31.9.9 Knowledge and Attitude of Pakistani Dentists Regarding Covid-19

Original Article

 

Knowledge and Attitude of Pakistani Dentists

Knowledge and Attitude of Pakistani Dentists Regarding Covid-19

Asma Munir Khan1, Arham Riaz4, Shazia Nawabi2, Muhammad Qasim Javed1, Khurram Shahzad3 and Farzana Kulsoom5

ABSTRACT

Objective: The objective of the study was to examine the knowledge, and attitude of Pakistani dentists, regarding novel COVID-19 disease.

Study Design: Descriptive, Cross sectional study.

Place and Duration of Study: This study was conducted at the Department of Conservative Dental Sciences and Endodontics, College of Dentistry, Qassim University, Al-Qassim, Saudi Arabia and Department of Oral Pathology, Frontier Medical and Dental College Abbottabad from 15th to 31st March, 2020 in Pakistan.

Materials and Methods: A self-designed e-questionnaire was administered through e-mail to 500 dentists. SPSS version 23 was used to analysis data. Descriptive statistics were presented as frequency and percentages. The association between the dependent and independent variables was determined by utilizing Chi-square test and the level of significance was set at p value <0.05. Moreover, the inferential statistics (Mann Whitney U and Kruskal Wallis tests, p-value<0.05) were used for determining the significance among study variables. The correlation between the attitude and knowledge scores was assessed by utilizing Spearman’s rank correlation coefficient.

Results: A total of 306 dentists responded. Participants’ mean knowledge score was 10.69± 2.14, with 91.5 % participants having sufficient knowledge. 242 (79.1%) respondents showed positive attitude (>4) towards COVID-19. The mean attitude score was 4.28±0.61. The results of current study showed a significant correlation of knowledge with both designation (p-value=0.002) and gender (p-value=0.04).

Conclusion: Pakistani dentists have exhibited adequate awareness about general symptoms, transmission mode, cross-infection control and dental practice management in perspective of the COVID-19 outbreak. However, their understanding to protect dental professionals from this highly contagious disease during specialized dental procedures was unsatisfactory.

Key Words: COVID-19, Attitude, practice management, cross-infection control.

Citation of article: Khan AM, Riaz A, Nawabi S, Javed MQ, Shahzad K, Kulsoom F. Knowledge and Attitude of Pakistani Dentists Regarding Covid-19. Med Forum 2020;31(9):34-40.

 

 

INTRODUCTION

Human coronaviruses are highly communicable pathogens that have lately received attention at a global level following pandemic outbreak of a COVID-19 disease caused by novel coronavirus strain1. This specific strain was isolated from a marketplace at Wuhan city, China in end of December, 2019 2.

 

 

1. Department of Conservative Dental Sciences and Endodontics, College of Dentistry / Prosthetic Dental Sciences2 / Deanship of Education3, Qassim University, Al-Qassim, Saudi Arabia.

4. Academy of Continuing Health Education and Research, Islamabad.

5. Department of Oral Pathology, Frontier Medical and Dental College Abbottabad.

 

 

Correspondence: Dr. Asma Munir Khan, Assistant Professor, Department of Conservative Dental Sciences and Endodontics Qassim University College of Dentistry, Saudi Arabia.

Contact No: 00966597472235

Email: dr.asma.munir@qudent.org

 

 

Received:    June, 2020

Accepted:    August, 2020

Printed:        September, 2020

 

 

Later, it spread rapidly to other parts of the world. On 8th January 2020, it was formally declared as a causative means of COVID -19 by the Chinese Centre for Disease Control and Prevention 3. Subsequently, because of its rapid progression it was confirmed as a public health emergency of international concern (PHEIC)4 by World Health Organization (WHO).  Later, in March, 2020 WHO officially proclaimed this outbreak as a pandemic owing to its persistent spread at an alarming rate. To date (April 10th, 2020) this deadly virus has reached over 209 countries worldwide with 1,470,441 confirmed cases and claimed 86,327 deaths 5.

COVID-19 is an extremely infectious viral disease that is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)6. It is single stranded RNA virus that belongs to a large family of coronaviruses named as “Coronavirade”. Its size ranges from 65-125nm in diameter. SARS-CoV-2 comprises of crown shaped spikes which are present on its outer surface that facilitates its entry into host cells7. Moreover, it possesses great binding affinity to the human angiotensin converting enzyme 2 receptors (ACE2) that facilitates its entry into host cells 8. It is further categorized into four subgroups; alpha (α), beta (β), gamma (γ) and delta (δ) type coronavirus 9. Alpha and beta types primarily infect human beings and mammals targeting their gastrointestinal tract, central nervous system and respiratory system 7.

SARS-CoV-2 is regarded as the seventh identified human coronavirus that phylogenetically resembles other two highly communicable respiratory coronaviruses i.e Middle East respiratory syndrome coronavirus (MERS -CoV) and severe acute respiratory syndrome coronavirus (SARS-CoV). The routes of spread in humans involve direct contact with respiratory droplets and indirect transmission through fomite 10.

The outbreak of COVID19 has undoubtedly placed healthcare workers at increased risk of acquiring nosocomial infection11. Bio-aerosols produced during dental procedures contain bacteria, fungi and viruses that have the potential to float in the air for considerable period of time. Bio-aerosols can be inhaled by dentists and patients12. Hence, excessive mutation, increased pathogenicity and various routes of transmission of SARS-CoV-2 may add to nosocomial spread in the dental offices.

Due to the distinctive features of dental treatment procedures that involve aerosol generation, close contact with patient’s oropharyngeal region, and direct contact of contaminated hands with mucous membrane, the routine infection control measures in dental practice are not adequate to prevent the COVID-19 spread 13. Therefore, dental health care professionals (DCP) are at increased risk of acquiring infection and becoming potential carriers. In this context American, Dental Association issued an update on 16th March 2020, where it was stated that all elective dental treatments should be postponed and only patients with actual dental emergencies should be accommodated 14.

The current coronavirus pandemic hit Pakistan in February 2020. As of 5th June 2020, the number of confirmed cases in the country is over 89249, with 31198 recoveries and 1838 deaths 15. Owing to limited resources and fragile health care system, Pakistan is facing a major COVID- 19 challenge. WHO has expressed concerns that if prompt and effective measures are not taken Pakistan might emerge as the next epicentre of this pandemic16. Health care workers being the frontline warriors are at an increased risk of acquiring nosocomial infections. Being a low-income country, limited data is available on infection prevention and control strategies but generally it is believed that basic infection control protocols are insufficient in health care settings in Pakistan.  One of the recent study concluded that Pakistani health care workers are not fully prepared to face threat of a COVID 19 epidemic as they are not aware of dynamics of disease transmission vis a vis strategy for its prevention and control 17. Effective implementation of infection control programs should be practiced which depends largely on awareness, training and cooperation of health care workers.

Therefore, the main aim of current study was to explore the level of knowledge and attitude of dentists towards the COVID19 disease. The results of this preliminary study will help in formulating future policies, training methods and robust infection control strategies that can be employed in dental settings for safeguarding dentist’s wellbeing.

 

MATERIALS AND METHODS

The present descriptive cross-sectional study was carried out on the dentists from 15th to 31st March, 2020 in Pakistan. A non-probability convenience sampling technique was employed. Self-administered e-questionnaire was sent through an electronic mail to 500 dentists in private and public sector, health and educational institutes across Pakistan. All the potential participants were informed about purpose of study. 306 dentists including Professors/Associate Professors, assistant professors, lecturers and general dental practitioners responded.

The study questionnaire was developed by authors after detailed literature review5,11. Subsequently, the questionnaire was reviewed by the senior dental professionals with the research background in dentistry to check for the relevancy, time required to fill and ease of understanding. Later, based on the suggestions of the professionals and local requirements the study instrument was simplified. The questionnaire had three sections. The first section embodied questions related to designation and gender of the participants. The second section of the e-questionnaire was comprised of thirteen questions with yes and no options in-order to explore knowledge of the respondents in relation to COVID-19 disease. The last section of the e-survey had nine questions to evaluate the dentists’ attitude towards novel COVID-19 disease. The questions were developed on a five point Likert scale with a neutral midpoint and balanced responses.

The participants’ knowledge was scored from zero to thirteen. The cut -off point equal to or more than nine (≥9) was set for sufficient knowledge and less than nine (<9) for insufficient knowledge. Assessment for attitude was made and responses were documented on five point likert scale. Scores of 5,4,3,2 and1 were assigned to strongly agree, agree, undecided, disagree and strongly disagree, respectively. The mean score of more than or equal to 4 (>4) was considered as positive attitude and mean score of less than 4 (<4) was taken as
negative attitude.

Data was analysed by utilizing SPSS version 23. Descriptive statistics were recorded as percentages and frequencies. The association between the dependent and independent variables was determined by utilizing Chi-square test and the level of significance was set at
p-value <0.05. Moreover, the inferential statistics (Mann Whitney U and Kruskal-Wallis tests, p-value<0.05) were used for determining the significance among study variables. The correlation between the attitude and knowledge scores was assessed by utilizing Spearman’s rank correlation coefficient. The study was approved by the institutional ethical review board (Ref no ST/6074/2020). The written consent was not taken from the respondents and returning of filled questionnaires was considered as implied consent. Furthermore, the potential participants were assured that confidentiality of data will be maintained.

RESULTS

A total number of 306 Dentists responded with an overall response rate of 61.2% with male to female ratio of 1:1.55. Majority of the participants were general dental practitioners (GDP) (35.3%) followed by lecturers (32.7%). The demographic details of the participants are shown in Table-3.

The average knowledge score of the respondents was 10.69±2.14. Adequate knowledge was displayed by 91.5% of participants (>9), whereas, 8.5% showed inadequate knowledge (<9). The respondents were most knowledgeable about the items related to the routes of transmission, urgent dental care techniques and personal protective equipment (>95%). On the other hand, minimum knowledge was noted in two questions, one concerning the use of ultrasonic devices while handling Covid-19 suspected cases (51.6%) and the other was associated with effectiveness of 1% of hydrogen peroxide mouthwash use as a pre-rinse (59.6 %). Table-1 is depicting the knowledge of respondents.

Attitude score of the participants is shown in Table 2. Out of 306 participants, 242 (79.1%) displayed positive attitude (>4) while 64 participants (20.9 %) showed negative attitude (<4) towards COVID19. The mean attitude score was 4.28 ±0.61. The highest mean attitude score was observed for the item regarding the treatment of emergency cases (4.68±0.76). Conversely, the lowest mean attitude score was noted for the item inquiring about the utilization of the chemo mechanical caries removal methods (3.83±1.04). Significant correlation was noted between the participants’ attitude and gender for the item exploring the fear of contracting COVID19 (p-value=0.003).

The association of gender and designation with mean knowledge and attitude among the dentist is displayed in Table 3. Results of the current study highlighted significant association of gender and designation with knowledge score. Spearman correlation showed significant correlation between the attitude and the knowledge score of the dentists (r=0.655, p value =0.01).

 

 

 

Table No.1: Knowledge of Dentists about COVID -19 Disease:

Knowledge of COVID19

Correct Answer

N (%)

Incorrect Answer

N (%)

Mode of transmission of COVID 19 is Fomite transmission and by respiratory droplets. (True)

302(98.7)

4(1.3)

WHO suggests that washing hands with water and soap for minimum 20 secs can help in the prevention of disease transmission (True)

262(85.6)

44(14.4)

Tele- screening via phone is recommended as first line of action to identify patients with possible COVID 19 (True)

222(72.5)

84(27.5)

Urgent dental care includes severe toothache, cellulitis, Ludwig’s angina, uncontrolled bleeding and Oro-facial trauma (True)

298(97.4)

8(2.6)

Most effective mouth wash as a pre- rinse to protect against COVID 19 infection is 1% hydrogen peroxide (True)

182(59.6)

124(40.5)

Four handed dentistry is highly recommended for controlling the spread of disease (True)

264(86.3)

42(13.7)

Face shields and eye wear are essential while examining the patients (True)

298(97.4)

8(2.6)

Ultrasonic devices can be safely used in dental office for patients (False)

158(51.6)

148(48.4)

After extraction resorbable sutures should be used in patients (True)

254(83)

52(17)

N -95 mask is essential while examining the patients (True)

274(89.5)

32(10.5)

Rubber dam isolation is a prerequisite for every patient (True)

258(84.3)

48(15.7)

High volume suction is mandatory in dental practice (True)

262(85.6)

44(144)

Antibiotics are the first line of treatment (True)

238(77.8)

68(22.2)

Note: Assessment of knowledge was done by awarding 0 for incorrect answer and 1 for correct answer. The range of knowledge score was from 0 to 13. Cumulative score of less than 9 was considered as insufficient score whereas greater than 9 was considered as sufficient knowledge score. Mean value of knowledge score=10.69 ± 2.14

 

 

Table No. 2: Attitude of Dentists towards Covid- 19 Disease:

Items

Faculty’s Responses** N (%)

p-value

SA

A

U

D

SD

Gender1

Designation2

Are you scared of getting infected with Covid -19 from a patient or a co -worker?a

114(37.3)

122(39.9)

42(13.7

6(2)

22(7.2)

0.003

0.06

Are you anxious of providing treatment to a patient who is suspected of being infected with Covid 19?b

122(39.9)

112(36.6)

38(12.4)

8(2.6)

26(8.5)

0.71

0.08

Currently every patient's travel history and body temperature should be taken before performing any dental procedure?c

206(67.3)

90(29.4)

2(0.7)

0(0)

8(2.6)

0.31

0.36

Relevant medical history i.e respiratory illness like cough, sputum, fever , difficulty in breathing  should be sought for every patientd

204(66.7)

90(29.4)

4(1.3)

0(0)

8(2.6)

0.39

0.63

Only emergency dental procedures should be carried out in current circumstancese

238(77.8)

56(18.3)

2(0.7)

2(0.7)

8(2.6)

0.09

0.91

Aerosol generating procedure such as use of triple syringe should be minimized as much as possiblef

204(66.7)

88(28.8)

8(2.6)

0(0)

6(2)

0.05

0.24

Chemo mechanical methods should be used for caries removal in patients with Irreversible pulpitisg

92(30.1)

110(35.9)

74(24.2)

20(6.5)

10(3.3)

0.77

0.32

Would you like to attend any training sessions to handle any untoward Covid 19 situation?h

142(46.4)

128(41.8)

20(6.5)

2(0.7)

14(4.6)

0.32

0.82

Would you like to volunteer for working in support of medical teams in case of emergency?i

130(42.5)

98(32)

56(18.3)

6(2)

16(5.2)

0.07

0.09

Derived from 1Chi-square test and 2Kruskal Wallis test

**Strongly disagree=SD; Disagree=D; Undecided=U; Agree=A; Strongly agree=SA

Note: Mean attitude score=4.28+0.61

Mean Attitude Score ± Standard Deviation (SD): a3.98 ± 1.11, b3.97 ± 1.88, c4.59 ± 0.76, d4.58 ± 0.77, e4.68± 0.76, f4.58 ± 0.73, g3.83 ± 1.04, h4.25+0.95, i4.05+1.08

 

 

 

 

 

Table No.3: Association of Gender and Designation with Mean Knowledge and Attitude score

Characteristics

n (%)

Mean Knowledge score with SD

Mean Rank

p-value

Mean Attitude score with SD

Mean Rank

p-value

Gender**

Male

120(39.2)

10.85+2.33

165.63

0.04

4.26+ 0.69

154.50

0.87

Female

186(60.8)

10.59+2.00

145.67

4.29+0.55

152.85

Designation*

Associate Prof/Professor

54(17.6)

11.07+2.24

178.76

0.002

4.26+0.62

154.35

0.99

Assistant Professor

44(14.4)

11.32+1.44

179.23

4.34+0.37

151.68

Lecturer

100(32.7)

10.74+1.86

151.02

4.30+0.55

155.56

GDP

108(35.3)

10.20+2.45

132.69

 

4.23+0.72

151.91

 

*Kruskal Wallis Test (p < 0.05) **Mann Whitney Test (p < 0.05).

 

 

 

DISCUSSION

COVID-19 pandemic has resulted in the global emergency. Currently, it is a topic of debate in the international media and among the general public. The rapid spread of novel COVID-19 disease has resulted in public-health concerns and collapse of world economy at large. It has laid massive pressure on both social stability and global health systems, particularly affecting the health care workers including the Dentists. Hence, it is imperative that prudent information should be conveyed to health care professionals in this hour of global catastrophe. Envisaging this, the present study has been conducted to explore knowledge and attitude of dentists about COVID-19 disease in Pakistan. There are very few studies that have particularly assessed the knowledge and attitude of dentists considering COVID-19 disease. Consequently, in the current study comparison of the outcome has been done with other related conditions. The results of present study conducted on Pakistani dentists displayed sufficient knowledge with positive attitude towards the COVID-19 disease.

The knowledge score of the respondents in present study ranged between 80 to 98% for the items that have investigated routes of transmission, hand hygiene, use of PPE and high-volume suction, urgent dental care procedures, practicing rubber dam isolation and employing four handed dentistry. These finding are in line with results of Khader et al, where Jordanian dentists exhibited knowledge score of more than 85% for items related to PPE, mode of transmission and hand hygiene18.The results were also in accordance with the outcome of other studies on SARS-CoV and MERS-CoV where the participants depicted sufficient knowledge regarding personal protection and hand hygiene19,20.

Participants also displayed good knowledge for questions regarding tele screening and antibiotics use (score range 70% to 80%). This might be attributed to some recently published studies that recommended the initial screening through telephone, while scheduling appointments, for identifying the patients with possible or suspected COVID-19 disease21. Contrary to our findings, khan and colleagues reported insufficient knowledge of participants regarding antibiotic use 18. The participants in current survey exhibited insufficient knowledge regarding the procedures utilizing ultrasonic apparatus for treating suspected Covid-19 patients. This may be due to their lack of understanding about this new disease and its connection with aerosol generating procedures22.

Current study suggested that the mean attitude score of Pakistani dentists regarding COVID-19 was in positive range (4.28 ±0.61), particularly when inquired about recording patient’s appropriate medical and recent travel history, checking body temperature and treating only emergency cases. These findings are in accordance with other researches that have reported mean positive attitude for physicians23.  Likewise, the findings are also in line with the studies on Jordanian dentists, and on healthcare workers 18,23. On the other hand, relatively lower mean attitude scores (<4) were noted when respondents were questioned about fear of contracting COVID-19, anxiousness to treat suspected patients and caries removal methods. The fearless attitude of the Pakistani dentists might be attributed to the fact that COVID-19 disease didn’t hit the region that bad as compared to west and majority of the European countries. This outcome resulted in common perception that disease is moderately dangerous especially for younger individuals. The results are again in accordance with the recent study done in Jordan, where 71.7 % of dentists identified COVID-19 as moderately hazardous and not a major community health issue 18. Furthermore, encouraging results came out regarding questions related to training workshops to deal with any unfortunate COVID-19 situation and volunteering their assistance as part of medical teams in case of potential emergencies. The findings were in line with the fact that was documented in the paper by United Nations where Pakistan was ranked 10th among the world with the total volunteer work force standing at 56 million 24. To the best of our knowledge the is no related data to evaluate the dentists’ attitude for their participation in the COVID 19 crisis support teams. Nevertheless, in recent study researchers has put forward dental outreach program model for managing the crisis situation during current pandemic25.

Significant correlation was noted between the participants’ attitude and gender for the item exploring the fear of contracting COVID19 (p-value=0.003). The significantly higher percentage (44%) of female dentists strongly agreed that they are scared of contracting the disease as compared to 30% of the male dentists. This finding is in line with the research finding where females reported greater anxiety and fear than male counterparts 26.

Mann-Whitney U and Kruskal Wallis tests were used to analyse the correlation of designation and gender with mean knowledge and mean attitude score. The results showed the mean knowledge score of female dentists were significantly lower than the male dentists (P-value=0.04). Likewise, significant correlation was noted between mean knowledge score and designation (0.002). Senior faculty members were found to have high mean knowledge score. This can be credited to the wisdom of senior faculty members gained through the years of experience as compared to the lecturers and GDPs. The application of Tukeys posthoc test suggested a statistically significant difference between the mean knowledge scores of GDP and Assistant professors (P-value=0.02). The difference may be due to the fact that more than 80% of the female dentists belonged to the GDP and lecturer groups. 

Positive knowledge and attitude correlation of dental health care workers noted in the present research reaffirms their association. Considering this, it can be concluded that dentists with positive attitude regarding COVID-19 are motivated to acquire more information. The strength of this study is that it has highlighted the area of highest concern. The findings of this study would be critical for designing effective training sessions and cross infection control measures in the current circumstances.

The limitations of the study are the moderate response rate, because the pandemic has caused many to be upset and taking care of personal affairs, that resulted in a smaller than expected sample size, which diminishes the generalizability of our results. Further investigations are warranted in this perspective.

CONCLUSION

Pakistani dentists have exhibited adequate awareness about general symptoms, transmission mode, cross-infection control and dental practice management in perspective of the COVID-19 outbreak. However, their understanding to protect dental professionals from this highly contagious disease during specialized dental procedures was unsatisfactory. Effective implementation of infection control programs depends on adequate knowledge, awareness and teamwork of individuals. Absence of proper knowledge and training will adversely affect the attitude of the dentist and results in the inadequate infection control measures and delay of emergency dental treatment required for the COVID 19 patients. Furthermore, it is imperative that guidelines formulated on the basis of recommendations released by international reputable institutions should be relayed and implemented by the regional dental associations.

Author’s Contribution:

Concept & Design of Study:

Asma Munir Khan

Drafting:

Arham Riaz, Shazia Nawabi

Data Analysis:

Muhammad Qasim Javed, Khurram Shahzad, Farzana Kulsoom

Revisiting Critically:

Asma Munir Khan, Arham Riaz

Final Approval of version:

Asma Munir Khan

Conflict of Interest: The study has no conflict of interest to declare by any author.

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