key: cord-0850186-scqdnt9n authors: Alkhalifah, Futun N.; Tobbal, Ayoub Y.; Fried, Jacquelyn L. title: COVID‐19 impact, knowledge and preparedness among dental hygienists in Saudi Arabia: A cross‐sectional study date: 2021-08-21 journal: Int J Dent Hyg DOI: 10.1111/idh.12544 sha: 478e6518724e476c2eb8122e026c01e62b30bf33 doc_id: 850186 cord_uid: scqdnt9n OBJECTIVES: The study investigates the impact of COVID‐19 on dental hygiene professionals practising in Saudi Arabia, and measuring the knowledge and preparedness of dental hygienists to provide care during the pandemic. METHODS: A non‐experimental, cross‐sectional study was conducted targeting dental hygiene professionals in Saudi Arabia. The online survey consisted of 31 close‐ended questions: 9‐items related to demographics, and 22‐items that are COVID‐19 related. Data were tested at two levels; descriptive and preliminary using Chi‐square test, and significance was set at the 0.05 level. RESULTS: One hundred and thirty‐one responses were received and the final sample included one hundred and eighteen responses as it excluded unemployed dental hygienists with estimated 39.6% response rate. The stress level to return to practice was considered moderate among 65.3% of participants. Over two‐thirds (73.7%) of dental hygienists were not providing any kind of care/treatment during quarantine. Generally, a moderate level of knowledge (57.8%) was demonstrated by participants. For preparedness level to practice during the pandemic, sixty‐four dental hygienists (54.2%) were adequately prepared to provide care. Significant correlations were found between impact and knowledge (p = 0.045), impact and preparedness (p = 0.053), and knowledge and preparedness (p = 0.024). CONCLUSIONS: Dissemination of COVID‐19 protocols, guidelines and scientific literature increased the respondents’ level of knowledge and preparedness to an adequate level. This study indicated that knowledgeable dental hygienists were significantly more prepared to treat patients during the pandemic and that stress positively influenced the COVID‐19 knowledge acquisition. Non‐practising dental hygienists during quarantine were more knowledgeable and more prepared to practice during the pandemic. On Dec 31, 2019, the World Health Organization (WHO) was officially notified by the Chinese Health Authority of 27 cases of an atypical fatal pneumonia. 1 The new strain was named by the International Committee on Taxonomy of Viruses (ICTV) as 'Severe Acute Respiratory Syndrome Corona Virus-2' (SARS-CoV-2). 2 The WHO named it 'COVID-19' and declared it a public health emergency on 31 Jan 2020. 3, 4 In China, soon after the fast spreading virus has already infected more than 3000 healthcare professional including dentists and had caused 22 deaths, 5,6 the first review paper was published alerting dental professionals to the possible route of transmission of COVID-19 in dental clinics and that asymptomatic patients could spread the virus. 7 On 2 March 2020, the first case of COVID-19 was detected in Saudi Arabia (SA) 8 and by 11 March 2020, 118,000 cases were reported in 114 countries. 9 The WHO declared COVID-19 a pandemic. 9 A Day after, Meng et al 10 confirmed the hidden danger of aerosolizing COVID-19 in dental practices and indicated that regular or standard Personal Protective Equipment (PPE) was not effective. However, aerosol-generating producers (AGP) and elective care in dental practices did not cease until a research study testing the virus viability in aerosol and fomites was published on 17 March 2020. 11 In response to the accumulating scientific evidence, the Centers for Disease Control and Prevention (CDC), 12 the American Dental Association (ADA), 13 the American Dental Hygienists' Association (ADHA) 14 and the Saudi Dental Hygiene Society (SDHS) 15 issued their statements to postpone all AGP and elective dental procedures. Results from an occupational risk exposure analysis to COVID-19 by the Occupational Safety and Health Administration (OSHA) and the Office for National Statistics (ONS) placed dental hygienists as one of the highest risk professions among all occupations for exposure to COVID-19 due to three main factors 16, 17 : First, dental hygienists have prolonged time of exposure to aerosols; secondly, they are in close proximity to patients; and lastly, they have frequent contact with others during a day. These elements earned them a 99.7 risk score to COVID-19. 18 Additionally, most dental hygienists work as solo practitioners with no dental assistant who would help in the assessment of patients, control of aerosol, instrument sterilization and surface disinfection. 19 The unprecedented circumstances give rise to many occupational safety and clinical questions in need of real-time evidencebased answers and clarification, before the resumption of AGP and elective dental hygiene care. 20 Dental hygienists are responsible and accountable for their practice, conduct and decision-making. Using the best scientific evidence in the Evidence-Based Decision-Making (EBDM) process concerning the delivery of dental hygiene care is of most importance during this period. 20 The aim of this study is to investigate the impact of COVID-19 on dental hygiene professionals in Saudi Arabia, and to measure the knowledge level and preparedness of dental hygienists to provide care during the pandemic. Preparedness to provide care during COVID-19 pandemic. During May 2020, a non-experimental, cross-sectional study was conducted targeting a convenience sample of dental hygiene professionals in Saudi Arabia. Inclusion criteria are employed dental hygienists, senior students and interns. Unemployed dental hygienists were excluded as they would not have to resume dental hygiene care provision during the pandemic. Google Forms platform was used to develop and deliver the study survey. The Saudi Dental Hygiene Society (SDHS) was selected to distribute the survey through the society social media, targeting both members and non-members. Following approval of the King Saud University Institutional Review Board (IRB), the survey was launched on 15 May 2020 to the targeted population. A second survey distribution occurred one week after the initial launch on 22 May 2020 and was available for a total of two weeks. All responses were anonymous. Respondents' participation and return of the survey were considered voluntary consent. The survey consisted of 31 close-ended questions: 9-items of demographics; 22-items that COVID-19 related; 4-items addressing impact; 12-items for knowledge and 6-items for preparedness. For the impact scale, responses were 'yes', 'no' or 'not applicable'; for treatment delivery, the following options were provided: frontline, regular clinical practice with the same hours, regular clinical practice with reduced hours, regular clinical practice without aerosols procedures, urgent dental hygiene care only, tele-dentistry or non-applicable. For the knowledge scale, statements offered responses of 'true', 'false' or 'I don't know'. Knowledge questions were worded with a mixture of positive and negative responses to reduce response bias. The self-perceived preparedness scale included three levels of preparedness: fully prepared, meaning the subject had received all required information and training; adequately prepared, meaning subjects had received some required information and training; and not prepared, meaning subjects did not receive any required information and training. Operational definitions for levels of preparedness were explained to participants within the survey. Survey items were validated through a panel of the SDHS scientific committee, and validation letter was provided. Fifteen dental hygiene professionals provided feedback on the face validity of the instruments, and factor analysis was used for content validity. Data were tested at two levels: descriptive and preliminary. Descriptive analysis included frequencies and percentages of demographics, impact level, knowledge level and preparedness level. The baseline to determine impact and knowledge levels is less than 50% for low level, (51%-70%) for moderate level, and more than 70% for high level. The frequency count of the self-perceived preparedness scale was used to determine the level of preparedness. For preliminary analysis, relationships were tested using Chi-square between impact and knowledge, impact and preparedness, and between knowledge and preparedness. Significance was set at the 0.05 level. Statistical analysis was performed using the IBM Statistical Package for the Social Sciences (SPSS) version 25. 1. How did COVID-19 impact dental hygiene professionals in Saudi Arabia? 2. What are dental hygiene professionals' levels of knowledge related to COVID-19? 3. What are dental hygiene professionals' levels of preparedness to provide care during COVID-19 pandemic? One hundred and thirty-one responses were received. Thirteen responses were excluded as twelve respondents were unemployed and one response did not include employment data. The final sample included one hundred and eighteen responses. The most recent data regarding the total number of dental hygienists in Saudi Arabia were reported by the Saudi Commission for Health Specialties in 2017. At that time, the number of licenced Saudi dental hygienists was 298 hygienists. 21 Accordingly, the estimated response rate of this study is 39.6%. Table 1 illustrates demographic variables. Over two-thirds of the participants were female and aged 20-30 years. For undergraduate education, governmental education reported more than private dental hygiene education. According to educational level, 103 of the 118 participants hold bachelor's degrees (four years of full-time study and one-year internship), followed respectively by masters, diploma and PhD. Forty-seven participants were senior dental hygiene students and interns. For region of practice, the middle region had the most respondents, followed by west, east, south and north. For the years of clinical practice, the two highest groups were 1-5 years, followed by less than one year of experience. Table 2 shows the impact of COVID-19 on dental hygienists practising in Saudi Arabia. Twenty-seven dental hygienists out of 118 were asked to work under conditions that could jeopardize their personal safety. Some dental hygienists were directed by their employers to provide elective procedures during postponing period (quarantine) or were working without recommended PPE during the pandemic. Over two-thirds of dental hygienists were not affected financially during the current pandemic. Seventy-seven dental hygienists felt stressed going back to provide dental hygiene care. Over two-thirds of dental hygienists were not providing any kind of care/treatment during quarantine. The following clinical care was delivered during quarantine from highest to lowest percentage, respectively; regular clinical care with reduced hours, urgent dental hygiene care only, frontline, regular clinical practice with same hours, tele-dentistry, regular clinical practice without aerosolization. Table 3 illustrates the correct responses for knowledge ques- For preparedness level to practice during the pandemic, dental hygienists generally reported to be adequately prepared to provide care (see Table 4 ). The following shows the descending order of 'not prepared' categories: treating confirmed COVID-19 patient; joining the frontline during the COVID-19 pandemic; dealing with aerosolgenerating procedures; wear/handle a respirator (N95); educating patients during COVID-19 pandemic; and treating patients during the COVID-19 pandemic with adequate infection control information/ training. (Table 5) shows the significant correlations between impact and knowledge, impact and preparedness, and knowledge and preparedness. No reported correlations were not statistically significant. Regarding impact and knowledge, stressed dental hygienists were more knowledgeable about the use of N95 masks compared with non-stressed dental hygienists; however, practising dental hygienists during quarantine were less knowledgeable about the transmission characteristics of COVID-19 and the viability of COVID-19 in the air compared with non-practising dental hygienists. Concerning impact and preparedness, non-practising dental hygienists during quarantine felt more prepared to provide care during the pandemic as compared to practising dental hygienists. Regarding the relationship between knowledge and preparedness, dental hygienists who were knowledgeable about aerosol management were significantly more prepared to treat patients during the pandemic and more prepared to join the frontline. As well as dental hygienists who have higher knowledge in effective PPEs and usage of N95 mask were significantly more prepared to deal with aerosolgenerating procedures and to treat a confirmed COVID-19 patient. TA B L E 2 Impact of COVID-19 on dental hygienists in Saudi Arabia (N = 118) An dental hygienists in the United States during the pandemic. 25 Among the 2,200 responses, 82% of RDHs had applied for unemployment, and 22% were using their savings for living expenses. Resultantly, some were evaluating changing their profession completely. 25 In the UK, dental hygienists reported their primary concern during the pandemic was the financial impact, as a majority of them are selfemployed. 26 Only 14.4% of Saudi dental hygienists were financially affected by the pandemic, perhaps because majority of dental hygienists in Saudi practising in governmental sector with greater job security relative to the private sector. 27 According to a study conducted in Saudi Arabia, health workers showed an increased probability of becoming mildly to severely distressed due to COVID-19, based on health professionals' high exposure to the risk of contracting and spreading the disease. 27 The findings showed that being a health worker, a frontline health worker, a young person and a private sector employee were related to distress in Saudi Arabia. 27 These contributing factors may apply to participants in this study, explaining the reported stress level of dental hygienists in Saudi Arabia (65.3%), which is considerably higher than US dental hygienist (25.7%). 28 This difference could be due to the fact that this study was conducted early in the pandemic and before the emergence of vaccination. Concerning the level of treatment provided during May 2020, nationally and internationally, most dental hygienists were not pro- Before COVID-19, studies conducted among dental professionals in SA and the USA showed a low level of knowledge regrading standard PPE. 29 Although an increase in the level of knowledge among Saudi dental hygienists was observed post-COVID-19, the majority of participants felt that EBDM practice depends mostly on clinical experience and judgement. While information learned in dental hygiene school and past clinical experience plays a role in EBDM, scientific research using a hierarchy of evidence is a key element of EBDM in dental hygiene practice for more than 20 years. 35 The EBDM model was developed to ensure precise and up to date best practice treatment interventions and to answer real-time clinical questions and situations that arise, such as COVID-19. 36 Having the ability to navigate and critically appraise recent, relevant, and reliable scientific knowledge are required skills for dental hygienists. Preparedness can be influenced by a variety of factors. It is not always possible to demonstrate a complete preparedness in all aspects of practice, especially when dealing with an evolving pandemic. 37 Preparedness evaluation is essential to determine areas of weaknesses, which can then address by appropriate education, training and consolidation. 37 In the light of COVID-19, dental hygienists globally face a significant uncertainty regarding their safety of practice. This uncertainty may impact their confidence and preparedness to provide care. Few United States dental professionals felt fully prepared to reenter their dental practices after a three-month Since this is a cross-sectional study, only a single point in time was measured, which was the beginning of COVID-19 pandemic. Ongoing evaluation is needed to analyse change over time with different peaks and evolving guidelines. Self-reporting and voluntary participation may introduce bias. However, using online surveys was the ideal option during the pandemic. Therefore, this study's participants had to have access to Internet and specifically social media. When not available, the generalizability of study findings could be threatened. Using social media may have limited the opportunity to participate in this study affecting the sample size. The target group was employed dental hygienists, senior students and interns. During the pandemic, the total number of the target population was not available; hence, the response rate was calculated according to the most recent report of total number of dental hygienists in Saudi during 2017. This approach may have affected the response rate reported in this study. Dental hygienists are concerned globally about the safety of practice during the pandemic as they have a prolonged time of exposure to aerosols, frequent contact with others during a workday and practice in close proximity to patients. This study indicated that dental hygienists with high level of knowledge were significantly more prepared to treat patients during the pandemic; and that stress played a positive role in COVID-19 knowledge acquisition. Non-practising dental hygienists during quarantine were more knowledgeable and more prepared to practice during the pandemic. A scale measuring dental hygienists' COVID-19 preparedness and knowledge would be useful to evaluate the need for educational and clinical training. The COVID-19 training should be customized for dental hygiene professionals to ensure the optimum gain of knowledge and preparedness. Knowledge levels, preparedness and impacts of COVID-19 varied among dental hygienists in Saudi Arabia. Like their global counterparts, constantly changing information, practice inconsistencies and stress levels were influencers. Periodic knowledge evaluation is crucial due to rapidly evolving science as the study showed a significant relationship between knowledge and preparedness. Stress related to COVID-19 has positively influenced the knowledge acquisition, yet reported stress level among Saudi dental hygienists is a concern. Non-practising dental hygienists during quarantine were significantly more knowledgeable and prepared to provide care. As the first national assessment of dental hygiene professionals and COVID-19, this study establishes a baseline reference for dental hygiene practice in Saudi Arabia. This baseline will help decisionmakers create strategic plans to address dental hygiene practice amid the current pandemic and potential future outbreaks. The authors extend their appreciation to the Deanship of Scientific The data that support the findings of this study are available from the corresponding author upon reasonable request. Futun N. 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