The health and quality of life of dental workers in jordan during COVID-19: A cross-sectional study

Abstract

BACKGROUND:

Dental team members are susceptible to high mental and physical stress levels, which could have increased during the Coronavirus disease 2019 (COVID-19).

OBJECTIVE:

This study aimed to evaluate Jordanian dental workers’ health-related quality of life (HRQoL) and determine its predictors during the COVID-19 Pandemic.

METHODS:

This was a cross-sectional survey study conducted on dental team members, namely; Dentists, dental Assistants, and Dental Technicians. The survey questionnaire was composed of questions related to stress during COVID-19, a short-form survey of 12 items (SF-12), a Depression, Anxiety, and Stress scale (DASS-21), and a Nordic musculoskeletal disorder questionnaire (NMQ). Descriptive analyses were used to describe the main outcome measures, and multiple variable regression analysis was conducted to identify the quality of life predictors.

RESULTS:

Participants’ HRQoL measured by SF-12 showed a mean±SD score of 67.1±17.19 for the physical component and 54.51±20.27 for the mental component. The Nordic scale showed symptoms of lower back pain as 63.9% over 12 months, 32% over 12 months’ functional limitation symptoms, and 45% in 7 days The regression model was found strong for our study with 53.8% variations (r2 = 0.538, F = 43.739, P < 0.001) in health-related quality of life.

CONCLUSIONS:

Keywords

Epidemiology Cross-sectional studies humans workers quality of life Health

1 Introduction

Dental team members are subjected to immeasurable sources of stress in their professional practice. The difficulties in dental team professional lives greatly influence their general physical and psychological health, leading to anxiety and depression. It has been reported that dentists’ personal and professional relationships and their health might be adversely affected by symptoms [1 –3].

Several researchers have reported that depression and anxiety are frequently present among dentists [4, 5]. Among these mental disorders, anxiety and depression were reported with the greatest adverse influence on dentists’ productivity [6 –8]. Many people who get affected by these diseases rarely seek treatment even with the knowledge that they can get better with mental health treatment or counselling.

The nature of work carried out by dental technicians has many negative elements that might lead to poor quality of life, such as the use of harmful materials generated by the process of fabricating dental restorations and prostheses [9, 10]. Various professions have occupational-related issues that can be mental or physical, one of which is musculoskeletal disorders, which have been identified as a risk factor for developing work-related health issues [11]. For dental professions, the awkward posture, repetitive movements in different joints, use of vibrating tools, as well as psychological stress are highly presented. It is also well-documented that back and neck pain is highly prevalent among dental technicians [12, 13].

Dental hygienists are important members of dental teams. Dental hygienists undertake complex clinical operative procedures [14]. Several studies show that most dental hygienists often change dental clinics, and more than 30% leave their profession after a short period of practice, which suggests that dental hygienists experience mental stress [15]. A review by Gorter published in 2005 reported that dental hygienists had a higher risk of burnout than other professions [16].

In the year 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also known as COVID-19 was announced as a pandemic by the year 2020 and became a major international public health issue [17, 18]. Jordan is a relatively small country in the Middle East that started its COVID-19-related safety procedures in February 2020 [19]. Extreme physical demand and mental distress were imposed on all governmental and private healthcare workers [20 –22]. In a study conducted in China, healthcare providers were found to commonly experience mental health-related issues [23]. According to a study on psychological distress, dentists were experiencing an increased level of fear of getting the virus from the patients or spreading it to their family members [24]. However, there are no studies related to the COVID-19 pandemic targeting other categories of dental workers worldwide.

According to our knowledge, no study has targeted dental workers in Jordan to assess psychological stress due to COVID-19. Therefore, this study aimed to investigate the level of HRQoL and its predictors among dental team workers in Jordan during the COVID-19 Pandemic.

2 Methods

2.1 Study design and sampling

A cross-sectional study was conducted, using a self-administered questionnaire. The target population included working dental team members namely; dentists, dental assistants, and dental technicians. The sample size for this study was calculated using “RaoSoft Calculator” and through the snowball sampling technique, which is a nonprobability sampling technique, where existing study subjects recruited future subjects from among their acquaintances. A total of 269 dental workers were included in the study. All other healthcare participants were excluded from the study. After explaining the study objective, informed consent was obtained from participants.

2.2 Study instrument

The study consisted of a self-administered questionnaire developed including demographics and participants’ characteristics, normal lifestyle, working style during the COVID-19 Pandemic, and questions related to work stress during the COVID-19 pandemic. It was composed of a Nordic musculoskeletal disorder questionnaire (NMQ), a Depression Anxiety Stress Scale (DASS21), and a short-form survey of 12 items (SF-12).

2.2.1 Nordic musculoskeletal disorder questionnaire (NMQ)

NMQ scale was used to measure musculoskeletal symptoms in all body segments and joints among the participants. It consisted of two sections, Section A contained 40 questions to identify the body area causative of musculoskeletal problems. Section B consisted of 25 forced questions to identify any accidents, any functional impact at work or home, or musculoskeletal problems in the past seven days. The test-retest method showed NMQ reliability of up to 23% and validity of up to 20% based on clinical history [25].

2.2.2 Depression, anxiety, and stress scale - 21-questionnaire (DASS-21)

A self-report DASS-21 instrument was used to assess psychometric properties among enrolled participants. It consisted of 21 items to assess depression, anxiety, and stress, and in every sub-scale seven statements were asked against a five-point Likert scale (0 to 4), where 0 referred to “never”, 1 referred to “applicable to me to some extent”, 2 referred to applicable to me in good part or considerate degree” and 3 referred to “very good applicability to me” and 4 referred to “totally applicable”. Total of each sub-scale was calculated and multiplied by two to attain a minimum score of “zero” for low distress on sub-scale to a maximum score of 42 indicating high distress on sub-scale. Based on scores on sub-scales participants were categorized into normal, mild, moderate, severe, and extremely severe. DASS-21 is considered a highly reliable scale with validity and reliability between 81% –97% [26]. The cut-off points indicating the presence of mental health symptoms are 10 for depression, 8 for anxiety, and 15 for stress.

2.2.3 Medical outcomes study short form (SF-12)

SF-12 measure the level of HRQoL among participants in their daily life. It consists of possible 35 variables with choice indicators and measures total score (SF-12 total) out of 100 through the use of 12 items score, both for (1) physical component score (PCS), and (2) mental component score (MCS), where “0” indicate lowest score and “100” indicate highest. A higher SF-12 score suggests better HRQoL33. SF-12 proved to be a valid and reliable tool with Cronbach alpha value between 0.79 to 0.84 [27, 28].

2.3 Reliability and validity

The survey items were evaluated by a panel of four experts in educational technology and science or medical fields to assess the content validity. A pilot study was conducted with 15 dentists and the value of Cronbach alpha was calculated to be 0.79, which is acceptable.

2.4 Data analysis

The data were analyzed using SPSS software version 25.0. Descriptive statistics were used to measure frequencies or proportions and mean or standard deviation. To quantify the association between variables, multiple variable regression analysis was used to determine HRQoL as the dependent variable and its associated level with predictors or collected independent variables. A p-value less than 0.05 was considered statistically significant.

2.5 Ethical considerations

After the approval of the university institutional review board (IRB), approval #133/132/2020, participants were asked to participate in the survey.

3 Results

3.1 Demographics

Table 1 shows dentists’ general and psychometric health characteristics during the COVID-19 pandemic. A total of 269 participants completed a survey with a mean±SD age of 33.07±9.5 years with the majority (50.9%) of the participants being males. Participants’ mean±SD work experience was 9.52±8.75 years (ranging from 1 to 38 years) work experience. The majority of participants were general dentists (32%) followed by dental technologists (31.2%) and most of the participants (67.7%) were working in private practice. Participants psychometric health outcome measures demonstrated overall mild with a mean±SD score of 12.59±10.17, normal level of anxiety with a mean±SD score of 6.68±7.33, and normal stress mean±SD score of 13.24±10.33 on DASS-21 scale. Regarding participants’ HRQoL, a dentist during COVID-19 demonstrated moderately low HRQoL levels on the SF-12 scale with a mean±SD score of 59.54 (16.39). Overall PCS mean±SD score was 67.1±17.19, while the MCS mean±SD score was 54.51±20.27.

Table 1
Participants general and psychometric health related characteristics

Characteristic Mean (SD) or N (%)

Age 33.07 (9.5)

Gender Male 137 (50.9%)

Female 132 (49.1%)

Work experience (years) 9.52 (8.75)

Major Dental technology 84 (31.2%)

Allied dental 53 (19.7%)

General dentist 86 (32%)

Specialized dentist 46 (17.1%)

Cigarette smoking 79 (29.4%)

Waterpipe smoking 67 (24.9%)

Presence of medical comorbidities 29 (10.8%)

Weight change during COVID-19 Decreased 34 (12.6%)

Same 146 (54.3%)

Increase 89 (33.1%)

Health self-evaluation Bad 6 (2.2%)

Good 194 (72.1%)

Excellent 69 (25.7%)

DASS depression 12.59 (10.17)

DASS anxiety 6.68 (7.33)

DASS stress 13.24 (10.33)

Visual analog pain scale 2.91 (2.55)

PCS SF-12 67.1 (17.19)

MCS SF-12 54.51 (20.27)

SF-12 total score 59.54 (16.39)

Characteristic		Mean (SD) or N (%)
Age		33.07 (9.5)
Gender	Male	137 (50.9%)
	Female	132 (49.1%)
Work experience (years)		9.52 (8.75)
Major	Dental technology	84 (31.2%)
	Allied dental	53 (19.7%)
	General dentist	86 (32%)
	Specialized dentist	46 (17.1%)
Cigarette smoking		79 (29.4%)
Waterpipe smoking		67 (24.9%)
Presence of medical comorbidities		29 (10.8%)
Weight change during COVID-19	Decreased	34 (12.6%)
	Same	146 (54.3%)
	Increase	89 (33.1%)
Health self-evaluation	Bad	6 (2.2%)
	Good	194 (72.1%)
	Excellent	69 (25.7%)
DASS depression		12.59 (10.17)
DASS anxiety		6.68 (7.33)
DASS stress		13.24 (10.33)
Visual analog pain scale		2.91 (2.55)
PCS SF-12		67.1 (17.19)
MCS SF-12		54.51 (20.27)
SF-12 total score		59.54 (16.39)

n: number, SD: Standard Deviation. DASS: Depression, Anxiety, Stress Scale, SF-12 : 12-item Short-Form Health Survey, PCS: Physical Component Summary, MCS: Mental Component Summary.

3.2 Nordic musculoskeletal disorder questionnaire (NMQ)

Table 2 compares the prevalence of different body parts in the last 12 months and 7 days, and their associated functional limitations during the COVID-19 pandemic. Nordic scale results showed that participants were affected by the lower back with a percentage of 63.9% followed by shoulders with 57.2% in the last 12 months. Furthermore, in the last 7 days, the lower back and shoulders reported the highest percentage (45% and 36.4%) respectively. Lower back and neck reported the highest functional limitation affecting the activity of daily living with (32% and 25.7%) respectively.

Table 2
Prevalence of musculoskeletal symptoms and their associated functional limitations as measured by Nordic scale

Body part 12-Month 12-Month 7 days

symptoms Functional symptoms

Limitations

symptoms

n % N % N %

Neck 143 53.2% 69 25.7% 88 32.7%

Shoulder 154 57.2% 63 23.4% 98 36.4%

Elbow 39 14.5% 15 5.6% 20 7.4%

Wrists/hands 60 22.3% 22 8.2% 32 11.9%

Upper back 118 43.9% 53 19.7% 62 23%

Lower back 172 63.9% 86 32% 121 45%

Hips/thighs 58 21.6% 12 4.5% 36 13.4%

Knee 105 39% 44 16.4% 61 22.7%

Ankles/feet 55 20.4% 21 7.8% 40 14.9%

Body part	12-Month	12-Month	7 days
Neck	143	53.2%	69	25.7%	88	32.7%
Shoulder	154	57.2%	63	23.4%	98	36.4%
Elbow	39	14.5%	15	5.6%	20	7.4%
Wrists/hands	60	22.3%	22	8.2%	32	11.9%
Upper back	118	43.9%	53	19.7%	62	23%
Lower back	172	63.9%	86	32%	121	45%
Hips/thighs	58	21.6%	12	4.5%	36	13.4%
Knee	105	39%	44	16.4%	61	22.7%
Ankles/feet	55	20.4%	21	7.8%	40	14.9%

3.3 Depression anxiety stress scale (DASS21)

As demonstrated in Table 3, participants were also asked about the impacts of COVID-19 on their health, life routine, social life, and work. 11 statements were responded to with a Likert scale from 1 to 5 about work conditions and infection control during COVID-19. Table 4 shows participants’ average evaluation of work conditions and infection control.

Predictors of HRQoL during the COVID-19 lockdown were determined using multiple linear regression analysis. The regression model explained 53.8% of the variations (r2 = 0.538, F = 43.739, P < 0.001) in HRQoL. Depression (β= –0.76 [95% CI –0.92 to –0.59], P < 0.001), Nordic last 7 days’ musculoskeletal pain (β= –1.74 [95% CI –2.53 to –0.94], P < 0.001), Visual Analog Scale (VAS) (β= –1.25 [95% CI –1.95 to –0.55], P = 0.001), age (β= –0.53 [95% CI –0.6 to –0.41], P < 0.001) and demands on the family due to online education during COVID-19 (β= –2.01 [95% CI –3.51 to –0.51], P = 0.009) were negative predictors of HRQoL (Table 5). On the other hand, working place (β= 1.82 [95% CI 0.51 to 3.13], P = 0.007), gender (β= 0.59 [95% CI 0.36 to 0.99], P < 0.001), risk of infection in working environment (β= 1.08 [95% CI 1.01 to 1.19], P = 0.040), adequate work staff (β= 2.37 [95% CI 1.29 to 4.18], P = 0.023), and health self-evaluation (β= 4.01 [95% CI 0.35 to 7.67], P = 0.032) were significant positive predictors of participants.

Table 3
COVID-19 effect on participants health, social life, and life routine

Characteristic Mean (SD) or N (%)

Family conflict Decreased 137 (50.9%)

Same 132 (49.1%)

Increased 0 (0.0%)

Helping family and shopping time Decreased 24 (8.9%)

Same 63 (23.4%)

Increased 182 (67.7%)

Time needed for kids’ education Decreased 12 (4.5%)

Same 46 (17.1%)

Increased 76 (28.3%)

Have no schools’ kids 135 (50.2%)

Sleep Comfortable 182 (67.7%)

Uncomfortable or irregular 9 (3.3%)

Diet Unhealthy 31 (11.5%)

Sort of healthy 179 (73.2%)

Healthy 41 (15.2%)

Working hours/week prior to COVID-19 25.12 (8.25)

Working hours/week during COVID-19 7.57 (3.48)

Doing sport hours/week During COVID-19 1.59 (0.14)

Day sleeping hours 2.52 (0.94)

Night sleeping hours 6.41 (1.60)

Characteristic		Mean (SD) or N (%)
Family conflict	Decreased	137 (50.9%)
	Same	132 (49.1%)
	Increased	0 (0.0%)
Helping family and shopping time	Decreased	24 (8.9%)
	Same	63 (23.4%)
	Increased	182 (67.7%)
Time needed for kids’ education	Decreased	12 (4.5%)
	Same	46 (17.1%)
	Increased	76 (28.3%)
	Have no schools’ kids	135 (50.2%)
Sleep	Comfortable	182 (67.7%)
	Uncomfortable or irregular	9 (3.3%)
Diet	Unhealthy	31 (11.5%)
	Sort of healthy	179 (73.2%)
	Healthy	41 (15.2%)
Working hours/week prior to COVID-19	25.12 (8.25)
Working hours/week during COVID-19	7.57 (3.48)
Doing sport hours/week During COVID-19	1.59 (0.14)
Day sleeping hours	2.52 (0.94)
Night sleeping hours	6.41 (1.60)

Table 4

Participants average evaluation on work’s conditions and infection control using DASS-21 scale

Statement	Mean±SD
Family financially suffers	3.40±1.10
Family pressure due to online education	3.49±1.09
Occupational imbalance	3.97±0.89
Work pressure	3.07±1.1
Fears of infections	3.74±1.21
Difficulties to reach work	3.23±1.22
Difficulties in dealing with clients	3.45±1.11
Lack of supplies and consumables	3.12±1.20
Lack of infection control consumables	2.86±1.20
Pressure due to failure to complete therapeutic tasks	3.14±1.21
Financial pressure	3.51±1.18
Insecure regarding career’s future	3.48±1.25
Average of COVID-19 work conditions evaluation	3.29±0.74

Table 5

Multivariable regression analysis associated factors with health-related quality of life measured by SF-12 survey total score

Factor	β coefficient	95% confidence		P-value
		interval
Pressure on family due to online education during COVID-19	–2.01	–3.51	–0.51	0.009**
Nordic (musculoskeletal pain in the last 7 days)	–1.74	–2.53	–0.94	<0.001***
Visual Analog scale (VAS)	–1.25	–1.95	–0.55	0.001**
Depression	–0.76	–0.92	–0.59	<0.001***
Working place	1.82	0.51	3.13	0.007**
Age	–0.53	–0.6	–0.41	<0.001***
Gender	0.59	0.36	0.99	<0.001***
Risk of infection in working environment	1.08	1.01	1.19	0.04*
Adequate work staff	2.37	1.29	4.18	0.023*
Health self-evaluation	4.01	0.35	7.67	0.032*

P < 0.05, **p < 0.01, ***p < 0.001, COVID-19: Coronavirus disease 2019.

4 Discussion

This cross-sectional study aimed to study HRQoL and its predictors among dental team workers in Jordan during covid-19 pandemic times. We aimed to characterize the physical and mental health status of dental workers, and the effect of the pandemic and its stress on our participants and their families. Although the level of HRQoL was never studied among dental workers in Jordan, this study participants’ HRQoL during COVID-19 (measured by SF-12) is considered relatively low compared to the general adult population worldwide. The mean score of depression lies under the mild depression range and anxiety and stress under the normal ranges. The results of the study were different from those of the previous study [24], which indicated an increase in depression among dentists. However, as the study also indicated that the severity was highly dependent on the culture and social environment of the country, it can be said that COVID-19 was not as stressful in Jordan dentists as was in other studied countries. Another reason could be that Jordan was hit by the pandemic later than other countries.

The highest musculoskeletal pain during COVID-19 was experienced in low back pain and the functional limitation among a quarter of participants was in the neck. The highest felt symptom in the last week was experienced in the lower back. This is to the previous systematic review on dentists which states that there has been a high prevalence of low back pain in dentists due to their ergonomics, and posture during procedures and practices [26]. A recent study by Al-Hourani et al. [13] has also suggested similar results among dental technologists in Jordan.

During the COVID-19 lockdown, none of the participants indicated an increase in family conflict, on the contrary, 51% indicated that their conflicts decreased. Similarly, their helping family time increased during quarantine. Among the ones who had kids, indicated they had to give more time to kids for their education. The majority responded to having more comfortable sleep and a sort of healthy diet. They also indicated that their working time decreased during COVID-19 and had more night sleep. More than average believed that their family suffered financially and had the pressure of online education. The majority believed that they were experiencing occupational imbalance, fear of infections, insecurity for future careers, and difficulties in dealing with clients. Whereas, their work pressure remained almost the same. The HR-QoL was decreased with an increase in depression, musculoskeletal pain, and online education pressure. According to a study regarding work-life balance among healthcare workers in the UK, it was found that there was less concern due to child care and work-life balance, and more concern was related to lack of training opportunities, personal protective equipment, and fear of contracting the virus [28].

To summarize the existing evidence of ergonomic interventions for the prevention of Musculoskeletal diseases and pain (MSDs) among dental professionals. Four out of eleven studies were of high quality, and eight studies were focused on prevention strategies. However, in five out of those eight studies, prismatic spectacles or magnification loupes were the subjects of ergonomic interventions. The study found that there were positive effects of ergonomic interventions on all study outcomes. To prevent MSDs in professional dentists’ numerous ergonomic interventions were found to have a positive effect on the prevalence of MSDs and working postures. A review study by de Pablo [29] found that occupational stress on the oral healthcare providers’ (OHP) bodies is the consequence of them being vulnerable to MSDs. The study also observed that commonly dentists have neuromuscular inhibition, muscular imbalance, pain, and dysfunction. Whereas, worker-related musculoskeletal disorders WMSDs in OHPs are unavoidable. The study concluded that paying attention to occupational and individual risk factors, symptoms, and prevalence of WMSDs and implementing the recommended safety and health measures can enable a long and healthy career.

Furthermore, a study was conducted to elevate the efficacy of a newly developed evidence-based low back pain (LBP) management smartphone application, which used a double-blinded controlled trial where participants were randomly assigned either two groups that were an experimental group (EG) or a control group (CG). The result of this trial after six weeks of using the application showed that there was a significant decrease in ODI score and pain intensity and there is a significant increase in the physical component of SF-12. The study concluded that the use of the application can be effective in minimizing pain, disability, and quality of life in an office worker nonspecific to low back pain [13]. Additionally, mental health support and counseling must be offered considering the anxiety level amid any epidemic situation for dental team workers to enhance their mental health status and quality of life during future similar emergencies [30 –33].

4.1 Limitations

Our study has some limitations, as this was a cross-sectional survey-based study that provided a snapshot of the psychological distress among various specialties in dentistry. A longitudinal study would be more insightful in providing a complete picture of the effect of COVID-19 on the psychological health of dentists in Jordan. Our study has a small sample size (N = 269) and is considered a sufficient sample size based on power analysis calculations using Raosoft [34]. Still, future studies are required at the national level with a large sample size to understand and develop national guidelines that could improve the quality of life of dentists during any pandemic or unforeseen public health crises. The study was also prone to selection biases, as we used the snowball sampling technique and dentists who had spare time participated in the survey and we have no details of a dentist who did not participate in the study or filled out the questionnaire. Also, the majority of the participants were from urban areas of Jordan, while those technicians living in non-urban areas with possibly different health-related complaints during the pandemic were underrepresented. The use of recent technologies will also aid in the widespread distribution of survey questionnaires and the generation of quick responses from healthcare workers from both private and government sectors.

4.2 Future implications

This study estimated the impact of psychometric health-related parameters to examine the quality of life of dentists who worked during the COVID-19 pandemic and provide baseline data of the Jordanian dentist for future prospective studies. The study’s findings about dental healthcare teams’ quality of life amid COVID-19 offer a plan for crisis-specific support in Jordan. These findings inform precise interventions targeting depression, anxiety, stress, and physical strain, vital for dentists during crises. Adapting these programs could enhance the well-being of healthcare workers universally, addressing broader mental and emotional health concerns. This study lays a foundation for customizable initiatives and holds promise for improving the overall quality of life among healthcare professionals beyond dental care.

5 Conclusion

Our study concluded that the level of HRQoL among Jordanian dental specialists during COVID-19 was observed to impact levels of physical and mental well-being which negatively influence the quality of life. Predictive factors like depression, stress, anxiety, musculoskeletal health, and individual everyday quality of life significantly affect the HRQoL of dental specialists. Therefore, future monitoring strategies and guidelines development to assess mental health levels and their association with predictive factors among healthcare workers are required in terms of support and interventional programs to improve the well-being, productivity, and retention of dentists during the time of public health crises.

List of abbreviations

NMQ Nordic Musculoskeletal Disorder Questionnaire

SF-12 Short Form Survey of 12 Items

SARS-Cov-2 Acute Respiratory Syndrome Corona 2

DASS Depression, Anxiety, and Stress Scale

MCS Mental Composite Score

PCS Physical Composite Score

VAS Visual Analogue Scale

HRQoL Health-Related Quality of Life

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by Institutional Review Board at Jordan University of Science and Technology (approval number 133/132/2020).

Informed consent

Informed consent was obtained from all individual participants.

Conflict of interest

The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report.

Footnotes

Acknowledgments

N/A.

Funding

This study was funded by Jordan University of Science and Technology, Irbid, Jordan under grant number 20200381. The funding agency had no role in designing, conducting, or writing up the study.

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