence and incidence of HCV between health care workers in Cairo, Egypt. This study revealed 7.3% per 1000 people per year incidence of HCV infection, which raised the risk of mortality and morbidity among dentists and health care workers in general [9]. A study was also conducted by Peeran et al. (2016) that aimed to understand and evaluate the knowledge and attitude toward HCV infection among undergraduate dental students and interns [10].
A recent study conducted by Rostamzadeh et al. (2018) to evaluate the basic infection control knowledge, attitudes and practices of dentists in the Iranian population revealed that there is an accceptepal knowledge and attitude of dentists towards different infections such as HIV,HBV and HCV. However, some gap in infection control knowledge and applications are observed and increasing awareness of dental practitioners is recommended to have good infection control protocols to prevent any possible risk [11].
Accordingly, the purpose of this research is to evaluate and assess the knowledge and attitudes among dental students and interns regarding hepatitis c virus infection in Saudi Arabian population especially in Riyadh region. This study will provide an insight into the current knowledge and practices of dental students and interns with regards to HCV and help dental educators and policy rethink education and training policies and incorporate changes in HCV infection control training if needed, based on the results of this research.

Study Design
The present study is a cross-sectional, survey based study. The survey was distributed through different social media platforms include, Twitter, Telegram, and WhatsApp among dental students and interns enrolled in the following eight dental colleges: Prince Sattam bin Abdulaziz University (PSAU), King Saud University (KSU), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh Elm University (REU), Princess Nora bint Abdulrahman University (PNU), DAU University, Majmaah University, and Al-Farabi Colleges in Riyadh, Saudi Arabia.

Study Instrument
A self-designed, close ended questionnair was used for the survey. The questionnaire was written in the English language. It was converted to an electronic format using Google Forms. The integrity of the questionnaire was maintained by keeping the options and answering fields as they would appear in paper format. The validity of questionnare was measured first among dental students and interns in Prince Sattam Bin Abdulaziz University to ensure the feasibility of the study before distributing the questionnaire to the partcipants.
The questionnaire was divided into two parts; the first part assessed general information of the participant like demographic information, academic level of the participant and the University they belonged to. The second part of the questionnaire assessed the knowledge and attitude of the participants with regards to HCV and including items that asked about the route of transmission of HCV infection, HCV infection signs and symptom, the vaccination of HCV infection, patient thoughts toward HCV infection, and the treatment modalities of HCV patients.

Sampling and Sample Size
A stratified random sampling technique was used to obtain the study sample from among dental students and interns in the chosen dental schools. Sample size calculation was performed using the following formula: Sample size calculation was performed using the following formula: n = Z1-α/2 2 [p(1 -p)]/d 2 Where, n is the sample size, Z1-α/2 2 is the standard normal variate (at 5% Type 1 error and 95% CI [p<0.05] it is 1.96), p is the expected proportion in population based on previous studies and, d is the absolute error or precision.
According to this formula, with a present knowledge level of 75% based on previous studies and a precision of 5%, a minimum sample of 198 participants were needed to produce statistically accurate results.

Statistical Analysis
Data was collected, tabulated and analyzed using SPSS software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.). Frequency distribution of demographic variables like gender, university and academic level of participants was calculated using descriptive statistics. Comparisons were made between knowledgebased variables and academic level, University and gender using Pearson's Chi-Square tests. Variables with non-binary responses were reported individually for better visualization.

RESULTS
A total of 218 students participated in this study. Table 1 represents the distribution of respondents with respect to demographic variables. Majority of the respondents were males (56.8%), from Prince Sattam bin Abdulaziz University (PSAU; 29.3%) and studying in 2nd year (38.9%). The least number of respondents were from Dar Al Uloom University (DAU; 2.7%). Similarly, only 1.3% of respondents studied in 1st year and were the least with respect to academic level. Table 2 depicts frequency distribution of responses of participants and chi-squared p values with respect to academic level of study. The responses of participants differed in various academic levels with a statistically significant difference in only two questions; in question 10 when they were asked whether or not they knew that a vaccine for HCV exists (p = 0.02) and question 20, if they believed that dental staff would be afraid to treat a patient if they found out his/her positive HCV status (p = 0.02). Participant responses to the rest of the questions did not differ significantly. Fig. 1 depicts the distribution of "yes" responses among males and females. It was observed that in all questions, a greater number of females responded with a yes than males except in question 25 (males =47%, females = 41%). Similarly, Fig. 2 depicts the frequency distribution of responses of male and female participants. When responses of participants were compared on the basis of gender, it was found that there was no statistically significant difference between responses of males and females (Table 3). Analyses were also done to compare knowledge of participants based on the university they studied in. Frequency distribution of responses are depicted in Table 4. There were differences that were statistically significant in eight of the total binary response questions in the questionnaire. These differences were found in Q.10 (p = 0), Q.13 (p=0.03), Q.14 (p=0.017), Q.15 (p=0.04), Q. 21 (p=0.007), Q.22 (p=0.01), Q.24 (p=0.001) and Q.25 (p=0.03). Distribution of participants who responded with "yes" to every question are presented in Fig. 3.
Responses to questions 2 and 3 were non and are presented in Table 5, Fig. 4.and Fig. 5. When asked about the preferred method of seeking more knowledge about HCV (Q.2), majority of the males (47.5%) chose books while Analyses were also done to compare knowledge of participants based on the university they studied in. Frequency distribution of responses depicted in Table 4. There were differences that were statistically significant in eight of the total binary response questions in the questionnaire. These differences were found in Q.10 (p = 0), Q.13 (p=0.03), Q.14 (p=0.017), 7), Q.22 (p=0.01), Q.24 (p=0.001) and Q.25 (p=0.03). Distribution of participants who responded with "yes" to every Responses to questions 2 and 3 were non-binary and are presented in Table 5 Similarly, majority of 2nd year students (38.8%) and 4th year students (44.2%) also chose books as their preferred source of additional HCV knowledge but the difference between academic level was not statistically significant (p=0.13). On the contrary, responses were significantly different among students of different universities (p=0.018). Additionally, when asked about the major route of transmission of Hepatitis C (Q.3), majority of the all the respondents with respect to gender, academic level and university responde chose blood (Table 5) but there were no significant differences in the responses between any variable (gender, academic level or university). Similarly, rity of 2nd year students (38.8%) and 4th year students (44.2%) also chose books as their preferred source of additional HCV knowledge but the difference between academic level was not statistically significant (p=0.13). On the nificantly different among students of different universities (p=0.018). Additionally, when asked about the major route of transmission of Hepatitis C (Q.3), majority of the all the respondents with respect to gender, academic level and university responded chose blood (Table 5) but there were no significant differences in the responses between any variable (gender, academic level or Shows the % of males and females that responded "yes" to every question  20

Frequency distribution of participant responses on the basis of gender
Shows the % of participants that responded "yes" to every question based on university ; Article no.JPRI.64842

Frequency distribution of participant responses on the basis of gender
Shows the % of participants that responded "yes" to every question based on

DISCUSSION
Very few studies in literature discuss the knowledge and attitude of dental student and intern towards HCV infection especially in Saudi Arabia.
Therefore, the main aim of this research was to understand the level of understanding regards the HCV infection, which in turn improves the awareness regards the implication of the infection control guidelines among dental students and interns.
A total of 218 respondents from both genders participated in this study from different academic levels and institutions in Saudi Arabia. There was no significant difference in knowledge between males and females, and between different academic levels. However, a similar study found that female practitioners have more negative attitudes towards infection compared to their male counterparts [12].
To the best of the authors' knowledge, this is the first study that investigates the knowledge and attitude of dental students and interns in Saudi Arabia. Other studies from different countries have the same aims but differ in the aspect of their samples.
Regarding knowledge of HCV infection, our findings show that most of the students in our sample lack basic knowledge of HCV infection that could help them to manage the patients diagnosed with HCV. A study published by Mtengezo et al. (2016) in Malawi that aimed to understand the knowledge and attitude of HIV, HBV and HCV virus infection among health care workers, showed that the majority of participants had less knowledge with regards to HCV infection [13]. The authors of this study recommend an educational program to improve this shortage in their knowledge. In our study we aim to understand the early knowledge of the students to overcome the weakness in early stage. Another study by Peeran et al. (2016) similar to our study investigated the knowledge and attitude of dental students from Libya. The result of that study indicates a gap in knowledge of HCV infection among the students [10]. These results show to be similar to findings in this study. The knowledge of participants is found to be equal between different academic levels and this lack of knowledge can elevate the stress level of students and interns when they plan to treat HCV patients. Furthermore, the rejection of treatment of HCV patients is not a positive attitude for the patients and can reflect a negative action that harms the patients. The students and interns should always follow universal infection control guidelines to treat any patients.
As for the attitude towards HCV infection, our results show that there is no clear answer from

uidelines to treat any
As for the attitude towards HCV infection, our results show that there is no clear answer from the participants with regards to the best approach to manage these kinds of patients. These results were also present in differ studies that investigate the attitude toward HCV patients [10,14,15].

Frequency distribution of responses to question 3
; Article no.JPRI.64842 the participants with regards to the best approach to manage these kinds of patients. These results were also present in different studies that investigate the attitude toward HCV

CONCLUSION
The present study demonstrated that the knowledge of HCV among dental students and interns in Riyadh region was not adequate, and their attitude toward HCV patients was not favorable. However, this research paper clearly shows that the student knowledge and attitude for HCV patient can be improved if further improvements are made in education and training to allow students and interns to handle HCV patients without discriminating against these types of patients.

LIMITATIONS
This study primary evaluates the knowledge and attitude of HCV infection among the students and interns in Riyadh region, Saudi Arabia. Response bias is intrinsic to all surveybased research and limits the application of results of such studies to the broader population and this is also a limitation in this study. Furthermore, a non-validated instrument was used in this study which hampers reproducibility of results on other similar samples. We recommend future researchers to develop standardized, validated instruments to assess self-reported measures of knowledge and attitudes.

CONSENT
As per international standard or university standard, Participants' written consent has been collected and preserved by the authors.

ETHICAL APPROVAL
Ethical approval for the study was obtained from the Ethical Committee of Prince Sattam bin Abdulaziz University.