Assessment of level of perceived stress and sources of stress among dental professionals before and during the COVID -19 outbreak

Abstract

INTRODUCTION In late December 2019, a novel viral pneumonia outbreak originated in Wuhan City, China,[1] which later came to be known as “coronavirus disease-2019 (COVID-19).”[2] As the epidemic spread rampantly to other parts of the world, becoming a major public health problem not only for China but also countries around the world, the World Health Organization (WHO) announced this outbreak a pandemic.[3] India reported its first confirmed COVID-19 case on January 30, 2020 and the cases thereby continued to rise.[4] The first case of COVID-19 in the Chhattisgarh state of India was confirmed on March 19, 2020.[5] As of writing this article, the nation continued to be under third phase of lockdown till May 17, 2020. To mitigate the spread, nationwide lockdown was initiated from the early hours of March 25, 2020.[6] Due to the specificity of the procedure, which involves face-to-face communication with patients, proximity to the patient’s oropharyngeal region, exposure to saliva, blood, and other body fluids, aerosol generation, and the handling of sharps, dental professionals invariably carry the risk of nosocomial spread of SARS-CoV-2 who can become potential carriers of the disease.[78] Hence, many health regulatory bodies globally as well as in India placed an advisory for their registered dentists to perform only emergency and urgent dental procedures and avoid all elective treatments like restoration and extraction of asymptomatic teeth, aesthetic dental procedures, orthodontic adjustments, and routine radiographs.[9] As a result, most of the dental practices, hospitals, and institutions pan-India have closed operations since then. The SARS-CoV-2 pandemic has likely put health care-workers across the world at an increased risk of mental health issues.[10] The reasons range from excessive workload/work hours, fear of contagion, concerns for self/family well-being, heightened need for infection control procedures domestics and at dental operatory, inadequate personal protective equipment, over-enthusiastic media news, feeling inadequately supported, procedural errors, along with core issues of financial insecurity and potential loss of income.[111213] Dentists being an integral part of the society are no exception to this. Even otherwise, dentistry has been identified as a stressful profession that generates more stress than any other line of work and work-related factors account for more than half of the dentist’s overall stress.[14] Although a lot of studies have documented about the work-related stress and stressors among dentists in usual circumstances, to the best of our knowledge no study has assessed the psychological stress perception and the reasons behind the stress among dental fraternity due to COVID-19 outbreak and its associated lockdown. Hence, this study being the first of its kind was done with the following aim and objective: a. To assess and compare the level of PS among dentists of Chhattisgarh state before the onset of SARS-CoV-2 spread in the state (phase I) and in the month immediately following the nationwide lockdown owing to SARS-CoV-2 outbreak (Phase II). b. To identify the various reasons of stress among dentists of Chhattisgarh state during the two phases. MATERIALS AND METHODS A cross-sectional online questionnaire-based survey was conducted in two phases among dentists working in the state of Chhattisgarh, India. The first phase of survey (phase I) started from 10:00 am of March 20, 2020 to continue till 10 pm of March 25, 2020. The second phase (phase II) started from 10:00 am of April 25, 2020 to 10:00 pm of April 30, 2020. A list of dentists across the Chhattisgarh state was obtained from the State Dental Council’s dentists’ directory which comprised of 3825 dentists. All the dentists whose contact number/e-mail id was available were contacted and a brief introduction and objectives of the study were given. If a dentist agreed to participate in the survey (which was considered as informed consent), a link to the survey was sent to him/her to fill up the questionnaire. To prevent duplication of response, limit to one response was activated in the settings of the Google forms and the participating dentist then needed to sign in through his/her Google account. Ethical clearance was obtained from the Institutional Ethical Committee of Government Dental College and Hospital, Raipur, Chhattisgarh. (GDCHR/ERB/2020/11). Dentists working in various regions of the Chhattisgarh state and who participated and completely filled the questionnaire in both the phases of survey were included in this study. Considering that presence of any kind of systemic disease could have a negative impact on psychological well-being and can act as a confounder in the present study, such dentists were excluded from the study. An online questionnaire designed in the English language using Google forms was used for the purpose of the study. The structured questionnaire comprised of three parts. The first part assessed the general information––age, gender, qualification, years of experience, type of work, and general health of the participating dentist (presence of one or more systemic diseases). Based on the type of work, the dental professionals were categorized into three groups––dental practitioners (group A), dental academicians (group B), and dentists who are practitioners as well as academicians (group C). The three groups were sub-classified as belonging to either private sector or government sector. The second part of the questionnaire assessed the level of perceived stress (PS) of dentists using perceived stress scale (PSS) given by Cohen et al.[15] The 10-item PSS measures global PS experienced across the past one month on a 5-point scale (0––never, 1––almost never, 2––once in a while, 3––often, 4––very often).[15] Total scores range from 0 to 40. The third part of the questionnaire was an open-ended question where the participant had to list out all the sources of stress that occurred very often or always during the two phases of survey. An online pilot study was first done on 30 dentists to test the reliability and validity of the questionnaire. Cronbach’s alpha was used to assess the internal consistency reliability of questionnaire and was found to be good (0.84). Mean content validity ratio was 0.80 which was based on the opinion of five subject experts. STATISTICAL ANALYSIS All the data collected were entered into a personal computer and subjected to analysis using Statistical Package for Social Sciences (SPSS) version 17 (IBM Corporation, New York, New York). Descriptive analysis was obtained in the study. Participant demographics and sources of stress were calculated in frequency and percentage distribution. Mean PSS was calculated for each of the participating dentists. The data followed a normal distribution (Shapiro-Wilk). Intra-group and intergroup comparisons were done using Student’s t test, paired t test, one-way ANOVA, and post-hoc Tukey HSD test. For all analyses, statistical significance was fixed at 0.05. RESULTS Considering an estimated prevalence of moderate to severe levels of PS among HCWs to be 59% based on the study by Du et al.,[16] the sample size estimated using the formula (Zα)2pq/d2 using an alpha error of 5% and an absolute precision (d) of 3% was 814. Considering the estimated response rate to be 25% (e-mail response rates may only approximately 25–30% based on the study done by Yun et al.),[17] the sample size with the other assumptions remaining constant, would be 835 and the number of invitees in order to achieve the required sample size would be 3340. Considering that certain number of questionnaires to have incomplete responses, it was decided to contact totality of dentists (3825). Of 3825 dentists across the state, 3389 dentists were approached for participating in the study as 436 dentists could not be contacted due to unavailability of/incorrect email id/contact number. A total of 1756 dentists agreed to participate in the study. Of 1756 participants, 306 dentists were excluded from the present study due to the presence of one or more systemic diseases and 197 dentists were excluded either due to drop-out (82, 4.66%) or incomplete filling of the questionnaire (115, 6.54%). Hence, a total of 1253 participants were included in the final study sample, which was well above the required sample size. About 55.62% (n = 697) of participants were less than 35 years of age, while 44.38% (n = 556) greater than 35 years of age, with a mean age of the responders being 33.28 ± 7.64 years. The study comprised slightly more number of females (n = 646, 51.55%) than males (n = 607, 48.45%). Most of the participants were Bachelors in Dental Surgery (BDS) (n = 705, 56.19%) and had a clinical experience of less than 10 years (n = 663, 52.91%). The mean year of clinical experience was 6.85 ± 3.47 years. 505(40.30%) dentists were dental practitioners, 348 (27.78%) dental academicians and 400 (31.92%) dentists worked as practitioners as well as academicians. The other details are presented in Table 1.Table 1: Participant characteristicsDuring phase I period, 62.5% of dentists were stressed (moderate level of PS––596 (47.56%), high level of PS––188 (15.3%)) while in phase II, 79.24% of dentists were found to be stressed (moderate level of PS––769 (61.37%), high level of PS––224, (17.87%)). The mean PSS of dentists during phase II was found to be significantly higher than in phase I (20.72 ± 1.95 Vs. 18.61 ± 6.87, P < 0.0001). Both the phases showed that dentists working in private sector had significantly higher mean PSS as compared to dentists used in government sector (19.33 ± 6.35 vs. 17.77 ± 6.27, P = 0.0002––phase I; 22.27 ± 6.12 vs. 18.96 ± 6.37, P < 0.0001––phase II). Moreover, dentists with an experience of less than 10 years had a significantly higher mean PSS than dentists having greater than 10 years work experience (20.86 ± 6.28 vs. 19.90 ± 6.81, P = 0.009) during phase II. When the mean PSS scores among different demographics were compared between phase I and phase II period, all the demographics showed highly significant results (P < 0.0001) and the higher value of mean PSS was reported in phase II period [Table 2].Table 2: Comparison of mean perceived stress score among participant demographicsDetails of group-wise and phase-wise comparison of mean PSS of dentists has been given in Table 3 that indicated the mean PSS was significantly higher in phase II as compared to phase I for all the three groups (P < 0.0001). During phase I period, female dentists of group C (19.21 ± 6.40 vs. 17.79 ± 6.51, P = 0.028) and group A dentists of less than 35 years of age (19.67 ± 6.25 vs. 18.28 ± 6.75, P = 0.016) and with BDS degree (19.90 ± 6.40 vs. 18.00 ± 6.25, P = 0.001) displayed higher mean PSS that reached significance. Moreover, dentists used in private sector of all the three groups were significantly more stressed as compared to those engaged in government sector (group A- P = 0.044,group B––P = 0.025, group C––P = 0.026). During phase II, dentists with less than 10 years of experience (21.94 ± 6.37 vs. 20.03 ± 6.46, P = 0.003) of group C, group A dentists less than 35 years of age (23.45 ± 6.14 vs. 21.83 ± 6.22, P = 0.003), with BDS degree (22.47 ± 5.68 vs. 21.24 ± 6.21, P = 0.027)and with work experience of less than 10 years (23.00 ± 6.25 vs. 21.26 ± 7.13, P = 0.003) were reported to have significantly higher mean PSS than their fellow dentists. Private dentists of all the three groups had significantly higher stress scores than government dentists during phase II also, the highest score being the private dentists belonging to group A. Other details are shown in Table 4.Table 3: Comparison of mean perceived stress score between the participant groupsTable 4: Comparison of mean perceived stress score among participant demographics of three different groups of dentists during Phase I and Phase IITable 5 shows the list of common stressors identified as occurring very often or always among the three different groups of dentists during phase I and phase II period.Table 5: Sources of stress during Phase I and Phase II among different participant groupsDISCUSSION Ample amount of available literature has classified dentistry as a stressful job, reporting increased stress among dentists. The present study reported that 62.5% of Chhattisgarh dentists were dealing with psychological stress even otherwise, regardless of the COVID-19 lockdown aftermath which was in line with the results of previous studies done by Pouradeli et al.,[18] Osehal et al.,[19] Moors et al.[20] and Myers et al.[21] However, the COVID-19 outbreak and associated lockdown seem to have exaggerated the prevailing stress among dentists as percentage of dentists reported to perceive stressful situations increased to 79.24% in the present study. This was similar to Chinese health care workers[22] and physicians of Iraq[23] who were exposed to COVID-19 patients. Nevertheless, the frequency was much higher than that of Indian general public during the same situation.[24] Similarly, when compared with the available literature of stress level of Indian orthopaedic surgeons[25] and trainee opthalmologists[26] during COVID-19 flare up, the level of stress that dentists in the present study were facing is much higher (22.5% in case of orthopaedic surgeons and 54.8% in trainee ophthalmologists). The results also revealed a significant increase in mean stress score during the lockdown, irrespective of dentist’s demographics (age, gender, qualification, years of experience or working in private or government sector) or whether the dentist is a practitioner, academician or both. In the present study, before the spread of COVID-19 disease in the state, Chhattisgarh dentists working as practitioner as well as academician were most stressed followed by their compatriots who were working as practitioners only and lastly by dental academicians, which was in agreement with the previous study done by Pravallika et al.[27] Nonetheless as the COVID-19 spread flared up and was followed by the nationwide lockdown, young, general dentists with new setups were reported to be more stressed out which supported the results of a recent study on COVID-19 lockdown by Wang et al.[28] Also, the clinical decision-making skills, job satisfaction, and experiencing different clinical situations and facing odds clinically as well at personal front is found to be higher in specialist dentists who are more likely to handle stress efficiently than a novice.[29] Moreover, the higher levels of stress in comparison to their respective counterparts could also be attributed to the fact that individuals may suffer similar negative life events but appraise the impact or severity of these to different extents as a result of certain factors like differences in their biological responses to stressors, self-concepts, coping styles, emotional intelligence and social support.[30] Evidence has suggested that stress among salaried government dentists is as high as that of private dental practitioners.[31] However, in the present study, regardless of the extraordinary circumstances of COVID-19 pandemic, dentists working in private sector (clinics/institutions) experienced higher level of stress than the dentists used in government hospitals or institutions. The results were in agreement with the previous studies done by Chukwuneke et al.,[32] Pravallika et al.,[27] and Newton et al.[33] This study also attempted to identify the various stressors occurring as very often or always among the three different groups of dentists working in Chhattisgarh before and during the COVID-19 outbreak in the state. A number of stressors were identified that varied considerably not only among the different strata of dentists but also between the two phases of survey. Before the COVID-19 outbreak in the state, stress of getting infected or family member getting infected was the least common stressor among all the groups of dentists although the country had started witnessing rise in the number of cases during this period. This might had been due to the insufficient knowledge about the novel disease among dentists during that period. While dental academicians were most stressed due to lack of resources and facilities in their institutions, poor relationship with colleagues and fear of losing job, dental practitioners and dentists working as both practitioner and academician were most concerned about the long working hours as a result of which they were unable to give adequate time to family followed by concern about earning enough to meet lifestyle needs and competition with fellow dentists, which was in agreement with the previous studies done by Cooper et al.,[34] Ayers et al.,[14] Myers et al.,[21] and Pouradeli et al.[18] As opposed to phase I, during the phase II period, the most commonly recognized sources of stress during usual times were replaced by altogether different and new forms of stressors. Concern about COVID-19 contagion and getting infected with it was one of the most frequent sources of stress among all three groups of dentists. Dentistry is a profession that involves working in close proximity to the oral cavity and its secretions, and use of aerosol producing devices is unavoidable in most of the dental procedures due to which the risk of getting infected is heightened and so also the anxiety associated with it.[35] Moreover, the unavailability of any specific treatment of the novel disease and the prevailing uncertainty adds to an individual’s sense of unease, leading to loss of hope and initiative.[34] Misinformation and sharing of fake news through social media are other factors that might cause increased stress related to contagion.[36] Financial stress and anxiety are important aspects of financial mental health that can impact a person’s cognitive, emotional, and relational well-being.[37] The COVID-19 pandemic has not only caused an unprecedented health crisis but has also triggered an economic downturn for almost all the large and small scale sectors, where millions of fellow citizens are on the verge of losing their jobs and the dental healthcare sector is no exception. In the present study also, ever since the lockdown was imposed, dentists, regardless of which group they belonged to be with financial as most of were concerned about losing their job or loss of earning in the or high in infection control The has to for Dental under no such are of any to dental academicians. financial stress has not been in COVID-19 related it to be compared with literature in this of the present study was an in like lack of personal and and need of the family among dental practitioners and dental academicians during the period of lockdown. results were reported by the studies done by et and Wang et among general This of increased psychological stress during COVID-19 outbreak and associated lockdown could be which may when the or when dentists and to the can be but can be to by various or in stress and However, this is in as in about of dentists, or even COVID-19 it might to on a person’s which would need dental practitioners need to be to identify and mental The dental opinion need to work with concerned to certain and that a for and care such that the stress level is COVID-19 lockdown for dentists also be that on working for infection and and available at rates and mental health and The was the major of the study. The response rate of the study was not The present study the dentists from the However, when the of our sample were compared with all dentists on the Dental no significant differences were the of the present study can be to all the dentists of Chhattisgarh that the two groups not with to any other the study was to dentists working in the Chhattisgarh state of India. among the dental fraternity of the country is for of the present The present study that Chhattisgarh dentists are under psychological stress the COVID-19 spread and its associated lockdown, the private dental practitioners experiencing the highest level of is a in the stressors experienced by the dentists, although concern about the infection and financial were the two most common sources of stress among the dentists. of and for a clinical and mental and to dental fraternity is the need of the AND are no of study literature data statistical data AND The study was by (GDCHR/ERB/2020/11). the data during this study is available from the The study was

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