Ansari, Paul, D’Lima, Parackal, Thomas, and Roy: Assessment of knowledge and perceptions in relation to COVID-19 pandemic among dental professionals during the first 40 days of national lockdown in India


Introduction

The coronavirus disease 2019 (abbreviated “COVID-19”) is an emerging, rapidly spreading disease caused by a novel coronavirus and is known to give rise to illnesses ranging from the common cold to a severe acute respiratory syndrome (SARS).1 Initially termed as 2019-nCoV, the virus was later renamed as syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV).2 The two unique features of this new virus that distinguishes it from other members of the coronavirus family such as SARS-CoV and MERS-CoV are low pathogenicity and high transmissibility.3 The most commonly observed clinical symptoms of the disease include fever, dry cough, fatigue, myalgia, and dyspnea. This new strain was first detected in December 2019 in Wuhan, Hubei Province, China. On 30 January 2020, the World Health Organization (WHO) declared COVID-19 as a public health emergency of international concern (PHEIC).4

CoV being a zoonotic pathogen can be transmitted via animal-to-human and human-to-human interactions.5 As viruses lack the properties of a living cell, they get activated and replicate only on entering the living cell of a host organism. Human-to-human transmission could be through droplet, feco-oral, or direct contact. In addition, it has been shown that corona virus survives on various inanimate surfaces for varying periods of time. This particular virus is known to have an incubation period of 2-14 days.6 The first week of March reported an alarmingly high number of new cases globally, and COVID-19 emerged as a pandemic and significant public health issue. As of 12 March 2020, there were more than 125,000 confirmed cases and around 4600 deaths across 118 countries around the world.6 The first case in India was however reported on January 30, 2020 in the state of Kerala. As of March 22, 2020, the number of cases in India rose above 300 and 7 deaths were reported according to the national health ministry. On March 24, 2020, the Government of India ordered a nationwide lockdown for 21 days initially, which was extended later limiting the movement of the entire 1.3 billion population there as a preventive measure against the COVID-19 pandemic. This included certain unprecedented measures such as the suspension of public transportation, the closing of public spaces, close management of communities, and isolation and care for infected people and suspected cases. All Indian residents, were also required to just stay at home to avoid contacting with others. The battle against COVID-19 is still continuing in India as its tally nears 53,000 and deaths have reached above 1,700.

No antiviral treatment or vaccine has been explicitly recommended for COVID-19 thus far. Therefore, taking all these factors into consideration, applying preventive measures to control COVID-19 infection is of utmost importance. Healthcare workers are inevitably the primary sector in contact with patients and among them, dentists are more prone to exposure due to infected cases in healthcare settings and are thus expected to be at high risk of infection.

By the end of January, the WHO and Centers for Disease Control and Prevention (CDC) had published recommendations for the prevention and control of COVID-19 for health care workers.7, 8 There is an enormous possibility that misconceptions among dentists could lead to the spread of infection in dental offices, thus, putting both the dentist’s and patient’s lives at risk. This necessitates rapid assessments of knowledge and perceptions of dentists regarding this new infection. In addition, we also aim to explore the role of different information sources and national lockdown in shaping their perceptions of COVID-19 during this global health crisis.

Materials and Methods

This is a web-based cross-sectional study conducted using a survey application (Google forms) to obtain responses from dentists all over India during the second week of April 2020. A self-constructed, structured questionnaire comprising of 22 questions among which four were open ended questions, was developed after reviewing pertinent literature and the international guidelines.9, 10, 11, 12 The developed draft survey instrument was distributed to ten randomly selected faculty members to assess its readability and validity before pretesting among 20 randomly selected dental professionals for clarity, relevance, and acceptability. Refinements were made as required to facilitate better comprehension before the final survey was distributed to the study population. The questionnaire was provided in English language. A convenient sampling method was used for data collection. Participants were classified on the basis of gender, age (24-35 years, 36-45 years, 46-55 years and >55 years), educational qualification (graduate, post-graduate students) and years of professional experience (<5 years, 5-10 years, 10-20 years, 20-30 years and >30 years). The time taken to complete the survey was approximately 5 minutes.

The 22-item questionnaire including socio-demographic details evaluated awareness of COVID-19, source of information, knowledge, different modes of transmission, precautions and risk prevention and perceptions regarding COVID-19. The participants were allowed adequate amount of time to read, comprehend, and answer all the questions. The information provided by each participant was maintained strictly confidential throughout the study by making the participants' information anonymous. Participation in this survey was voluntary and not compensated for. An informed consent (E-consent) was obtained from each participant prior to participation. The study was performed following the Helsinki Declaration as revised in 2013. The study was conducted following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines.13

Statistical analysis

The data obtained were coded, validated, and analysed using statistical package for social sciences (SPSS) version 24 (IBM, Armonk, NY, USA). Descriptive analysis was applied to calculate the frequencies and proportions. The chi-square test was used to investigate the level of association among variables. The p-value was set at < 0.05 for statistical significance.

Results

A total of 670 dental professionals participated in the survey, including 315 (47%) males and 355 (53%) females. Most of the participants belonged to the age group 24-35 years (56.1%) [Figure 1]. The majority of the respondents were post graduates (55.5%) and had less than 5 years of experience after graduation (42.1%). A good number of the dentists who participated were practising in the state of Kerala (77.3%). Almost all of the participants agreed to having heard of the novel corona virus (99.6%). According to majority of the participants, the primary sources of information about COVID-19 were social media, TV and newspapers with most participants relying on social media (37.2%).

Figure 1

Number of participants in various age groups

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/621482b2-f1cd-40c0-b65f-b4c9ca5d8262image1.png

There is a significant difference between age categories in knowledge about source of origin of COVID-19 (p < 0.05) [Table 1]. Around 54% of the 24-35 age category respondents agree the origin of COVID-19 is viral genetic transformation. Here 61.8% of the respondents agree with the mode of transmission as contact with body fluids [Figure 2].

Table 1

Comparison between age and the knowledge about source of origin of COVID-19

Age

Source of origin of COVID-19

Total

Pearson Chi-Square

p value

Bats

Biological weapon

Viral genetic transformation

24-35

117

55

204

376

14.39

0.026 (<0.05)

36-45

47

12

86

145

46-55

57

15

64

136

above 55

2

0

11

13

Total

223

82

365

670

Figure 2

Knowledge of participants regarding the mode of transmission of COVID-19

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/621482b2-f1cd-40c0-b65f-b4c9ca5d8262image2.png

Majority of the participants voted for carrying out only non-aerosol generating procedures as one of the protective measures during this time followed by safe distancing and use of PPEs. Approximately 70% respondents believe the incubation period of COVID-19 to be 14 days and 42% of those who say that belong to the 24-35 age category indicating a significant difference between the age categories regarding the knowledge of incubation period of COVID-19 (p < 0.05) [Table 2]. There also exists a significant difference between the years of experience in the field of dentistry and the knowledge of incubation period of COVID-19 (p < 0.05). Here 32% of the respondents with less than five years of experience believe the incubation period to be 14 days [Table 3]. No significant difference was observed between males and females regarding knowledge of incubation period of COVID-19 (p > 0.05).

Table 2

Comparison between age and the knowledge about incubation period of COVID-19

Age

The incubation period of COVID-19

Total

Pearson Chi-Square

p value

14 days

21 days

28 days

7 days

I don't know

24-35

285

33

38

14

6

376

22.823

0.029 (<0.05)

36-45

92

11

29

7

6

145

46-55

85

10

30

5

6

136

above 55

10

1

2

0

0

13

Total

472

55

99

26

18

670

Table 3

Comparison between years of professional experience and the knowledge about incubation period of COVID-19

Experience after graduation in years

The incubation period of COVID-19

Total

Pearson Chi-Square

p value

14 days

21 days

28 days

7 days

I don't know

< 5

216

23

31

8

4

282

29.31

0.022 (<0.05)

5 - 10

84

13

13

4

3

117

10 - 20

82

7

27

9

5

130

20 - 30

82

11

26

3

6

128

> 30

8

1

2

2

0

13

Total

472

55

99

26

18

670

A good majority of the participants (79%) suspect a second round of viral spread with 94.6% of them anticipating a change in post lockdown practice including both a change in infection control procedures and a hike in service charges [Table 4].

Table 4

Proportion of participants expecting various changes in post lockdown practice

Changes expecting in post lockdown practice

Frequency

Percent

Both of the above (infection control procedures and hike in service charges)

347

51.8

Infection control procedures

279

41.6

Hike in service charges

2

0.3

Others:

Demand for better care

1

0.1

Inclusion of newer criteria during case history

1

0.1

Lack of confidence in both patient and dentist

1

0.1

Less number of patients as the business lot has been affected

1

0.1

May have to reduce the charges due to economic crises

1

0.1

More patient campaigning

1

0.1

Need to educate patients so that they get right information amidst the social media slurry

1

0.1

Patient education and awareness to be made a routine practice

1

0.1

Payment capacity of patients may fall

1

0.1

People with good knowledge regarding Aerosol may abstain from Dental treatment for quiet some time.

1

0.1

Reinforcement of infection control, emphasis to medical history, flawless patient documentation & rendering care to the standards of an apex institution under government sector.

1

0.1

Strictly based on appointments

1

0.1

Unemployment

1

0.1

Will take detailed history including travel and strict personal protective measures be incorporated

1

0.1

With all of the above, there will be a limitation in treatment options like the patients wouldn't entertain themselves with treatments having multiple visits to the dental office and hospitals.

1

0.1

In addition, approximately 83% of the dentists felt that personal hygiene combined with social distancing could help to prevent COVID-19 transmission [Figure 3].

Figure 3

Perception of participants regarding preventive measures of COVID-19

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/621482b2-f1cd-40c0-b65f-b4c9ca5d8262image3.png

A considerable number of dental professionals refrained from practice during lockdown due to moral obligation towards society. Questions regarding COVID-19-related perceptions among dentists in the study were analysed separately using the chi-square test to examine their association with age and sex and across different categories of people. There is a significant difference between the male and female study populations with regard to mental health (p < 0.05) during the lock down period where around 59% of the males are relaxed and calm while around 33% of the females have fear of future [Table 5]. A significant difference in mental health was also observed between various age categories (p < 0.05) with around 47% of them in the 24-35 age category being relaxed and calm during the lock down period [Table 6]. It is also noteworthy that dental professionals all over India were able to engage themselves in various activities during the lockdown days with a good number among them being able to spend quality time with their families (73.4%).

Majority of the participants expect to resume full scale dental practice within 60 days post lockdown [Figure 4]. When asked about the various means by which dentists are maintaining body fitness during these days most of them answered with home exercises [Figure 5].

Table 5

Comparison between gender and mental health during the lockdown period.

Gender

Mental health in lockdown days

Total

Pearson Chi-Square

p value

Fear of future

Relaxed and calm

Stressed

Male

95

187

33

315

7.166

0.028 (<0.05)

Female

120

178

57

355

Total

215

365

90

670

Table 6

Comparison between age and mental health during the lockdown period.

Age

Mental health in lockdown days

Total

Pearson Chi-Square

p value

Fear of future

Relaxed and calm

Stressed

24-35

140

179

57

376

21.123

0.002 (<0.05)

36-45

43

90

12

145

46-55

31

86

19

136

above 55

1

10

2

13

Total

215

365

90

670

Figure 4

Number of participants that agree with the time required to resume full scale dental practice

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/621482b2-f1cd-40c0-b65f-b4c9ca5d8262image4.png

Figure 5

Number of participants involved in various activities to maintain their fitness during the lockdown period

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/621482b2-f1cd-40c0-b65f-b4c9ca5d8262image5.png

Discussion

This survey aids us in gaining an insight into the level of awareness, knowledge and perception of Indian dentists on infection control with a special emphasis on COVID-19 outbreak in 2020 at the time of the national lockdown. Currently, COVID-19 is a global topic of discussion in the media and among the public, especially among health care workers and patients. With the currently mounting COVID-19 transmission causing apprehensions in everyone, including health officials and health systems, an important question arises regarding how we as dentists manage information to help out at this hour of public health crisis. The distance between the working field and the dentist is approx. 35–40 cm, and certain procedures can be very time-consuming, which puts the dentist at a higher risk of contracting COVID-19.9, 14 Knowledge and perceptions of the participants regarding COVID-19 varied among the different categories of age and also according to the years of experience in the field of dentistry.

Our study revealed that dentists in India are well aware of the emergence of novel corona virus pandemic. We also found that most of the respondents depended on social media, TV and newspapers primarily for accessing information about COVID-19. Relying on authentic sources for data related to COVID-19 is of prime importance for the preparedness and response of dentists due to the unfathomable diversity of information available on the Internet, including unverified malicious information that can spread quickly and mislead individuals. In particular, health authorities and scientists have warned that widespread misinformation about COVID-19 is a serious concern causing xenophobia worldwide.15, 16, 17, 18 The findings of this study suggest significant knowledge gaps between the dental professionals in India, particularly about the mode of transmission and incubation period of COVID-19. For instance, less than half (42%) of the participants aged 24-35 years agreed to an incubation period of 14 days for COVID-19. The estimated incubation period of COVID-19 is up to 14 days.5, 19 Dentists in this study varied in their knowledge about the incubation period of the disease, but being the key factor in determining the safe period to treat suspected patients, it is essential to know the right incubation period.20 However, it’s imperative for dentists to carry on with preventive measures for all their patients, all the time. Nonetheless, nearly 83% of the respondents believed that a combination of personal hygiene measures and social distancing is effective in preventing COVID-19. A vast majority of them strongly agreed that carrying out non-aerosol generating procedures in the dental office is of utmost importance.

The recent national lockdown in India in connection with the global outbreak of COVID-19 has definitely had its impact on the mental health of the masses. This is particularly applicable to the dental society as they have been included in the high risk categories with 33% of the female dentists under study expressing concerns regarding the uncertainty that prevails. Our study revealed a significant difference in the mental state of dentists between males and females. On the other hand, this also gave an opportunity for many of them to plan ahead the changes to be introduced in their post lockdown practice to combat such situations effectively with the improvement in infection control measures being given the topmost priority. Furthermore, dentists being known for their hectic professional schedule were able to use this period to their benefit by indulging themselves in more productive activities and by spending quality time with their families. This could also be the chief reason for the more relaxed and calm nature of the male dentists under study. This time could also be utilized effectively by young dentists to expand their knowledge and to prepare for upcoming exams being that time of the year. So, a larger part of the study population being postgraduates and therefore likely to fall in the 24-35 age category could be the reason for the increasingly relaxed mental state among them.

A good part of the questionnaire was limited to closed-ended questions to reduce information bias. Nevertheless, it is important to stress that this survey had some limitations that need to be addressed, including the relatively low response rate, which resulted in a smaller than expected sample size. This could have been due to the short period of data collection. However, we did manage to obtain a moderate sample size. Moreover, this could also be attributed to the fact that the recent COVID-19 outbreak might have caused many to get engrossed in watching the news and taking care of personal affairs paving way to selection bias and sampling errors, thus, making it difficult to generalize our results. In addition, the data presented in this study are self-reported and partly dependent on the participants' honesty and recall ability; thus, they may be subject to recall bias. Finally, due to the 40 day national lockdown in India that involved the closure of higher educational institutions during the COVID-19 outbreak, the institutional review board could not be approached. Despite these limitations, we cannot overlook the valuable information regarding the knowledge and perceptions of dental professionals in India, which this survey has furnished us with during the most testing times the world has witnessed recently in relation to a pandemic.

Conclusion

Our survey unveiled a significant gap in the knowledge levels, and discrepancies in perceptions of COVID-19 among our study participants. As the global threat of COVID-19 continues unabated, there lies a greater responsibility with the dental professionals in India to educate themselves and the general population regarding the risks and preventive measures of COVID-19. Be that as it may, the current global scenario undeniably puts our technological advancements and scientific accomplishments to test. This warrants further research on the topic so that we may become better equipped to fight off these microorganisms that threaten the very existence of human species.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest.

Acknowledgment

We thank all the study participants for their voluntary participation and for providing essential information.

References

1 

Y Yin RG Wunderink MERS, SARS and other coronaviruses as causes of pneumoniaRespirology2018232130710.1111/resp.13196

2 

M Cascella M Rajnik A Cuomo SC Dulebohn Features, evaluation and treatment coronavirus (COVID-19)StatPearls Publishing2020

3 

S Jiang Z Shi Y Shu J Song GF Gao W Tan A distinct name is needed for the new coronavirusLancet20203951022894910.1016/s0140-6736(20)30419-0

4 

Eurosurveillance Editorial Team. Note from the editors: World Health Organization declares novel coronavirus (2019-nCoV) sixth public health emergency of international concernEurosurveillance2020255200131e

5 

Q Li X Guan P Wu X Wang L Zhou Y Tong Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumoniaN Engl J Med20203821311991207

6 

World Health Organization. Novel coronavirus (COVID-19) situationhttps://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

7 

World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance, 19 March 2020

8 

Centers for disease control and prevention. Update and interim guidelines on outbreak of 2019 Novel coronavirus (2019-nCoV)https://emergency.cdc.gov/han/han00427.asp

9 

L Meng F Hua Z Bian Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral MedicineJ Dent Res2020995481710.1177/0022034520914246

10 

World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance, 13 March 2020. World Health Organization; 2020

11 

Centers for Disease Control and Prevention. 2020 Mar 27. CDC recommendation: postpone non-urgent dental procedures, surgeries, and visitshttps://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html

12 

The American Dental Association. 2020 Mar 27. Coronavirus frequently asked questionshttps://success.ada.org/en/practice-management/patients/coronavirus-frequently-asked-questions

13 

G Eysenbach Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES)J Med Internet Res200463e3410.2196/jmir.6.3.e34

14 

C Pîrvu I Pătraşcu D Pîrvu C Ionescu The dentist’s operating posture-ergonomic aspectsJ Med life201472177

15 

CC Lai TP Shih WC Ko HJ Tang PR Hsueh Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challengesInt J Antimicrob Agents202055310.1016/j.ijantimicag.2020.105924

16 

Z Thomas BBC News: Misinformation on coronavirus causing 'infodemic'13Feb2020https://www.bbc.com/news/technology-51497800

17 

K Shimizu 2019-nCoV, fake news, and racismLancet2020395102256856

18 

Y Mejova K Kalimeri Advertisers Jump on Coronavirus Bandwagon: Politics, News, and Businesshttps://arxiv.org/abs/2003.00923v1

19 

JA Backer D Klinkenberg J Wallinga Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20–28 January 2020Eurosurveillance202025520810.2807/1560-7917.es.2020.25.5.2000062

20 

BO Gaffar ME Tantawi AA Al-Ansari AS AlAgl FA Farooqi KM Almas Knowledge and practices of dentists regarding MERS-CoVSaudi Med J20194077142010.15537/smj.2019.7.24304



jats-html.xsl

© This is an open access article distributed under the terms of the Creative Commons Attribution License Attribution 4.0 International (CC BY 4.0). which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


  • Article highlights
  • Article tables
  • Article images

Article History

Received : 23-02-2021

Accepted : 25-02-2021

Available online : 21-04-2021


View Article

PDF File   Full Text Article


Downlaod

PDF File   XML File   ePub File


Digital Object Identifier (DOI)

Article DOI

https://doi.org/10.18231/j.ijohd.2021.007


Article Metrics






Article Access statistics

Viewed: 121

PDF Downloaded: 64