Mothers’ Knowledge, Attitudes, and Fears About Dental Visits During the COVID-19 Pandemic

Abstract

INTRODUCTION In early 2020, the world witnessed the massive spread of coronavirus disease 2019 (COVID-19), believed to have originated in Wuhan, China.[1] It is capable of causing severe acute respiratory symptoms, typical signs and symptoms being fever, cough, and fatigue, especially in adults.[23] On March 11, 2020, the World Health Organization (WHO) categorized it as a pandemic.[4] As of December 1, 2020, the disease is believed to have affected over 62.66 million people worldwide and has been responsible for the loss of at least 1.46 million lives.[5] From the evidence available at the time of publication, children do not appear to be at higher risk for COVID-19 than adults, who make up most of the known cases so far.[6] Nevertheless, undiagnosed children should be regarded as asymptomatic carriers of the disease.[7] COVID-19 is caused by a novel coronavirus (2019-nCoV or SARS-CoV-2) that possesses high transmissibility potential.[18] Common transmission routes are direct transmission through cough, sneeze, and droplet inhalation and contact transmission through oral, nasal, and eye mucous membranes.[9] In addition, 2019-nCoV can be transmitted directly or indirectly through saliva.[9] Studies have suggested that 2019-nCoV may be airborne through aerosols formed during medical procedures.[10] With their unique characteristics, dental settings warrant specific infection control considerations. Dental procedures typically generate aerosols that can contain saliva or blood particles and thus carry the risk of large-scale transmission of the virus.[11] Although dental clinics typically perform strict infection control measures, even stricter measures have been called for since the beginning of the pandemic.[712,13] In March 2020, most dental practices were encouraged to provide management based on the urgency and acuity of symptoms, while routine care was deferred. As conditions returned to normalcy, more routine care was being provided under the new infection control norms. Detailed and frequently updated guidelines have been published by the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatric Dentistry (AAPD), and the American Dental Association with recommendations to consider prior to the dental visit, at arrival, and during treatment to minimize exposure to the virus and protect staff and patients.[1314] The public has received much information about COVID-19 through social media that could be inaccurate and unnecessarily alarming, potentially leading to confusion and panic. A recent study in China reported that of 1,210 respondents, 53.8% expressed enduring moderate-to-severe psychological impacts from the pandemic.[15] Given COVID-19's high contagion and fast spread, it is not uncommon for mothers to be alarmed and their attitudes toward dental visits to change. In a recent study by Sun et al., 81% of parents expressed confidence in the clinic; however, 83.78% reported that they would take their child to a dentist only for severe pain.[16] In a study of 1,003 parents in Brazil, only 18% were willing to take their children to the dental clinic for any procedure, while 67% reported they would take them only for emergencies, and 15% denied dental care altogether.[17] This is one of the first studies that evaluated parents’ knowledge and attitudes regarding dental visits during the pandemic, although a handful of studies have investigated the impact of COVID-19 on dentists.[1819] Thus, the aim of the present study was to assess mothers' knowledge of COVID-19 and to evaluate their attitudes and fears about dental visits during the pandemic. MATERIALS AND METHODS POPULATION AND SURVEY This cross-sectional study targeted mothers of children 17 years and younger in Jeddah, Saudi Arabia. The ethics committee at the Faculty of Dentistry at King Abdulaziz University (KAUFD) approved the study protocol (069-06-20), and the Saudi Center for Disease Prevention and Control approved the study proposal (202007251). A structured self-administered questionnaire was developed from questionnaires used by Sun et al. and Yip et al.[1620] Questions were added to collect additional relevant information. The questionnaire contained 34 close-ended questions that were divided into six sections (demographic data; COVID-19-related home practices; COVID-19 knowledge; willingness to visit a dentist, attitudes toward visiting a dentist, and barriers to visiting a dentist during the pandemic). The questionnaire was validated independently by three experts at KAUFD for comprehensibility and objectiveness (a professor in pediatric dentistry, a professor in medical education, an associate professor in dental public health). For face validity, each question was rated for its importance on a five-point scale (1 = very important, 2 = important, 3 = moderately important, 4 = of little importance, and 5 = not important) and whether or not it should be included in the survey on a three-point scale (0 = yes, 1 = no, and 2 = not sure). For content validity, each question was rated in four domains; relevance, clarity, simplicity, and ambiguity on a four -point scale (1 = needs major revision, 2 = needs some revision, 3 = needs minor revision, and 4 = no need for revision).[21] We considered the development of a bilingual survey essential to cover most of the population of interest. The questionnaire was drafted in English and translated into Arabic; it was then translated back to English and compared with the original in accordance with the well-recognized forward-backward translation technique.[22] The questionnaire in its English and Arabic forms was piloted with 10 mothers from different socio-economic backgrounds. The final questionnaire was digitized on an online survey portal, SurveyMonkey (San Mateo, California, USA). A link to the survey was sent via phone as a WhatsApp message to eligible mothers’, from different socioeconomic backgrounds. Snowball sampling methods took place by asking participants to help recruit further participants by sharing the link with eligible mothers in their networks. The cover page of the survey explained the study's purpose and included the contact information of the principal investigator. The first question was, “Are you a mother of at least one child who is 17 years or younger who resides in Jeddah and consents to participate in this study?” This question was used as consent for participation and to exclude ineligible participants. To test the validity of the responses and ensure that respondents were reading the questions well and answering accordingly, we added a question halfway through the questionnaire with the following direction: “Please choose the word dentist from the list below.” Participants who chose an answer other than “dentist” were excluded from the study. To ensure privacy, the names and contact information of the participants were not recorded, and they were assured that the results were (and will) not be publicly displayed or shared beyond the scope of the study. Furthermore, participation was voluntary, and recipients willingly participated without incentive or pressure. Data were collected during June 2020. At the end of the data collection period, the data were retrieved for analysis from the collected responses in the online survey software. STATISTICAL ANALYSES Frequencies and percentages of categorical variables were presented. Predictors of willingness to visit a dentist during the pandemic were examined by logistic regression, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Willingness to visit a dentist had three response options: no, yes, only for emergency. For ease of interpretation and to allow a sufficient number of participants for statistical analyses, the variable was recategorized into a binary variable: no/only for emergency and yes. Polytomous regression on the three-category variable was run, and results were similar. The predictors assessed were mothers’ age, marital status, education level, and occupation; monthly household income, type of dental clinic last visited, perception of danger of dental clinic for 2019-nCoV transmission compared with that in public places; willingness of mothers to go to the dentist themselves during the pandemic; worry about contracting the virus from the dental clinic; and mothers’ feelings since the beginning of the pandemic. A P-value of 0.05 was considered statistically significant. Data analyses were conducted with Stata, version 13.0 (StataCorp LP, College Station, Texas, USA). RESULTS The link was visited by 2,306 participants, with 1,159 taking the survey. Of these, 324 were excluded because they answered “no” to question 1, and two because they incorrectly answered the validity question. The final sample comprised 833 respondents. Table 1 presents the characteristics of the included respondents. Respondents reported on their COVID-19-related practices at home, 5% of them did not talk to their children about COVID-19, 14% did so when the pandemic first started, and 37% did so only when their children asked, while 23% and 21% spoke to their children about COVID-19 on a weekly and a daily basis, respectively.Table 1: Characteristics of the study participantsThe most trusted source of COVID-19 information was the Saudi Ministry of Health (MOH) (68% of respondents), followed by international health entities such as the WHO and the CDC (17% of respondents), then doctors known personally (8%), and news (3%). Doctors in the media and family/friends were the most trusted source for 2% of the participants. Regarding feelings of respondents toward COVID-19, 57% felt sometimes anxious and sometimes hopeful since the beginning of the pandemic, 34% felt generally positive, and 9% felt generally anxious and depressed. With regards to parents worry about them or their children contracting the virus from the dental clinic, 26% of the respondents were very worried, 64% were somewhat worried, and 10% were not worried. Regarding knowledge of COVID-19, 79% of participants believed that cross-infection in the dental clinic occurs by transmission from patient to staff, and 77% that it occurs in the opposite direction, while 62% believed that the infection occurs from patient to patient, and from staff to staff. When participants were asked about which healthcare workers, they believed are at risk of contracting the virus; 85% and 78% reported that nurses and doctors are at risk, respectively, while 70% believed that paramedics are at risk and dentists, followed by other staff (69%). In addition, most respondents reported that the virus can be transmitted even if no fever or symptoms are present (76%), while 4% believed that it can’t be transmitted, and 20% did not know. Also, 39% of the respondents believed that dental treatment could cause children to be infected by 2019-nCoV. Concerning the perception of risk of infection with 2019-nCoV in dental clinics and hospitals/medical clinics compared with that in public places such as malls and parks; 36% of respondents believed that dental clinics were more dangerous than public places. Similarly, 42% believed that hospitals/medical clinics were more dangerous than public places. Perceptions of danger in the dental clinic and hospitals/medical clinics were statistically associated (P < 0.001). Table 2 demonstrates the predictors of willingness to take the child to the dentist during the COVID-19 pandemic. In terms of a perceived barometer for safety to seek dental care, 40% of participants reported that the development of a vaccine would make them feel comfortable taking their children to the dentist during the pandemic, and 39% that a marked decline in daily positive cases in Jeddah would do so. Among the respondents, 6% reported that lifting the curfew would make them feel comfortable taking their child to the dentist; 4% reported that reopening of schools would do so. Only 1% of the mothers reported that nothing would make them feel comfortable taking their child to the dentist; <1% reported that other factors would make them comfortable.Table 2: Predictors of willingness to take the child to the dentist during the COVID-19 pandemicAs illustrated in Figure 1, the most common perceived barrier to taking children to the dental clinic was fear of contracting the virus from someone there. Table 3 demonstrates the attitudes of the mothers regarding taking their children to the dentist during the pandemic, the main reason for dental visits during the pandemic were orthodontic treatment and emergencies (38%). Table 4 presents the importance of the measures taken against COVID-19 in the dental clinics according to the respondents. The majority (82%) reported that dental personnel wearing personal protective equipment (PPE) and the dentist changing gloves frequently were extremely important.Figure 1: Perceived barriers to taking children to the dental clinic during the COVID-19 pandemicTable 3: Attitudes regarding taking children to see a dentist during the COVID-19 pandemicTable 4: Importance of measures taken against COVID-19 infection in the dental clinic (n = 649)Among the respondents, 54% reported that they would prefer teledentistry over bringing their child to the dental clinic. Most of the respondent's children did not experience teledentistry during the pandemic (93%), but 6% experienced it once, and 1% experienced it more than that. DISCUSSION At the dawn of a new decade, the COVID-19 pandemic extended globally, and the first positive case in Saudi Arabia was confirmed on March 2, 2020. The Saudi government undertook rapid measures to contain the spread of the disease, including shutting down schools on March 8 and instituting a nationwide lockdown on March 23.[23] The lockdown was lifted on June 21; most cities in the country were able to gradually return to normalcy under the new norms (e.g., social distancing, obligatory mask wearing). In the three months of lockdown, people in Saudi Arabia experienced sudden substantial changes to their daily routine and social infrastructure, and many families were negatively affected financially and psychologically. The Saudi MOH disseminated timely educational messages, videos, and brochures on several platforms, including easily accessible social media. In Saudi Arabia, mothers are usually children's primary caregivers, spending the most time with them and often accompanying them to medical visits. The school shutdown was alarming to many mothers and demonstrated the magnitude of the pandemic. Like most people in the country, mothers in Saudi Arabia are concerned with the pandemic and follow the news regularly. The study targeted this population in particular because mothers would be making most decisions about pediatric dental visits during the pandemic. Recruitment occurred the week before the lockdown lift. The results show that most mothers relied on credible sources of information and that 32% followed COVID-19 news weekly and 62% daily. 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Only a of them reported that their child had to the dentist during the pandemic. than dental clinics as being a more dangerous place to the virus than public places The fear was in their practices as as only were willing to take their children to the dentist and the majority they would do so for an emergency only (69%). than of the mothers teledentistry over visiting the clinic. more than of them had little or no confidence in infection control measures taken at dental fear of with infection control measures was their perceived barrier to dental only to fear of contracting the virus from someone in the clinic. et al. reported that of children who dental during the pandemic did not seek dental that parents with higher fear and that when the number of COVID-19 cases parents are to take their children to dental The a specific predictors and willingness to take the child to the dentist during the COVID-19 pandemic. For mothers who perceived the dental clinic as being of than or danger to public places were more to take their children to the dentist than were who perceived it to be more who were willing to go to the dentist compared with who were were more to take their children to the Furthermore, mothers who were somewhat or not about contracting the virus from the dental clinic were more willing to take their children to the dentist than were who were very mothers who had been generally positive since the beginning of the pandemic were more willing to take their child to the dentist than were who felt generally anxious and depressed. In mothers over years were more to take their children to the dentist during the pandemic than were younger who may be more have a or have younger a dental health care did not to a willingness to take child to the dentist compared with mothers who were or had other Furthermore, the perceived barriers of mothers to dental care during the pandemic were to of other In of mothers expressed fear that their child may the virus from the clinic compared with 79% of other 78% of mothers had regarding with infection control measures compared with 64% of other 54% of mothers of other mothers perceived the dental clinic to be a more dangerous place to the virus than public places. could the that for perceived to their mothers and of their educational and of the major the pandemic be with its Dental health care has changes on many the beginning of the pandemic, to routine dental care has been more as have taken a to risk of infection transmission and to for other who are with COVID-19 may have not to visit the In 57% of mothers children had dental or Furthermore, many mothers were with to their children with while at This not only on but the time available to to other such as practices and factors may have to the development of new in children the of In of we to that health care to and treatment with We the to with the of who have not been during the pandemic. that to dental care, as with the COVID-19 pandemic, are a of of disease and public health are of Dental health care should take this to assess their in public health care and be to a more in the against by being available for emergency treatment and as in their in the against the of the it has is the of in the respondents because they participated willingly when they received the Furthermore, online may to or of the population because only who were on WhatsApp during the of data collection had the to participate in the study. the survey took an of and to which may have for some participants, and could were some the of data collection been more participants would have been we felt that the lockdown would in data that do not the targeted acute of the pandemic. although the study mothers from different socio-economic and educational they were from Jeddah, from the results on a higher In most mothers relied on credible sources of information on COVID-19, but not of them spoke to their children about were concerned about the pandemic and need to be encouraged to up to their children to any This would not only be for but for A of including had little confidence in dental infection control measures and perceived the dental clinic as a place to the virus; they were thus to take their children to the dentist during the pandemic for information about dental infection control measures should be to this population and more toward mothers to routine dental care to disease AND The study and the are are no of to the the questionnaire data the for the questionnaire data statistical analysis and approved the AND The data used in the study is available The the and received from and in of this study. the mothers' to in

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