Italy was the first European country to report a case of Coronavirus Disease (COVID-19) on February 19, 2020. In the ensuing weeks, there was an exponential increase in the number of cases and deaths due to COVID-19 spreading rapidly to neighboring regions (1) with major disruptions to academic centers of higher learning.

Alma Mater Studiorum–University of Bologna is a major academic institution located in Northern Italy with 87,590 students, including two cohorts enrolled in the Medicine and Surgery program (2). On February 23, 2020, the Dean of the University instructed all faculty, staff, and students to take precautionary measures to prevent the spread of COVID-19. This included suspension of all teaching and training activities and transitioning to online learning.

On March 9, 2020, the Italian government enforced a national lockdown restricting mobility between jurisdictions and forcing closure of non-essential services and educational institutions. By March 11, 2020, 94% of courses at Bologna University were online (3). In keeping with this transition, the medical school suspended all teaching activities and clinical rotations. Separately, self-organized medical students (n = 300) created a volunteer group (“A un metro da te” or one meter distance) to help alleviate the workload of healthcare providers delivering care in and out of hospital settings (4). May 2020 witnessed a considerable reduction of COVID-19 cases throughout Italy (5). At that point, the Medical School Board requested information regarding medical students' opinions about the possibility of returning to in-person activities.

In this context, we conducted a survey to collect information regarding medical students' perceptions of the pandemic in relation to their educational activities. The goals of the survey included learning more about sources of COVID-19 information, students' trust in these sources, practices regarding protective measures, perceived risk of contracting COVID-19, and students' knowledge of using personal protective equipment (PPE). In addition, we wanted to learn whether training on PPE usage and volunteering (e.g., healthcare settings) during the pandemic influence students' perceived risk and knowledge. Medical students were recruited to support healthcare workers during the initial stages of the pandemic when hospitals were inundated with COVID-19 cases. This occurred not only in Italy but also in other countries (6–9). Importantly, the study highlights the crucial role of infection disease prevention and PPE usage, both of which can influence medical students' safety. The recent literature suggests that medical students may not receive adequate training in infectious disease prevention (10–12). Thus, our study adds to literature by examining the role of medical students training along with other factors that may influence their ability to handle public health emergencies (PHE).

During the early stages of the pandemic Italian medical students were recruited to support the healthcare fight against COVID-19. As a result, it becomes important to examine students' PRoI and more specifically what factors influence risk that may be amenable to educational intervention. The findings of this study provides initial evidence of the role of information trust, adoption of prevention measures, training, and volunteering on both PRoI and knowledge of PPE usage. Each one of these findings is discussed accordingly.

In terms of preferred sources of information, students favored online sources and social media, consistent with previous studies (22, 23). Medical students reported they had greater trust in scientific publications compared to other sources of information. However, scientific journals were not in the top-ranked sources used. This gap may arise from lack of access, lack of understanding of scientific literature, language barriers, and lack of knowledge how to use university libraries (24). Knowledge and ability to consult online libraries and scientific literature web search engines are skills that could be easily incorporated into the medical school curriculum (25, 26). A previous study (27) showed that medical students share information with their families and friends. The same students also rely heavily on social media to share their medical knowledge. As a result, students can play an important role in promoting health, for instance during a pandemic, to the general population. This will help to offset factors that precipitate infodemics, which that can produce misleading health information.

The adoption of preventive measures contained multiple items assessing standard practices that medical providers should be aware of on a day-to-day basis. Medical students in our sample, especially females, reported they adopted most of the recommended preventive measures as part of their everyday life during the pandemic, a finding in line with other studies (22, 28, 29). With respect to training, a minority of students indicated they were sufficiently educated in infectious disease prevention and PPE usage. Consistent with other studies, students also indicated there is an urgent need for additional instruction and continued training on PPE use (30, 31). Furthermore, students preferred peer-to-peer education and mentoring approaches compared to more traditional educational methods. The current findings are consistent with other recent studies demonstrating the lack of practical experience of PPE usage (10, 11, 30, 31). Effective use of personal protective equipment (PPE) is essential to protect personnel and patients in healthcare settings (11).

Overall, students reported moderate levels of perceived risk of infection; this risk was higher for attending clinical training compared to academic or daily living activities. Student also reported a lack of essential skills for using PPE, being able to use on average only four out of seven different types of protective equipment. When set in the multivariate framework we obtained a clearer picture of how all of the exogenous factors relate not only to each other but also to PRoI. Higher trust in information sources related differently to higher perceived risks. Trust in scientific sources was associated with higher risk only in daily activities whereas trust in web-based media was associated with risk in both academic and healthcare activities. One possible reason for these differences may involve the different appeal that each media source has on different people as their tastes in information sources may vary considerably. Adoption of preventive measures was associated with higher perceived risk in all three settings. Moreover, the largest effect overall in the model was between adoption of preventive measures and perceived risk in healthcare activities. The positive relationship could potentially indicate that medical students at risk for viral infection respond by implementing preventive practices. The non-recursive nature of this relationship in a cross-sectional survey can also mean these relations are reciprocal and perceived risk precedes adoption of preventive measures.

The path model also revealed that training on both biological risk and use of PPE was associated with less perceived risk both in the hospital setting and in academic activities and to a lesser extent daily activity. This difference in the effect of training arises perhaps because medical students are less concerned about viral transmission when going about their daily business. Moreover, the training on PPE usage may have facilitated the development of skills that reduce their PRoI. Because medical students providing care to patients are at high risk for contracting as well as transmitting COVID-19 (28), training on biological risk and PPE usage could serve to reduce virus spread. Notably, the early stages of the pandemic particularly affected healthcare workers, with 305 deaths due to COVID-19 among Italian healthcare workers, as of January 31, 2021 (32). One explanation for this alarming figure is perhaps a lack of access and ability to use PPE (33). In our study, the multivariate Poisson regression model confirmed that knowledge of PPE usage was directly associated with the training medical students received. This finding highlights that one remedy to the lack of knowledge and ability to use PPE includes extending specific training on PPE usage to medical students early in their education and especially during their clinical rotations, when they encounter patients and spend considerable time at the hospital.

Volunteering during the pandemic was associated with a higher perceived risk of contracting COVID-19 in daily living activities and a lower perceived risk of contracting COVID-19 in a hospital setting. These findings could perhaps indicate that volunteer experiences coupled with training in PPE usage helps medical students understand the risk of viral infection. The same training that they receive in the hospital may not mitigate the risk of infection in the real world where they perceived to have less control. Results from the Poisson model also reinforce the beneficial effect of volunteering on students' knowledge about PPE usage. During the COVID-19 pandemic, many student-driven initiatives and volunteer efforts were reported worldwide, highlighting benefits for students and healthcare services (6–9, 34, 35). Combined, these results collectively show that volunteer activities should be encouraged by educational institutions.

Compared to males, females reported higher risk perception. Females also reported adopting a greater number of preventive measures, but, at the same time they reported having less knowledge of PPE usage. These results are in line with other studies (10, 36) and perhaps suggest that females may not feel as adequately prepared for dealing with the pandemic as males, moreover this gap in their knowledge exacerbates their perception of risk.

Finally, age related positively to perceived risk, especially in academic and healthcare activities. Moreover, age was also positively associated with knowledge of PPE usage. Given the nature of the medical curricula for Italian students, most of the older students were obtaining hands-on training during clinical rotation as opposed to classroom-based education. As a result, they are more aware of the need for infectious disease prevention, a finding in line with other studies (29).

There are several limitations associated with this study worth noting. First, only Italian medical students comprised the sample and their training may be unique compared to other programs. However, worldwide medical students were recruited to assist in healthcare settings to address the pandemic. Therefore, our findings may have relevance for different healthcare settings as well as different countries. Second, the sample may have some selection bias because students voluntarily participated in the survey. Indeed, the sample overrepresented students attending the latter years of medical school. Their advanced state of medical education and interest in clinical rotations could have also potentially influenced their participation and responses. Moreover, there was a limited timeframe for data collection (<2 weeks) suggesting limited coverage. Third, the cross-sectional design does not allow us to determine causality between training and/or volunteer work and the outcome measures. Fourth, the associations found could be spurious because of other non-explored factors, e.g., variables that measure personality traits, all of which can influence perceived risk and knowledge. Despite these limitations, we believe our results highlight important facets of medical school education; ones that should be addressed, especially during critical periods when healthcare is in high demand such as during the pandemic.

Efforts are already under way to translate the results of this survey and implement them into practice. For example, PPE training is now available for all medical students at the University of Bologna in order to increase their knowledge of and skills to deal with the virus. This training was mandatory for the students returning to clinical rotations. Furthermore, medical students were engaged in public health outreach efforts, they developed brochures and infographics about personal protective measures addressed to patients, their families, and surrounding communities. These materials are available in different languages (Italian, English, Chinese, and Arabic) and disseminated to diverse communities to increase awareness about protective measures, in particular in hard-to-reach populations (i.e., homeless and migrants).

The present study adds to the growing literature on medical students' education during the pandemic. An important distinction that comes from this study is that adoption of preventive measures and trust in information sources are efficient predictors of perceived risk but not knowledge whereas training and volunteering work affect both outcomes. Training and volunteer activities influence students' effort to counteract the COVID-19 pandemic. Taken as a whole, this suggests that there is a continued need for implementing training strategies targeting medical students' education in public health measures, use of personal protective equipment that reduces their exposure to biological risk transmission, and ensuring this training commences at the earliest part of their medical education. In addition, our findings highlight the role of students' engagement in voluntary work to enhance hospital capacity and as a means for professional development. Medical students will become future medical professionals, thus a specific training responding to contemporary challenges is fundamental to support the healthcare system's ability to address pandemic situations that may arise in the future.

The raw data supporting the conclusions of this article will be made available by corresponding author on reasonable request (research purpose).

The studies involving human participants were reviewed and approved by Bologna University Bioethics Committee (https://www.unibo.it/en/research/research-facilities/ethics-committees/bioethics-committee). The patients/participants provided their written informed consent to participate in this study.

MG, FR, MPF, and DG contributed to conception and design of the study. MG, FR, and DT collected the data. MG and EM organized the database and wrote the first draft of the manuscript. EM performed the statistical analysis. FR and CR helped in writing sections of the first manuscript draft. MPF, ES, and DG supervised and edited the first manuscript draft. EM, MG, and LS revised the manuscript in depth after first-cycle revisions. All authors read and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.