Advances in Oral and Maxillofacial Surgery 3 (2021) 100141

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Advances in Oral and Maxillofacial Surgery

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Anxiety among Cameroonian dentists during the COVID-19 pandemic: A

cross-sectional web-based survey
Messina Ebogo a, *, Celestin Danwang b, Francky Teddy Endomba c, d
a
Department of Oral and Maxillofacial Surgery. Idrissa Pouye General Hospital, Dakar, Senegal
b
Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
c
Research Department, Medical Mind Association, Yaoundé, Cameroon
d
Psychiatry Internship Program, University of Bourgogne, 21000, Dijon, France

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To assess anxiety among dentists practicing in Cameroon during the coronavirus disease 2019 (COVID-
Anxiety 19) pandemic. We conducted a cross-sectional web-based survey, and used the Hamilton Anxiety Rating Scale
COVID-19 (HAM-A) to appraise anxiety symptoms and severity.
Cameroon
Results: Overall, 82 questionnaires were fully completed and retained for analysis. The mean age (standard de­
Dentists
viation) of participants was 30.2 (2.6) with 52 (62.2%) being male. The mean (standard deviation) HAM-A score
was 10.5 (4.6), with minimum and maximum values of 4 and 26/56. We found that 13 (15.8%) had moderate to
severe anxiety (with 11 having moderate symptoms and 2 having severe), and 69 (84.2%) had no, minimal or
mild anxiety. Participants working in health facilities with more than one dentist, where less likely to have
moderate/severe anxiety (OR: 0.22, 95% CI: 0.05; 0.78).

1. Introduction
According to daily epidemiological updates of the World Health
Organization (WHO), on January 15, 2021 the global count of corona­
virus disease 2019 (COVID-19) deaths crossed the “two million” mark
[1]. Specifically addressing the case of Africa, by January 23, 2021 the
Center for Disease Control and prevention (CDC) reported 3,421,417
confirmed cases, the Southern African region being the most impacted in
terms of morbidity and mortality [2]. In Cameroon, on January 24,
2021, we counted 29,617 cases for 462 deaths [3]. By these pandemic
times, health professionals are exposed to a greater risk of somatic
consequences via a higher risk of transmission, but also a greater risk of
psychological negative outcomes [4,5].
Previously published research works revealed high levels of psy­
chological distress related to the COVID-19 pandemic among health care
professionals including dental health care workers [6,7]. For instance, a
study assessing fear and anxiety among 650 dental care professionals
from 30 countries, revealed that 87% were afraid of getting infected
with COVID-19 from either a patient or a co-worker, and 90% were
anxious while treating a patient with cough or someone suspected to be
infected [6]. Similarly, a study on anxiety among Iraqi dentists reported
that more than 8/10 of them were anxious of catching COVID-19 [7];
and another one in Egypt showed that more than 9/10 of dental pro­
fessionals were afraid of becoming infected [8]. These higher rates
seems mostly linked to the fact that dentists usually work in close con­
tact of patients, and are exposed to aerosol and droplets splattering out
of these latter’s oral cavities [6,9].
Considering the ongoing progression of the pandemic in sub-Saharan
Africa [2]; and particularly in Cameroon [3], and the scarcity of studies
addressing the psychological impact of COVID-19 on dental practi­
tioners among sub-Saharan African settings, we undertook this study. It
aimed to appraise anxiety among Cameroonian dentists during the
COVID-19 pandemic.
2. Main text
2.1. Methods
We conducted a cross-sectional web-based survey between June 9th
and July 28th, 2020. Through a non-probabilistic sampling method, we
recruited consenting dentists practicing in Cameroon and registered at
the National Order of Dental Surgeons of Cameroon. Participants’
enrolment was realized through an anonymous and pre-tested online
form, which link was sent through social media and by emails. The

* Corresponding author.
E-mail address: wilfriedebogo@gmail.com (M. Ebogo).

https://doi.org/10.1016/j.adoms.2021.100141
Received 28 June 2021; Accepted 7 July 2021
Available online 9 July 2021
2667-1476/© 2021 The Author(s). Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Ebogo et al. Advances in Oral and Maxillofacial Surgery 3 (2021) 100141

questionnaire, available as supplementary file 1 (link: https://docs.goog Table 1

le.com/forms/d/1tYDUhMKT8HyaIzuWpBJpxWRmOSnlzDFbSP1rFYP Summarized characteristics of our study population.
Xq-0), was developed for this study and have not been published in a Whole sample
previous one. Incomplete forms, i.e., without the completion of the tool
N = 82
used to assess anxiety levels, as well as dentist who didn’t practiced
during the previous sixth months, were excluded from the analysis. n %

Automatically, individuals who agreed to respond to the form confirmed Age [Mean (SD)] 30.2 (2.6)
their agreement electronically. Since we worked on a population Gender
Male 51 62.2
without known presupposed health problems, the studied community
Region 0.0
vulnerability was medium. The harmful potential of the study was low Adamawa 19 23.2
and participants’ confidentiality was ensured through anonymization of Centre 27 32.9
the distributed form. This form was fragmented in three main sections. East 4 4.9
The first section provided a succinct description of the general objective, Littoral 17 20.7
North 4 4.9
indications on the form composition, and information about the confi­ Far North 6 7.3
dentiality (and anonymity) of the study. The second section was focused South 5 6.1
on general characteristics of participants including socio-demographic Working sector 0.0
profile and working practices (experience years, weekly working days, Public sector 61 74.4
Private sector 14 17.1
daily count of patients). The last section was dedicated to the assessment
Army 2 2.4
of anxiety, through the Hamilton Anxiety Rating Scale (HAM-A), a Confessional 5 6.1
longstanding and commonly used tool addressing anxiety symptoms/ Number of dentists inside the hospital 0.0
severity [10,11]. The scale consists of 14 items, each defined by a series 0 4 4.9
of symptoms, and measures both psychic anxiety (mental agitation and 1 35 42.7
2 43 52.4
psychological distress) and somatic anxiety (physical complaints related Mean number of patients treated by day 0.0
to anxiety) [10,11]. These 14 items are anxious mood, tension, Less than 5 50 61.0
insomnia, fears, intellectual, depressed mood, somatic (muscular), so­ At least five 32 39.0
matic (sensory), cardiovascular symptoms, respiratory symptoms, Number of working days per week 0.0
0 to 3 26 31.7
gastrointestinal symptoms, genitourinary symptoms, autonomic symp­
3 to 5 33 40.2
toms and behaviour at interview [10,11]. Each item is rated on a ≥5 23 28.0
five-point scale ranging from 0 (symptoms not present) to 4 (severe Number of years of practice 0.0
symptoms), with a total score range of 0–56, where [10,11]. The optimal Less than 5 50 61.0
HAM-A score ranges were: mild anxiety = 8–14; moderate = 15–23; At least five 32 39.0
Hamilton score 0.0
severe ≥24 (scores ≤ 7 were considered to represent no/minimal anxi­ <8 24 29.3
ety) [11]. 8 to 15 45 54.9
Statistical analyses were conducted using R version 4.0.2. The t-test 15 to 24 11 13.4
was used to compare means score between two categorical variables, ≥24 2 2.4
and analysis of variance (ANOVA) for more than two categories. The
proportions of participant in each defined class according to anxiety
minimal or mild anxiety (Tables 1 and 2). Notwithstanding the statis­
severity were compared with the Chi2 test or Fisher exact test when
tically unsignificant difference, the number of participants with mod­
appropriated. A univariate logistic regression was conducted to deter­
erate/severe anxiety was higher within those working in the public
mine factors associated with moderate/severity of anxiety. A multivar­
sector. Compared to their counterparts, the proportion of participants
iate logistic regression using a stepwise variable selection process was
with moderate/severe anxiety was lower among those working more
used to determine the adjusted odd ratio (aOR). Only variables signifi­
than one day per week (n = 3, 3.7% Vs n = 10, 12%). The highest
cantly associated with moderate/severe anxiety in the univariate anal­
proportion of respondent with moderate/severe anxiety was found in
ysis were included in the multivariate logistic regression. All point
the Centre region (6.1%).
estimates are given with their variances or confidence interval. A p-
In the univariate logistic regression, only the number of dentists in­
value < 0.05 was considered statistically significant.
side the hospital was found to be significantly associated with moderate/
severe anxiety. Indeed, compare to those working in hospital with one
2.2. Results dentist only, participants working where there was more than one
dentist where less likely to have moderate/severe anxiety (OR: 0.22,
2.2.1. General characteristics 95% CI: 0.05; 0.78) (see Table 3).
Overall, 82 questionnaires were fully completed and retained for Because only one variable was significantly associated with moder­
analysis. The mean age (standard deviation) of participants was 30.2 ate/severe anxiety in the univariate analysis, a multivariate logistic
(2.6) with 52 (62.2%) being male. Most of the responders were from the regression was not conducted.
Centre region (32.9%), Adamawa (23.2%), and littoral (20.7%). The
public sector was represented by 62 out of 82 participants. Thirty-three 3. Discussion
participants (40.2%) worked between 3- and 5-days days per week, and
32 (39.0%) see at least five patients per day. All the general character­ The present cross-sectional study intended to assess anxiety symp­
istics of our sample are depicted in Table 1. The mean (standard devi­ toms and severity through an online survey questionnaire. To our
ation) HAM-A score was 10.5 (4.6), with minimum and maximum values knowledge, it is the first one addressing dentists’ psychological state at
of 4 and 26/56. the time of COVID-19 pandemic in sub-Saharan Africa and by using a
validated assessment tool. Its findings revealed that nearly one Camer­
2.3. Prevalence of anxiety and factors associated with moderate/severe oonian dentist on seven had moderate to severe anxiety. It also high­
anxiety lighted that dental practitioners working in health facilities having more
than one dentist, were less likely to experience moderate/severe anxiety
In total, 13 (15.8%) had moderate to severe anxiety (with 11 having symptoms. Noteworthy, the younger age, the lesser number of
moderate symptoms and 2 having severe ones), and 69 (84.2%) had no,

2
M. Ebogo et al. Advances in Oral and Maxillofacial Surgery 3 (2021) 100141

Table 2 Table 3
Proportions of moderate/severe anxiety according to socio-demographic and Univariate logistic regression on factors associated moderate/severe anxiety.
working pattern data. Unadjusted
Severity of anxiety
n uOR 95%CI P-value
No/Mild Moderate/
Number of dentists inside the hospital 0.03a
Severe
No more than 1 39 (reference)
Overall N (%) N (%) P- More than 1 43 0.22 (0.05; 0.78)
valuea Age (years) 0.17
<30 30 (reference)
Total 82 69 (84.1) 13 (15.9) <0.001 ≥30 52 0.43 (0.12; 1.43)
Age (years) 0.20 Gender 0.5
<30 30 23 (28.0) 7 (8.5) Female 31 (reference)
≥30 52 46 (56.1) 6 (7.3) Male 51 0.66 (0.20; 2.26)
Gender 0.54b Region 0.5
Female 31 25 (30.5) 6 (7.3) Centre or Littoral 44 (reference)
Male 51 44 (53.7) 7 (8.5) Others 38 1.43 (0.43; 4.87)
Region <0.001 Working sector 0.64
Adamawa 19 18 (22.0) 1 (1.2) Private sector 21 (reference)
Centre 27 22 (26.8) 5 (6.1) Public sector 61 0.74 (0.21; 2.99)
East 4 3 (3.7) 1 1.2) Mean number of patients treated by day
Littoral 17 16 (19.5) 1 1.2) Less than 5 50 (reference) 0.57
North 4 3 (3.7) 1 (1.2) At least five 32 1.42 (0.42; 4.72)
Far North 6 4 (4.9) 2 (2.4) Number of working days per week 0.57
South 5 3 (3.7) 2 (2.4) <3 26 (reference)
Working sector 0.73b ≥3 56 0.7 (0.21; 2.55)
Public sector 61 52 (63.4) 9 (11.0) Number of years of practice 0.57
Private sector 21 17 (20.7) 4 (4.9) Less than 5 50 (reference)
Number of dentists inside 0.04 At least five 32 0.71 (0.21; 2.41)
the hospital
a
No more than 1 39 29 (35.4) 10 (12.2) Statistically significant; uOR: unadjusted Odds Ratio.
More than 1 43 40 (48.8) 3 (3.7)
Mean number of patients treated by 0.79
day
Scale (HADS) [21]. The previous papers explicitly focused on dentists’
Less than 5 50 43 (52.4) 7 (8.5) anxiety regarding COVID-19, revealed higher rates than ours. For
At least five 32 26 (31.7) 6 (7.3) instance, Mahdee et al. in an Iraqi sample of dentists, as well as Aly et al.
Number of working days 0.75b in an Egyptian population of dentists, respectively reported 88.7% and
per week
92.6% of anxiety and fear regarding the contamination risk [7,8]. This
<3 26 21 (25.6) 5 (6.1)
≥3 56 48 (58.5) 8 (9.8) inconsistency between our reports could be predominantly explained by
Number of years of 0.79 the fact that these publications didn’t reported the use validated eval­
practice uation scales [7,8]. Indeed, they principally used surveys conceived
Less than 5 50 43 (52.4) 7 (8.5)
specifically for the concerned study, with a consequent part of anxiety
At least five 32 26 (31.7) 6 (7.3)
appraisal through participants’ subjective feelings.
a
P-value of the Pearson chi2 test. The fact that in our study dentists working alone in a structure were
b
Fisher exact test. significantly more anxious than those working with at least one
colleague, could be explained by two main factors. On one hand we
experience years, the region of origin as well as the type of working might mention professional isolation, and the miss of a counterpart who
sector, were not associated with greater proportions of moderate/severe share the same experience, in order to ensure a mutual support [4,22].
anxiety cases. On another hand, we could evoke more stressful conditions of work, and
We found an upper rate of anxiety than the one for African pop­ the lack of supply possibility in case of exhaustion.
ulations, reported at 5.3% (3.5–8.1%) [12]. This could be chiefly related
to the fear of contamination, itself sustained by the fact that the primary 4. Conclusion
route of transmission of the novel coronavirus 2019 is through droplets
and aerosols [6,9,13]. Our rates could be worse in structures dedicated This survey aimed to assess in which extent dentists practicing in
to dental care and lacking personal protective equipment, especially Cameroon were anxious during this COVID-19 pandemic time, and
considering the reported want of preparedness of dentists to face highly revealed high proportions of moderate/severe anxiety, especially for
infectious respiratory diseases [14,15]. As other participating factors those working alone in a health facility providing dental care. It impli­
regarding anxiety among dentists, we have the negative impact of the cates a particular attention regarding this population, and calls to un­
pandemic on consultation rates, and thereby economic downturn dertake other studies for the confirmation (or not) of our findings and/or
[16–19]. the appraisal of long-term outcomes.
Our proportions of HAM-A scores ≥14 was higher than the one re­
ported by Lu and colleagues [20]. Indeed, in a study assessing psycho­ Limitations
logical status of medical staff members in a Chinese setting, they found
that 2.9% had scores ≥14/56 [20]. We also had a higher mean of HAM-A This study presents some limitations, including the sampling tech­
score than the one they reported (10.5 ± 4.6 Vs 4.7 ± 6.2) [20]. This nique which was not probabilistic, the small sample size, and the
difference might be related to the large one of our sample sizes (82 Vs potentially rapid change in mindsets with the evolution of the pandemic.
2042) [20]. A recently published paper addressing anxiety and depres­ Therefore, our results should be interpreted with caution.
sion associated with the management of COVID-19 among healthcare
workers in Cameroon revealed that 41.8% had moderate or severe Acknowledgments
anxiety [21]. The dissimilarity of their findings compared to ours might
be due the ones in sample sizes and tools used to assess anxiety, The authors would like to thank all the dentists who accepted to
considering the fact that they used the Hospital Anxiety and Depression participate to the study by responding to our survey.

3
M. Ebogo et al.
Abbreviations
COVID-19 Coronavirus disease 2019
HAM-A Hamilton Anxiety Rating Scale
Supplementary files
Supplementary file 1: English version of the survey’s form used for
data collection.
Disclosures
Ethics approval and consent to participate
The first section of the study form contained clear and concise in­
formation about the aim of the study, the main author and the structure
of the form. Automatically, individuals who agreed to respond to the
form confirmed their consent electronically. Indeed, in the first page of
the form, it was precise to participant that “by clicking on the area
allowing access to the following section of the questionnaire, they are
giving automatically their consent”. Since we worked on a general
population, the studied community vulnerability was medium. The
harmful potential of the study was low and participants’ confidentiality
was ensured through anonymization of the distributed form.
Funding
No funding was available for the study.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ME: Study conception, data collection, CD: Method conception, data
analysis, FTE: Drafting of the manuscript, All the authors approved the
final version of the manuscript before its submission.
Availability of data and materials
The datasets used and/or analysed during the current study are
available from the corresponding author on reasonable request.
Consent for publication
Not applicable.
Advances in Oral and Maxillofacial Surgery 3 (2021) 100141
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