Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 526-531  

Knowledge, perceived need for education, and willingness to participate in bioterrorism preparedness among students in an indian dental institute: A questionnaire study


1 Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Himachal Pradesh, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India

Date of Submission22-Mar-2017
Date of Acceptance18-Jun-2017
Date of Web Publication17-Jan-2018

Correspondence Address:
Dr. Sumeet Bhatt
Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_61_17

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  Abstract 


Objectives: An act of bioterrorism may compromise the local medical system and require whole of the healthcare workforce. The purpose of the present study was to assess the knowledge, perceived need for education, and willingness to participate in bioterrorism management among students in an Indian dental institute. Materials and Methods: A total of 231 dental students, including undergraduates and postgraduates, participated in this study conducted in the year 2014. Dental students' knowledge, perceived need, and willingness were assessed using a self-administered questionnaire. Results: More than 90% of both undergraduate and postgraduate students were willing to provide care during a bioterrorism attack. The actual knowledge was observed to be very low in both groups. Perceived knowledge as well as actual knowledge was statistically higher in the postgraduate group (P < 0.05). Most of the participants were of the opinion that they need more education regarding bioterrorism and that it should be added to dental curriculum. The majority of the participants showed willingness to attend continuing education programs on bioterrorism. Conclusions: The dental students demonstrated low knowledge but high willingness to provide care. A policy-driven approach to include bioterrorism management in dental education and organization of more continuing education programs is recommended to improve knowledge and develop necessary skills. This will help develop a workforce efficient in providing care during a possible act of bioterrorism.

Keywords: Bioterrorism, continuing dental education, dental students


How to cite this article:
Bhatt S, Rajesh G, Thakur D. Knowledge, perceived need for education, and willingness to participate in bioterrorism preparedness among students in an indian dental institute: A questionnaire study. Med J DY Patil Univ 2017;10:526-31

How to cite this URL:
Bhatt S, Rajesh G, Thakur D. Knowledge, perceived need for education, and willingness to participate in bioterrorism preparedness among students in an indian dental institute: A questionnaire study. Med J DY Patil Univ [serial online] 2017 [cited 2018 May 27];10:526-31. Available from: http://www.mjdrdypu.org/text.asp?2017/10/6/526/223370




  Introduction Top


Abioterrorism attack is the deliberate release of viruses, bacteria, or other such agents used to cause illness or death in people, animals, or plants. Such agents are characteristically found in nature, but it is possible to modify them to enhance their ability to cause disease, make them resistant to existing treatment modalities, or to augment their ability to be spread into the environment. Biological agents can be disseminated through the air, through water, or in food. These biological agents may be used by terrorists because they can be very difficult to detect and do not produce symptoms for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from one person to another whereas some, like anthrax, cannot.[1]

The terrorist attacks of September 11, 2001, in the United States and recently in France, taught the world that the acts of terrorism can occur anywhere. India has been a target of terrorist attacks since decades. Since 2001, India has faced several acts of terrorism including 2001 attack on the Indian parliament and 2008 Mumbai attacks.

Such incidents have heightened the threat of bioterrorism over the past few years which was long ignored and denied. The health-care professionals today are ill prepared to deal with a terrorist attack that employs biological weapons. The medical community should educate the public and policymakers about the threat. In the longer term, we need to prepare ourselves to detect, diagnose, characterize epidemiologically, and respond appropriately to biological weapons use and the threat of new and reemerging infections.[2]

Concerns still remain regarding the existing health system's readiness to respond to a bioterrorist attack.[3] Readiness includes preparing health professionals, who play a key role in public health emergencies.[4]

A mass disaster event, such as an attack of bioterrorism, has the potential to overwhelm the local medical system. Physicians, nurses, and other first responder healthcare professionals may not be able to respond to the demand for required services. Other health professionals may need to step forward and fill this gap.[5] In such a situation, the dental profession can contribute valuable assets, both in personnel and facility, for preparation and immediate response to a bioterrorism attack. These benefits can make a significant difference in the outcome. In a major bioterrorist attack, the local needs could be massive and immediate. As hospitals become filled, alternate sites for the provision of health care may be required, and dental offices could fill that need.[2] It is the recommendation of the American Dental Association (ADA) that the dental professionals can be a resource and with targeted education and training can effectively respond and assist during natural and other catastrophic disasters.[6] To carry out these roles effectively, a thorough knowledge and adequate training in bioterrorism preparedness and management, as well as the willingness to provide them are essential. It might be of significance to include bioterrorism preparedness in the dental curriculum so as to familiarize dental students with bioterrorism at the undergraduate level.

There is a paucity of data regarding Indian dental professionals' knowledge about bioterrorism and their keenness to participate in preparedness of its management. There are virtually no studies in the literature on the subject of knowledge and willingness of dental students in this regard. Therefore, the present study was an attempt to assess the knowledge, perceived need for education, and willingness to participate in bioterrorism preparedness among dental students in Himachal Institute of Dental Sciences, Paonta Sahib, India.


  Materials and Methods Top


A questionnaire-based cross-sectional survey was conducted among dental students in Himachal Institute of Dental Sciences, Paonta Sahib. Undergraduate program (Bachelor of Dental Surgery) in India consists of 4 years of dental training followed by 1 year of compulsory internship. Postgraduation (Masters of Dental Surgery) is a 3-year course in different specialties of dentistry. For the present study, undergraduate students from 3rd year onward including internship and all the postgraduate students were included. Exclusion criterion was unwillingness to participate in the study.

The permission to carry out the study was obtained from the Principal, Himachal Institute of Dental Sciences, Paonta Sahib, and the study began after approval from the Institutional Ethics Committee. Informed consent was taken from every study participant before data collection, and confidentiality of the participants was assured at every stage of the study. The inclusion in the study was entirely on the will of the participants although none of the students declined participation.

The undergraduate students were contacted at the end of their classes during the college hours. The interns and the postgraduate students were contacted in their respective departments. The students were informed about the purpose of the study and a questionnaire to assess their knowledge, perceived need for education, and willingness to participate in bioterrorism preparedness was distributed to them. Data were also collected on participants' demographic characteristics. The questionnaire used for this study was developed from earlier surveys on bioterrorism preparedness among health professionals.[7],[8] The ten ADA-recommended roles which dental professionals should play in the event of a bioterrorist attack were listed on the questionnaire, and the participants were asked to choose the most appropriate roles in their opinion. Both closed and open-ended types of questions were used in the questionnaire. Most questions were either Likert scale, with response categories ranging from strongly disagree to strongly agree (strongly disagree, disagree, no opinion, agree, strongly agree), or Yes/No type of questions.

New variables were created based on the study done by Bhoopathi et al. on dental professionals.[7] A new variable to determine the number of roles advocated by ADA that the respondents thought dental professionals were willing to play or should play was formed by adding up the total number of positive responses to the ten ADA-recommended roles listed (score range 0–10). The opinion-based questions used Likert scale answers to find out the respondents' opinions about (1) bioterrorism being a serious national issue, (2) the possibility of bioterrorism attack in their local community, and (3) dental professionals as a part of the first responder teams. Self-perceived knowledge questions assessed respondents' self-perceived ability (1) to recognize the signs and symptoms of bioterrorism-related diseases, (2) to know where to call during a bioterrorist attack, (3) to know how to get information about an attack, (4) to know how to get clinical information about a bioterrorism-related disease, and (5) to have good current knowledge about management of bioterrorism. These five questions with Likert scale responses were summed to derive a self-perceived knowledge variable (score range of 0–25).

Actual knowledge about bioterrorism was assessed using two questions. One question asked where to report a suspected case of bioterrorism-related disease. The two correct responses were the State Public Health Department and the Local Public Health Department. The second question asked respondents to name four of the top six Category A bioterrorism diseases (smallpox, anthrax, plague, botulism, viral hemorrhagic fever, and tularemia, according to the Centers for Disease Control and Prevention).[9] Responses to these questions were added up to derive a new actual knowledge variable with a score range of 0–6. Finally, four questions related to self-perceived need and willingness to participate in bioterrorism education with Yes/No type responses assessed respondents' (1) need for more education related to bioterrorism, (2) previous attendance in a bioterrorism-related continuing education (CE) course, (3) opinion about including bioterrorism preparedness education in the dental/dental hygiene curriculum, and (4) willingness to attend a CE course.[8]

The statistical analysis was done using SPSS version 16 (SPSS Inc., Chicago IL, USA). Descriptive statistics were performed using frequencies, percentages, and means. Chi-square test was used to analyze categorical data, and Student's t-test was used to analyze parametric continuous data. Multivariate linear regression model was created to predict dental professionals' actual knowledge on bioterrorism preparedness and management. The level of significance for the present study was fixed at P < 0.05.


  Results Top


The present study was conducted on 231 dental students in Himachal Institute of Dental Sciences, Paonta Sahib. The mean age of the participants was 22.95 ± 2.53 years, with the age range of 19–37 years. The majority of the participants were females (74%), Hindus (71%), and in the undergraduate stage of the course (76.2%) [Table 1].
Table 1: Distribution of participants according to the demographic factors

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Male participants assigned higher mean roles to dental professionals in responding to bioterrorism (9.02 ± 1.73), as compared to female participants (8.77 ± 2.07). Male participants also reported higher perceived as well as actual knowledge related to bioterrorism. However, these findings were not statistically significant (P > 0.05).

[Table 2] shows that more than 90% of both undergraduate and postgraduate students were willing to provide care in the event of a bioterrorism attack. Similarly, most of the participants felt that bioterrorism is a serious national issue. The postgraduate students were more likely to feel that bioterrorism was a serious national issue and that a bioterrorism event was possible in their local area. Significantly more number of undergraduate students felt that dental professionals should be on the first responder team in response to a bioterrorist attack (odds ratio [OR] =0.46, 95% confidence interval [CI]: 0.24–0.88, P = 0.019).
Table 2: Comparison of undergraduates and postgraduates

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Mean number of roles suggested for dental professionals was 8.73 ± 2.11 by undergraduate students and 9.21 ± 1.45 by postgraduate students. The only statistically significant difference observed was regarding “Performing victim triage.” More number of postgraduates felt that the dentists should perform victim triage in such an event (OR = 0.33, 95% CI: 0.13–0.82, P = 0.014).

Regarding the self-perceived knowledge, the postgraduate students were more than twice as likely to feel that they would be able to recognize signs and symptoms of an attack of bioterrorism (OR = 2.84, 95% CI: 1.47–5.5, P = 0.001) and self-perceived knowledge regarding where to call during an attack (OR = 2.19, 95% CI: 1.13–4.26, P = 0.018). The overall self-perceived knowledge was significantly different in the two groups (P< 0.05). The postgraduates had a higher self-perceived knowledge (14.92 ± 3.86) as compared to undergraduates (13.50 ± 3.38).

When the actual knowledge was assessed, the postgraduate students identified significantly more number of Category A bioterrorism diseases than the undergraduates (P< 0.05). The mean overall actual knowledge was also significantly higher in the postgraduate group (P< 0.05).

About 97% undergraduate students and all of the postgraduate students felt that they need more education regarding bioterrorism. Significantly higher number of postgraduate students had attended a CE program related to bioterrorism (OR = 0.27, 95% CI: 0.09–0.81, P = 0.014). Although not statistically significant, more number of undergraduate students felt that bioterrorism preparedness should be added to the dental curriculum and that they would be willing to attend a CE program on bioterrorism.

The linear regression model predicting actual knowledge included the following variables: age, gender, course, number of roles by dental professional, self-perceived knowledge and whether the student would attend a CE course [Table 3]. However, only those who suggested higher roles to be played by dental professionals (P = 0.047) and students in postgraduation (P = 0.000) had significantly higher actual knowledge.
Table 3: Linear regression model predicting dental professionalsí actual knowledge regarding bioterrorism preparedness and management

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  Discussion Top


With the increasing threat of terrorism worldwide, it is imperative for the entire healthcare workforce to be better educated and well trained about the management of bioterrorism. A meeting of ADA in 2002, identified several areas in which dental professionals can assist in the event of a major attack. These included surveillance and notification, diagnosis and monitoring, referral, immunizations, medications, triage, medical care augmentation, decontamination, and infection control.[10] A similar workshop organized by the ADA and the American Dental Education Association in 2003, concluded that dental professionals should have the appropriate knowledge and training regarding possible bioterrorism agents, how to respond during such an event, and communicating relevant surveillance information to appropriate sources.[11] Some of the previous studies report a lower actual knowledge and preparedness in bioterrorism management among the dental health-care professionals.[12],[13]

Keeping this in view, the present study was an attempt to assess the knowledge regarding bioterrorism and its preparedness among the dental students in an Indian dental institute. The study also explored the willingness of students in the management of bioterrorism and their perceived need for education regarding the same. There is a scarcity of data related to this topic in the literature, and to the best of our knowledge, this is the first study to assess these factors in Indian dental students.

There was an overwhelming response regarding the willingness to provide care during an attack with positive response from over 90% of both undergraduates and postgraduates. Similarly, the majority of the participants felt that bioterrorism is a serious national issue. However, only about 63% undergraduates and about 70% postgraduates felt that an act of bioterrorism is possible in their area. Since there has never been any major incident of an act of bioterrorism in India, some students might have felt that such an attack was unlikely in their locality. Interestingly, more undergraduate students believed that the dental professionals should be on the first responder team as compared to the postgraduate students (OR = 0.46, 95% CI = 0.24–0.88, P = 0.019).

When asked about the ADA-recommended roles that dental professionals should play in the event of bioterrorism attack, both undergraduates and postgraduates reported an average of about nine possible roles, which is encouraging. The most common roles mentioned by participants were: reporting an attack, counsel the public, keeping dental records, and giving vaccines and medications. The only significant difference was found regarding performing victim triage, where postgraduate students were more likely to think that dental professionals should play this role (OR = 0.33, 95% CI = 0.13–0.82, P = 0.014). This difference might stem from the possibility that the existing dental curriculum in India does not give enough stress on practical aspects of victim triage during an emergency. Since whole of the healthcare workforce may be required in such incidents, the dental professionals and students should be educated and trained regarding emergency management in such events.

The postgraduate students showed a higher self-perceived knowledge compared to the undergraduates. The postgraduates were more than twice likely to think that they would recognize the signs and symptoms of an attack (OR = 2.84, 95% CI = 1.47–5.5, P = 0.001) and that they know where to call during an attack (OR = 2.19, 95% CI = 1.13–4.26, P = 0.018). The overall self-perceived knowledge score was also significantly higher for postgraduate students (P = 0.024). However, the actual knowledge regarding the bioterrorism was low for both groups. Both undergraduates as well as postgraduates did not differ much in their actual knowledge regarding where to call during an attack (P = 0.29). The postgraduate students were able to report significantly higher number of Category A bioterrorism-related diseases than undergraduates (P = 0.000). The mean overall actual knowledge was also statistically higher for postgraduate students (P = 0.000).

Despite the high willingness to provide care by both groups, the findings of the study demonstrate that there is a clear lack of knowledge and training regarding bioterrorism and its management among the dental students. There was a gap in the self-perceived and the actual knowledge in both groups. Similar results of high willingness and low actual knowledge have been reported previously.[13],[14]

Most of the participants felt that they need more education regarding bioterrorism. More number of postgraduates had previously attended a CE program related to bioterrorism than the undergraduates (P = 0.014). Overall, both groups showed very low participation in CE program. This might be because of a lack of such programs in India which are focused on the issues of bioterrorism. It is highly recommended that CE programs focused on bioterrorism and its management should be organized by dental associations through conferences and student conventions to familiarize dental students as well as dental professionals in the concept of bioterrorism. Such programs can prove useful in improving the knowledge, attitude, and skills regarding bioterrorism as has been demonstrated in a previous study done on New York City clinicians.[15]

Another finding of interest was that a higher percentage of undergraduates felt that bioterrorism should be added to the dental curriculum, and that given a chance, they would be willing to attend a CE program on bioterrorism. Considering this and the apparent lack of knowledge, there is a clear need to add bioterrorism and its management to the dental curriculum. This may go a long way in improving knowledge and develop necessary skills necessary for understanding and management of bioterrorism.

Since there is very limited data in the literature related to bioterrorism preparedness among dental professionals, further studies are needed on this topic. The present study can serve as a preliminary research in this area. Studies can also be done to evaluate the effects of CE programs on the improvement of knowledge, attitudes, and perceptions about bioterrorism. Furthermore, a more varied sample of dental students or dental health professionals can be used in future to improve the results obtained.


  Conclusions Top


This study demonstrated that there is low knowledge about bioterrorism and its management among the dental students. There was a clear difference in the perceived and actual knowledge in both undergraduate as well as postgraduate students. Despite this, a high willingness to provide care during an attack in both groups is an encouraging sign. To overcome this gap of knowledge and willingness, bioterrorism preparedness should be added to the dental curricula. There is also a need to have focused CE programs on bioterrorism to improve the knowledge and develop proficiency in the management of bioterrorism.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Centre for Disease Control and Prevention. Bioterrorism. Available from: http://www.bt.cdc.gov/bioterrorism/overview.asp. [Last accessed on 2014 Jun 12].  Back to cited text no. 1
    
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Bhoopathi V, Mashabi SO, Scott TE, Mascarenhas AK. Dental professionals' knowledge and perceived need for education in bioterrorism preparedness. J Dent Educ 2010;74:1319-26.  Back to cited text no. 7
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Chmar JE, Ranney RR, Guay AH, Haden NK, Valachovic RW. Incorporating bioterrorism training into dental education: Report of ADA-ADEA terrorism and mass casualty curriculum development workshop. J Dent Educ 2004;68:1196-9.  Back to cited text no. 11
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Scott TE, Bansal S, Mascarenhas AK. Willingness of New England dental professionals to provide assistance during a bioterrorism event. Biosecur Bioterror 2008;6:253-60.  Back to cited text no. 12
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Katz AR, Nekorchuk DM, Holck PS, Hendrickson LA, Imrie AA, Effler PV. Dentists' preparedness for responding to bioterrorism: A survey of Hawaii dentists. J Am Dent Assoc 2006;137:461-7.  Back to cited text no. 13
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Alexander GC, Wynia MK. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22:189-97.  Back to cited text no. 14
    
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Gershon RR, Qureshi KA, Sepkowitz KA, Gurtman AC, Galea S, Sherman MF. Clinicians' knowledge, attitudes, and concerns regarding bioterrorism after a brief educational program. J Occup Environ Med 2004;46:77-83.  Back to cited text no. 15
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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