The Psychology of Coronavirus Fear: Are Dentists of Pakistan Suffering from Corona-Phobia?

INTRODUCTION:

Aviral respiratory disease that emerged in Wuhan, China by the end of 2019 that turned in to a global pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2). Coronavirus disease 19 (COVID- 19) is a highly contagious disease.1

In March 2020, the World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19) a pandemic, affecting over 110 countries and territories globally where the coronavirus illness is present.2 It can be transmitted by droplet inhalation, coughing, sneezing, and contact with the mucous membranes of the oral cavity, nasal cavity, and eye.3

Widespread outbreaks of infectious diseases, such as COVID-19, are associated with psychological distress and symptoms of mental illness.4 Infectious diseases and especially in the case of pandemic,psychological responses emerge. However, it is different in different people.5

Healthcare professionals (HCPs) are the most vulnerable group of individuals where fear, anxiety, depression and other psychological symptoms are the common problems due to the direct exposure and interaction with the patients or suspected individuals. Furthermore, studies have reported that workload, lack of protective type of equipments, isolation, and higher rate of infection among HCPs may result in anxiety and fear.6

A significant element for health care professionals is the fear that relates to COVID-19 exposure and subsequent concern of transmitting the infection to their families.7,8 A recent study conducted in China demonstrated that more than 70% of HCPs reported moderate to severe fear and 22.6% of medical staff showed mild to moderate anxiety whereas 2.9% had severe anxiety.9 Moreover, studies conducted after the outburst of the severe acute respiratory syndrome (SARS) also suggested that HCPs are at greater threat of developing anxiety, fear, depression and other psychological issues.10

Pakistan is a developing country with limited health care facilities and during the current crisis of COVID-19 many HCPs along with general public in Pakistan have lost their lives.11 This situation has created fear and anxiety among the HCPs which includes medical doctors, dental surgeons, nurses and other paramedical staff. In the current study. It is reported that dental health care professionals along with the associated staff dental nurses are at the risk of COVID-19 due to routine aerosol-generating procedures in and around the patient’s mouth.12 It has always been challenging for the staff of dental setup to maintain crossinfection control and, especially when doing selected dental procedures that produce aerosols. Due to the nature of dental care surroundings, the hazard of cross-infection is elevated among patients, dentists and their coworkers.13

To evaluate the fear among the dentists of Pakistan due to the current pandemic, we conducted this study.

METHODOLOGY:

Study Design: It was an online survey-based cross-sectional study conducted in May 2020 during the period of strict lockdown as per government orders to prevent the spread

and transmission of the coronavirus. Sampling: Rao soft was used to determine the sample size. The minimum required sample size was 377 considering 50% response rate, 95% confidence interval (CI), and a 05 % margin of error. A supplementary 05 % (n=19) was added to overcome any flaws or discrepancies in the filling up of the survey form. So the final calculated sample size of 396 dentists of Pakistan was considered.

Study Population: Participants of the current study were the dentists working in different clinics, hospitals and teaching institutes of Pakistan having at least Bachelors of

Dental Surgery (BDS) degree and more than 1-year experience. Non Practicing dentists were excluded. Dentists were approached by the Principal investigator and coinvestigators through their personnel contacts as per convenience snowball technique and also recruited through a Facebook group “DENTISTS OF PAKISTAN” with over 6000 dentists.

Questionnaire Design: In the current study, we used a previously validated Fear of Corona Virus Scale (FCV-19S) with Cronbach’s alpha value of 0.82, to check the fear among the dentists of Pakistan. The FCV-19S is 7 items measured on five points Likert Scale.14 The FCV-19S is ranging between 7-35, greater the score, higher the fear.

The survey instrument for the current study was comprised of 2 sections; Demographics and FCV-19S. A pilot study was performed on dentists from different cities of Pakistan,

to furnish their views and ideas to make the current survey instrument easier and concise. After a detailed and thorough discussion with medical educationists, the current survey

instrument was finalized. The reliability coefficient of the survey instrument for the current study was computed using SPP v.21 and Cronbach’s alpha was found to be 0.807 which

is considered good.

Ethics: Ethical approval was obtained from the ethics and review committee of Altamash Institute of Dental Medicine, Karachi, Pakistan (AIDM/EC/04/2020/04).

Statistical Analysis: Data was downloaded in MS excel and afterwards transferred to SPSS V.21 for analysis. Categorical variables (Gender, Age Group, Category i.e. General Dentist

or Specialist ) were stated as frequencies and percentages and Qualitative values ( Score of FCV -19S) were calculated as mean and standard deviation. To check the significance

of demographic characteristics Chi-square test was used. Independent sample t-test was performed to access any difference in FCV-19S among genders and different

categories of dentists. Differences in mean fear among different age groups were accessed by one-way ANOVA. A p-value of less than 0.05 considered significant in all tests.

RESULTS:

Total of 409 dentists participated in the current study. Due to the discrepancies in the data, analysis of 386 individuals was carried out and data of 23 participants were excluded. The analysis showed that there is a significant difference among genders (X2= 36.073, p <0.001), Age Groups (X2= 350.953, p <0.001) and between the 2 categories of dentists i.e. General Dentist and Specialists ((X2= 269.477, p <0.001). Out of 386 , females were 252 (65.3%), in the 18 to 30 age group 236 (61.7%) participants were present and 265 (68.7%) participants were general dentists.

(Table I).

In Table II the mean levels of central tendencies along

with skewness and Kurtosis of each item of FCV-19S has been reported. The total mean score of FCV-19S was 26.22 ± 4.907 which is towards the higher side (Table II).

Table II: Item properties of Fear of Coronavirus-19 Scale

We performed an independent t-test to find out the mean score among the gender for each item of FCV-19S. We analyzed that females showed higher scores of fear and the difference is highly significant. We further analyzed the difference among genders for a total score of FCV-19S. As per independent t-test, we found a significant t value (t (229.34) = -4.763, p<0.001). The analysis further revealed that males had a lower mean score (M=24.54±5.371) as compared to females (M=27.11 ±4.399). (Table III).

To analyze the statistical difference among 2 categories of dentists i.e. General Dental Practitioner (GDP) and Specialist Dentists (SD), we executed independent t-test. We evaluated that GDP showed higher scores of fear in all the 7 items of FCV-19S and the difference is highly significant (p<0.05). We further analyzed the difference between GDPs and SDs for a total score of FCV-19S. As per independent t-test, we found a significant difference (t (384) =-4.557, p<0.001). The analysis further revealed that GDP had a higher score (M=26.97 ±4.648) as compared to females (M=24.57 ± 5.077). The results show that GDP has more fear of COVID-19 as compared to the SD. (Table III).

A one-way ANOVA was performed to find out the impact of Age on fear. Participants were divided into 4 age groups: Less than 30 years old, 31 to 40, 41 to 50 and more than 51 years old. The test revealed that there were significant differences in Total Fear Score of FCV-19S for four different age groups [F (3,382) = 8.618, p< 0,001].The findings also indicate that young adults and elderly people had higher scores on the FCV-19S than middle-aged (Fig I).

Figure 1: Mean of total FCV-19S among different age group

DISCUSSION:

In the current study, we observed that the mean fear score. According to FCV-19S was towards the higher side and fear is highly prevalent among the dental professionals of Pakistan. In agreement with our findings a study, conducted on HCPs, observed high fear and anxiety among the dentists as compared to medical doctors and pharmacist.8

Studies have reported that dental professionals are more prone to infections because of the aerosols generating procedures and confined environment of the dental offices.15,16 In the current study, we observed that that female dentists are more afraid of these crises and there is a significant difference in all item of FCV-19S as compared to males. This can be elucidated by the fact that women have more burden than men and they are responsible for house chores, take care of the family members and other domestic issues,17 furthermore females are more sensitive by nature. Moreover, in agreement with our findings, previous studies have also shown higher levels of anxiety among women18 and female doctors.19

Similarly, the current study expressed a higher score of fear in general dental practitioners as compared to the specialist dentist. In accordance with the finding of our study, other studies targeted physicians also showed lower levels of anxiety among the specialists as compared to nonspecialist doctors.20,21 However, an Iranian study has contradictory results.22 In our opinion, persistent jobs and salaries could be the reason of lower level of fear among the specialists, moreover their capability to buy expensive personnel protective equipments and carry forward the patients to the junior dentist may have a pivotal role. Majeed MM et al have also reported anxiety and stress among the young dentists and postgraduate dental trainees due to the closure of dental outpatient departments and dental hospitals, likewise anxiety is also reported among those dental professionals who are associated with teaching due to online classes.23

Similarly the young dentists below the age of 30 years expressed higher anxiety levels as compared to the dentists between the ages of 31 to 50 years. On the other hand dentists above 50 years of age had the highest level of anxiety among all age groups. By the current study findings, another study conducted on the general population in Pakistan reported higher fear among young individuals.24 Comorbidities and social issues could be the reason for higher FCV-19S score among the dentists above 50 years.

The observations and findings of the high level of fear in the current study are consistent with studies regarding the epidemic of SARS and MERS.25,26 Studies conducted in different parts of the world and in Pakistan about anxiety and fear among the HCPs revealed that HCPs are the most vulnerable group and because of the current COVID-19 pandemic have shown higher levels of stress, anxiety, fear, depression and other psychosomatic problems.27,28 In another study, primarily targeting the fear among dentists during the current crisis revealed that fear of being infected from the patients or colleagues, transmission of infection to family members, economic and financial insurgencies, panic and anxiety of getting quarantined, etc. are the major factors causing fear among the dentists.29-31

The probabilities of getting infected as well as transmission of the disease are highly common from the dental office. The dentist comes under the high-risk zone and the chances of the spread of infection from the handpiece, ultrasonic scalers, triple syringe, and other aerosolgenerating procedures have been reported along with the possibility of transmission of infection to the patient or dentist.32

Due to the highly contagious nature of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), professional dental organizations asked the dentist to stop performing aerosol-generating as well as elective procedures. In a few countries, dental clinics were completely closed and many dentists started giving consultancies from home.33 Due to a high level of fear among the dentists of Pakistan, it is mandatory for them to practice coping strategies and if required intervention from psychologists and psychiatrists can be obtained.

We also recommend conducting a longitudinal study facilitate identification of the prevalence of fear, anxiety, depression and other psychological issues. The strength of this study is the data was collected from all the provinces of Pakistan. There are few limitations in the current study that due to COVID-19 and lockdown we were bound to conduct online survey and results may not be generalized and may have source bias effects.

CONCLUSION:

Due to the current crisis dental professionals of Pakistan are in a state of fear. To overcome such issues, government or medical and dental association should arrange sessions with the psychologist and psychiatrists. Moreover during the crisis dentist should only perform the emergency procedures following all the necessary protocols. Furthermore, policies for such pandemics should be made and implemented to prevent or to control the spread.

ACKNOWLEDGEMENTS:

We acknowledge the support of the ethic and review committee of Altamash Institute of Dental Medicine, Karachi, Pakistan. We would like to thank all the respected participants for their participation and special thanks to the Professor of Psychiatry Dr. Munir Hamirani for the ideas, encouragement and support at every step of the research.

CONFLICT OF INTEREST:

None

FUNDING:

None

AUTHORS CONTRIBUTION:

SZ: Initial draft writing, literature search, data collection and final approval of the manuscript. IN: Data collection, write up, Critical revision and final approval of the manuscript. RZ: Study Concept and design and critically revised and approved the final draft of the manuscript. SH: Data collection, write up, tables and figure and final approval of the manuscript. NMM: Data collection, statistical work and final approval of the manuscript. MMM: Conceived the study, supervised the project and is responsible for the integrity of the research. Comprehensively contributed to Data collection, statistical work, writing of the manuscript

and critically revised and approved the final draft of the manuscript.

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37. Assistant Professor. Department of Oral Biology, Altamash Institute of Dental Medicine, Karachi.
38. MDS-Trainee, Department of Oral Surgery, Dow University of Health Sciences, Karachi.
39. Lecturer, Department of Operative Dentistry, Dow University of Health Sciences, Karachi.
40. Assistant Professor, Department of Psychiatry, Dow University of Health Sciences, Karachi.
41. Assistant Professor, Department of Oral and Maxillofacial Surgery, Dow University of Health Sciences, Karachi.
42. MDS Trainee and Lecturer, Department of Periodontology, Dow University of Health Sciences, Karachi.
43. Corresponding author: Dr. Muhammad Mansoor Majeed < mmansoormajeed@gmail.com >