Original Article

Public Health

Kasmera 48(1):e48106042020, Enero-Junio, 2020

P-ISSN 0075-5222   E-ISSN 2477-9628

https://doi.org/10.5281/zenodo.3827988

Validation of a short scale for measuring the level of basic knowledge about Coronavirus, Peru (KNOW-P-COVID-19)

Validación de una escala breve para la medición del nivel de conocimientos básicos acerca del Coronavirus, Perú (KNOW-P-COVID-19)

Mejia Christian R (Autor de correspondencia). https://orcid.org/0000-0002-5940-7281. Universidad Continental. Facultad de Medicina Humana. Huancayo-Junín. Perú. Dirección Postal: Av. Las Palmeras 5713, Los Olivos, Lima, Perú. CP: 15304. Teléfono: (511) 997643516. E-mail: christian.mejia.md@gmail.com

Rodríguez-Alarcón J Franco. https://orcid.org/0000-0003-4059-8214. Universidad Ricardo Palma. Facultad de Medicina Humana “Manuel Huamán Guerrero”. Lima, Perú. Asociación Médica de Investigación y Servicios en Salud. Lima, Perú. E-mail: franco.investigacion.peru@gmail.com

Carbajal Macarena. https://orcid.org/0000-0003-1960-2952. Universidad Hermilio Valdizán. Sociedad Científica de Estudiantes de Medicina de Huánuco. Huánuco-Huánuco. Perú. E-mail: macarena_cv10@hotmail.es

Sifuentes-Rosales Jhesly. https://orcid.org/0000-0003-3740-2188. Universidad Hermilio Valdizán. Sociedad Científica de Estudiantes de Medicina de Huánuco. Huánuco-Huánuco. Perú. E-mail: jhesly0131@gmail.com

Campos-Urbina Alejandra M. https://orcid.org/0000-0003-3187-4846. Universidad Nacional Hermilio Valdizan. Facultad de Medicina Humana. Huanuco, Huanuco, Perú. E-mail: alecampur0196@gmail.com

Charri Julio C. https://orcid.org/0000-0002-3613-3791. Universidad Nacional Daniel Alcides Carrión. Facultad de Medicina Humana. Cerro de Pasco-Pasco. Perú. E-mail: juliocesarcv1907@gmail.com

Garay-Rios Lizet. https://orcid.org/0000-0002-0577-7391. Universidad Nacional del Centro del Perú. Facultad de Medicina Humana. Huancayo-Junín. Perú. E-mail: ligari98822@gmail.com

Al-Kassab-Cordova Ali. https://orcid.org/0000-0003-3718-5857. Universidad Peruana de Ciencias Aplicadas. Escuela de Medicina. Sociedad Científica de Estudiantes de Medicina de la Universidad Peruana de Ciencias Aplicadas. Lima. Perú. E-mail: aliac1998@gmail.com

Mamani-Benito Oscar. https://orcid.org/0000-0002-9818-2601. Universidad Peruana Unión. Escuela Profesional de Psicología. Juliaca-San Román. Perú. E-mail: psicobenito@gmail.com

Apaza-Tarqui Edison Effer. https://orcid.org/0000-0002-6520-3795. Facultad de Ingeniería y Arquitectura. Universidad Peruana Unión. Lima, Perú. E-mail: effer@upeu.edu.pe

Abstract

The coronavirus has generated the last pandemic, therefore, knowing this disease is important in all populations. For this, a short scale was validated to measure basic knowledge about Coronavirus (KNOW-P-COVID-19). First, it carried out a bibliographic search, then it was systematized and obtained the most important aspects, then a validation of the construct with experts, then exploratory factor analysis and the survey was applied to a large Peruvian population group. All items received a favorable evaluation from the experts (Aiken's V> 0.70); all the lower limit values (Li) of the 95% CI are appropriate (Li> 0.59) and all the values of the V coefficient were statistically significant. In the Exploratory Factor Analysis (AFE), the KMO Coefficient = 0.690 and the p value of the chi square <0.001; the GFI index (Goodness of Fit Index) = 0.992; the CFI (Comparative Fit Index) = 0.916 and the RMSEA indicator (Root Mean Square Error of Approximation) = 0.034. The final scale was left with 9 indicators, with two factors: "indications or actions post infection" and "the previous symptoms and knowledge". A basic knowledge scale in the disease caused by COVID-19 was validated.

Keywords: validation study, coronavirus, knowledge, pandemic, SARS-CoV-2

Resumen

El coronavirus ha generado la última pandemia, por lo que, el conocer a esta enfermedad es importante en todas las poblaciones. Para eso se validó una escala breve para la medición de los conocimientos básicos acerca del Coronavirus (KNOW-P-COVID-19). Primero realizó una búsqueda bibliográfica, luego se sistematizó y obtuvo los aspectos más importantes, luego una validación del constructo con expertos, posteriormente el análisis factorial exploratorio y se aplicó la encuesta a un gran grupo poblacional peruano. Todos los ítems recibieron una evaluación favorable de los expertos (V de Aiken > 0,70); todos los valores del límite inferior (Li) del IC 95% son apropiados (Li > 0,59) y todos los valores del coeficiente V fueron estadísticamente significativos. En el Análisis Factorial Exploratorio (AFE), el Coeficiente de KMO = 0,690 y el valor p del chi cuadrado <0,001; el índice GFI (Goodness of Fit Index) = 0,992; el CFI (Comparative Fit Index) = 0,916 y el indicador RMSEA (Root Mean Square Error of Approximation) = 0,034. La escala final se quedó con 9 indicadores, con dos factores: “indicaciones o acciones post infección” y “los síntomas y conocimiento previos”. Se validó una escala del conocimiento básico en la enfermedad causada por COVID-19.

Palabras claves: estudios de validación, coronavirus, conocimiento, pandemias, SARS-CoV-2

Received: 06-04-2020 / Accepted: 09-05-2020 / Published: 18-05-2020

Hot to Cite: Mejia CR, Rodríguez-Alarcón JF, Carbajal M, Sifuentes-Rosales J, Campos-Urbina AM, Charri JC, Garay-Rios L, Al-Kassab-Cordova A, Mamani-Benito O, Apaza-Tarqui EE. Validación de una escala breve para la medición del nivel de conocimientos básicos acerca del Coronavirus, Perú (KNOW-P-COVID-19). Kasmera. 2020;48(1):e48106042020. doi: 10.5281/zenodo.3827988

Introduction

The coronavirus has generated the most recent pandemic and highlighting that it is the first pandemic caused by a coronavirus (1). This is because currently more than 200 countries have confirmed cases and deaths. Some of them, even have tens of thousands of infected and deceased, which as of April the fourth amounts to 1.2 million infected. One quarter of these cases are in the United States. Furthermore, more than a quarter of the 64,000 deaths have occurred in Italy (2,3).

This situation requires that people from all sectors must have up-to-date knowledge about this new disease. Thus, various entities, such as the World Health Organization (WHO) and the governments of each country, have been providing information through different media (4,5). This is also due to the short time the virus has spread since its discovery (6). However, time has not been a limitation for researchers from around the world who have been developing different documents with new useful information (7). Although this information has been available to the vast majority of the world's population, it is known that it has not reached all, or that not all of them had taken sufficient interest to lead them to search for this data, so it is possible to speak of the "other pandemic", which is disinformation (8). This is why it has been necessary to synthesize and generate measurement scales that can be used to assess knowledge about the virus. Taking as a reference the countries that have already passed the first stages of this pandemic, and that now use this experience to inform the rest of the world (9).

It is important to know the information that the population handles about this disease, since having basic knowledge about the symptoms or knowing how to detect the disease are protective factors against a pandemic (10). If it is shown that the population does not have enough knowledge in this regard, it will be imperative to generate strategies to solve it, since they may be exposed to not knowing how to detect it, acting inappropriately, a greater probability of becoming infected and even complications. For example, there could be indiscriminate use of antibiotics even though the disease is known to be viral in etiology (11). For all these reasons, the objective of this study is to validate a short scale to measure basic knowledge about Coronavirus. (KNOW-P-COVID-19) in the healthcare personnel, patients with comorbidities and the general population.

Methods

Type and design of research: a instrumental analytical cross-sectional study was carried out for validation (12). This was carried out in the Peruvian cities of Amazonas, Áncash, Apurímac, Arequipa, Ayacucho, Cajamarca, Cusco, Huancavelica, Huánuco, Ica, Junín, La Libertad, Lambayeque, Lima, Loreto, Madre de Dios, Moquegua, Pasco, Piura, Puno, San Martin, Tacna, Tumbes and Ucayali.

Population and sample: the background validation of the instrument was carried out in two stages. In the first, 30 professionals from different specialties collaborated, such as: epidemiologists, infectologist, internists, critical care physicians, clinical pathologists, health workers, nurses, among others. In the second stage, 9 professionals collaborated to verify the final test, which shows the Aiken's V values in Table 1. In neither of the two stages did these professionals participate in the form validation, since they did not answer the items contained in the data collection instrument.

On the other hand, the validation necessary for the factor analysis was carried out through a sample of 3913 participants of both sexes (convenience sampling), where 1745 were men (44.8%) and 2148 were women (55.2%) , whose ages ranged from 18 - 87 years (median age = 23 years and interquartile range = 20-28 years).  This sample was made up of health personnel (including doctors, nurses, medical interns, and others), patients in risk groups (older adults, cancer patients, diabetics, hypertensive patients, immunosuppressed patients, etc.) and the general public. These were recruited and the instrument was applied to them through the internet, due to the quarantine state in which our country has been during the realization of the project. Children under 18 years of age, those who did not complete the instrument or who did not want to participate were excluded. Although non-probability sampling was carried out during all stages of the study, an attempt was made to include proportional numbers of participants from the 3 regions of the country (coastal, highlands and jungle).

Procedures: in order to determine which variables were the most accurate to evaluate within the proposed scale, a bibliographic search was carried out in the most consulted databases: PubMed, Cochrane and SciELO; as well as in the Google Scholar search engine. The following terms were used as keywords: SARS-CoV-2, COVID - 19, coronavirus. In addition, filters were used for the dates from December 2019 (to differentiate previous publications from other Coronavirus infections). With these data, the first draft of the scale was carried out, which was evaluated and improved.

Instrument: the knowledge scale about COVID-19 (KNOW-P-COVID-19) measures knowledge about basic aspects of the coronavirus such as mortality, vulnerable populations according to their mortality, transmission routes and prevention. It was created by the authors of the present study based on the conceptual model according to Germain, 2016 (13). It was validated through the judgment of 30 experts and the reconfirmation of 9 experts, in order to determine if the content of the evidence was clear, precise and consistent. In conclusion, the scale consists of 9 items with a multiple-choice answer, with a single correct or valid option, where the participant must choose the most appropriate option.

Data collection: The study had several phases. First, the KNOW-P-COVID-19 Scale was analyzed and reviewed by the research team. Second, the evidence of the content validity was analyzed with the help of 30 experts, in order to determine the relevance, representativeness and clarity of the items (14). Third, the necessary changes were made based on the expert´s observations, and after the author's last approval, the final version of the scale was prepared. Fourth, the variables of the scale were transferred to a sheet of Google Forms, with the aim of being able to share it digitally with thousands of patients, respondents and health personnel. The call for participants was made through invitations through social networks, emails, invitation to friends and family, phone calls, among others. All this information was transferred to a database, using a Microsoft Excel 2019 sheet. Fifth, the statistical analysis was carried out (descriptive, factor analysis and others). Finally, a final consultation was made with 9 experts to corroborate the final version.

Data analysis: firstly, to analyze the validity evidence, 4 classificatory criteria were taken into account to evaluate each of the items. These criteria evaluated by the experts ranged from 0 to 3, with 0 not at all relevant / representative / clear and 3 totally relevant / representative / clear. In addition, the quantification of the degree of relevance, representativeness and clarity was determined by means of the Aiken’s V coefficient and its 95% confidence intervals (95% CI), with significant values that were taken from ≥ 0.70 and ≥ 0.59; respectively for each one.

Then an exploratory factor analysis (EFA) was performed, according to the unweighted least squares and with a Promax rotation. In addition, the KMO and chi square coefficient values (with 36 degrees of freedom) were obtained. Thus, the distribution of the items in 2 generated factors was determined. In addition, a goodness-of-fit index was generated, as a parameter to demonstrate how robust the instrument is, taking into account the values of the GFI (Goodness of Fit Index), CFI (Comparative Fit Index) and RMSEA (Root Mean Square Error of Approximation); determining as acceptable values for GFI> 0.950, CFI> 0.9 and RMSEA <0.05. Finally, the standardized regression coefficients were obtained to determine the contribution of each item on each factor. Analysis were run on IBM SPSS Amos 24 software.

Ethical aspects: this research work took the following ethical considerations: protection of the identities of each participant, free entry to the research (with prior consent), the right to answer questions and respect for international standards for this type of research. This project was accepted by an ethic committee of a north Peruvian university.

Result

Table 1 shows the results of the relevance, representativeness and clarity of the items on the KNOW P-COVID-19 Scale, obtained using the Aiken’s V coefficient. All the items received a favorable evaluation by the experts (V> 0.70). Regarding relevance, it is observed that item 8 is more essential or important (V = 1.00; 95% CI: 0.88-1.00). Regarding representativeness, it can be seen that items 5 and 6 are more representative (V = 0.96; 95% CI: 0.82-0.99). Regarding clarity, item 4 was the best evaluated (V = 0.93; 95% CI: 0.77-0.98). Likewise, it can be seen that all the values of the lower limit (Li) of the 95% CI are appropriate (Li> 0.59) and all the values of the coefficient V were statistically significant. Therefore, KNOW-P-COVID-19 reports evidence of content-based validity.

 

Table 1. Aiken’s V for evaluating the relevance, representativeness and clarity of items on the KNOW-P-COVID-19 Scale

Items

Relevance (n = 9)

Representativeness (n = 9)

Clarity (n = 9)

M

DE

V

IC 95%

M

DE

V

IC 95%

M

DE

V

IC 95%

Item 1

2,89

0,33

0,96

0,82-0,99

2,78

0,44

0,93

0,77-0,98

2,56

0,73

0,85

0,68,094

Item 2

2,89

0,33

0,96

0,82-,099

2,56

0,73

0,85

0,68-,094

2,56

0,73

0,85

0,68-,094

Item 3

2,78

0,67

0,92

0,77-0,98

2,56

0,73

0,85

0,68-0,94

2,67

0,71

0,89

0,72-0,96

Item 4

2,33

1,12

0,77

0,59-0,89

2,56

0,73

0,85

0,68-0,94

2,78

0,67

0,93

0,77-0,98

Item 5

2,89

0,33

0,96

0,82-0,99

2,89

0,33

0,96

0,82-0,99

2,67

0,50

0,89

0,72-0,96

Item 6

2,89

0,33

0,96

0,82-0,99

2,89

0,33

0,96

0,82-0,99

2,44

1,01

0,81

0,63-0,92

Item 7

2,67

0,71

0,88

0,72-0,96

2,44

0,88

0,81

0,63-0,92

2,44

0,88

0,81

0,63-0,92

Item 8

3,00

0,00

1,00

0,88-1,00

2,56

0,88

0,85

0,68-0,94

2,44

0,88

0,81

0,63-0,92

Item 9

2,56

0,73

0,85

0,68-0,94

2,56

0,73

0,85

0,68-0,94

2,33

0,87

0,78

0,59-0,89

Item 10

3,00

0,00

1,00

0,88-1,00

2,78

0,67

0,93

0,77-0,98

2,44

0,88

0,81

0,63-0,92

M: mean; DE: standard deviation; V: Aiken coefficient V; IC 95%: 95% confidence interval for Aiken's V.

 

Table 2 presents the result of the Exploratory Factor Analysis (EFA), where a KMO coefficient = 0.690, a Chi square value = 1645.66, with 36 degrees of freedom and a p value of <0.001 (which indicates that the model is suitable). The method for finding the factors was the unweighted least squares method, which had a better result than the Principal Components method. In addition, Promax rotation was used, since the indicators were nominal. Finally, a result with 9 indicators was obtained. Item 9, which inquired about incorrect coronavirus prevention measures, is not relevant. With these 9 questions, 2 factors were found, which explain the variable under study. Therefore, it is valid to be able to carry out a Confirmatory Factor Analysis (CFA).

 

Table 2. Exploratory factor analysis of the KNOW-P-COVID-19 Scale.

Indicators

Factor

1

2

p7. What indication should be given to a person who has initial (non-severe) coronavirus infection?)

r7. Blood transfusion, relieve respiratory symptoms, antibiotics, send to nearer hospital.

0,625

 

p10. What would you do if you have symptoms of a cold and suspect that you are infected with coronavirus?

r10. I Will go to hospital, I will stay in home until I will feel better, I will go to the drugstore, I will follow with my normal life.

0,447

 

p5. What is the probability of dying (mortality percentage) from coronavirus in the general population?

r5. Less than 50%, less than 30%, less than 10%, less than 5%.

0,398

 

p8. What is the diagnostic method used to confirm a coronavirus infection?

r8. Blood analysis, echography, nasal and oral swabbed, urine analysis.

0,235

 

p3. What are the common symptoms that a person with coronavirus infection can have?

r3. Like a flu/cold, cardiac symptoms, neurological symptoms, stomach symptoms).

 

0,370

p4. Which of the following is NOT one of the most common symptoms of coronavirus infection?

r4. Diarrhea, cough, fever, dyspnoea.

 

0,367

p6. Of the following alternatives, in whom is the coronavirus mortality rate higher?

r6. Women, men, elders, children.

 

0,335

p2. How long is the incubation time or how long can coronavirus symptoms manifest?

r2. Until 5 days, until 10 days, until 14 days, until 60 days.

 

0,295

p1. How is coronavirus transmitted or what is the transmission mechanism?

r1. Sexual, air way, vertical way, by infected animals.

 

0,263

Extraction method: unweighted least squares.  Rotation method: Promax with Kaiser normalization

 

The Figure 1 shows the Structural Equation System (SEM), where two factors were found through Exploratory Factor analysis. The first factor contains 5 indicators, which have a high effect on it. The second factor contains 4 indicators, which also have a high effect or influence on it. Furthermore, the relationship between the factors which is 0.5, indicating a strong relationship between the two dimensions of the KNOW-P-COVID 19 Scale.

Figure 1. Distribution of the questions recorded in the two factors of the KNOW-P-COVID-19 Scale

 

Table 3 presents the validation of the construct. A Chi square = 161.75 was obtained, with 26 degrees of freedom (p <0.01). The goodness of fit indices had the following results: the GFI (Goodness of Fit Index) = 0.992 (which, being greater than 0.950, indicates that the proposed model is acceptable); the CFI (Comparative Fit Index) = 0.916 (which is acceptable for being greater than 0.9); while, the RMSEA indicator (Root Mean Square Error of Approximation) = 0.034 (which is acceptable for being less than 0.05).

 

Table 3. Goodness of fit index of the KNOW-P-COVID-19 Scale

Chi cuadrado

gl

p valor

GFI

CFI

RMSEA

161,75

26

<0,001

0,992

0,916

0,034

 

Table 4 presents the standardized regression coefficients, which shows a highly significant effect or influence for each factor found, with p2 having the strongest weight within the first factor (0.359), followed by indicator p4 (0.354). While, for the second factor, those with the greatest weight were indicator p7 (0.57) and indicator p5 (0.437). The first factor measured the "indications or actions after COVID-19 infection" and the second "the symptoms and knowledge prior to COVID-19 infection"

 

Table 4. Standardized regression coefficients of the KNOW-P-COVID-19 Scale

Questions by factor

Estimates

p value

p1

<---

F1

0.260

0,000

p2

<---

F1

0.359

0,000

p3

<---

F1

0.288

0,000

p4

<---

F1

0.354

0,000

p6

<---

F1

0.338

0,000

p5

<---

F2

0.437

0,000

p7

<---

F2

0.570

0,000

p8

<---

F2

0.260

0,000

p10

<---

F2

0.435

0,000

 

 

Discussion

A quick survey on the knowledge of COVID-19 was validated. This scale can be used in the student population, general population, health population or others in which it has been validated. Considering that this only measure basic knowledge of the disease, there is a limitation that it cannot measure advanced knowledge or more specific elements about the disease. However, this scale can help in rapid testing of those who have a basic understanding of symptoms, prevention, important mortality data, and to know what actions should be taken once the disease is established or suspected.

The first factor that the instrument measures is related to the indications or actions after COVID 19 infection. This evaluates what indication should be given to a person who has a non-serious initial infection, what they would do if they have symptoms or suspect that they are infected, what is the probability of dying from coronavirus in the general population and what is the diagnostic method used to confirm a coronavirus infection. It is important that the population knows the symptoms of the coronavirus so that they know how to act when they suspect they have been infected or when they are infected (15). Some of the distracting alternatives make mention of going to the hospital, knowing that going to the hospital immediately is not recommended. All international organizations recommend that when you suspect an infection, what you should do is stay home, treat the initial symptoms as if it were a cold and, if necessary, call the emergency lines that have been established in each country , so they can go to the home to make a diagnosis (16). If these recommendations are not taken into account, there could be a greater chance of having to go to a hospital or health service and getting infected from other patients who are infected. This is due to the possibility of confusion due to the fact that the symptoms are very similar to those of a cold or flu. As for the question 10, about what to do if you have cold symptoms, the appropriate answer is to treat respiratory symptoms, especially until you have confirmed that you have the coronavirus disease. The option of taking antibiotics when the initial symptoms appear is totally inadequate, not only due to the fact that a self-medication should not be generated, but, the same question refers to cold symptoms or suspicions of Coronavirus, which in both cases are of viral etiology, where antibiotics have no effect (17).

The probability of dying from COVID-19 in the general population is also mentioned, knowing that in most populations the mortality rate is less than 5% (18). Although there are some exceptions, such as in the case of Italy, which has reached values close to 10% (19,20). Conversely, some countries have reached very low values (even less than 1%), such as in South Korea or Germany (21). This is important to verify that the population knows that the disease has a low mortality, but despite this, they must follow the indications and remain calm. The last question that corresponds to this factor tells us which is the best method to confirm a coronavirus infection, so far the most widely used diagnostic method is real-time RT-PCR, which detects the RdRp gene (envelope gene [E] and nucleocapsid gene [N]) from nasopharyngeal swab samples (22,23). It is important to know that there are other tests, such as serological tests that detect IgG and IgM in early stages of the infection, being also useful to support the diagnosis of SARS-CoV-2 or in the follow-up of cases, but they can produce a cross-reaction with SARS-CoV or false positives for dengue (24–26). This is because it does not detect genetic material, as in the gold standard test.

Another important factor is the one that encompasses five questions that inquire about symptoms and knowledge prior to coronavirus infection. The first two questions are about the common symptoms of the disease, which are of vital importance to inquire whether the population knows how to recognize which are the most frequent and which are not, due to their great similarity with other respiratory diseases. It is important that they have this knowledge so that a false alarm is not generated in the population and to avoid that for any minimal symptom they think they have the disease (27).

This test also shows us who has the highest mortality rate and who has a higher risk factor, taking into account that the elderly are more affected by this disease. In addition, it asks about the incubation time or in what time the virus symptoms can manifest, knowing that the average range is up to 14 days. We cannot forget that there may be very exceptional cases, where there is evidence of a shorter or longer incubation time; but at a general level the WHO and many organizations have shown that the incubation period is from 2 to 14 days.

Finally, the question shows how the coronavirus is transmitted or what the transmission mechanism is. This is very important to reassure the population about the form of transmission of this disease, since many other forms of transmission have been speculated (especially the one that mentions that it is transmitted by animals). Actually, the most common form of transmission is through air because it is a coronavirus, which belongs to the family of cold viruses (28).

It is relevant to mention that there is a limitation that is a scale that only measures basic knowledge, with important questions to know the most basic and essential aspects of the disease, the symptoms and other aspects before or during the disease. Therefore, it is important that other scales be developed with a greater number of questions or with a more technical content, which could be used by doctors or other populations. However, our objective was to generate a short scale that includes very important aspects that the general population and other important populations should know. Another important limitation is that in view of the great research that is generated daily on the coronavirus, it is probable that some concepts may vary slightly over time. For example: the patients could have a shorter or longer incubation time, different presentations, rare symptoms, among other possible variations that may occur. However, we consider that the validity of the scale will remain in force since it tries to measure basic concepts that have already been widely proven.

Conflict of relationships and activities

The authors declare not to have any relationships or activities conflict.

Financing

This research was financed by the authors.

Acknowledgments

We thank the participants of the 18th Research Group of the SOCEM's (GIS) Huánuco-2019, since, in this activity, the test was developed. Furthermore, we thank the research group COVID-19-GIS-Peru, which supported the collection of the almost 4,000 surveys throughout Peru. Finally, we thank the members of the following scientific societies of medical students: Sociedad Científica de Estudiantes de Medicina de Huánuco SOCIEMHCO), Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional Daniel Alcides Carrión-Pasco (SOCIEM UNDAC-PASCO), Sociedad Científica de Estudiantes de Medicina del Centro (SOCIEMC) and Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional Federico Villareal (SOCEMVI).

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Authors Contribution:

MJR, RAJF, CM, SRJ, CUAM, CJC, GRL, AKCA, MBO y APEE: participaron en la conceptualización, metodología, software, validación, análisis formal, investigación, recursos, curación de datos, redacción-preparación del borrador original, redacción-revisión y edición.

©2020. Los Autores. Kasmera. Publicación del Departamento de Enfermedades Infecciosas y Tropicales de la Facultad de Medicina. Universidad del Zulia. Maracaibo-Venezuela. Este es un artículo de acceso abierto distribuido bajo los términos de la licencia Creative Commons atribución no comercial (https://creativecommons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial, distribución y reproducción sin restricciones en cualquier medio, siempre y cuando la obra original sea debidamente citada.