key: cord-0916639-pb2soayk
authors: Srivastava, Kumar Chandan; Shrivastava, Deepti; Sghaireen, Mohammed Ghazi; Alsharari, Abdalkarem Fedgash; Alduraywish, Abdulrahman Abdulwahab; Al-Johani, Khalid; Alam, Mohammad Khursheed; Khader, Yousef; Alzarea, Bader Kureyem
title: Knowledge, attitudes and practices regarding COVID-19 among dental health care professionals: a cross-sectional study in Saudi Arabia
date: 2020-12-13
journal: J Int Med Res
DOI: 10.1177/0300060520977593
sha: b79d18b4385bc565e37f2930d9d26eaedcba56a5
doc_id: 916639
cord_uid: pb2soayk

OBJECTIVES: With the increasing severity of the coronavirus disease (COVID-19) pandemic, it is essential that dental health care professionals (DHCPs) are prepared. The study aim was to assess the knowledge, attitudes and practices (KAP) regarding COVID-19 among DHCPs in Saudi Arabia. METHODS: A cross-sectional study using a web-based survey was conducted. A validated and reliable questionnaire was developed that comprised 44 questions. Using Qualtrics survey software, DHCPs working in different settings were approached across five geographical regions of Saudi Arabia. RESULTS: A total of 318 respondents voluntarily participated in the survey. Most DHCPs showed a moderate level of knowledge (51.6%), a positive attitude (92.1%) and adequate practice standards (86.5%). We found that 94.7% of DHCPs had an adequate overall level of KAP. DHCPs with a doctorate significantly outscored DHCPs with other educational levels with respect to knowledge and practice. Older (51–60 years) DHCPs reported significantly more knowledge than younger DHCPs. CONCLUSION: DHCPs displayed an average level of knowledge that needs to be enhanced through continuing education programmes. However, they showed a positive attitude and an acceptable level of practice, as they were abiding by guidelines issued from various international and national health agencies.

In the last few decades, there have been several global viral epidemics. Recently, coronavirus disease (COVID-19) has become a viral pandemic. In December 2019, people in Wuhan, in China's Hubei Province, reported many linked cases of unexplained pneumonia-like symptoms. 1 The etiological agent of this pneumonia was later discovered to be a virus, and was named 2019-nCoV. 2 This virus belongs to the same family of b-coronaviruses that caused the severe acute respiratory syndrome (SARS) outbreak in 2003 and the Middle East respiratory syndrome (MERS) outbreak in 2012. 3, 4 To date, six human coronaviruses have been identified. The International Committee on Taxonomy of Viruses has named the latest virus SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2). The disease caused by this virus was named COVID-19 in February 2020 by the World Health Organization (WHO). 1 Owing to the contagious nature of COVID-19, it has spread widely across the world. In January 2020, the National Health Commission of China categorized COVID-19 as a Group B infectious disease (along with influenza and SARS). Despite this categorization, health care workers (HCWs) were instructed to follow the same infection control and prevention protocols as for Group A diseases such as chlorella and plague. 2, 5 The WHO later declared COVID-19 to be a public health emergency of international concern. 1 The Kingdom of Saudi Arabia (KSA) reported its first case of COVID-19 on 2

March 2020. The number of infections increased until June, when a nationwide lockdown was imposed. From June 21, the country started reopening in sequential phases as the recovery rate increased. 6 However, the risk from asymptomatic cases cannot be ruled out. Additionally, the highly contagious nature and rapidly mutating viral genome that characterizes COVID-19 are of great concern for society generally and for HCWs. 7 It is therefore essential that the authorities, HCWs and the public are aware of the nature of the disease and ways to prevent its spread.

HCWs are the frontline workers in any pandemic. Along with elderly people and individuals with comorbidities such as cardiovascular disease, respiratory disease, diabetes and cancer, HCWs are at an increased risk of acquiring COVID-19. 8, 9 Dental health care professionals (DHCPs) are no exception 10, 11 As dental treatment requires close proximity to patients, DHCPs are constantly exposed to infectious oral fluids, which can play a pivotal role in the dissemination of infection. 8 Furthermore, DHCPs experience fear and psychological stress because of considerable work overload and low self-efficacy. 12, 13 Thus, it is important that DHCPs are kept abreast of the latest guidelines and recommendations to effectively treat patients and simultaneously protect themselves from disease. To address these issues, studies on DHCPs of different nationalities [14] [15] [16] [17] [18] [19] [20] have been carried out to assess their knowledge, attitudes and practices (KAP) regarding COVID-19. To the best of our knowledge, there are no studies assessing practice standards of DHCPs across KSA, although Khan et al. 20 assessed practice standards in the dental faculties of a single government university. Another study by Quadri et al. 19 assessed COVID-19 awareness levels across the nation. Along with international agencies such as the WHO and the Centers for Disease Control and Prevention (CDC), the KSA Ministry of Health (MOH) issued guidelines for conducting various dental procedures in the categories of emergent, urgent and regular dental care. [21] [22] [23] It is imperative that DHCPs strictly adhere to the guidelines to mitigate the spread of COVID-19. Thus, the primary aim of this study was to evaluate and compare the KAP regarding COVID-19 of DHCPs working in different health care sectors in various regions of KSA.

Given the objectives, a nationwide observational study was planned and a hospital/ institutional-based cross-sectional study design developed. Ethical approval (14- 

This survey was carried out to assess KAP regarding COVID-19 among DHCPs in KSA. The study excluded medical professionals (e.g. physicians, surgeons, auxiliaries and allied HCWs). Students enrolled in any health care-related course, and health care professionals not licensed to work/practice in KSA were also excluded.

To obtain a representative sample from the heterogeneous study population of DHCPs, a multistage sampling technique was used. In the first stage of sampling, based on geographical boundaries, the entire population of DHCPs in KSA was divided into five clusters (north, east, west, central, and south). Using a simple random method, one academic and non-academic centre each was subsequently selected from each geographical cluster. Thus, a total of 400 DHCPs from 10 randomly selected clusters were approached via WhatsApp groups.

A questionnaire was used to assess different aspects of COVID-19-related KAP among DHCPs. An expert committee was formed that comprised members from various disciplines, including dental public health, respiratory medicine, oral medicine and biostatistics, and several translators with expertise in both English and Arabic. The committee developed the questionnaire based on the available guidelines and information about COVID-19. 5, 14, 25, 26 As a large portion of the study population comprises Arabic speakers, forward and backward translation of the questionnaire was conducted by two independent groups of bilingual translators. Construct and content validity was assessed and suggestions were incorporated into the final version of the questionnaire. Reliability was assessed by distributing the questionnaire to 20 subjects at an interval of 1 week. The reliability coefficient was 0.85, which indicates an acceptable level of consistency. The questionnaire comprised 44 closed questions with 15, 14 and 15 questions, respectively, on knowledge, attitudes and practices. The knowledge and practice domain response options were 'yes', 'no' and 'I don't know'. For the attitude domain, a 5-point Likert scale was used.

The questionnaire was developed using Qualtrics survey software and circulated via an electronic portal. The first part of the questionnaire informed participants about the study and explained that participation was voluntary. The identity of participants who filled in the questionnaire was kept anonymous.

The responses to the three KAP domains were collated and entered into a Microsoft Excel spreadsheet. Prior to the analysis, all correct item responses were given a value of 1 and inappropriate/incorrect responses received 0. These values were summed to produce an outcome total score for every respondent. In addition, individual scores on each KAP domain were combined to obtain an overall score. Following Alduraywish et al. (2020) , 27 cutoff values were created to code each KAP domain score and the overall score using an ordinal scale with three categories. Correspondingly, the knowledge and practice scores were categorized as 'adequate' (11) (12) (13) (14) (15) , 'average' (6) (7) (8) (9) (10) and 'inadequate' (0-5). For the attitude domain, the categories were 'positive' (52-70), 'neutral' (33-51) and 'negative' (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) . Similarly, the overall KAP score was categorized as 'adequate' (72-100), 'average' and 'inadequate' .

Data are presented as numbers and percentages. Inferential analysis was carried out using the chi-square test and 95% confidence interval. Significant associations were subjected to Spearman's correlation and ordinal logistic regression. All analysis was carried out using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY, USA). Results were considered significant at P < 0.05.

A total of 318 DHCPs responded with completed questionnaires, a response rate of 79.5%.

The sample comprised mainly young (20-30 years; 44.3%) male (66%) professionals. Although, this was a nationwide survey, most (44.7%) of the responses were from the northern region of KSA and the fewest from the eastern region. Regarding educational background, most respondents (55.7%) had a bachelor's degree with work experience of 1 to 3 years (45%). In terms of work setting, more than half (62.6%) of the DHCPs were employed in the government sector, and 38.1% worked in academic-based institutions ( Table 1 ). The MOH website was the most popular source of information (79.2%), compared with the other available options of professional colleagues (16.4%), social media (56.9%) and specialty journals (24.2%) ( Table 1) .

We found that 94.7% of DHCPs had an adequate overall level of KAP. Most (51.6%) respondents had an average level of knowledge; only 2.2% had inadequate knowledge. Most respondents provided correct answers, except to the questions on the WHO guidelines for hand hygiene (correct response: 7.9%). DHCPs showed adequate knowledge of the COVID-19 incubation period (95.3% correct responses) and symptoms (97.5%) ( Table 2) . A significant positive correlation (r ¼ 0.131; P ¼ 0.020) was observed between the total knowledge score and age. Respondents aged 51 to 60 years were more likely to have adequate knowledge than their younger counterparts (Table 3) . A positive correlation (r ¼ 0.207; P < 0.001) was also observed between knowledge and educational level. DHCPs holding a diploma degree were the least likely to have an adequate level of knowledge compared with DHCPs with a doctorate ( Table 3) .

Most (92.1%) DHCPs had a positive work attitude; only 1.3% had a negative attitude. Correct responses to infection control protocol questions ranged from 33.6% to 87.2%. Respondents showed the best attitude toward one set of particular infection control scenarios, which asked about the importance of personal protective equipment (PPE) (correct response 84.9%) in general and when transferring patients (87.2%). In contrast, most respondents replied incorrectly (5% correct response) to a question about the importance of the N95 mask (Table 4 ). A total of 71.1% of DHCPs did not agree with the statement that standard precautions should be followed, especially during an outbreak ( Table 4 ).

Adequate standards of practice were reported by a large number (86.5%) of respondents, with only 0.6% having inadequate standards. Practice aspects related to awareness of infection (98.4%), associated risk factors (96.9%), infectious nature of patients (97.8%) and the procedures to be followed during COVID-19 infection (96.5%) showed extremely good standards (Table 5) . However, 36.5% of respondents answered incorrectly that PPEs should be used only during an outbreak. Total practice scores were significantly (P ¼ 0.001) associated with educational level (Table 1) ; however, there was no significant correlation between total KAP scores and educational level.

Cases of COVID-19 in KSA are increasing daily. COVID-19 is a rapidly spreading and contagious disease that has surpassed SARS and MERS in mortality and rate of transmission. 6,28 A game changer that could 

We found that most DHCPs depended on the KSA MOH website to obtain information, which reflects the positive role of the Saudi government in addressing the current situation. This could be attributed to KSA having experienced the MERS epidemic in 2013. 25, 29 Hence, the Saudi government's understanding of the disease and preparedness may have played a pivotal role in the prevention of disease transmission. Similarly, previous KSA-based studies of DHCWs, 19 dental faculty 20 and HCWs 27 have also praised the efforts and role of the Saudi Arabian government in timely dissemination of information. Contrary to the present findings, some studies indicate that more COVID-19-related information is obtained from physician websites or social media. 17 However, instant access of information through social networking sites in this digital era is a double-edged sword; the rapid propagation of misinformation through social media can mislead both the public and HCWs. 30 Because of this, the KSA MOH has issued advisory information warning DHCPs about the propagation of fake news and advising them to focus on reliable sources. 20 The DHCPs were well aware that COVID-19 can be transmitted by an infected person, and through respiratory droplets or contact. Our results were comparable with those of other studies. 14, 16 As per the WHO, CDC and MOH guidelines, respiratory and cough etiquette should be followed to prevent the transmission of the disease. 5, [31] [32] [33] [34] Regarding the COVID-19 incubation period and symptoms, DHCPs showed good knowledge (95.3% and 97.5%, respectively). The COVID-19 incubation period ranges from 2 to 14 days, with an average of 5 to 6 days. 5, 35 During this period, the disease is infectious and the patient will show initial symptoms of fever, dry cough and shortness of breath. As the disease progresses, symptoms such as fatigue, diarrhoea and pneumonia may develop. 36 Recent reports have identified loss of taste and smell as additional symptoms of HCWs are a potential source of disease transmission from patients to themselves and subsequently to their friends and family, 17 and may experience stress and fear of transmitting the disease. DHCP awareness of the initial symptoms may play a pivotal role in mitigating the disease. In our study, DHCPs showed adequate knowledge of the initial symptoms of the disease and the knowledge level was much higher than reported in previous studies. 14 This may be because DHCPs actively obtained timely information from the MOH website.

When DHCPs were asked about the stipulated duration of hand hygiene (with soap and water), 89.6% gave incorrect responses. As mentioned in the WHO guidelines, hand hygiene should be maintained either by washing hands with soap and water for at least 40 s (20 s is sufficient if alcohol-based hand rub is used). 26 This shows a lacuna in DHCPs' knowledge of the duration of hand hygiene protocol, which needs to be emphasized. However, during the SARS and MERS epidemics, the WHO recommended washing visibly soiled hands with soap and water for 20 s, followed by the use of an alcohol-based hand rub technique. 37 Regarding COVID-19 treatment, most participants responded that antibiotics are not the first-line treatment. Similar responses were reported in a few previous studies. 15, 16 Although various drugs for COVID-19 are being tested, none have been approved as first-line treatment. Hence, the current treatment modality is supportive rather than imperative. 4 DHCPs were well aware that a COVID-19 vaccine remains to be developed. To date, no vaccines are available on the market, although many countries are engaged in the development of vaccines and multiple trials are in various phases.

In this study, age and educational level were significant influencing factors for the knowledge domain. Older DHCPs and those with doctorates had adequate knowledge compared with their counterparts. These findings support the widespread assumption that greater age and years of experience lead practitioners to adopt a rational and evidence-based approach to tackle any situation. 27 These practitioners are more likely to keep up-to-date with current knowledge, which was probably reflected in our observations. These findings suggest that substantial measures are needed to increase the level of knowledge among young DHCPs. Implementation of mandatory continuing education programmes, with verifiable points in key areas such as infection control, is highly recommended. To foster a positive approach toward infection control protocols, such topics should be incorporated into dental education curricula.

DHCPs strongly agreed that they should obtain and disseminate up-to-date information about COVID-19. As the disease progresses, the rate of change in relevant information and guidelines has increased. Therefore, it is a positive sign that DHCPs are showing a keen interest in acquiring knowledge. Contrary to this finding, some studies have found that DHCPs' attendance of continuing professional development programmes is lower than expected. 17 Although continuing education programmes about COVID-19 could increase anxiety in DHCPs, they could also inform and motivate them to fight the pandemic in a rational way. Many DHCPs responded correctly to the question about patient referral. As COVID-19 is rapidly and easily transmitted, it is important that DHCPs can immediately recognize its symptoms and refer patients to medical experts for management. DHCPs showed an appropriate attitude toward the importance of restrictions in travel, general movement and large mass gatherings. These norms have been well explicated in advisories and guidelines issued by the WHO 1,31 and MOH. 33, 34 Correct responses to questions about the infection control protocol ranged from 33.6% to 87.2%. The use of an N95 respirator by an undiagnosed patient is currently emphasized. Some reports have pointed out that dentists face a shortage of PPE, including masks. 14, 17 The CDC and WHO have recommended the use of surgical masks for undiagnosed patients; however, the N95 respirator should be worn by HCWs. The appropriate use of such devices could reduce the shortage of PPE and ensure that HCWs are protected; this in turn would help the community to obtain better treatment. 32, 38 In the present survey, 71.1% of DHCPs had negative attitudes to the assertion that standard precautions should be followed, especially during an outbreak. However, CDC guidelines recommend that all patients, at all times, should be considered potentially infectious and standard precautions should be practiced. 5, 26 The rationale for such a practice is based on the fact that COVID-19 can be transmitted during the recovery phase or carrier state, even if the patient shows no obvious symptoms or signs. Consequently, in these phases, both HCWs and patients have a risk of transmitting the disease to each other. [39] [40] [41] DHCPs' practice standards during COVID-19

As per recent recommendations, 5 a screening triage should be established to obtain information related to symptoms, medical history, travel history and close contact with suspected cases of COVID-19. 42 Despite a screening protocol, a recent travel history may place a patient in the high-risk category. Kamate et al. 16 found that 92.6% of DHCPs record travel history as a screening protocol to aid in the diagnosis and prevention of disease transmission. Telephone triage has also been recommended to avoid unnecessary travelling and to prioritize cases. 42 Our respondents scored well on questions related to the referral protocol, identification of risk factors and screening protocol, indicating that they practiced the above-mentioned guidelines.

DHCPs scored well when questioned about infection control protocols to be followed during COVID-19 outbreaks. To a negatively worded question regarding the use of PPE, 36.5% of respondents answered incorrectly by agreeing to the statement that PPEs should be used only during an outbreak. However, they performed well on questions about the indications of PPEs in aerosol-generating clinical procedures. These conflicting responses may reflect the effect of negatively worded questions. Few studies have reported a consensus of proper PPE usage among dentists. 14, 15 As per the CDC guidelines on infection control protocols, universal precautions should be taken at all times irrespective of the pandemic or epidemic status. The highly contagious nature of COVID-19 warrants proper infection control protocols. The use of PPE, including N95 or FFP2/FFP3 masks, gloves, gowns, protective glasses, visors and headgear caps, is of the utmost importance during any dental procedures. 20, 43 DHCPs demonstrated good practice management regarding clinical procedures. They agreed that during the COVID-19 pandemic, rubber dams, four-handed dentistry and saliva ejectors should be used along with minimal aerosol-producing procedures. 44 The presence of saliva in the oral cavity is a potential source of infection 10,28 that can be exacerbated by various aerosolgenerating procedures. Thus, wearing goggles and shields can prevent the virus from coming into contact with the conjunctiva epithelium. 42, 44 Therefore, DHCPs should focus on procedures that produce fewer aerosols, 5,10,45 which could help to reduce disease transmission. This is in consensus with the guidelines of the CDC, the WHO and various dental societies. DHCPs had a good level of awareness of the WHO guidelines posted on 21 March, which state that treatment should be provided only for emergency cases and treatment of nonemergency cases should be postponed. 31 Similar responses have been noted in other studies showing that only emergency dental care is being provided to patients, and procedures that can reduce aerosol production and salivary contamination are prioritized. 14, 15 Limitations and future prospects

The study was conducted during the period when the spread of COVID-19 was accelerating, and when DHCPs were stressed and acclimatizing to disruptions in their social, economic and professional life. Owing to the lockdown across KSA, the only feasible option for data collection was a web-based survey. For these reasons, the response rate was relatively low and the chances of response bias cannot be completely ruled out.

The current study assessed the present state of COVID-19-related KAP among DHCPs. Future studies should be conducted at intervals using quasiexperimental designs to provide a comparative analysis. This would also help to evaluate the effect of continuing education programmes during the pandemic phase. The results of such future studies could help in planning and developing supportive policies and programmes.

The successful management of any pandemic requires adequate knowledge, a positive attitude and evidence-based practice protocols. Although no variation in KAP was observed between the five geographical regions of KSA, DHCPs' levels of attitudes and practice standards were higher than their knowledge. Therefore, efforts should be made to enhance the knowledge of DHCPs across the nation, particularly younger professionals. This could be achieved through the collaborative efforts of global health agencies and government. Indeed, the effect of such efforts is apparent in KSA, where the MOH has played a significant role in enhancing the KAP of DHCPs. 

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The authors declare that there is no conflict of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Yousef Khader https://orcid.org/0000-0002-7830-6857