Knowledge, Attitude, and Practice of Dental Healthcare Providers regarding SARS-CoV-2 and COVID-19 Vaccination, and their Level of FearABSTRACT
Objective: To assess the knowledge, attitude, and practice (KAP) of dental healthcare providers (DHCPs) in Guilan Province of Iran regarding COVID-19 and vaccination, and their level of fear before and after vaccination.
Material and Methods: A questionnaire was designed, uploaded to Porsline, and administered to 617 DHCPs in Guilan Province via social media in 2022. The questionnaire included a demographic section, as well as questions to assess KAP regarding COVID-19 and vaccination, and the level of fear of COVID-19 before and after vaccination. Data were analyzed by independent t-test, ANOVA with Tukey's test (for pairwise comparisons), Kruskal-Wallis test with Mann-Whitney U test and Bonferroni adjustment (for pairwise comparisons), and Spearman’s correlation test (α=0.05).
Results: A total of 345 DHCPs (55.9%) responded to the questionnaire, out of which 330 met the eligibility criteria. The mean scores of KAP regarding SARS-CoV-2 were 13.53±1.43 for knowledge, 3.91±0.98 for attitude, and 3.94±0.98 for the practice domain. The mean knowledge score about COVID-19 vaccination was 8.10±2.58. A significant reduction in fear of COVID-19 was observed after vaccination (p < 0.001). No correlation was found between KAP regarding SARS-CoV-2 and fear of COVID-19 before vaccination (p > 0.05).
Conclusion: DHCPs in Guilan Province had a high level of KAP regarding SARS-CoV-2 and vaccination, and vaccination significantly decreased their fear of COVID-19.
Keywords:
Dentists; Coronavirus; Vaccination
Introduction
Coronavirus disease 2019 (COVID-19) became a pandemic after its widespread global dissemination in March 2020 [1]. The first case of COVID-19 in the Middle East was reported in Iran [2]. The main symptoms of COVID-19 include fever, fatigue, and cough [3]. Since this virus can be transmitted through aerosols, surface particles, hand contact, saliva, nasal discharge, and close contact with an infected patient [4], dental healthcare is associated with a high risk of COVID-19 transmission [5]. Therefore, dental healthcare providers (DHCPs), including dental clinicians, dental technicians, and assistants, must adhere to the recommended preventive protocols to control the prevalence of COVID-19 [5]. Knowledge, attitude, and practice (KAP) are key to the successful implementation of preventive measures and controlling COVID-19 [6].
In addition to preventive measures, safe and efficient vaccination is the most effective strategy to control COVID-19 and its effects [7]. Although several COVID-19 vaccines have shown optimal efficacy [8], concerns regarding their side effects, the rapid development process, a misperception of herd immunity, and conspiracy theories about the artificial creation of the virus for population control purposes have raised concerns about the necessity of vaccination [9]. Thus, wrong information and inadequate knowledge can adversely affect the acceptance of COVID-19 vaccines [9]. Moreover, attitude is a significant factor influencing the tendency to undergo vaccination [10]. Since healthcare workers, particularly DHCPs, are among the first to receive vaccines, their attitude towards vaccination can affect the public vaccination rate through their recommendations to their family and friends [11]. Assessment of KAP regarding vaccination can help identify the influential factors contributing to existing concerns about vaccination [12].
Some people experience fear during pandemics [13]. Fear is a psychological and physiological phenomenon related to knowledge and attitude [14]. Fear can create a stigma and decrease the capacity of individuals to confront disease [15]. Knowledge about the level of fear in different groups within a society can aid in the design and implementation of educational and preventive programs [16]. A meta-analysis reported a high level of fear among dental clinicians regarding COVID-19, and suggested enhancing their knowledge, providing personal protective equipment, and administering extensive vaccination to improve this status [17]. Thus, the sources of anxiety and fear of dental clinicians should be identified to be able to support them [18].
Assessment of KAP in a specific population is an effective tool for evaluating their health behaviors and can provide information about the knowledge, attitudes, and practices of the respective population [19]. Several studies have assessed the attitudes, perceptions, knowledge, and practices of dental clinicians in different countries regarding the novel coronavirus [20-23]. Nonetheless, despite the high number of COVID-19 patients in Iran and the high risk of COVID-19 in DHCPs [24], their KAP regarding the SARS-CoV-2 and COVID-19 vaccination has not been previously investigated. Assessment of the fear of DHCPs from COVID-19 in different countries and populations has also been recommended [25,26]. Nonetheless, studies on the fear of DHCPs regarding COVID-19 in Iran are limited [24,27]. Moreover, although vaccination is effective in improving the psychological status and decreasing the anxiety level of dental clinicians [28], the effect of COVID-19 vaccination on the level of fear of DHCPs has not been previously studied.
The Guilan Province is among the first provinces in Iran to be hit by COVID-19 [29]. Thus, the present study aimed to assess the KAP of DHCPs practicing in Guilan Province regarding SARS-CoV-2 and COVID-19 vaccination, as well as their fear of COVID-19 before and after vaccination. The null hypotheses of the study were as follows: (I) KAP regarding SARS-CoV-2 would have no significant correlation with fear of COVID-19 before vaccination; (II) demographic factors would have no significant correlation with KAP regarding the SARS-CoV-2, knowledge about COVID-19 vaccination, and fear of COVID-19 before and after vaccination; (III) no significant difference would be found in fear of COVID-19 before and after vaccination.
Material and Methods
Study Design and Ethical Clearance
This cross-sectional study was conducted among DHCPs practicing in Guilan Province, Iran. The identity of the participants remained confidential throughout the study, and the study protocol was approved by the Ethics Committee of Guilan University of Medical Sciences (IR.GUMS.REC.1400.022).
Participants
The inclusion criteria were a minimum age of 18 years, willingness to participate in the study, work experience of at least 6 months, an educational level of more than a high school diploma, and a job related to the dental healthcare profession during the COVID-19 pandemic between 2021 and 2022. Participants with psychological disorders or neurological diseases, retired individuals, and those with incomplete questionnaires were excluded.
The minimum sample size was calculated to be 324 using the sample size calculation formula for a single population for the knowledge variable, based on a previous study [5], with the following assumptions: a standard deviation of 2.5, alpha = 0.05, and d = 0.50. The link to the questionnaire was sent to 617 DHCPs, out of which 345 responded and completed the questionnaire.
Data Collection
To observe social distancing during the COVID-19 pandemic, data were collected using an online questionnaire. The questionnaire link was created in Porsline, an online system for questionnaires (similar to SurveyMonkey). It was shared with the participants through social media such as Telegram, WhatsApp, and LinkedIn. To increase the response rate, the questionnaire link was also made available in the social media groups of DHCPs in Guilan Province. Completing the questionnaire took approximately 10 minutes.
Three questionnaires were used in this study. First, the demographic information of participants (gender, age, specialty, level of education, work experience, presence of underlying diseases, history of COVID-19 in a family member, and location of work) was collected. The first questionnaire was a researcher-designed instrument used to assess the KAP of participants regarding COVID-19. It was designed in accordance with the World Health Organization's protocols. This questionnaire included 26 questions. One score was allocated to each correct answer, and a zero score was assigned to wrong or I do not know answers. The total score can range from 0 to 16 in the knowledge domain, 0 to 5 in the attitude domain, and 0 to 5 in the practice domain. The total score of the questionnaire could range from 0 to 26. In each domain, a higher score indicated better status in the respective domain. To assess the validity and reliability of the questionnaire, it was administered among 15 dental specialists and 15 physicians with specialties related to COVID-19, such as infectious disease specialists, and its validity and reliability were confirmed with a content validity index of 0.93, a content validity ratio of 0.94, and a Cronbach's alpha of 0.75. The second questionnaire assessed the KAP of DHCPs regarding COVID-19 vaccination, which was developed according to the questionnaire designed by Kumari et al. [30]. In the present study, the original version of this questionnaire was first translated from English to Farsi by three dental specialists. Then, two other specialists, who were fluent in both English and Farsi, back-translated it from Farsi to English. The authors then assessed the final translation to ensure clarity and understandability. A pilot study was subsequently conducted with 15 participants, who were asked to complete the questionnaire. The problems related to the questions were identified, and the questionnaire was revised accordingly. The optimal validity and reliability of this questionnaire were confirmed by a content validity index of 0.94, a content validity ratio of 0.95, and a Cronbach's alpha of 0.76. This questionnaire included 39 questions. The knowledge domain consisted of 11 questions, and each correct answer was assigned a score of 1, while incorrect and 'I do not know' answers were assigned a score of 0. The responses to other questions were reported descriptively.
The third questionnaire was used to assess fear of COVID-19. It was developed according to the FCV-19S questionnaire, which was designed by Ahorsu et al. [31] to determine the fear of COVID-19 in an Iranian population. This questionnaire consists of seven questions with 5-point Likert scale answer choices, ranging from 'totally disagree' to 'totally agree'. The total questionnaire score could range from 7 to 35. Acquiring a high score would indicate a greater fear of COVID-19. This questionnaire has shown optimal psychometric properties (correlation of each item with the total score of 47.0 to 56.0, a weighting factor of 66.0 to 74.0, internal consistency of 82.0, and test-retest reliability of 72.0). This scale had positive correlations with perceived susceptibility, hospital anxiety, and depression [31]. Mohammadpour et al. [32] reported the Cronbach's alpha of 82.0 for this scale. The fear of participants related to COVID-19 was assessed twice, before and after vaccination.
Data Analysis
The frequency and percentage values were reported to describe qualitative data, while the mean and standard deviation values were reported for quantitative data. In each domain, scores < 33rd percentile were considered low, scores between 33rd and 66th percentile were considered moderate, and scores > 66th percentile were considered high. The Kolmogorov-Smirnov test was used to assess the normality of data distribution, while the Levene’s test was applied to analyze the homogeneity of variances. If the assumptions were met for quantitative variables, an independent t-test, ANOVA, and Tukey's test (for pairwise comparisons) were applied. If the assumptions were not met, the Kruskal-Wallis test and the Mann-Whitney U test with a Bonferroni adjustment (for pairwise comparisons) were used, along with Spearman's correlation test, for data analysis. All statistical analyses were performed using SPSS version 26 (IBM Corp., NY, USA) at a significance level of 0.05.
Results
A total of 345 participants completed the questionnaire, of which 330 were eligible for study inclusion. The majority of participants were females (59.7%) and were between 30 and 39 years old (49.3%). The majority of participants (92.7%) had no underlying disease. Of all participants, 11.8% were laboratory technicians, 30.9% were dental assistants, 41.8% were general dentists, and 15.5% were dental specialists. Regarding educational level, 42.4% held a doctorate, 15.15% had a specialty degree, 0.3% had a Master's degree, 24.84% had a Bachelor's degree, 10.3% had a college degree, and 6.6% had a high school diploma. Regarding work experience, 58.18% had work experience over 10 years, 21.21% had 5-10 years of work experience, 10.3% had 2-5 years of work experience, and 8.7% had work experience < 2 years. Overall, 63% reported a positive history of COVID-19 in a family member. At the time of conduction of this study, 83% had received two doses of the COVID-19 vaccine, and 13.6% had received one dose of the COVID-19 vaccine.
The mean knowledge score of the participants regarding COVID-19 was 13.53±1.43, their mean attitude score was 3.91±.98, and their mean practice score was 3.94±.98. Moreover, the knowledge score regarding COVID-19 vaccination was 8.10±2.58. The responses of participants to attitude and practice domains of vaccination are presented in Tables 1 and 2.
Participants’ responses to questions in the attitude and practice domains regarding COVID-19 vaccination.
The mean fear score of participants was 19.31 ± 4.94 before vaccination and 17.20 ± 5.05 after vaccination (Table 3). The results showed a significant reduction in fear of COVID-19 following vaccination (p < 0.001, Table 4).
Mean scores of KAP of Guilan Province DHCPs regarding SARS-CoV-2 and knowledge about vaccination, and their fear of COVID-19 before and after vaccination.
Assessment of the correlation between demographic factors and KAP regarding SARS-CoV-2 and vaccination knowledge revealed significant correlations between age and attitudes and practices regarding SARS-CoV-2, as well as knowledge about vaccination. Additionally, gender, level of education, and occupation showed substantial correlations with knowledge and attitudes regarding SARS-CoV-2 and vaccination knowledge. Moreover, work experience, having an underlying disease, and a history of COVID-19 in a family member showed significant correlations with the attitude towards SARS-CoV-2 (p < 0.05). Fear after vaccination had a significant correlation with work experience, and as work experience increased, so did fear after vaccination (p < 0.001).
Additionally, fear after vaccination showed a significant correlation with occupation (p < 0.001), with the mean fear score in dental assistants being significantly higher than in the remaining three groups. The mean score of fear after vaccination was considerably lower in dental specialists compared to general dentists, laboratory technicians, and dental assistants (p < 0.001). Additionally, the fear score of general dentists was significantly lower than that of dental assistants (p = 0.003). The correlation between fear after vaccination and level of education was significant (p < 0.001). The mean score of fear in participants with a Bachelor's degree was higher than in the other three groups.
Pairwise comparisons revealed that the mean fear score after vaccination in specialists was significantly lower than that of general dentists (p = 0.003), those with a high school diploma (p = 0.024), those with a college degree (p = 0.001), and those with a Bachelor's degree (p < 0.001). Additionally, the fear score of general dentists was significantly lower than that of those with a Bachelor's degree (p = 0.016). The fear of COVID-19 after vaccination showed no significant correlation with age, gender, underlying diseases, or a history of COVID-19 in a family member (p > 0.05). The fear of COVID-19 before vaccination showed no significant correlation with age, gender, work experience, occupation, level of education, underlying diseases, or a history of COVID-19 in a family member (p > 0.05, Table 5).
Correlation of demographic factors with KAP regarding SARS-CoV-2, knowledge about vaccination, and fear of COVID-19 before and after vaccination.
As shown in Table 6, the KAP of participants regarding SARS-CoV-2 had no significant correlation with their fear of COVID-19 before vaccination (p = 0.345, p = 0.170, and p = 0.758, respectively).
Correlation of KAP regarding SARS-CoV-2 and fear before vaccination by the Spearman’s correlation test.
Discussion
In the present study, the mean scores were calculated to be 13.53 ± 1.43 for knowledge, 3.91 ± 0.98 for attitude, and 3.94 ± 0.98 for practice regarding SARS-CoV-2. Fear of COVID-19 was 19.31±.4.94 before and 17.20±5.05 after the vaccination, and the difference was statistically significant. The results showed no significant correlation between KAP regarding SARS-CoV-2 and fear of COVID-19 before vaccination. Demographic factors had a significant correlation with KAP regarding SARS-CoV-2, knowledge about vaccination, and fear of vaccination. Thus, the null hypotheses of the study were partially rejected.
Since the announcement of the COVID-19 pandemic by the World Health Organization, the KAP regarding COVID-19 has been constantly developing to encourage the communities to adhere to the established policies and guidelines for effective control of the pandemic [6].
The present results revealed a high level of KAP regarding SARS-CoV-2 in the DHCPs of Guilan Province of Iran. Similarly, previous studies have demonstrated a high level of knowledge among dentists regarding COVID-19 risks [22,33]. Additionally, moderate knowledge levels, positive attitudes, and acceptable practices regarding COVID-19 have been reported among DHCPs in Saudi Arabia. Adequate knowledge levels among Mexican dentists have also been reported [21]. A systematic review of studies on the level of KAP of dentists regarding SARS-CoV-2 in 2020 revealed a suboptimal knowledge level [34]. It should be noted that cross-sectional studies may overestimate the knowledge and practice regarding COVID-19 and underestimate the level of fear and anxiety [35].
The present results reported a higher level of knowledge and attitude in males than in females. Latif et al. [14] evaluated healthcare workers in Cureus and found a higher overall knowledge score among females than among males. In the present study, the mean knowledge and attitude scores of specialists were higher than those of general dentists and dental assistants. Also, the values in general dentists were higher than those in dental assistants. It should be noted that a higher level of education may be responsible for a higher level of KAP regarding SARS-CoV-2 [36]. The present results indicate that optimal practice of DHCPs in this regard was achieved, and no significant difference existed among specialists, general dentists, and dental assistants in this respect. Similarly, Shirahmadi et al. [24] evaluated DHCPs in western Iran and showed that over 70% of them followed the preventive measures recommended by the Iranian Ministry of Health and Medical Education.
Although herd immunity is believed to be the primary solution to stopping the COVID-19 pandemic, low vaccine acceptance and concerns regarding vaccination can hinder its achievement [1]. A comprehensive literature search revealed high acceptance of COVID-19 vaccines among dentists [1]. Their attitude towards vaccination can influence the attitudes of other social groups regarding vaccination, as well as policy-making aimed at addressing existing doubts about vaccination [37]. In the present study, COVID-19 vaccines were highly accepted among DHCPs in Guilan Province. This result was in agreement with the findings of Lataifeh et al. [38] on healthcare providers in Jordan and Papagiannis et al. [39] on healthcare workers in Greece. It should be noted that approximately 30% of the participants of the present study expressed some concerns regarding the immediate serious complications of vaccines, their too fast development, and fake vaccines.
Of the community members, healthcare providers, including DHCPs, are more susceptible to fear and anxiety due to their direct contact with patients suspected of COVID-19 [26]. Thus, the sources of their anxiety and fear should be identified to be able to provide support for them [18]. The present results revealed a moderate level of COVID-19 fear among the study population both before and after vaccination. Similarly, Salehiniya and Abbaszadeh [27] reported a moderate level of anxiety in dentists practicing in the west of Iran. A moderate level of fear of Iranian dentists may indicate their higher tolerance to environmental stressors and psychological pressures, including the COVID-19 crisis [27]. The present results showed a significant reduction in the fear of DHCPs after vaccination. One possible reason for this finding may be that over 50% of the participants believed that vaccination can control the COVID-19 pandemic. This finding was in agreement with the results of Karayürek et al. [28], in their study on Turkish dentists. In the present study, fear before vaccination had no significant correlation with the age and gender of participants. However, in the survey by Kakkar et al. [35], the majority of university instructors over 50 years of age had a lower level of fear. Also, Suryakumari et al. [26] reported that female dentists were more afraid of death due to COVID-19 than male dentists. They attributed this finding to the traditional family system in India, where females are the primary care providers in the family, which increases their responsibility towards their family and subsequently their fear of disease transmission to the entire family and the related consequences [26]. In the present study, the history of an underlying disease had no significant correlation with fear of COVID-19 before or after vaccination. In the present study, fear after vaccination had a direct correlation with the work experience of DHCPs, which was in line with the results of Karayürek et al. [28]. Higher work experience directs DHCPs towards adopting a more logical and evidence-based approach to confront any situation. Also, lower patient visits by dentists with over 21 years of work experience may be another reason for this difference in the results [28].
The present results found no significant correlation between KAP regarding SARS-CoV-2 and fear of COVID-19 before vaccination. Although knowledge and attitude can profoundly affect the level of stress and anxiety of individuals [13], dentists may still experience a high level of anxiety, stress, and depression despite having a high knowledge level about modifying their practice during the pandemic [35]. Approximately 90% of dentists who participated in a study by Ahmed et al. [40], from 30 different countries, reported experiencing anxiety and fear despite having high standards of knowledge and practice.
The possibility of social desirability bias was a limitation of this study. In other words, it is possible that participants reported social norms instead of their actual beliefs. Additionally, it is worth noting that although cross-sectional studies are suitable tools for informing future longitudinal studies, they cannot establish causal relationships [24]. Moreover, this study was conducted on DHCPs practicing in Guilan Province, and the results may not be generalizable to other communities. Thus, assessing KAP regarding SARS-CoV-2 and COVID-19 vaccination, as well as fear levels before and after vaccination, is recommended in different communities and countries.
Conclusion
Dental healthcare providers practicing in Guilan Province, Iran, had a high level of KAP regarding SARS-CoV-2 and COVID-19 vaccination. Their fear of COVID-19 was moderate, and vaccination significantly decreased their level of fear. No correlation was found between KAP regarding SARS-CoV-2 and fear of COVID-19 before immunization. Age, gender, and level of education had a significant correlation with knowledge about SARS-CoV-2. All demographic factors had a significant correlation with the attitude regarding SARS-CoV-2. Age had a significant correlation with practice regarding SARS-CoV-2, and age, gender, occupation, and level of education showed substantial correlations with knowledge about COVID-19 vaccination. Moreover, work experience, occupation, and level of education were significantly correlated with the level of fear after COVID-19 vaccination.
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Financial Support
This work was supported by the Dental Sciences Research Center of Guilan University of Medical Sciences (#IR.GUMS.REC.1400.022).
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
References
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Academic Editor:
Wilton Wilney Nascimento Padilha
