key: cord-0796791-fbl6c5tc
authors: Generali, Luigi; Iani, Cristina; Macaluso, Guido Maria; Montebugnoli, Lucio; Siciliani, Giuseppe; Consolo, Ugo
title: The perceived impact of the COVID‐19 pandemic on dental undergraduate students in the Italian region of Emilia‐Romagna
date: 2020-12-14
journal: Eur J Dent Educ
DOI: 10.1111/eje.12640
sha: 421d4e814b3617f6434bd37e88d8cc3bb9342a5a
doc_id: 796791
cord_uid: fbl6c5tc

INTRODUCTION: The outbreak and diffusion of the novel SARS‐CoV2 coronavirus have caused an emergency status in the dental education system. MATERIALS AND METHODS: An anonymous survey composed of 34 questions was delivered to students of the Master Degree Programme in Dentistry and Dental Prosthodontics of the Universities of Emilia‐Romagna, the fifth Italian region most affected by the pandemic. The psychological impact of COVID‐19 was assessed by means of the Generalised Anxiety Disorder‐7 scale (GAD‐7). Numerically recoded data were analysed using the Analysis of Variance (ANOVA), whilst to investigate the association between quantitative variables, the Pearson correlation coefficient (R) was computed. RESULTS: The questionnaire was completed by 399 students (75%) out of 532. Most students experienced difficulties in working at the thesis during the COVID‐19 emergency. For over half of them, online teaching could only partially replace traditional face‐to‐face lessons. The negative impact on the study career was judged as particularly high by sixth‐year students. Clinical training activities were considered as exposing to the risk of contracting COVID‐19 infection by the majority of the students. The level of concern of contracting COVID‐19 infections during future university activities was positively correlated to risk perception related to clinical training. CONCLUSION: The results of this survey could be used to train students to a correct risk assessment. Students reported experiencing concern whilst thinking of COVID‐19 and 6.5% of them showed symptoms related to high levels of anxiety. These data may guide Universities in trying to reduce students' anxiety by means of correct communication strategies.

Coronavirus disease 2019 (COVID- 19) is an infectious disease caused by a newly discovered coronavirus that originated in Wuhan, the largest metropolitan area in China's Hubei province, in December 2019. 1 The virus that causes COVID-19 was initially called as 2019-nCoV and, subsequently, the task of expert of the International Committee on Taxonomy of Viruses (ICTV) termed it the syndrome coronavirus 2 (SARS-CoV-2). 2 Since the Covid-19 outbreak spread rapidly in several countries, the World Health Organisation (WHO) declared a pandemic public health emergency on 11 March 2020. 3 As of November 1 2020, they have been confirmed more than 48 196 862 cases and 1 226 813 deaths globally. 4 The common human to human transmission routes of COVID-19 are represented by direct transmission (droplets release through exhalation, cough or sneeze) and contact transmission (contact with contaminated surfaces and oral, nasal and eye mucous membrane). 5 The main symptoms are represented not only by fever, dry cough, shortness of breath and myalgia 6 but also anosmia, ageusia, headache and, in few cases, diarrhoea have been reported. 7 The incubation period of COVID-19 has been estimated to be 1-14 days 8, 9 ; it has been reported that even asymptomatic people can spread the virus, 10 and, in this way, they may be fuelling the spread. Given the routes of transmission, dental professionals are at high risk of contagion due to frequent exposure to saliva, blood and aerosols and droplets production during the majority of dental therapies. 11 Particularly, aerosols and droplets have a small size and they can remain in the air for a long period of time before settling on environmental surfaces of the dental setting or entering in the respiratory tract through inhalation. 5 Italy has seen a rapid expansion of the COVID-19 disease and, to date, have been confirmed 935 104 cases and 41 394 deaths. 4 It is the eleventh country worldwide and the fifth in Europe by number of contagions and the sixth country in the world and the second in Europe, after the United Kingdom, to have the highest official numbers of deaths. 4 At the time of the initial outbreak of the pandemic, northern Italy was mostly hit, and the Emilia-Romagna region was the third Italian region most affected by the pandemic. 12 As of 23

February 2020, all the Italian Schools and Universities suspended teaching, training and laboratory activities and closed all facilities such as libraries and study rooms 13 in order to avoid direct contacts between persons and to minimise the transmission between persons of different areas. 14 In particular, since dentists and consequently dental students and dental chairside assistants were classified in the very high-risk category because of the potential of exposure to coronavirus through aerosol-generating procedure, 15 all Dental Schools in Italy suspended clinical and preclinical activities except for dental emergencies, that could not involve students. Lectures, exams and graduation sessions were organised through distance education and even the training activities were supplied with e-learning methods such as complex clinical cases discussion, seminars and journal club.

The continuous spread of the pandemic, the restrictions imposed by the government with the DL 23/02/2020, 13 along with the delays in the preparation of research theses due to the closure of dental clinics and laboratories were expected to have a negative impact on undergraduate students, which could experience higher levels of anxiety and stress. Besides, Dental Schools had to manage the students' increasing anxiety related to the resumption of teaching and clinical activities 15 and the modified perception of the risks associated with dental practice. It was therefore important to gain an insight on the impact of COVID-19 on students' perceptions and psychological state. Based on these considerations, the purpose of this study was to investigate the perceived impact of the COVID-19 pandemic on the career of dental students, the emotions and concerns following the spread of the epidemics and the restrictive measures introduced by the Italian government, along with the students' level of awareness about COVID-19, the level of concern of being infected during daily and university activities (ie, teaching and training) and their perception of the likelihood of infection during clinical activities for dental practitioners and patients. Our analysis was focused on the students enrolled in the Universities of the Italian region Emilia-Romagna, that has been particularly hit by the pandemic. 12

The target population consisted of the students enrolled in the Single Cycle Master Degree Programme in Dentistry and Dental Prosthodontics of the Universities of Modena and Reggio Emilia, Parma, Bologna and Ferrara. The total number of students was 532 and 399, whilst (75%) of them completed the survey. Given this sample size, the margin of error with a confidence level of 95% was 2%.

Data were collected by means of an online structured anonymous survey composed of 34 questions. The survey was created using the free-access Google Forms application, and the link to the online survey was sent through Email by the administrative offices to all students. The survey took approximately 5 minutes to complete. Data were collected in the time period from 21 April to 5 May 2020.

The survey was composed of six sections ( Table 1 ). The first section included questions aimed at gathering demographic data (age, sex, region of residence). The second was composed of questions aimed at gathering information related to the course of study (study year, number of exams to be taken to conclude the study course, completion of clinical traineeship hours), and at assessing whether students were working at the master thesis before COVID-19 outbreak and the entry into force of the DL 23/02/2020. 13 For those who responded "yes," further questions TA B L E 1 The survey administered to dentistry and dental prosthodontics students level of concern about contracting COVID-19 during daily activities, the level of concern about other family members contracting COVID-19 during daily activities, precautions and risk prevention measures used during daily activities, the perceived likelihood of contracting COVID-19 during clinical internships and university lessons and the level of concern of contracting COVID-19 during these activities. Furthermore, this section included questions assessing the students' perception of infection likelihood for dentists and patients during dental services, which measures they believed could prevent the infection during dental services, which personal protective equipment (PPE) will be necessary to use in the future to prevent the infection during clinical activity. Finally, they were asked whether they had been thinking about changing degree course in the preceding 2 weeks.

The sixth section was aimed at assessing the psychological reactions to COVID and included questions regarding the feelings and emotions experienced by students whilst thinking at COVID-19 outbreak. We also assessed the presence of symptoms of anxiety by means of the Generalised Anxiety Disorder 7-item (GAD-7) scale, 16 which is commonly used to assess the presence of general anxiety symptoms across various populations and settings. Specifically, we included seven items assessing how often, considering the last 2 weeks, individuals had been bothered by the following problems: (a) feeling nervous, anxious or on edge; 32 

The survey was anonymous. Responders received the link to the survey by email and accessed it directly by clicking on the link. At the beginning of the survey participants were informed that their participation was voluntary, their responses were anonymous, and that they could drop out at any time. Then they were explicitly asked if they wanted to participate in the research study before starting the survey.

Data were analysed using the SPSS version 26.0 statistical software.

Descriptive statistics were applied to calculate frequencies and percentages, and the independence chi-square (χ 2 ) test was applied to assess the association between variables.

For the questions with the following possible answers "not at all," "a little," "moderately," "a lot" and "extremely," response categories were assigned a score ranging from 0 to 4 (0 = "not at all," 4 = "extremely"). For the question, "Which of the following emotions (fear, anxiety, threat, concern, sadness, anger) do you feel when thinking about the Coronavirus?" response categories were assigned a score ranging from 0 to 4 (0 = "I do not feel it," 4 = "I feel it intensely").

For each of the 7 items of the GAD-7 scale, we assigned the scores 0, 1, 2 and 3 to the response categories "not at all," "several days,"

"more than half the days," and "nearly every day", respectively. The scores for each item were then summed to obtain a total score ranging from 0 to 21. Scores from 0 to 4, from 5 to 9, from 10 to 14 and from 15 to 21 are indicative of minimal, mild, moderate and severe anxiety, respectively. Numerically recoded data were analysed using the Analysis of Variance (ANOVA). When necessary, post hoc multiple comparisons were performed using the Bonferroni procedure.

Furthermore, to investigate the association between quantitative variables, we computed the Pearson correlation coefficient (R). A p value of less than .05 was considered as statistically significant.

Of the total responders, 56.9% (n = 227) were females, 43.1% 

Of the total number of responders, 18.3% (n = 73) were first-year, 11 .5% (n = 46) were second-year, 16 .3% (n = 65) were third-year, 16 .5% (n = 66) were fourth-year, 16% (n = 64) were fifth-year and 20.8% (n = 83) were sixth-year students, whilst 0.5% (n = 2) were students who had not passed all the exams within the prescribed period of time ("fuori corso" students).

The For 55.1% (n = 220) of the students, COVID-19 emergency will change for the worse the way they will be trained for their future career. Significant differences were found amongst years of study, 

for 96.5% (n = 385) of students, and by touching contaminated objects and bringing hands to mouth, nose and eyes for 94.5% 

70.2% of students knew someone, either an acquaintance or more (62.7%, n = 250) or a relative or more (7.5%, n = 30), who con- F I G U R E 2 Distribution of the responses, in percentages, to the question "In your opinion, can COVID-19 emergency have a negative impact on how you will be trained for your future career?"

As regards the emotions experienced when thinking about COVID-19, students mostly reported to feel concern and sadness ( Table 2) .

As regards concern, 33.1% (n = 132) reported to feel it moderately, whilst 23.8% (n = 95) reported to feel it quite intensely. Only 7%

(n = 28) felt concern intensely. As regards sadness, 30.3% (n = 121)

reported to feel it moderately, 21.3% (n = 85) quite intensely and 11.5% (n = 46) intensely. The Chi-square test indicated differences between year of study for concern (χ 2 = 33.26, df = 20, p < . The GAD-7 score was positively correlated with the reported levels of fear, anxiety, concern, sadness and anger (ps < 0.01). The strongest correlations were with the anxiety (r = 0.54, p < .001) and

concern (r = 0.42, p < .001) levels. It was also positively correlated with the levels of concerns of contracting COVID-19 during daily and university activities and the levels of concern about family members contracting COVID-19 and with the perceptions of risk likelihood.

To date, little has been published that focused specifically on the perceived impact of the COVID-19 pandemic on dental undergraduate students. 14, 15, 17, 18 The results of the present study give an insight on the impact of COVID-19 on dental students attending the four universities of the Emilia-Romagna region, one of the Italian regions that, during the first outbreak of the pandemic, was amongst the most affected. that online teaching could replace traditional face-to-face lessons.

Indeed, online delivery of learning may not replace clinical instruction provided within dental schools. Moreover, as said, the transition from face-to-face to online lessons occurred quite fast in reaction to the restrictions imposed by the pandemic outbreak, and faculty members mostly adapted their courses to the new modality, without having the time to redesign them. In the case the emergency situation will protract or reoccur in the next months, degree courses will have to be carefully redesigned to exploit all the potential of online teaching and to assure a high level of effectiveness of teaching.

Importantly, the negative impact of COVID-19 on the study career was judged as moderate to extreme by the majority of the responders, whilst it was judged as low by only 28.8% of the responders. Importantly, the number of students who judged it as ex- 20 and it may derive from the assumption that dentists are more exposed to the risk of contracting the virus due to the continuous activity in which they perform therapies on many patients every day, whilst patients visit the dentist only for a few appointments. Consistently, studies on previous outbreaks of similar infections such as the severe acute respiratory syndrome (SARS) showed that exposed healthcare workers experienced fear of getting infected whilst treating an infected patient and of infecting family members. [24] [25] [26] As indicated by recent studies, the COVID-19 pandemic has caused fear and anxiety not only amongst healthcare workers but also amongst the general population. 27 Due to the nature of dental treatment procedures, dental patients may be particularly concerned of being infected and this may lead to delays in seeking treatment or even in avoiding necessary treatments. Dental practitioners may adopt operational protocols to reduce the risk of contagion for themselves and patients. Since it has been widely established that the primary route of transmission of COVID-19 is through droplets and aerosol 29 and students showed to be aware of this, the majority of them considered as necessary during procedures generating aerosol the use of several PPE: FFP2 or FFP3 respiratory masks, 30 protective glasses/face shield, disposable gown and cap. These protection systems protect the dentists from contracting the virus, but they are also likely to help reducing stress levels.

Measuring anxiety by the means of self-report questionnaires is useful 31 and has been already performed amongst dental practitioners and patients. 20, 32 When thinking of the COVID-19, most of the students reported feeling light-to-moderate levels of fear, anxiety, concern, sadness and anger. Only small percentages reported to experience those emotions in an intense way. Overall, only 6.5% of the responders showed a score to the GAD-7 scale indicative of a severe level of anxiety, whilst the majority of them showed minimal to mild levels of anxiety. These anxiety levels are slightly lower than those found in the survey administered to Italian dentists working in the same geographical area. 20 The levels of anxiety found in our study may be due to two main reasons. First of all, COVID-19 mortality rate varies with age. As of 17 March 2020, the case-fatality rate in the age range of our responders (18-44 years) was less than 0.6%. 33 Second, in the time period the survey was administered the number of deaths in Italy was already decreasing. It should be, however, noted that using the same scale to assess anxiety levels amongst medical students in China, Cao et al 34 reported that 21.3% of the students were experiencing mild anxiety, 2.7% were reporting moderate anxiety, and only 0.9% were suffering from severe anxiety. Importantly, in our survey, the GAD-7 score 16 was higher amongst first-and sixth-year students and was strongly associated with the level of concern of contracting COVID-19 infection during daily and university activity, the level of concern for family members getting infected and the perception of risk for themselves, for dentists and for patients.

To conclude, students perceived the COVID-19 emergency as having a negative impact on their study career and on how they will be trained for the future career. The negative impact on the study career was judged as particularly high by sixth-year students mostly 

The Authors would like to thank all the students at the Universities of Modena and Reggio Emilia, Parma, Bologna and Ferrara -Italy.

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The data that support the findings of this study are available from the corresponding author upon reasonable request.

The authors have no conflicts of interest to disclose.

https://orcid.org/0000-0003-3764-7046Guido Maria Macaluso https://orcid.org/0000-0003-2203-3092