Information sources of Brazilian undergraduate dental students during the COVID-19 outbreak: a cross-sectional study

Aim: This cross-sectional study aimed to investigate where Brazilian dental students seek information about COVID-19 by a self-administered web-based questionnaire. Methods: A social network campaign on Instagram was raised to approach the target population. The dental students responded to a multiple-response question asking where or with whom they get information about COVID-19. The possible answers were government official websites or health and education institutions websites, TV Programs, professors, social media, scientific articles, health professionals, and family members. The data were analyzed by descriptive statistics, and the frequency distributions of responses were evaluated by gender, age, type of institution, and year of enrollment. Results: A total of 833 valid responses were received. The main source of information used by the dental students were government official websites or health and education institutions websites, which were reported by 739 (88.7%) participants. In the sequence, 477 (57.3%) participants chose health professionals while 468 (56.2%) chose scientific articles as information sources. The use of social media was reported by 451 (54.1%) students, while TV programs were information sources used by 332 (39.9%) students. The least used information sources were professors, reported by 317 (38.1%) students, and family members, chosen only by 65 (7.8%) participants. Conclusion: Brazilian dental students rely on multiple information sources to stay informed about COVID-19, mainly focusing their information-seeking behavior on governmental and health professional’s websites.


Introduction
COVID-19 is a virus-mediated disease caused by a member of the coronavirus family SARS-Cov-2 originated in Wuhan, Hubei, China in December 2019 1,2 . A few months after the first cases, the disease became pandemic, affecting more than 100 million people and causing over 2.5 million deaths (March 8 th of 2021), according to the World Health Organization (WHO) COVID-19 dashboard 3 . In Latin American countries, Brazil has risen to the spotlight of leading nations with the highest number of cases and deaths episodes due to COVID-19, experiencing health system collapse and ranking number 3 globally. Since the first diagnosed case in Brazil, there have been more than 10 million cases confirmed along with staggering 264,000 numbers of death episodes by 8th March 2021 3 .
As the cases of COVID-19 increased globally, and the pathophysiology of the disease began to be constantly studied, an avalanche of information on this issue started to be shared. By 21 August 2020, the keyword "COVID-19" yielded over 42,000 and 60,000 indexed articles on PubMed and Google Scholar, respectively, let alone over 6,5 billion results were acquired on Google search engine only in 2020. Even more impressive is the number of posts on social media platforms, which spread rapidly and easily 4,5 . This social media content has a high potential to carry on misleading information, hindering public health policies. Ultimately, it can create a global epidemic of misinformation [6][7][8][9] . Recent reports revealed that individuals who get their news from social media are more likely to have misperceptions about COVID-19, whereas those who consume more traditional news media have fewer misperceptions and are more likely to follow public health recommendations like social/physical distancing 10 . Along with these concerning findings, the information-seeking patterns can also modulate attitudes and behaviors towards this crisis 11 .
Once the exposure to online health information has been associated with health-related behaviors in different populations and contexts [12][13][14][15] , understanding the information-seeking behavior of dental students and their infosphere can be a necessary step toward building efficient educational planning in the context of COVID-19. These students are in direct contact with patients 16,17 and can funnel information to their niches. In this sense, educational institutions have such a role in fostering and providing the academic community with scientifically-oriented and official information to battle the current wave of infodemic, so that dental students can be better prepared to tackle any related issue 16 .
In Brazil, 350 tertiary institutions are responsible for the formal dental education of up to 125,585 students across the country 18 . During the current university recess and social/physical distancing, the e-learning regimen has taken place while hands-on experience has been discontinued for a while, profoundly affecting up to the totality of these students. However, considering social inequalities regarding information access 19,20 , the overload of information regarding COVID-19 9 , and the infosphere as a behavioral modulator 15 , identifying the information sources of dental students about COVID-19 is paramount to fight off misperceptions and misinformation among this population. Moreover, knowing from where and with whom the dental students get informed about the pandemic will facilitate the schools to reach their attention and enforce educational policies toward this end. Thus, this study aimed to identify the source of information Brazilian dental students use regarding COVID-19.

Ethical aspects
This research protocol was approved by the Research and Ethics Committee of the School of Dentistry of Ribeirão Preto at the University of São Paulo (CAAE: 33608320.5.0000.5419). The research was performed following the Helsinki declaration. All participants signed a written consent informing that they accepted to participate in the investigation. The study consists of a cross-sectional survey directed to a sample of undergraduate dental students. All data used for this manuscript are available in Portuguese at https://doi.org/10.7910/DVN/CMAD57 .

Survey content
This cross-sectional study is part of a broader investigation and the details on how the questionnaire was developed and administered have been published elsewhere 21 . In summary, a self-administered questionnaire about the awareness and knowledge of Brazilian dental students about COVID-19 and its impact on the undergraduate dental practice was hosted online (Google Forms). The questionnaire contained 20 mandatory close-ended items, divided into four sections: 1) demographic and academic profile (6 questions); 2) general knowledge about COVID-19 (4 questions); 3) knowledge about the preventive measures to avoid COVID-19 spread on the undergraduate dental practice (2 questions); 4) perceptions about the COVID-19 impacts on the undergraduate dental courses (8 questions). The current work covers only the part of the 4 th section in which the students responded where or with whom they usually get information about COVID-19. The possible answers were government official websites or health and education institutions websites, TV Programs, professors, social media, scientific articles, other health professionals, and family members. This was asked as a multiple-response question. Thus, each participant could choose more than one option as their information source.

Recruitment and data collection
According to data from the last Brazilian Tertiary Education Census 18 , there are 125,585 undergraduate students enrolled in dentistry courses in Brazil, considering public and private institutions. All these students were eligible to participate in the research. Recruitment was conducted through an Instagram® (Facebook, Menlo Park, CA) social networking campaign, which started on July 4 and lasted until July 14.

Data analysis
The data collected were extracted from Google Forms and converted to Excel (Microsoft, USA) sheets. The frequency distribution for the source of information about COVID-19 was analyzed by gender, age, and type of institution (public and private).
It was considered valid the response obtained from a questionnaire answered by a participant who signed yes to the question: "do you agree to participate in this research?", which was provided after the presentation of the consentient form. Moreover, the participants had to fill in the entire questionnaire for their answers to be considered valid.

RESULTS
Government official websites or health and education institutions websites were the answer more frequently chosen, reported by 739 (88.7%) participants. Interestingly, 477 (57.3%) students also referred to other health professionals as those with whom they seek information about the disease. A very small proportion of dental students, 65 (7.8%) in total, obtained their information from family members. More than half of the students, accounting for 468 (56.2%) respondents, used scientific articles as a source of information about COVID-19, while the use of social media was reported by 461(54.1%). Such a proportion overcame the one for TV programs and professors, accounting for 332 (39.9%) and 337 (38.1%) responses, respectively.
We observed that 88.9% of men and 88% of women sought information twice as much in official websites than in TV programs (40.3% for male participants and 38% for female participants) or professors, who were chosen only by 37% of male respondents and 42.2% of female participants (Table 1). Scientific articles were more used as information sources by men than social media (59% and 50%, respectively), which was not observed for female respondents (Table 1). Table 2 shows that official websites were more frequently used as sources of information by those who study dentistry in private institutions (91%), while the acquisition of information from scientific articles was more frequently used by students from public dental schools (60%). Moreover, comparable proportions of dental students from the public (54.2%) and private (54.1%) institutions used social media as an information source ( Table 2).  Table 3 displays that the use of official websites increased with age, being it absolute in those older than 39 years old. On the other hand, the use of social media decreased with age, dropping from 56.6% in the group of students younger than 25 years old to 20% in the group older than 39 years old. The use of scientific articles by students aging 25 to 32 years old was more frequent (68.6%) than by those aging between 18 to 25 years old (54.4%). Likewise, the use of scientific articles doubled in the group of dental students older than 39 years (87%) in comparison to the ones aging 25 to 32 years old (43.5%). TV programs were a source of information less frequently used by students older than 32 years old, and those older than 39 years old were less likely to obtain information with their family members.  Table 4 shows that the use of official websites increased as the year of undergraduate enrollment increased, reaching 91.9% in the group of students from the 5 th year of dental school. On the other hand, the frequency of students who had professors as information sources decreased as the time of enrollment increased from the third to the fifth year of dental school. Moreover, while 52.1% of last-year dental students used social media to stay informed about COVID-19, only 30.8% of them saw their professors as someone with whom they could obtain information.

DISCUSSION
The outbreak of COVID-19 has challenged individuals, communities, and educational institutions given the need for social distancing and due to the sanitary measures imposed by the pandemic 2,21 . Health care students and professionals have been strongly affected given the imminent risk of infection spread associated with their process of learning and working [22][23][24][25] . As dentists are at the top of professionals at risk 22,26 , so are dental students, who have been facing a hard time trying to complete their education during these uncertain times 16,[27][28][29][30] . As it has been demonstrated, the course of infection control can be shaped by how governments enact timely policies and disseminate information 11 . Thus, here we investigated where Brazilian dental students usually seek information about COVID-19. These data might aid dental schools in choosing the best platforms to display educative campaigns.
As far as we know, this is the first study to investigate information-seeking behavior of Brazilian dental students about COVID-19. Our study might be subjected to sample selection bias as we used social media to disseminate the questionnaire, allowing the participation of any dental student who had an Instagram account. In this regard, we believe that given the sanitary measures imposed by the pandemics, the use of social media to disseminate web-based surveys is an alternative to aid in recruiting difficult to reach populations. Besides that, the participants' responses might also present the social desirability bias, which consists of choosing the options that are more socially accepted as right. To avoid such an effect, we asked where or with whom the students usually seek information about COVID-19, making it clear in the way the question was written that there was not a right nor a wrong answer. Moreover, we allowed the participants to choose more than one option as the information sources more frequently used by them. By doing that, we allowed them to express their true behavior.
Regarding our results, we observed that regardless of gender, age, type of institution, and year of enrollment, dental students had government official websites or health and education institution's websites as their main source of informa-tion about COVID-19. Thus, we stress the importance of government websites to provide information with transparency. Moreover, As dental schools in Brazil offer dental undergraduate courses to over 125,000 students 18 , knowing that they are familiarized with getting informed on official websites might reveal the students' precaution in getting information through reliable online platforms. In this context, data of the national portals of the 193 United Nations Member States showed that by 8 April 2020, around 86 percent of nations (167 countries) had included information and guidance about COVID-19 in their portals 31 . However, it has been shown that a more advanced strategy is having a dedicated portal or section about COVID-19 11 . Thus, we suggest that dental schools could display a COVID-19 page on their school's website, where they could provide information about preventive measures and on the statistics about the outbreak, focusing on the local situation of the city and campus 17 . Such information helps people make informed decisions about their daily routines and build public trust 11 .
Contrary to what we expected, social media did not figure among the top source of information used by dental students. Such findings are also contrary to what other investigations with university students have been showing 32 . In this regard, we decided to use Instagram to recruit the participants because the use of social media in Brazil increased significantly during the social distancing period 33 . Thus, we saw Instagram as a tool to spread our call for participants. Instagram as a recruitment tool was a choice also based on the need to reach a large population (dental students) during a time of movement restrictions and heavy sanitary measures. As we recruited the respondents via Instagram, we expected that such a tool would be more frequently reported by the students as information sources.
In this sense, even not being at the top of the most used information source, more than half of the respondents used social media to get informed about the pandemics, mainly the younger ones. These findings are an alert to dental school directors to the importance of social media in disseminating information to the students, especially during the pandemic. In this scenario, it is concerning the fast and uncontrolled spread of news, which might be associated with misinformation 6,7,9,11,[13][14][15]34 . Moreover, social media users are more likely to believe false information. For instance 10 , manipulation of information with doubtful intent might be amplified through social networks, spreading farther and faster like a virus, the so-called infodemics 11,34 . Thus, an effort should be made by dental schools to keep their social media active and updated to provide their students with trustable information, fighting fake news 17 .
Interestingly, we also observed that the respondents considered other health professionals as someone with whom they obtain information. Such data represents the acknowledgment of the critical role of healthcare workers during the pandemic, as it has also been stressed by health care authorities 35 . Surprisingly, professors were one of the least chosen sources of information of the dental students, which might be associated with the social distancing imposed by the pandemics. In this aspect, it is known that COVID-19 has strongly impacted teaching and learning in dental schools, which had to move online, challenging the interaction among students and professors 17, 36,37 . Corroborating with which has been shown to other uni-versity students, family members were at the bottom of the list when evaluating with whom the students get informed about COVID-19 32 . Moreover, as it has been shown elsewhere, university students seem to seek information in scientific publications 38 , as we observed in our sample of dental students. In this regard, according to the Nature Index, there have been published 67,753 scientific publications about COVID-19 39 . As the rise in publications represents the massive effort of scientists to overcome the pandemic crisis, it also signifies that it is becoming difficult to follow all daily updates, mainly for undergraduate students, who are at the beginning of their academic life. Thus, we reinforce the role of dental schools in funneling the available information, providing the students with reliable sources, and leading them to a safer return to hands-on activities.
Contrary to other studies with university students, the most used information sources of the Brazilian dental students who participated in our research where official government and educational websites, followed by other health professionals and scientific articles. However, the use of social media was also reported by a high proportion of the respondents. Therefore, we might conclude that the Brazilian dental students rely on multiple information sources to stay informed about COVID-19, mainly focusing their information-seeking behavior on governmental and health professional's websites. Moreover, as a final remark, we emphasize that knowing where the dental students seek information about COVID-19 might facilitate dental school directors to approach such public continuously, providing them with trustable information on different platforms. Once it has been shown that when individuals face risks, they seek information to reduce uncertainty, dental schools in countries such as Brazil, where the epidemic is rocketing in cases and deaths, should implement strategies to keep their students updated. Such precaution would provide students with the knowledge, guiding them to proper attitudes.

ACKNOWLEDGMENT
We especially acknowledge all students who participated in this study, as well as those who engaged in our divulgation via social media. The first and second authors of this manuscript hold FAPESP Ph.D. scholarships (2020/02658-7 and 2019/14285-3, respectively).
The third author holds a CNPq scientific initiation scholarship (Project 2020-1004)