IRCMJ logo


Knowledge, Attitude, Fear, and Practice towards Coronavirus Disease-2019 Preventive Measures among Iranian Dentists

Isa Mohammadi Zeidi1,* and Banafsheh Mohammadi Zeidi2

  1. Ph.D, Associate Professor, Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
  1. Ph.D, Assistant Professor, Nursing and Midwifery Department, Tonekabon Branch, Azad University of Medical Sciences, Mazandaran, Iran

* Corresponding author: Isa Mohammadi Zeidi, Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran. Tel:+989124146500; Email: [email protected]

 

Received 2021 February 11; Revised 2021 June 24; Accepted 2021 June 29.

 

Abstract

Background: Dentists are more at risk of respiratory infectious diseases, compared to other Health Care Workers (HCWs).

Objectives: This study aimed to determine the relationship of knowledge, attitude, and fear with Coronavirus Disease-2019 (COVID-19) preventive measures amongst Iranian dentists.

Methods: This cross-sectional study was conducted in the northern provinces of Iran. In total, 340 dentists were selected using a multi-stage sampling method, and they were requested to complete the data collection tools, such as demographic characteristics form, knowledge scale, fear scale, attitude scale, and COVID-19 preventive measures scale. The obtained data were then analyzed by independent t-test, chi-square test, one-way ANOVA, correlation coefficient, and stepwise regression.

Results: Dentists' knowledge about issues, such as incubation period, laboratory test, virus survival time on surfaces, and method disinfection was weak. Nearly, 60% of the dentists had a favorable attitude towards the prevention of COVID-19, while their belief was not good on issues, such as adequacy of routine protocols, vulnerability towards COVID-19, suppressed immune system, patient's responsibility, and stigma. Moreover, 82.1% of dentists were fearful of being infected by patients, providing treatment to the suspected ones, the possibility of transmitting the infection to family members, post-infection quarantine, and treatment costs. Additionally, the total score of practice toward COVID-19 preventive measures in dentists was relatively high (21.88±3.8), whereas their practice in criteria, such as presenting a special disinfectant solution or mask for patients, disinfecting surfaces, air conditioning, and examining patients' symptoms was not satisfactory. Regression analysis demonstrated that job history, knowledge, attitude, and fear were significant predictors of dentists' practice describing 62.7% of the variance in practice towards COVID-19 preventive measures.

Conclusion: The findings revealed that dentists had a comparatively good level of knowledge, attitude, and practice towards COVID-19 preventive measures. The current study suggests that dentists' anxiety, fear, and attitude could be remarkably reduced through providing adequate Personal Protective Equipment and subsequently enhancing preventive practice, raising awareness via online training regarding new guidelines, and presenting real-time statistics on the number of HCWS infected with COVID-19.

 

Keywords: Attitude, COVID-19, Dentist, Fear, Knowledge, Preventive measures


1. Background

Background: Dentists are more at risk of respiratory infectious diseases, compared to other Health Care Workers (HCWs).

Objectives: This study aimed to determine the relationship of knowledge, attitude, and fear with Coronavirus Disease-2019 (COVID-19) preventive measures amongst Iranian dentists.

Methods: This cross-sectional study was conducted in the northern provinces of Iran. In total, 340 dentists were selected using a multi-stage sampling method, and they were requested to complete the data collection tools, such as demographic characteristics form, knowledge scale, fear scale, attitude scale, and COVID-19 preventive measures scale. The obtained data were then analyzed by independent t-test, chi-square test, one-way ANOVA, correlation coefficient, and stepwise regression.

Results: Dentists' knowledge about issues, such as incubation period, laboratory test, virus survival time on surfaces, and method disinfection was weak. Nearly, 60% of the dentists had a favorable attitude towards the prevention of COVID-19, while their belief was not good on issues, such as adequacy of routine protocols, vulnerability towards COVID-19, suppressed immune system, patient's responsibility, and stigma. Moreover, 82.1% of dentists were fearful of being infected by patients, providing treatment to the suspected ones, the possibility of transmitting the infection to family members, post-infection quarantine, and treatment costs. Additionally, the total score of practice toward COVID-19 preventive measures in dentists was relatively high (21.88±3.8), whereas their practice in criteria, such as presenting a special disinfectant solution or mask for patients, disinfecting surfaces, air conditioning, and examining patients' symptoms was not satisfactory. Regression analysis demonstrated that job history, knowledge, attitude, and fear were significant predictors of dentists' practice describing 62.7% of the variance in practice towards COVID-19 preventive measures.

Conclusion: The findings revealed that dentists had a comparatively good level of knowledge, attitude, and practice towards COVID-19 preventive measures. The current study suggests that dentists' anxiety, fear, and attitude could be remarkably reduced through providing adequate Personal Protective Equipment and subsequently enhancing preventive practice, raising awareness via online training regarding new guidelines, and presenting real-time statistics on the number of HCWS infected with COVID-19.

 

Keywords: Attitude, COVID-19, Dentist, Fear, Knowledge, Preventive measures


2.Objectives

This study aimed to determine the relationship of knowledge, attitude, fear, and practice with COVID-19 preventive measures among Iranian dentists.


3.Methods

The present cross-sectional study was conducted from April 4 to July 18, 2020, in the northern and central provinces of Iran.

3.1. Participants and sampling process

The study population included all dentists working in public and private sectors in five provinces of Tehran, Qazvin, Mazandaran, Gilan, and Golestan, Iran.

The sample size (n=340) was determined on the basis of a study performed by Gambhir et al. (2020) (27), G*Power software, 95% confidence interval, and a tolerable error value of 0.05 (d).

Regarding the significant difference in the total number of dentists working in each province, the number of dentists required for this study was determined according to the ratio of the total population of dentists in each province as follows: Tehran (n=113), Mazandaran (n=75), Gilan (n=66), Qazvin (n=46), and Golestan (n=40). The inclusion criteria were: 1) voluntary participation in research, 2) a general dentist or higher, 3) employment in public clinics or private offices, and 4) residency in one of the five provinces while conducting research. The dentists' selection to participate in the study was carried on using a table of random numbers. Subsequently, the research team contacted the selected ones by telephone and explained the investigation objectives to them. Phone numbers and e-mail addresses were received from all dentists who volunteered to partake in the study in order to explain how to participate in it.

3.2. Data gathering process

Questionnaires were provided to partakers both physically and via e-mail or WhatsApp Messenger, and all individuals were asked to reply to questions within 20 days. During this time, four reminders were sent to each participant through SMS, as well as WhatsApp to complete the questions. It should be noted that along with the questionnaires, two forms were provided to the participants, including written consent and a guide to answering the queries. After the mentioned time, the questionnaires were collected by trained experts in order to be reviewed in terms of answering all questions, not including the name and surname, as well as providing an educational package comprising an educational pamphlet, a CD with the subject of prevention of COVID-19, a pocket calendar, and a participation certificate (as prizes for engagement in the research).

All participants in the study were assured that their information would definitely be kept confidential by the research team, with the questionnaires being anonymous. Moreover, it was emphasized that their participation in the research was voluntary. The present study has been  approved by the Ethics Committee of Qazvin University of Medical Sciences, Qazvin, Iran (IR.QUMS.REC.1399.190).

3.3. Data collection instruments

Data were collected using a set of self-administrative questionnaires. The tools utilized in this research were as follows:

3.3.1. Demographic characteristics form

It covers such information as age (year), gender, marital status, job experience (year), type of dental specialty, province (city), history of participation in the training course related to COVID-19 (yes/no), number of daily visits in the past month, decrease in the number of dental visits since the outbreak of COVID-19 (yes/no), self-assessment of information about COVID-19 (How do you rate your  knowledge on COVID-19 in general? Excellent/good/average/poor), and source of information about COVID-19.

3.3.2. COVID-19 Knowledge Scale

It consists of 15 items aiming at assessing dentists' knowledge regarding disease-relevant details, such as virus type, common symptoms, methods of transmission, access to the vaccine, and various prevention measures. Participants were demanded to respond to the questions using “true-false” and “I don’t know” options. Each true answer was given a score of one, with the false answers a score of zero. The sum of the answers was utilized to calculate the total score of knowledge, with the range of scores varying between 0 and 15. The final score of knowledge was classified into three levels of low (5-0), medium (6-10), and high (11-15). The items used in this scale were “COVID-19 is not transmissible from asymptomatic patients” and “all contaminated surfaces should be cleaned with a dilute disinfectant solution”.

The validity and reliability of the knowledge scale have been well established in previous studies (26, 27). In the present study after the back translation process, the face and content validity of the knowledge scale was also confirmed by an expert panel consisting of a general dentist, an infectious disease specialist, a general physician, a psychologist, and a health education specialist. Content Validity Rate (CVR) and Content Validity Index (CVI) were obtained at 0.83 and 0.87, respectively. Moreover, the knowledge scale was completed by a group of 15 dentists at two-week intervals, where the correlation coefficient of the answers in two stages showed good reliability of the scale (r=0.92). The sample was randomly chosen from the main population, with their findings not being included in the results of the main study.

3.3.3. COVID-19 Fear Questionnaire

This scale was developed by Putrino et al. (2020) (26) and consists of eight items. Dentists were requested to respond to items using the “true-false” and “I don’t know” options. Examples of items relevant to this questionnaire were as follows: “if a patient speaks to me at a very close distance, I get nervous” and “I'm afraid that I might pass the infection on to my family because of my dental work”. The face and content validity of this questionnaire was approved by a panel of experts (CVR=0.75, CVI=0.78). In addition, Cronbach's alpha coefficient (α=0.79) and retest coefficient (r=0.82) confirmed the internal consistency and reliability of the questionnaire, respectively.

3.3.4. The Attitude Scale

It comprises of eight items, and the participants were asked to answer the items using a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The scores ranged from 8 to 40, and higher scores indicate a more favorable attitude towards COVID-19 preventive measures. Some items in this questionnaire include “Most patients who go to dental clinics are responsible people, and I am not worried about getting the disease through them” and “dentists are more likely to get COVID-19 than other HCWs”. The psychometric properties of the scale have been confirmed in previous studies (30, 31). After the translation process in the current study, its face and content validity was approved by an expert panel. In addition, a sample of 15 dentists completed the questionnaire twice in two weeks intervals in which a correlation coefficient between the two-step answers was used to assess the reliability of the questions. Content validity, reliability, and internal consistency of the questions were confirmed by CVI=0.86, CVR=0.81, r=0.94, and α=0.89, respectively.

3.3.5. COVID -19 preventive practice questionnaire

Regarding previous studies, this questionnaire included items, such as regular disinfection of equipment and places, the use of a high volume suction and Rubber Dam isolation, requesting patients to rinse their mouth with an antibacterial mouthwash before treatment, and washing hands with antibacterial solution pre-post dental treatment (30, 32, 33). Dentists were demanded to reply to 12 items of this questionnaire using “yes, no” and “I do not know” options.

Some related items were: “I always use personal protective equipment such as gloves, face shield, head cover, and masks” and “I accurately assess the symptoms of upper respiratory tract infection and patients' body temperature”. The validity and reliability of this questionnaire have been proven in previous studies (32, 33). In this study, CVR and CVI (0.81 and 0.85, respectively) confirmed the content validity, and Cronbach's alpha coefficient (α=0.90), as well as a test-retest coefficient (r=0.88) proved the internal consistency and reliability of the questionnaire, respectively.

3.4. Statistical analysis

The data were entered into SPSS software (version 25.0), and their normality distribution was assessed using the Kolmogorov-Smirnov test. Following that, they were subjected to the following analyses: Chi-square test (to examine the relationship between qualitative variables, such as gender and levels of knowledge), independent t-test (to compare the mean of a quantitative variable between two independent groups, such as the mean score of attitude between married and single dentists), ANOVA (to compare the mean of quantitative variables between either two independent groups or more, such as the mean score of fear between dentists based on job experience less than 2 years, 2-5 years, and more than 5 years), and Pearson correlation coefficient (to examine the relationship among quantitative variables, such as the mean score of knowledge, attitude, fear, and practice). In addition, stepwise regression analysis was used for identifying the factors affecting the preventive behaviors of COVID-19 in dentists. A p-value less than 0.05 was considered statistically significant.


4.Results

4.1. Demographic characteristics of participants

The mean age of dentists participating in this study was obtained at 37.54±11.5 years (age range: 26-60 years), and the mean of job experience was determined at 9.30±6.44. Furthermore, the majority (53.23%) of the participants were male, and 72.35% of them were general dentists. Approximately, 70% of the respondents had received no formal training about COVID-19, and only 30.29% of them used the protocols and instructions of the Ministry of Health as a source of information regarding COVID-19. The other demographic characteristics are provided in Table 1.

4.2. Dentists' knowledge toward COVID -19

Table 2 describes the dentists' responses to their knowledge regarding COVID-19. Of the 340 dentists, 81.63% of them answered the knowledge questions correctly and according to Table 2, 73.53% of the dentists had a high level of knowledge. In addition, 7.47% of the participants responded to the knowledge questions incorrectly with 6.76% having a low level of knowledge. Wrong answers were clearly reported in the questions related to the incubation period (18.82%), laboratory test (20.0%), virus survival time on surfaces (12.94%), and methods of surface disinfection (11.47%).

4.3. Mean score of knowledge of dentists in terms of demographic variables

The results of comparing the mean score of knowledge of dentists in terms of some demographic variables are given in Table 3. According to the outcomes of one-way ANOVA, the mean score of knowledge in terms of job experience was significantly different amongst the participated dentists (P=0.001). In other words, the mean score of knowledge in dentists with job experience of more than 10 years was significantly superior to that of the others (12.33±2.3, P=0.001). Moreover, the mean score of knowledge of dentists who reported the Ministry of Health, WHO, and Centers for Disease Control and Prevention (CDC) as main sources to access information about COVID-19 prevention was significantly higher than that of others (12.45±2.38, P=0.001).

4.4. Dentists' attitude toward COVID-19 preventive behaviors

Table 4 tabulates the dentists' responses to

 

 

Table 1. Demographic characteristics of dentists participating in the study (n=340)

Variables

Frequency (%)

Variables

Frequency (%)

age (year)

 

How much do you know about COVID-19?

 

Less than 30

75 (22.06)

Excellent

251 (73.82)

31-45

163 (47.94)

Good

53 (15.59)

More than 45

102 (30.0)

Medium

25 (7.35)

Gender

 

Weak

11 (3.24)

Male

181 (53.23)

What is the number of daily visits? (case)

 

Female

159 (46.77)

less than 5

31 (9.12)

Marital status

 

6-10

118 (34.70)

Married

207 (60.88)

12-15

121 (35.59)

Single  

106 (31.18)

more than 15

70 (20.59)

Divorced

27 (7.94)

Have daily referrals decreased since the outbreak?

 

Job experience (year)

 

Yes

218 (64.12)

Less than 2

31 (9.12)

No

65 (19.12)

2-5

66 (19.41)

No difference

57 (16.76)

5-10

107 (31.47)

Main source of information about COVID-19?

 

More than 10

136 (40.0)

Ministry of Health, WHO, and CDC

103 (30.29)

Dental specialty

 

Mass media, such as television, radio, newspapers

116 (34.12)

General dentist

246 (72.35)

Web, Whats App, and Instagram

94 (27.65)

Orthodontic

30 (8.82)

Significant others as colleagues, family, and friends

27 (7.94)

Surgery

35 (10.29)

Province

 

Children

8 (2.35)

Tehran

113 (33.24)

Periodontology

11 (3.24)

Mazandaran

75 (22.06)

COVID-19 formal training?

Guilan

66 (19.41)

Yes

103 (30.29)

Qazvin

46 (13.53)

No

237 (69.71)

Golestan

40 (11.76)

Table 2. Dentists' knowledge toward COVID-19 (n=340)

Items

Yes

Frequency (%)

NO Frequency (%)

Don’t know

Frequency (%)

The incubation period of COVID -19 is 1 to 21 days.

248 (72.94)

64 (18.82)

28 (8.24)

The main symptoms of COVID-19 include fever> 38°C, cough, sore throat, runny nose, and dyspnea.

322 (94.71)

8 (2.35)

10 (2.94)

Dentists must take strict personal protective measures and avoid or minimize operations that can produce droplets or aerosols.

313 (92.06)

13 (3.82)

14 (4.12)

COVID-19 can be prevented by prescribing the vaccine

330 (97.06

4 (1.18)

6 (1.76)

All patients should gargle before treatment during the COVID-19 epidemic.

302 (88.82)

16 (4.71)

22 (6.47)

rRT-PCR is an available laboratory test to detect COVID-19.

245 (72.06)

68 (20.0)

27 (7.94)

During the COVID-19 epidemic, treatment is given if there is a pain in cases undergoing orthodontic treatment in which the brackets and wires are dislocated or broken

309 (90.88)

14 (4.12)

17 (5.0)

COVID-19 is transmitted through direct contact with respiratory secretions.

300 (88.24)

8 (2.35)

1 (0.29)

COVID-19 can remain on the surface for hours or even days.

268 (78.82)

44 (12.94)

28 (8.24)

COVID-19 is not transmissible from asymptomatic patients.

315 (92.65)

8 (2.35)

17 (5.0)

The use of personal protective equipment (including masks, gloves, or face shields) is recommended to protect the skin and mucous membranes from potentially contaminated blood or secretions.

322 (94.71)

12 (3.53)

6 (1.76)

Hand hygiene is the most important measure to reduce the risk of transmission of COVID-19 to patients

293 (86.18)

35 (10.29)

12 (3.53)

All infected surfaces of patients with COVID-19 infection should be cleaned with dilute disinfectant solution (5%)

264 (77.65)

39 (11.47)

37 (10.88)

Pneumonia, respiratory failure, and death from COVID-19 are more common in the elderly and people with chronic diseases.

305 (89.71)

20 (5.88)

15 (4.41)

Keeping a safe distance from patients and avoiding eye, mouth, and nose contact is effective in preventing COVID -19.

311 (91.47)

12 (3.53)

17 (5.0)

 

Table 3.Comparison of mean±SD of dentists' knowledge score related to COVID-19 in terms of some demographic variables (n=340)

Variables

 

KnowledgeM±SD

Significant Level

Age (Year)*

Less than 30

10.67±1.56

0.390

31-45

10.14±1.65

More than 45

10.43±2.14

Job experience (year)**

Less than 2

10.14±1.77

0.001

2-5

10.25±1.86

5-10

9.93±2.05

More than 10

12.33±2.15

Training about COVID-19 **

Yes

10.34±2.26

0.713

No

10.52±1.94

Dental specialty**

General dentist

10.42±2.08

0.713

Orthodontic

10.00±1.97

Surgery

10.28±1.72

Pediatric

10.94±2.00

Periodontology

11.13±2.17

Others

10.41±2.05

COVID-19 information source**

Ministry of Health, World Health Organization, and the Centers for Disease Control and Prevention

12.45±2.38

0.001

Mass media, such as television, radio, and newspapers

9.52±1.95

Web, WhatsApp, and Instagram

10.50±2.35

Significant others as colleagues, family, and friends

10.39±2.13

*One way ANOVA; **Independent t-test

 

 

various items of the attitude scale. According to the results, 73.83% of the dentists agreed that they could prevent COVID-19 by following routine hygiene protocols with 32.94% believing that they were more susceptible to COVID-19, compared to other HCWs. Moreover, 26.76% of the dentists believed that they would not probably get infected with COVID-19 unless they had an underlying disease or a suppressed immune system. In addition, 73.23% of the dentists believed that their colleagues would blame them if they got COVID-19. In total, 23.79% of the dentists had an unfavorable attitude with 59.96% having a desirable attitude towards the prevention of COVID-19.

4.5. Dentists' fears and anxieties on COVID-19

Dentists' fears and anxieties on COVID-19 are presented in Table 5. Results revealed that 85.29% of the dentists were fearful of getting infected with COVID-19 via patients or colleagues. It was also found that the treatments of patients with suspected COVID-19 caused anxiety in 89.12% of dentists, and 72.94% of them decided to stop their dental activities until a reduction in the prevalence of COVID-19. Additionally, more than 74.41% of the participants reported that talking to patients at very close distances would make them nervous, with more than 93.53% of the dentists being feared for transmitting the disease to their family through dental activity.

 

Table 4.Dentists' attitudes toward COVID-19 (n=340)

Items of Attitude Scale

Completely disagree

Disagree

I don’t know

Agree

Completely agree

Adherence to routine hygiene protocols is sufficient to prevent COVID-19 in dentistry.

31

(9.12)

39

(11.47)

19

(5.59)

201 (59.12)

50

(14.71)

Dentists are more likely to get COVID-19 than other HCWs.

29

)8.53)

137  (40.29)

62 (18.24)

106 (31.18)

6

(1.76)

If I do not have an underlying disease or a suppressed immune system, I am less likely to get COVID -19

213 (62.65)

12

(3.53)

24

(7.06)

51

(15.0)

40 (11.76)

In the current situation, only patients with serious conditions should be visited in the dental clinic.

6

(1.76)

10

(2.94)

14

(4.12)

116 (34.12)

194

(57.06)

Most people who go to dental clinics are responsible people, and I am not worried about getting infected through them.

71

(20.88)

39 (11.47)

69 (20.29)

46

(13.53)

115 (33.82)

Due to my good physical condition, even if I get infected with COVID-19, I will recover after a few days of rest.

171

(50.29)

99 (29.12)

19

(5.59)

31 (9.12)

20

(5.88)

If a dentist is infected with COVID-19, society will blame him/her.

13

(3.82)

48 (14.12)

30

(8.82)

83 (24.41)

166

(48.82)

COVID-19 is a severe and deadly infectious disease.

19

(5.59)

12

(3.53)

24

(7.06)

245 (72.06)

40

(11.76)

 

Table5.Measurement of fear and anxiety in dentists (n=340)

Items

Yes

N (%)

No

N (%)

I don’t know

N (%)

I'm afraid of getting infected with COVID-19 through patients or colleagues.

290

(85.29)

43

(12.65)

7

(2.06)

I get anxious when I provide treatment to a patient who coughs or is suspicious of getting infected with symptoms of COVID-19.

303

(89.12)

27

(7.94)

10

(2.94)

I want to close my office or reduce my working hours until the number of patients with COVID-19 decreases.

248

(72.94)

79

(23.24)

13

(3.82)

I get nervous if a patient talks to me at very close distances.

253

(74.41)

72

(21.18)

15

(4.41)

I'm worried that my family might get infected with COVID-19 because of my dental activities.

318

(93.53)

15

(4.41)

7

(2.06)

I'm afraid of being quarantined if I get infected with COVID-19.

272

(80.0)

57

(16.76)

11

(7.65)

The potential cost of treatment for COVID-19 makes me anxious.

252

(74.12)

75

(22.06)

13

(3.82)

I'm afraid to hear that people I may know have died of COVID-19.

297

(87.35)

39

(11.47)

4

(1.18)

 

Post-infection quarantine and treatment costs also resulted in fear and anxiety in 80% and 74.12% of the dentists, respectively, whereas hearing about the death of people due to COVID-19 caused fear in 87.35% of them.

4.6. Dentists practice towards COVID-19 prevention measures

Table 6 represents the practice of dentists towards COVID-19 prevention measures. Results showed that 87.72% of the dentists had good practice toward COVID-19 preventive measures, whereas 7.97% of them had poor practice. Although dentists' practice did not satisfactorily meet the criteria, such as providing a special disinfectant solution or mask for patients (12.82%), disinfecting surfaces every two hours (12.06%), regular air conditioning (11.18%), examining patients' symptoms (10.88%), and cleaning surfaces in workplaces (10.29%), their practice regarding changing gloves after treatment procedures for each patient (97.94%), changing gloves and washing hands before and after the treatment (95.29%), and observing hand hygiene before and after changing gloves (95.0%) was excellent.

4.7. Correlation coefficients between research variables

Correlation coefficients among age, job experience, and other psychosocial variables are shown in Table 7. Except for the correlation between age and job experience, the strongest correlation coefficients were observed between fear and knowledge (r=0.614, P<0.05), as well as practice and knowledge (r=0.581, P<0.05), respectively. Moreover, the correlation coefficients between fear and attitude (r=0.118, P<0.05), as well as knowledge and age (r=0.121, P<0.05) were reported as the weakest ones. All variables showed a positive and significant

 

Table 6. Dentists' performance toward COVID-19 prevention measures (n=340)

Items

Yes

N (%)

No

N (%)

I don’t know

N (%)

I accurately assess the level of risk and travel history of each patient.

303 (89.12)

16

(4.71)

21

(6.18)

I carefully evaluate the signs of upper respiratory tract infection and patients' body temperature.

280 (82.35)

37

(10.88)

23

(6.76)

I clean my hands using soap and water or an alcohol hand rub.

321 (94.41)

13

(3.82)

6

(1.76)

I regularly disinfect the environment and surfaces in the workplace.

274 (80.59)

35

(10.29)

31

(9.12)

I always use Personal Protective Equipment, such as gloves, a face shield, and masks.

312 (91.76)

15

(4.41)

13

(3.82)

I wash my hands before and after each patient treatment.

324 (95.29)

9

(2.65)

7

(2.06)

I change my gloves after the treatment procedure for each patient.

333 (97.94)

7

(2.06)

0

(0)

I observe hand hygiene before and after wearing and taking off gloves.

323

(95.0)

8

(2.35)

9

(2.65)

I avoid crowded clinics and make separate appointments with enough time intervals.

320 (94.12)

8

(2.35)

12

(3.53)

I prepare a special alcoholic disinfectant and mask for each patient in the waiting rooms.

221

(65.0)

98

(28.82)

21

(6.18)

I disinfect all surfaces, such as chairs and door handles, every two hours with chlorine solution and other substances.

277

(81.47)

41

(12.06)

22

(6.47)

I regularly ventilate the clinic air.

291 (85.59)

38

(11.18)

11

(3.24)

 

Table 7.Correlation coefficients among the variables used in the study (n=340)

Variables  

1

2

3

4

5

6

1. Age

1

 

 

 

 

 

2. Job experience

0.792*

1

 

 

 

 

3. Knowledge

0.121*

0.242**

1

 

 

 

4. Attitude

0.10

0.413**

0.374**

1

 

 

5. Fear

0.12

0.146**

0.614*

0.118*

1

 

6. Practice

0.09

0.164**

0.581*

0.202*

0.482**

1

*P<0.05, **P<0.01

 

relationship with practice towards COVID-19 preventive measures, except for age. Most correlation coefficients were reported at the medium level (P<0.05).

 

4.8. Predictive variables related to COVID-19 preventive measures

The linear regression analysis using the stepwise method was utilized in order to evaluate the predictive power of the variables based on different studies, as well as appraise the correlation coefficients in the present study (Table 8).

Job experience, knowledge, attitude, and fear were considered variables affecting the preventive practice of COVID-19 in dentists. In the first step, job experience was entered into an equation where the correlation coefficient (R) with dependent variables (preventative practice) was 0.748. At this stage, the values of R2 and adjusted R2 were 0.560 and 0.555, respectively. After entering knowledge as the second variable, the value of R2 (0.763) and adjusted R2 (0.583) increased, subsequently. Similarly, by adding the third variable, attitude, in the third phase, an enhancement was observed in the value of R (0.780) and adjusted R2 (0.608). Finally, by adding four variables, such as job experience, knowledge, attitude, and fear in the final model, the values of R2 and adjusted R2 raised to 0.792 and 0.627, respectively. In other words, regarding the adjusted R2 in the final model, 62.7% of the variance in the dependent variable (preventive practice) was explained by these four variables. Moreover, based on the β coefficients obtained in Table 9, it can be concluded that job experience, knowledge, attitude, and fear described the highest variance ofpreventive practice in descending order.

 

Table 8. Summary of a stepwise regression model with R, R2 adjusted, F, and P

Variables

R

R2

adjusted R2

std. error of estimate

F

P

1. Job experience

0.748

0.560

0.556

2.44

137.254

P<0.001

2. Knowledge

0.763

0.583

0.575

2.40

74.693

P<0.001

3. Attitude

0.780

0.608

0.597

2.34

54.758

P<0.001

4. Fear

0.792

0.627

0.613

2.29

44.093

P<0.001

Table 9. Stepwise regression with β coefficients, standardized β coefficients, T, and P

Step

Variables

β

Standardizedβ coefficients

T

P

1

Job experience

0.482

0.748

11.716

0.000

2

Job experience

0.469

0.729

11.570

0.000

 

Knowledge

0.614

0.153

2.429

0.017

 

Job experience

0.443

0.689

10.898

0.000

3

Knowledge

1.306

0.325

3.618

0.000

 

Attitude

0.202

0.234

2.607

0.010

 

Job experience

0.361

0.562

6.779

0.000

4

Knowledge

1.364

0.340

3.835

0.000

 

Attitude

0.200

0.231

2.632

0.010

 

Fear

0.995

0.187

2.313

0.023

 


5.Discussion

This study was conducted from April to July 2020 in the middle of the COVID-19 pandemic. It should be noted that the prevalence of COVID-19 in Iran was far higher than expected due to the government's inappropriate actions as well as people's non-compliance with health protocols. Therefore, the current study aimed to determine the status of knowledge, attitude, and fear in dentists, in addition to appraising the effect of these variables on their preventative practice towards COVID-19.

Although Iran had made great strides between April and June 2020 in controlling and preventing the death of patients, compared to some developed countries, there were still several problems in managing the epidemic. Insufficient information and lack of awareness, along with disbelief in vulnerability, led to an acceleration of the disease outbreak in some provinces, such as Tehran and other Northern provinces, Iran. In addition to psychosocial factors, numerous holidays resulted in an increase in trips to Northern provinces, such as Mazandaran, Gilan, Golestan, and Qazvin with respect to tourist attractions, which subsequently elevated the prevalence (34).

In the present study, 73.53% of the dentists had good knowledge about COVID-19; however, their mean knowledge scores on topics, such as incubation period (18.82%), laboratory testing (20.0%), the duration of lasting the virus on surfaces (12.94%), and methods of disinfection of surfaces (11.47%) were weak. Our findings on the dentists' high level of knowledge about COVID-19 were in line with the results of studies conducted in Italy, Brazil, and Lebanon, as well as the findings of a study performed by Kamate et al. (2020) who found that the majority of dentists, being from several countries, had an appropriate level of knowledge in this issue (26, 30, 35, 36).

Moreover, according to the current study, 74.8% of the dentists had not formally contributed to any training program on the prevention of COVID-19, whereas given the results of a study conducted by Arora et al. (2020), not only 60.7% of the dentists were formally trained in infection control but also 49.7% of them received specific training for COVID-19 prevention protocols (37). Additionally, 30% of the dentists participating in the study reported the educational resources of the Ministry of Health, WHO, and CDC as the main reference of information, and consequently, the mean score of knowledge in this group of dentists was significantly higher than the others (P<0.001).

As demonstrated by Saqlain et al. (2020), the mean score of knowledge in HCWs, mostly using social media as the main source of information about COVID-19 prevention, was significantly lower than others (38). Therefore, the lack of application of valid educational resources (WHO, CDC, and Ministry of Health) may be considered one of the reasons for the dentists' lower mean score of knowledge in the study. Bhagavathula et al. (2020) emphasized that HCWs would better apply reliable sources to seek information on COVID-19, such as guidelines published by WHO and CDC (18). The absence of monitoring of the health content of social media, such as Instagram and public websites, could remarkably lessen the scientific credibility of this resource. As a result, a pandemic of misinformation would strongly influence the decision of HCWs to prevent COVID-19 (39).

Considering the optimal attitude and effective performance of HCWs, such as dentists depend on their level of knowledge about COVID-19, an increase in their knowledge concerning coronavirus is an undeniable necessity. In addition, updating the scientific content of websites relevant to the Ministry of Health and related institutions and focusing on the prevention of COVID-19 in dentists, can play an important role in enhancing the level of knowledge in dentists and preventing their misinformation.

Our results also showed that almost 79.42% of the dentists did not have the desired attitude toward implementing more protocols to prevent COVID-19 and believed that following routine protocols were sufficient for it. This is while during the COVID-19 pandemic, dentists must consider themselves vulnerable to COVID-19, with having a proper comprehension of the risk of disease. Dentists should also be aware that coronavirus can last on surfaces for hours or more depending on the type of surface, temperature, and humidity (40).

Therefore, performing routine protocols may not be adequate to manage the risk of transmission of infection. According to this study, 48.82% of the dentists believed that they were likely to get infected with COVID-19 similar to other HCWs. It has been reported that the proximity between patients and dentists (approximately 35-40 cm), as well as some time-consuming special treatment procedures could put dentists at a greater danger of infection with COVID-19, compared to other HCWs (41). Moreover, nearly one-third of participants believed that with a strong immune system, they would no longer be infected with COVID-19, with more than 45% believing that the possibility of infection transmission through their patients will be too low since they are responsible people. Overall, 59.96% of the dentists had a very unfavorable attitude, with 30.44% having a desirable attitude.

Dentists are encouraged to follow health protocols when their colleagues and other HCWs carefully follow preventive protocols (17). In other words, high perceived vulnerability along with a high level of knowledge had a positive relationship with attitude towards COVID-19 preventive measures. Even dentists' knowledge of the number of HCWs infected with COVID-19 is likely to increase their perceived vulnerability to the disease. On the other hand, dentists without enough knowledge on COVID-19 would have an optimistic attitude about rapid recovery after it similar to other infectious diseases. If dentists accept that they are vulnerable to COVID-19, they will probably engage in preventative behaviors. In this regard, Taghrir et al. (2020) have highlighted the significant relationship between risk perception and adherence to preventative behaviors (42). Therefore, optimistic assessments of the likelihood of infecting and misunderstanding of the consequences of a threat could be considered obstacles to the full implementation of COVID-19-related hygiene protocols. Accordingly, reflecting the experience of other dentists accompanied by providing real statistics on the number of HCWs infected with COVID-19 and focus group discussions through video conferencing can be good strategies to change dentists' attitudes about the importance of adhering to COVID-19-related hygiene protocols.

The mean score of attitude had a significant correlation with the mean score of knowledge (P<0.01, r=0.368), which was in parallel with the results of a study conducted by Abdel Wahed et al. (2020) (43). The link between HCWs' level of knowledge and their attitudes toward COVID-19 preventive measures has been reported in previous studies (14, 42, 44). The knowledge of HCWs is a momentous prerequisite for positive attitudes, prevention beliefs, as well as promoting preventive practice, with some effects on coping strategies (45). Simultaneously, inadequate knowledge alongside factors, such as the type and frequency of exposure, could intensify the risk of infection (46). Despite the high level of knowledge of dentists, our results revealed that they do not have a favorable attitude towards COVID-19 preventative measures, at least in some cases, such as the responsibility of patients and their own vulnerability. In the present study, approximately, 33% of the dentists believed that they were more susceptible to COVID-19 than any other HCWs, contradicting the findings of previous research, in which roughly, 83% of the participants considered themselves vulnerable to COVID-19 (14, 46). The amount of perceived risk can strongly affect both the preparedness to react to risk and the mental health of individuals to exposure dangers (47). Accordingly, determining the perceived risks in dentists can be regarded as a crucial tool to alter attitudes and make their workplace safer.

Regarding another important finding of this study, 83.21% of the dentists declared that they would be severely blamed by the community if they got infected with COVID-19. The rates of blame in the studies conducted by Wahed et al. (2020) and Abdelhafiz et al. (2020) were reported to be 66% and 23%, respectively (43,48). Fear about the high mortality of a disease and the possibility of transmitting its infection to family members are considered the main determinants of stigma (45).

In addition, parts of the stigma may be due to the legal restrictions on conducting religious funeral services. On the other hand, by getting HCWs infected with COVID-19, the majority of society would become frustrated at its prevention, and as a result, the disease will outspread. In this regard, proper training and the implementation of stigma reduction programs accompanied by the announcement of health care policies could be employed as approaches to counteracting stigma (49).  

This study also identified that the majority of dentists (82.11%) had fear and anxiety towards various issues listed in the fear scale. This was consistent with the results of a study performed by Ahmed et al. (2020) who reported that most dentists were afraid of issues as being infected by patients or colleagues and providing treatment to suspected patients (20). Aly and Elchaghaby (2020) also highlighted 90% fear of similar issues in dental professionals (50). Dentists' knowledge of incubation periods accompanied by the unique features of dental processes (e.g., proximity to patients) can intensify their fear and anxiety, as well as predicting a significant correlation between knowledge and fear of COVID-19.

In line with the results of previous studies, infection with COVID-19 through patients or colleagues, treatment of suspected patients, non-observance of social distance with patients, the possibility of transmitting the infection to family members, post-infection quarantine, and treatment costs due to COVID-19, as well as news related to mortality were the main causes of dentists' fear and anxiety in this study (20, 51).

One of the factors influencing fears was the perceived risk of transmitting the infection to the family members (93.5%), which was in accordance with the study of De Leo et al. (2020) (52). Previous studies have displayed that HCWs having children, the elderly, or the sick at home show higher levels of fear (16, 51, 52). Moreover, according to studies, extra risks and exposure can be diminished by taking appropriate precautions at home, such as washing hands, changing work clothes and bathing, keeping a reasonable social distance, especially with children and the elderly, avoiding sharing dishes, and using a separate plate/glass/bowl (16).

Although HCWs are at a higher risk of infecting with COVID-19, compared to non-HCWs, even so, the majority of them (97%) will not get infected (53). Furthermore, even though providing care to patients with COVID-19 makes HCWs more at risk, the effective application of PPE reduces the risk of infection to a minimum (54). Lai et al. (2020) reported that even in front-line health workers working in high-risk areas, the incidence of COVID-19 was only 0.55% (55). Moreover, the risk of HCWs becoming infected with COVID-19 was 0.14% in comparison with 0.10% in the general population (56).

Exposure to dramatic images of malignant patients and high mortality rates from social media can lead to overestimation of the personal risk of infection by HCWs and dentists (57). Therefore, there is no sensible basis for dentists' fear of transmitting the infection to the family. In this regard, the provision of PPE and increased preventative practice along with supplying real statistics on the number of HCWs infected with COVID-19 through changing dentists' attitudes could remarkably lessen dentists' anxiety and fear.

The total score of practice towards COVID-19 preventative measures in dentists was relatively high, and 87.72% of them had an optimal performance. However, they did not meet all the criteria, which was in agreement with the findings of previous studies (30, 36, 38). It was also identified that their practice towards COVID-19 preventative measures was significantly associated with job experience, knowledge, attitude, and fear (P<0.05). Nonetheless, weakness in some preventive measures could accelerate the spread of the virus in the community. It is recommended that the Ministry of Health provides appropriate preventive protocols to all dentists during the COVID-19 pandemic and get ensured that these protocols comply with all the items relevant to preventative measures.

Regression analysis showed that job experience, knowledge, attitude, and fear were significant predictors of dentists' practice towards COVID-19 preventive measures, and 62.7% of the variance of preventive practice could be explained by these variables, which was consistent with the findings of previous studies (20, 27, 38). The association among these variables and preventive practice clearly emphasizes the importance of improving dentists' knowledge through health education, which may lead to an improvement in their attitude and practice towards COVID-19. Additionally, weaknesses in some practice items may be due to a lack of adequate training. Online training courses should be considered an accessible and effective strategy to increase dentists' adherence to infection control guidelines.


6.Conclusion

The findings of the present study demonstrated that dentists had a relatively good level of knowledge, attitude, and practice towards COVID-19 preventive measures. The pandemic of COVID-19 has had a significant impact on the dental profession, causing the majority of dentists to overestimate their risk of getting infected with COVID-19 due to high fear and anxiety.

Limitations

Despite the impressive results, it should be emphasized that our study faced some limitations. First, the dentists participating in this study were selected from five Northern provinces of Iran, which cannot represent the entire dental community. Therefore, the selection of larger samples from all geographical areas of Iran will strengthen the generalizability of the results. Second, the utilization of a self-report method to collect data may be biased. Therefore, the possibility of recording some variables, such as preventive behaviors via observation or reporting by colleagues can decline bias to some extent. Third, given the feasibility of transmitting the disease through physical contact, using online methods can be useful tools for collecting data quickly, safely, and cost-effectively. Finally, concerning the cross-sectional nature of the present study, it would only show associations and not be able to provide cause-effect relationships.

Recommendation

Our findings would have important implications for the development of strategies for reducing dentists' anxiety and fear via changing attitudes, which could be achieved through providing adequate PPE and subsequently enhancing preventive practice, raising awareness via online training regarding new guidelines (e.g., WHO or CDC), and presenting real-time statistics on the number of HCWS infected with COVID-19.


Acknowledgments

The authors would like to appreciate the cooperation of all dentists of Tehran, Qazvin, Gilan, Mazandaran, and Golestan Universities of Medical Sciences in this study. The authors are also grateful to all dentists who contributed to this investigation.


Footnotes

Authors’ Contribution: Study concept and design: Isa Mohammadi Zeidi; acquisition of data, analysis, and interpretation: Banafsheh Mohammadi Zeidi.

Conflicts of Interest: The authors have no conflict of interest to declare.

Ethical Approval: This study was approved by the Ethics Committee of Qazvin University of Medical Sciences (Ethical code: IR.QUMS.REC.1399.190)

Funding/Support: This research was funded by the Research and Technology Deputy of Qazvin University of Medical Sciences, Iran.

Financial Disclosure: None

Informed consent: Informed consent was obtained from all participants at the start of the study.

 


References

  1. Gralinski LE, Menachery VD. Return of the coronavirus: 2019-nCoV. Viruses. 2020;12(2):135. doi: 10.3390/v12020135. [PubMed: 31991541].
  2. Neher RA, Dyrdak R, Druelle V, Hodcroft EB, Albert J. Potential impact of seasonal forcing on a SARS-CoV-2 pandemic. Swiss Med Wkly. 2020;150:w20224. doi: 10.4414/smw.2020.20224. [PubMed: 32176808].
  3. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):1-6. doi: 10.1038/s41368-020-0075-9. [PubMed: 32127517].
  4. Fu L, Wang B, Yuan T, Chen X, Ao Y, Fitzpatrick T, et al. Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: a systematic review and meta-analysis. J Infect. 2020;80(6):656-65. doi: 10.1056/NEJMoa2002032. [PubMed: 32109013].
  5. Zhang L, Liu Y. Potential interventions for novel coronavirus in China: a systematic review. J Med Virol. 2020;92(5):479-90. doi: 10.1002/jmv.25707. [PubMed: 32052466].
  6. Wu P, Hao X, Lau EHY, Wong JY, Leung K, Wu JT, et al. Real-time tentative assessment of the epidemiological characteristics of novel coronavirus infections in Wuhan, China, as at 22 January 2020. Eur Surveill. 2020;25(3):2000044. doi: 10.2807/1560-7917.ES.2020.25.3.2000044. [PubMed: 31992388].
  7. Schwartz J, King CC, Yen MY. Protecting health care workers during the COVID-19 coronavirus outbreak -Lessons from Taiwan's SARS response. Clin Infect Dis. 2020;71(15):858-60. doi: 10.1093/cid/ciaa255. [PubMed: 32166318].
  8. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7. doi: 10.1177/0022034520914246. [PubMed: 32162995].
  9. Barbieri T, Basso G, Scicchitano S. Italian workers at risk during the Covid-19 epidemic. Italian Econ J. 2021;23:1-21. doi: 10.1007/s40797-021-00164-1.
  10. Peditto M, Scapellato S, Marcianò A, Costa P, Oteri G. Dentistry during the COVID-19 epidemic: an Italian workflow for the management of dental practice. Int J Environ Res Public Health. 2020;17(9):3325. doi: 10.3390/ijerph17093325. [PubMed: 32403248].
  11. Sarkarat F, Tootoonchian A, Haraji A, Rastegarmoghaddam M, Mostafavi SM, Naghibi S. Evaluation of dentistry staff involvement with COVID-19 in the first 3 month of epidemiologic spreading in Iran. J Res Dent Sci. 2020; 17(2):137-45. doi: 10.29252/jrds.17.2.137.
  12. Krithikadatta J, Nawal RR, Amalavathy K, McLean V, Gopikrishna A. Endodontic and dental practice during COVID-19 pandemic: position statement from the Indian Endodontic Society, Indian Dental Association, and International Federation of Endodontic Associations. Endodontology. 2020; 32(2):55-66.
  13. Occupational Safety and Health Administration. Guidance on preparing workplaces for COVID-19. Washington, D.C: Occupational Safety and health Administration; 2020.
  14. Mceachan R, Hons BA, Taylor N, Lawton R, Gardner P, Conner M. Meta-analysis of the reasoned action approach (RAA) to understanding health behaviors. Ann Behav Med. 2016; 50(4):592-612. doi: 10.1007/s12160-016-9798-4. [PubMed: 27169555].
  15. Geldsetzer P. Use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: a cross-sectional survey on COVID-19. J Med Internet Res. 2020; 22(4):e18790. doi: 10.2196/18790. [PubMed: 32240094].
  16. Ge Z, Yang L, Xia J, Fu XH, Zhang YZ. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci. 2020;21(5):361-8. doi: 10.1631/jzus.B2010010. [PubMed: 32425001].
  17. Gan WH, Lim JW, Koh D. Preventing intra-hospital infection and transmission of coronavirus disease 2019 in health-care workers. Saf Health Work. 2020;11(2):241-43. doi: 10.1016/j.shaw.2020.03.001. [PubMed: 32292622].
  18. Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: cross-sectional study. JMIR Public Health Surveill. 2020;6(2):e19160. doi: 10.2196/19160. [PubMed: 32320381].
  19. Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020;15(4):564-7. doi: 10.1016/j.jds.2020.02.002. [PubMed: 32296495].
  20. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17(8):2821. doi: 10.3390/ijerph17082821. [PubMed: 32325888].
  21. Shacham M, Hamama-Raz Y, Kolerman R, Mijiritsky O, Ben-Ezra M, Mijiritsky E. COVID-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in Israel. Int J Environ Res Public Health. 2020;17(8):2900. doi: 10.3390/ijerph17082900. [PubMed: 32331401].
  22. Harper CA, Satchell LP, Fido D, Latzman RD. Functional fear predicts public health compliance in the COVID-19 pandemic. Int J Ment Health Addict. 2020;27:1-14. doi: 10.1007/s11469-020-00281-5. [PubMed: 32346359].
  23. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17:1729. doi: 10.3390/ijerph17051729. [PubMed: 32155789].
  24. Ren SY, Gao RD, Chen YL. Fear can be more harmful than the severe acute respiratory syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic. World J Clin Cases. 2020;8(4):652-7. doi: 10.12998/wjcc.v8.i4.652. [PubMed: 32149049].
  25. Consolo U, Bellini P, Bencivenni D, Iani C, Checchi V. Epidemiological aspects and psychological reactions to COVID-19 of dental practitioners in the northern italy districts of Modena and Reggio Emilia. Int J Environ Res Public Health. 2020;17(10):3459. doi: 10.3390/ijerph17103459. [PubMed: 32429193].
  26. Putrino A, Raso M, Magazzino C, Galluccio G. Coronavirus (COVID-19) in Italy: knowledge, management of patients and clinical experience of Italian dentists during the spread of contagion. BMC Oral Health. 2020;20(1):200. doi: 10.1186/s12903-020-01187-3. [PubMed: 32650753].
  27. Gambhir SR, Dhaliwal SJ, Aggarwal A, Anand S, Anand V, Kaur Bhangu A. Covid-19: a survey on knowledge, awareness and hygiene practices among dental health professionals in an Indian scenario. Rocz Panstwow Zakl Hig. 2020;71(2):223-9. doi: 10.32394/rpzh.2020.0115. [PubMed: 32519827].
  28. Michie S, van Stralen MM, West R. The behavior change wheel: a new method for characterizing and designing behavior change interventions. Implement Sci. 2011;6:42. doi: 10.1186/1748-5908-6-42. [PubMed: 21513547].
  29. Araújo-Soares V, Hankonen, N, Justin P, Rodrigues A, Sniehotta FF. Developing behavior change interventions for self-management in chronic illness. Eur Psychol. 2018;24(1):7-25. doi: 10.1027/1016-9040/a000330. [PubMed: 31496632].
  30. Kamate SK, Sharma S, Thakar S, Srivastava D, Sengupta K, Hadi AJ, et al. Assessing knowledge, attitudes and practices of dental practitioners regarding the COVID-19 pandemic: a multinational study. Dent Med Probl. 2020;57(1):11-7. doi: 10.17219/dmp/119743. [PubMed: 32307930].
  31. Khader Y, Al Nsour M, Al-Batayneh OB. Dentists' awareness, perception, and attitude regarding COVID-19 and infection control: cross-sectional study among Jordanian dentists. JMIR Public Health Surveill. 2020;6(2):e18798. doi: 10.2196/18798. [PubMed: 32250959].
  32. Prasetyo Y, Castillo AM, Salonga LJ, Sia JA, Seneta JA. Factors affecting perceived effectiveness of COVID-19 prevention measures among Filipino during enhanced community quarantine in Luzon, Philippines: integrating protection motivation theory and extended theory of planned behavior. Int J Infect Dis. 2020;99:312-23. doi: 10.1016/j.ijid.2020.07.074. [PubMed: 32768695].
  33. Bakaeen LG, Masri R, AlTarawneh S, Garcia LT, AlHadidi A, Khamis AH, et al. Dentists knowledge, attitudes and professional behavior towards COVID-19 pandemic: a multi-site survey of dentists’ perspectives. J Am Dent Assoc. 2021;152(1):16-24. doi: 10.1016/j.adaj.2020.09.022. [PubMed: 33250171].
  34. Mohammadzadeh N, Shahriary M, Shirmohammadlou N, Lohrasbi V. A glance at the prevalence of coronavirus disease 19 (COVID-19) in Iran: strengths and weaknesses. Inf Control Hosp Epidemiol. 2020;41(12):1479-82. doi: 10.1017/ice.2020.193. [PubMed: 32362292].
  35. Sezgin GP, ŞirinoĞlu Çapan B. Assessment of dentists' awareness and knowledge levels on the Novel Coronavirus (COVID-19). Braz J Oral Res. 2020;34:e112. doi: 10.1590/1807-3107bor-2020.vol34.0112. [PubMed: 32876114].
  36. Nasser Z, Fares Y, Daoud R, Abou-Abbas L. Assessment of knowledge and practice of dentists towards coronavirus disease (COVID-19): a cross-sectional survey from Lebanon. BMC Oral Health. 2020;20(1):281. doi: 10.1186/s12903-020-01273-6. [PubMed: 33050914].
  37. Arora S, Abullais Saquib S, Attar N, Pimpale S, Saifullah Zafar K, Saluja P, et al. Evaluation of knowledge and preparedness among indian dentists during the current COVID-19 pandemic: a cross-sectional study. J Multidiscip Healthc. 2020;13:841-54. doi: 10.2147/JMDH.S268891. [PubMed: 32922024].
  38. Saqlain M, Munir MM, Ur Rehman S, Gulzar A, Naz S, Ahmed Z. Knowledge, attitude, practice and perceived barriers among health‑ care professionals regarding COVID-19: a cross-sectional survey from Pakistan. J Hosp Infect. 2020;105(3): 419-23. doi: 10.1016/j.jhin.2020.05.007. [PubMed: 32437822].
  39. Huynh G, Nguyen TN, Vo KN, Pham LA. Knowledge and attitude toward COVID-19 among healthcare workers at District 2 Hospital, Ho Chi Minh City. Asian Pac J Trop Med. 2020;13(6):260. doi: 10.4103/1995-7645.280396.
  40. Pîrvu C, Pătraşcu I, Pîrvu D, Ionescu C. The dentist's operating posture - ergonomic aspects. J Med Life. 2014;7(2):177-82. [PubMed:25184007].
  41. Fusco FM, Pisaturo M, Iodice V, Bellopede R, Tambaro O, Parrella G, et al. COVID-19 among healthcare workers in a specialist infectious diseases setting in Naples, Southern Italy: results of a cross-sectional surveillance study. J Hosp Infect. 2020;105(4):596-600. doi: 10.1016/j.jhin.2020.06.021. PubMeD: 32565367].
  42. Taghrir MH, Borazjani R, Shiraly R. COVID-19 and Iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception. Arch Iran Med. 2020;23(4):249-54. doi: 10.34172/aim.2020.06. [PubMed: 32271598].
  43. Abdel Wahed WY, Hefzy EM, Ahmed MI. Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. J Community Health. 2020;45(6):1242-51. doi: 10.1007/s10900-020-00882-0. [PubMed: 32638199].
  44. Zhang M, Zhou M, Tang F, Wang Y, Nie H, Zhang L, et al. Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. J Hosp Infect. 2020; 105(2):183-7. doi: 10.1016/j.jhin.2020.04.012. [PubMed: 32278701].
  45. Jiang l, Ng IHL, Hou Y, Li D, Tan L, Ho H, et al. Infectious disease transmission: survey of contacts between hospital-based healthcare workers and working adults from the general population. J Hosp Infect. 2018;98(4):404-11. doi: 10.1016/ j.jhin.2017.10.020. [PubMed: 29097147].
  46. Maleki S, Najafi F, Farhadi K, Fakhri M, Hosseini F. Knowledge, attitude and behavior of health care workers in the prevention of COVID-19. BMG Med Educ. 2020;3:1-17. doi: 10.21203/rs.3.rs-23113/v1.
  47. Yesilgul G, Cicek H, Avci M, Huseyniklioglu B. Nurses’ knowledge levels and perceptions regarding occupational risks and hazards. Int J Caring Sci. 2018;11(2):1117-24.
  48. Abdelhafiz AS, Mohammed Z, Ibrahim ME. Knowledge, perceptions, and attitude of Egyptians towards the novel coronavirus disease (COVID-19). J Community Health. 2020; 45(5):881-90. doi: 10.1007/s10900-020-00827-7. [PubMed: 32318986].
  49. Kabbash IA, Abo Ali EA, Elgendy MM, Abdrabo MM, Salem HM, Gouda MR, et al. HIV/AIDS-related stigma and discrimination among health care workers at Tanta University Hospitals Egypt. Environ Sci Pollut Res Int. 2018;25(31):30755-62. doi: 10.1007/s11356-016-7848-x. [PubMed: 27752955].
  50. Aly MM, Elchaghaby MA. Impact of novel coronavirus disease (COVID-19) on Egyptian dentists' fear and dental practice (a cross-sectional survey). BDJ Open. 2020;6:19. doi: 10.1038/s41405-020-00047-0. [PubMed: 33072400].
  51. Kumar J, Katto MS, Siddiqui AA, Sahito B, Ahmed B, Jamil M, et al. Predictive factors associated with fear faced by healthcare workers during COVID-19 pandemic: a questionnaire-based study. Cureus. 2020;12(8):e9741. doi: 10.7759/cureus.9741. [PubMed: 32944456].
  52. de Leo D, Trabucchi M. COVID-19 and the fears of Italian senior citizens. Int J Environ Res Public Health. 2020;17(10):3572. doi: 10.3390/ijerph17103572. [PubMed: 32443683].
  53. COVID-19 Scientific Advisory Group. COVID-19 Scientific advisory group rapid response report. Edmonton, AB: Alberta Health Services; 2020.
  54. Liu M, Cheng S, Xu K, Yang Y, Zhu, QT, Zhang H, et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: Cross sectional study. BMJ. 2020;369:m2195. doi: 10.1136/bmj.m2195. [PubMed: 32522737].
  55. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3): e203976. doi: 10.1001/jamanetworkopen.2020.3976. [PubMed: 32202646].
  56. Kluytmans-van den BF, Buiting AG, Pas SD, Bentvelsen RG, van den Bijllaardt W, van Oudheusden A, et al. Prevalence and clinical presentation of health care workers with symptoms of coronavirus disease 2019 in 2 Dutch hospitals during an early phase of the pandemic. JAMA Netw Open. 2020;3(5):e209673. doi: 10.1001/jamanetworkopen.2020.9673. [PubMed: 32437576].
  57. Taylor S. The psychology of pandemics: preparing for the next global outbreak of infectious disease. Newcastle upon Tyne: Cambridge Scholars Publishing; 2020.

Appendix:

Part-1 Socio-demographic features

1)   How old are you?

A)   18-24

B)   25-39

C)   40-59

D)  60

 

2)  Choose your gender,

A)  Male

B)   Female

 

3)   Choose your marital status,

A)   Single

B)   Married

 

4)   Choose the school you graduated from,

A)   Primary school

B)   High school

C)   University

 

5)   Choose your employment status,

A)   Employed

B)  Unemployed

 

6)   Choose your monthly income,

A)  700 USD

B)  700 USD

 

7)  Do you have a kid?

A)   Yes

B)   No

 

8)   Do you have a school kid?

A)   Yes

B)   No

 

9)   Do you smoke?

A)   Yes

B)   No

 

10)  How long have you been caring for your patient?

A)  3 years

B)  3 years

 

11)  What is your patient's illness?

A)  Alzheimer’s disease

B)   Stroke

C)   Cancer

D)   Other

 

Part-2 Patient knowledge level

It is possible to have more than one correct option, check all the options you think are correct.

1)   What is the cause of COVID-19?

A)  Virus -1 point

B)   Bacterium -0 point

C)   Fungus -0 point

D)   Parasite microorganism -0 point

E)  Immune deficiency -0 point

F)   Hereditary -0 point

 

2)   What are the ways of transmission of the disease?

A)   Droplets that spread through coughing, sneezing, etc. -1 point

B)   Contact of people to each other -1 point

C)   Contact of people to surfaces -1 point

D)   Use of common items with sick individuals -1 point

E)   Stool contamination -1 point

F)   Sexually (0 points if marked, 1 point if not marked)

 

3)   Where did the disease start?

A)   China -1 point

B)  Iran -0 point

C)   Italy -0 point

D)   ABD -0 point

E)   Russia -0 point

 

4)   What are the symptoms of the disease?

A)   Pain -1 point

B)   Nasal congestion -1 point

C)   Runny nose -1 point

D)   Sore throat -1 point

E)   Diarrhea -1 point

F)   Fever -1 point

G)   Cough -1 point

H)   Shortness of breath -1 point

İ)   Loss of appetite -1 point

J)   Difficulty in swallowing -1 point

K)   Some may have no complaint -1 point

 

5)   Which groups are at risk of being a carrier?

A)   Newborns -1 point

B)   Childs -1 point

C)   Adolescents -1 point

D)   Young adults -1 point

E)   Middle-aged adults -1 point

F)   Older adults -1 point

G)   Immunosuppressive drug users -1 point

H)   Cancer patients -1 point

İ)   Chronic disease patients -1 point

 

6)   Which groups are at high risk for disease?

A)   Newborns (0 points if marked, 1 point if not marked)

B)   Childs (0 points if marked, 1 point if not marked)

C)   Adolescents (0 points if marked, 1 point if not marked)

D)   Young adults (0 points if marked, 1 point if not marked)

E)   Middle-aged adults (0 points if marked, 1 point if not marked)

F)   Older adults -1 point

G)   Immunosuppressive drug users -1 point

H)   Cancer patients -1 point

İ)   Chronic disease patients -1 point

 

7)   Is there a proven treatment for the disease?

A)   Yes

B)   No -1 point

 

8)   Are there any recommended treatments for the disease?

A)   Yes -1 point

B)   No

 

9)   Has vaccination begun in any country??

A)   Yes -1 point

B)   No

 

10)   Is there a proven preventive treatment for the disease?

A)   Yes

B)   No -1 point

 

11)   Is there any preventive food for the disease?

A)   Yes

B)   No -1 point

 

12)   Is there a proven nutritional treatment for the disease?

A)   Yes

B)   No -1 point

 

13)   How long is the incubation period?

A)   0-2 days

B)   1 week

C)   2-14 days -1 point

D)   1 month

E)   1-3 months

 

Part – 3 Please tick the choice according to your opinion about the measures taken for COVID-19.

1)   Do not share personal equipment

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

2)   Wearing masks and social distance

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

3)   Washing hands

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

4)   Prohibition of social organizations

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

5)   Prohibition of travelling abroad

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

6) Restrictions on trips outside the province

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

7)   Quarantine of those coming from abroad

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

8)   Closing social activity venues

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

9)   Remote support for the elderly

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

10)  Washing clothes at least 60 degrees

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

11)   Distance education

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

12)   Working in the home office

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

13)   Restricting young people from going out

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

 

14)   Prohibition of old people from going out

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

15)   Shopping via the internet and the phone

A)   Strongly agree

B)   Agree

C)   Neutral

D)   Disagree

E)   Strongly disagree

 

Strongly agree: 5 points

Agree: 4 points

Neutral: 3 points

Disagree: 2 points

Strongly disagree: 1 point