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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 115-121

Assessment of mental health among dental professionals in North India during COVID-19 global pandemic: A web-based survey


1 Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi, India
2 Department of Public Health Dentistry, GIDSR, Ferozpur, Punjab, India

Date of Submission26-Jun-2020
Date of Decision06-Apr-2021
Date of Acceptance02-Jun-2021
Date of Web Publication2-Aug-2021

Correspondence Address:
Amit Khatri
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_132_20

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  Abstract 


Background: The COVID-19 pandemic has taken a toll on mental health status of all health-care workers. Among them, dentists are at high risk due to being in close contact, facing moral responsibilities to reduce routine work, and financial implications which follow. We performed a study to assess the mental health status of dental professionals all over North India in present times. Materials and Methods: A structured 27-item questionnaire developed on Google forms was circulated to dentists across North India. Patient Health Questionnaire-9 Scale was used to assess/grade depression, Generalized Anxiety Disorder-7 was used to screen/grade anxiety and worry/fear regarding other related aspects was studied. Results: One hundred and fifty-five responses were obtained, and data were analyzed using the SPSS software version 25.0. All participants belonged to the age range of 23–65 years with 78 males, 76 females, and 1 other. A majority of dentists (59.4%) were experiencing depression and considerable proportions (46.5%) were experiencing anxiety. Nearly all dentists (98.1%) were worried about changing dental practices and majority (72.9%) were fearful of doing aerosol procedure despite using protective equipment. The data were further analyzed for variation based on gender, qualification, years of experience, and job. Conclusion: In a pandemic, amidst burden of physical/financial needs, psychological needs are often overlooked. Currently, a considerable portion of dentists across North India are already experiencing mental health issues, there is a need to implement strategies to tackle the same.

Keywords: Anxiety, COVID-19, dentists, depression, mental health


How to cite this article:
Khatri A, Sabherwal P, Oberoi SS, Kalra N, Tyagi R, Yangdol P. Assessment of mental health among dental professionals in North India during COVID-19 global pandemic: A web-based survey. J Indian Assoc Public Health Dent 2021;19:115-21

How to cite this URL:
Khatri A, Sabherwal P, Oberoi SS, Kalra N, Tyagi R, Yangdol P. Assessment of mental health among dental professionals in North India during COVID-19 global pandemic: A web-based survey. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Nov 29];19:115-21. Available from: https://www.jiaphd.org/text.asp?2021/19/2/115/322856




  Introduction Top


The coronavirus derives its name from its microscopic “crown like structure” and causes a range of respiratory symptoms ranging from mild to severe resulting in respiratory failure.[1] The novel coronavirus disease officially designated as COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020.[2] Currently, COVID-19 has become a public health emergency of global concern. The responsiveness to this disease worldwide has been variable according to differing health-care systems, political ideologies, and economies.[3]

Literature reveals psychological impact in health professionals in infectious disease outbreaks of the past.[4],[5] The health-care workers facing the situation on the frontline who are directly or indirectly involved in the diagnosis, treatment, and care of patients during the present scenario are at risk of developing psychological stress and other related mental health conditions.[6]

Among health-care workers, dental professionals in particular, are exposed to a higher risk of getting infected due to close proximity with infected patients. Furthermore, dentists bear exposure to aerosol and droplets splashing out of patients' oral cavity.[7],[8]

Being on the list of high-risk professions, dentists are expected to develop severe anxiety during the current pandemic situation.[9] The American Dental Association has published the guidelines for emergency/urgent dental care to be performed in an organized manner with directives to defer routine dental work as per clinical judgment.[10] In compliance with such guidelines, many dentists have felt a moral duty to reduce routine dental care. Among dentists, there is a constant, looming anxiety of encountering COVID-19-infected patients. The reluctance and fear while treating patients for emergencies/urgencies still prevails. This, however, bears unavoidable financial burden and cumulates the mental stresses on dental professionals.[3] Various psychosocial factors such as health threats/harm to oneself and close ones are associated with pandemics which are also contributory to stresses mentioned above.[11]

The mental health issues pose to be major health concern among dentists are expected to increase with each passing day. There is a paucity of research that evaluated the mental health concerns among dentists during this pandemic. Therefore, the aim of the study was to assess the mental health condition of dental professionals across the various parts of North India (Uttar Pradesh, Uttarakhand, Punjab, Haryana, Himachal Pradesh, Rajasthan, Delhi NCR region, Jammu and Kashmir, Ladakh, and Chandigarh) using a web survey. The study objectives were to ascertain the prevailing anxiety, depression, and to evaluate the worry/fear regarding aspects such as future financial investments, paying capacity, doing aerosol procedures, and changing trends in dentistry in the following years.


  Materials and Methods Top


Ethical considerations and informed consent

The cross-sectional observational study was conducted during the period from May 7, 2020 to May 25, 2020. During the pandemic as the hospital became a designated COVID-19 facility, a dire need was understood to study the mental impact among dentists; therefore, the web-survey was carried out in compliance with the Helsinki Declaration, 2000. Furthermore, the study protocol was in accordance with the checklist for reporting result of internet E-surveys (CHERRIES) guidelines.[12] Informed consent was obtained from each participant before answering the survey questions. All participants were requested to confirm their willingness to participate by choosing from dichotomous options (Yes/No) ensuring voluntary participation. Confidentiality for all study participants was maintained.

Study participants and sample size calculation

The study participants consisted of the dentists registered with directory of the Indian dental association. From this, the dentists were chosen randomly using the simple random sampling technique. The sample size was calculated using the manual method.[13] The power of the study was taken to be 80% and confidence interval (CI) of 95% was taken. The sample size calculation was done as per the pilot study on 30 participants which revealed an estimated prevalence of 59.0% having experienced depression.

N = (Z2 × p × [1−p]/d2)

Where, p: expected prevalence; d: absolute precision required on either side of prevalence (10%); Z: 1.96;

N = 93; the minimum sample size required came out to be 96.

Questionnaire characteristics

The online self-reported questionnaire was developed using Google forms which comprised of 27 item structured into four sections. The first section included demographic details such as age, gender, region, mode of income, job sector, and their years of experience after graduation.

In the second section, Patient Health Questionnaire (PHQ-9) originally developed by Dr. Spitzer et al., 1999 at Columbia University was administered for screening/measuring severity of depression. PHQ-9 has sound psychometric property due to satisfactory reliability and validity as a tool for depression (sensitivity, specificity = 88%).[14],[15] The PHQ-9 is a 9-item questionnaire [Figure 1]a with response options as follows: 0 means “not at all,” 1 means “several days,” 2 means “more than half the days” and 3 means “nearly every day.”
Figure 1: (a) Patient Health Questionnaire-9 with scoring criteria; (b) Generalized Anxiety Disorder-7 questionnaire with scoring criteria

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The third section focused on screening/measuring anxiety using Generalized Anxiety Disorder (GAD-7) questionnaire which is a 7-item, self-rated scale developed by Spitzer et al., 2006 with good internal consistency, validity and sensitivity.[16] [Figure 1]b The response options were as follows: 0 means “not at all,” 1 means “several days,” 2 means “more than half the days,” and 3 means “nearly every day.” In pretested pilot questionnaire, internal reliability of the PHQ-9 and GAD-7 questionnaires was graded as good, with a Cronbach's alpha of 0.82 and 0.84, respectively. The face validity of the questionnaires was evaluated by experts in the Department of Psychiatry and found to be satisfactory.

The fourth section was directed toward assessing the worry/fear among dentists regarding various aspects such as future financial investments, paying capacity, doing aerosol procedures, and changing future practices of dentistry with the current pandemic. The online questionnaire was circulated through social media platforms and E-mail to various dental health professionals.

Statistical analysis

Descriptive statistics were performed by calculating mean and standard deviation for the continuous variables. The software used for the statistical analysis was SPSS (Statistical Package for Social Sciences, SPSS version 25.0 IBM INC., USA). The statistical test used was the Chi-square test is used to investigate whether distributions of categorical variables differ from one another. The P value was taken significant when < 0.05 (P < 0.05) and CI of 95% was taken.


  Results Top


Demographic details

Taking a response rate of about 30.0% and sample size of 96, the questionnaire was sent to 310 participants, of which 155 responses were gathered. All the participants were of Indian origin with age distribution range between 23 and 65 years with 76 females, 78 male and 1 other gender respondents. The summary of demographic characteristics such as age, gender, qualification, years of experience, and setting of work place is depicted in [Table 1].
Table 1: Demographic characteristics of the study sample

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Depression and anxiety assessment

[Table 2] presents the overall variation in depression and anxiety among all dental professionals. As per the PHQ-9 questionnaire, majority of the dental professionals, i.e., 40.6% showed no depression, 38.7% showed mild depression, whereas 3.2% showed severe depression. As per the GAD scale, 53.5% did not have any anxiety, 30.3% had mild anxiety, and severe anxiety was noted in 6.5% dentists. No gender-based discrepancy in the grades of anxiety and depression was observed.
Table 2: Overall variation in depression and anxiety among the dental health professionals assessed using the patient health questionnaire-9 scoring criteria and Generalized Anxiety Disorder-7 scoring criteria

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The variation in depression as well as anxiety was evaluated among undergraduate and postgraduate subjects using the Chi-square test. Moderate and severe PHQ-9 scores were significantly more among undergraduates as compared to postgraduate participants (P < 0.05*). The same was found true for anxiety wherein moderate and severe GAD-7 scores were recorded more frequently among undergraduate participants (P < 0.05*). More experienced participating dentists with 5–10 years of experience postgraduation revealed higher prevalence of moderate, moderately severe, and severe PHQ-9 scores (P < 0.05*). In contrast, the anxiety did not show any significant differences among dentists with varying experience or job sectors [Table 3].
Table 3: Distribution of subjects as per qualification (undergraduate/postgraduate) with variation in the grade of depression using patient health questionnaire-9, variation in the anxiety using generalized anxiety disorder-7 and worry about payment of salaries/rentals/other expenses

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Additional worry-attributing factors

The worry among dentists was exacerbated and related to cumulative effect of various factors with 52.9% dentists being worried regarding future financial investments and 29% were worried about payment of rentals and salary to their staff. The worry in doing aerosol-related procedures despite wearing personal protective equipment was noted to be high with 72.9% dental professionals. A vast majority, i.e., 98.1% of the dentists felt that the future practises of dentistry will change in the years to follow [Figure 2]. No statistically significant variation in the pattern of worry was noted between male and female respondents.
Figure 2: Representation of worry/fear due to other aspects among dental health professionals, namely future financial investments, paying capacity, doing aerosol procedures, and changing dental practices in future

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Worrying about paying staff salaries/rentals/other expenses was significantly more among postgraduate subjects compared to undergraduate subjects (P < 0.05*). The same showed a highly significant increase among the dentists who had more experience (5–10 years and > 10 years) (P < 0.001*) using the Chi-square test. The experienced dentists showed more worry on paying capacity in contrast to the lesser experienced dentists [Table 4].
Table 4: Distribution of dentists based on years of experience after graduation and the variation in grade of depression using patient health questionnaire-9 and Worry about payment of salaries/rentals/other expenses

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The dentists employed in the private sector were found to be significantly (P < 0.001*) more worried regarding paying capacity compared to those employed in the government sector [Table 5].
Table 5: Distribution of dental professionals as per job sector (government/private) and its impact on concern regarding paying capacity

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  Discussion Top


Literature demonstrates that health-care workers under the present scenario are experiencing variable degree of anxiety, stress, depression, insomnia due to the COVID-19 pandemic.[17] The COVID-19 pandemic has had a profound impact on mental health due to speculation/uncertainty about its mode of transmission, rapidity of its spread, and lack of definitive cure or treatment protocols or successful vaccine.[18]

Dental professionals globally have modified their practises for emergency management only or closed down altogether.[10] The fear/anxiety is expected to hit dentists hard due to being at high risk which bears emotional and financial burden.[19]

The present study, therefore, attempted to study the impact of the COVID-19 pandemic on the mental health of dental professionals all over North India. A majority of dentists (59.4%) were found to be experiencing depression. Among them, mild depression was most common (38.7%) and others ranged from moderate to severe varieties. This is similar to study done by Lai et al., 2020 in Wuhan, China where a considerable proportion, i.e., 50.4% of the health-care workers were found to have depression as measured using the PHQ-9.[6] Similarly, Lai et al., 2020 found anxiety to prevail among 44.6% health-care workers in Wuhan.[6]

The effect of multiple factors cumulates increasing the burden of fear/worry in the mind of dentists. Nearly all dentists (98.1%) were worried about changing dental practises in future; a vast majority (72.9%) were also worried about doing aerosol procedures despite using personal protective measures. This is on lines of study by Ahmed et al., 2020 where more than 2/3rd of the dentists world-over were found to be anxious/fearful while working during the current scenario.[19]

The pattern of worry/anxiety/depression showed no gender-based variation. Based on qualification, it was found that moderate and severe scores of anxiety and depression were more common among undergraduate as compared to postgraduate dental professionals. Similarly, larger percentage of dentists between 0–5 years and 5–10 years of experience showed scores of moderate and above on the PHQ-9. This may be logically attributed to decreased job security among them. As per a recent study by Al-Amad and Hussein, 2021,[20] moderate-to-severe anxiety was prevalent among one-third dentists and found to be higher among younger age group. This may be due to more social media usage and in-turn additional information procurement about COVID-19. However, further well-planned trials will enable an enhanced understanding of the association and possible anxiety aggravating factors.

The worry regarding paying salaries and rentals was more among postgraduates (P < 0.001*). Similarly, worry regarding paying capacity was more in dentists having 5–10 years or > 10 years of experience in practice including both undergraduates and post-graduates. Dentists working in the private sector also demonstrated significantly high worry regarding paying output. We attributed the above-mentioned findings to the fact that postgraduates and experienced dentists (irrespective of their level of qualification) may have more dependent personnel, staff or larger costs of maintenance of dental practises. Similarly, in literature, other costs which may lead to financial stagnation despite multiple years of practise include decreased access to care during COVID-19, increased closures of many practises, additional time and expenditure on infection prevention and control measures and reduced paying capacity of the service-consumers, i.e., patients.[3],[21] Future studies may validate these findings in the Indian scenario. Thus, a domino effect sets in wherein the demand for elective dental care is reduced thereby leading to financial concerns among dental practitioners.

During pandemics, it is only natural for the concerned authorities to focus on meeting the physical, biological, and financial needs of the people, the psychological needs are often unmet.[17] A four-pronged approach was suggested in China comprising of a psychosocial response team, psychological intervention technical support team, psychological intervention medical team, and psychological assistance hotline teams.[17] Similar suggestion was put forth by Rana et al., 2020.[22]

The strengths of the present study include the use of standardized psychometric tools for measurement of anxiety and depression and a multidisciplinary approach wherein a trained hypnotherapist was among the team of investigators for assessing mental health among dental professionals. The inclusion of additional worry attributing factors which are common day to day problems but less frequently addressed opens doors to future research arenas. Amidst the pandemic, responses were obtained using a web-based survey, thus self-selection and under-coverage may be responsible for bias in the present study.

Future research direction and recommendations

Future studies to ascertain the mental impact of COVID-19 may be done using a more systematic approach with the aid of respective State Dental Councils. We therefore suggest a dire need to address the psychological impact on all healthcare workers particularly dental health professionals and requirement of future nation-wide strategies to tackle the same. We therefore advocate the need to plan and implement nation-wide strategies such as tele-counselling, online yoga or group relaxation as part and parcel of daily routine to manage mental health optimally. In the era of increased use of social media, the use of mobile or computer-aided easy to use relaxation learning programs may be beneficial.

A need was realized for a more detailed understanding of the inter-play of factors which influences anxiety, depression and worry among different sub-groups (based on qualification, experience and job sector) of dental surgeons. This will enable us to better understand the sub-groups of dentists who may be more risk-prone to the mental handicap of the pandemic in India. This understanding will enable us to more effectively address the high-risk groups while administering a stress-busting program for dentists across the country.


  Conclusion Top


The impact of the COVID-19 pandemic on mental health of all health-care professionals is profound. It has been over a year since India's battle with the pandemic began and significant numbers of dental health professionals all over North India are already showing significant anxiety and depression alongside worry/fear on paying capacity and changing practises.

Acknowledgment

We would like to thank Mr. Rahul Dhaneja for formatting the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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