Impact of COVID-19 Outbreak in Dental Service Utilization Reported by Patients Visiting a Tertiary Care Centre: Mixed Quantitative-qualitative Study

Background: COVID-19 poses a major public health calamity. Its wider impact on health service utilization is yet to be studied. The study aims to assess dental problems faced by patients during the COVID-19 outbreak and the possible reasons in failing to seek dental care Methods: A cross-sectional quantitative-qualitative design was employed to assess the outcomes among patients reporting to a tertiary care centre. Participants were selected by convenient sampling and interviewed using structured questionnaire. Responses were transcribed, translated and coded before analyzing for the themes by thematic analysis. Quantitative component of the study was analyzed by descriptive and inferential methods. Result: were grouped as of transmission, lack of and lockdown, unavailability misinformation, lack communication from hospital regarding and treatment by the hospitals.


Background
Corona Virus Disease of 2019 (COVID-19) has been declared a pandemic situation by the Director-General of WHO on March 11, 2020.(1) Current evidence suggest that COVID-19 virus is primarily transmitted through respiratory droplets and contact routes. Droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (e.g., coughing or sneezing). Thereby, this increases risk of having his/her mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. Airborne transmission may be possible in speci c circumstances and settings in which procedures or support treatments that generate aerosols are performed.(2) Unique characteristics of dental procedures lead to a large number of droplets and aerosols generated. (3) The standard protective measures in daily clinician work seem to be ineffective in halting the spread of the virus. Recent observations have hinted that even patients with asymptomatic COVID-19 can be carriers of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This has posed an extreme challenge to identify and quarantine such patients. Dentists are, therefore, required to undertake stringent personal protective measures for all cases and avoid or minimize operations that produce droplets or aerosols. For areas of COVID-19 spread it has been recommended that nonemergency dental practices be postponed. (4) United States Centre for Disease Control and Prevention (CDC) recommends postponing elective procedures, surgeries, and non-urgent dental visits, and prioritize urgent and emergency visits and procedures during the outbreak. (5) American Dental Association (ADA) has urged the dental clinics to treat only emergency patients. The recommendations have been made to screen for dental emergencies using tele-dentistry or other remote modalities.(6) WHO, meanwhile, has emphasized on proper personal protective measures for healthcare professionals during the outbreak. (7) In the light of these events, the non-urgent dental services were halted all over the country. The healthcare centres have halted their regular out-patient resources and limited their services to keep the scarce resources in standby for any unforeseen events. A major tertiary care centre in Eastern Nepal has suspended all non-emergency outpatient procedures citing the situation. However, treatment requiring urgent care is still available following strict protocol. Besides these, alternative forms of treatment modalities like tele medicine and helpline consultation services were made available to the public.
The outbreak has resulted in many emergency measures taken by governing states. Limiting social contact through enforcing lockdown measures have resulted in decreased public mobility. Stringent con nement measures for general public in high risk areas has shown to have potential to slow down the spread of COVID-19. (8) Other evidence also support the idea of using a combination of containment and mitigation activities with the intention of delaying major surges of patients and levelling the healthcare demand for controlling the outbreak.(9) Moreover, lack of adequate Personal Protective Equipment (PPE) and safety measures at tertiary care centres, as mentioned earlier, have resulted in closure of regular outpatient services leading to substantial decrease in patient turnover at dental departments. These resulting measures can have a signi cant impact in seeking dental care. The impact of such measures has not been assessed till date, Guo et al (10) in China have demonstrated that COVID-19 epidemic had a strong in uence on emergency dental services with the proportion of dental and oral infection raised from 51.0% of pre-COVID-19 to 71.9% during COVID-19, and dental trauma decreased from 14.2-10.5%. It is worthwhile important to generate evidence on the impact that such measures can have on dental care need so that recommendations can be drawn to anticipate and prepare for such incidences in the future.
This study intends to assess perceived unmet dental care needs during COVID-19 outbreak among patients visiting a tertiary care centre in Eastern Nepal and assess the dental problems faced by patients and possible reasons of the patients in failing to seek dental care during the outbreak using a mixed design approach.

Study design, setting, and participants
The study used hospital based Cross-sectional mixed quantitative-qualitative study design. Sample size was calculated with prevalence of 50% which gives maximum sample size (11) and adjusted for nonresponse to 108. All patients above 18 years of age reporting to Dental help desk at College of Dental Surgery (CODS), BPKIHS (tertiary care centre) for orofacial complaints were included in the study using convenience sampling. Participants were requested by the interviewer to enrol into the study. None who were approached declined to participate. Interviewer introduced himself and his credentials to the participants and read out the Participant Information Sheet explaining the study goals before interview. The participants volunteering to participate were interviewed in person alone at a separate desk in dental help desk. Interviewer was conducted in person alone and maintaining personal protective etiquettes to ensure personal and patient safety. The data collection was conducted from July, 2020 to August, 2020.

Study variable
The questionnaire had two components: quantitative and qualitative. The participants were interviewed by a single male investigator (UG) to elicit their response on both components. The responses on quantitative component were obtained by closed ended structured questionnaire. Responses on predictor variable of dental service utilization in the past and participants belief on regular dental visit were assessed using single questionnaire each. A questionnaire, adapted from Chae et al (12) and modi ed, was used to assess outcome variable of interest on perceived unmet dental care need by asking whether they were unable to seek dental treatment. Whereas, the responses for qualitative component were obtained, using structured questionnaire, from participants who responded to have been unable to seek dental treatment due to COVID-19 outbreak. For the same, a guide with two open ended questions constructed by the investigators were used. Responses were obtained for dental problems faced during the outbreak and reasons for being unable to seek dental care. The questionnaires can be found in additional le [Additional le 1].
The questionnaires were translated into Nepali language by standard WHO translation technique. Questionnaires were examined for face validity by experts in the related eld. The responses were recorded verbatim in a notebook by the interviewer. The interview lasted for maximum of 15 minutes. The recorded transcript from the participants were, then, read back to them to ensure respondent validation. Field summary notes were also included. A wide range of responses was incorporated to ensure not including a single opinion. (13) The responses were, later, translated into English for further analysis. The transcripts were read to generate initial codes by the study team. All investigators then compared the themes, and re-examined the data to develop consensus Data from questionnaires were entered in Microsoft Excel and exported to Statistical Package for Social Sciences software (SPSS) Version 11.5 software for statistical analysis. Descriptive analysis and inferential statistics using Chi-square test was done for assessing quantitative component. Level of signi cance was considered at p < 0.05. The analysis of qualitative component involved qualitative description approach with thematic analysis. Analysis ensured the con dentiality and safeguard of identity of the participants. The responses were manually coded and theme were generated from the responses obtained.

Quantitative component
Mean age of the participants was 43.7 years (SD: 16.1). All participants were included in the analysis. Of the 108 participants, 65 (60.2%) were female and 24% of the participants (n = 26) were illiterate. Most of them (63%) reported not having had an oral examination in the past year. Another majority (62%), 67 of 108, reported they needed dental care but couldn't receive due to COVID 19 outbreak. Meanwhile, only half of the participants believed that regular dental check-up is necessary.
The characteristics of participants classi ed across different study variables on the basis of their response is shown in Table 1. Thematic analysis of the data from interview generated three themes for perceived dental problems during COVID 19 outbreak while seven themes were generated for reasons for inability in seeking dental care during the COVID-19 outbreak.
Pain is the major problem A major dimension of dental problem faced by the participants during COVID 19 outbreak was 'toothache'. Some participants reported having mild pain whereas other reported have progressive to severe toothache. Not all of them reported developing pain suddenly. Most of them reported having slightest of hints that something was problematic. A female student conveyed her sentiment about pain: "I develop severe toothache whenever I eat anything cold. Also, the tooth gets broken down when I chew from that side." However, the symptoms reported by all participants was not sudden in onset. Some reported having noticed some problem beforehand before they were troubled by the pain as another housewife reported: "I had noticed a decayed tooth and wanted to get treatment for long… but now it started to pain suddenly". An adult from Dharan was recorded saying: "there was a wound inside mouth; had been under medication for it… pain started to be unbearable since few days".
Another middle-aged adult described his suffering as: "there was swelling in the gums; pain, however, started few days back". Similar to him, pain was often reported with other symptoms by other participants as well. An elderly woman mentioned: "huge swelling in face was present... discharged pus inside the mouth. (I) Decided to come after pain became unbearable". This highlighted how pain was the leading factor to determine the patient's urge for seeking dental care despite prevalence of other problems. Similar reports were made by other participants as well. Another male student mentioned: "… had a tooth broken while playing… (it) was not problematic but now started having pain and swelling for few days".
Participants also reported seeking medications as a measure of pain relief. A young clerk mentioned her situation as: "… toothache for 3 days; been taking 'brufen' for the same… since then there was no pain; pain is now only occasional while chewing". Another male reported: "pain was there since few months; been taking medication since then but doesn't seem to work now". Pain was also reported by participants who were under treatment before the pandemic. Another participant explained his scenario as: "(I) was undergoing RCT for a painful tooth but now I've been experiencing pain since few days". A housewife mentioned: "I was undergoing treatment in lower right back tooth… so wanted to come here for the same".

Consequences from pain
There seemed to be negative sequelae from pain in reports made my several participants. A female was recorded reporting her frustrations as: "... couldn't sleep due to severe toothache since few weeks. I had to take pain relieving medications for the same". Alike her, several mentions regarding impact of pain on daily activities were reported by other participants. Another housewife recorded saying: "Painful tooth has made it di cult (for me) to have food and proper sleep". Another participant went on to state that "severe pain in the tooth; sometimes there is headache; makes it di cult to do anything".
Perceived urgency of treatment for other causes However, not all the participants reported having faced pain as the major complaint. A rather young housewife was reported saying: "there was swelling in gums with toothache; now it started to discharge pus; thought it could turn out to be cancer". A mid aged adult reported "sharp fractured tooth causes discomfort" as the reason for wanting to seek treatment. Another adult participant reported: "there is a broken tooth; sometimes it turns sensitive". An illiterate housewife reported: "My tooth lling fell off … di culty in having food".
Lack of knowledge on oral health was re ected in reports made by few participants as they insisted on having desire to get their tooth removed and hence wanted to come to the dental hospital. An elderly mentioned: "… developed decayed tooth… wanted to get the tooth removed". Another adult female reported: "… wanted to remove my teeth". The nature of perceived need was not same for all participants as illustrated by response from an illiterate elderly male as: "(Facing) very di cult to have food… had all my teeth removed… wanted to get new set of teeth".
The Illustrative quotes from participant interviews regarding dental problems faced by patients during the COVID-19 outbreak is given in Table 2 in additional le [Additional le 2].
Qualitative component for reasons for inability in seeking dental care during the COVID-19 outbreak While describing their problem faced during the outbreak, the participants responded to question on the reason for not being able to seek treatment through variety of responses. Lack of service availability due to closure of hospital was considered as the major reason for being unable to seek care by majority of the participants.

Lack of transportation services and lockdown
Few of the participants reported having problem with assessing the transportation facilities. An elderly male mentioned: "No transportation facility was available; couldn't hire an ambulance by myself to come here; came here today by accompanying another patient with severe condition in an ambulance".
Misinformation about hospital services were reported by few participants. This misinformation seemed to have spread through the participants own relative as an elderly housewife mentioned: "they told hospitals were closed, all my relatives".

Lack of communication from hospital regarding its services
Most of them seemed to be unaware about the urgent care services that were in function despite the closure of general outpatient services. A housewife explained the reason as: "didn't know hospitals were open… so stayed at home taking 'brucet'… came here as soon as I knew OPD (out-patient department services) was open". Another elderly housewife reported similar reason: "(I) thought hospitals were closed… so didn't come". The responses hinted that patients decided for hospital visit after they were assured that treatment was available. A female participant reported: "(I) Didn't know if services were available; a neighbor informed me that treatment is available now... so I came here".

Deferring of treatment services
Few participants even reported looking for alternate sources of treatment but were largely deprived of services. A housewife reported: "Didn't know ghopa (this hospital) was open… went searching for private clinics but (they) were of no use". Another illiterate participant from a rural area mentioned: "couldn't come due to lockdown; went to local health post but treatment was unavailable there; so, waited for few weeks". A literate male participant even reported being denied treatment by private clinics as he stated: "Tried to visit the clinic where treatment was done before but they refused to do anything; came here in a hope something will be done for the tooth". A handful number of respondents, from the response, re ected their knowledge regarding additional patient services like telemedicine and helpline being conducted free of cost by the institution. However, some even responded to have relied on the suggestions received through telephone helpline services. An adult participant stated: "… had a problem but didn't want to come due to corona; relied on helpline for suggestion but then doctor instructed me to come".

Fear of transmission
Another majority of the participants cited their fear of coronavirus for seeking dental treatment. A young housewife mentioned: "Was very afraid to come outside of home; everyone said how danger corona is". Some believed that visiting hospitals during the pandemic might expose them to undue risks of COVID 19 as "fear of going to the treatment" was cited by another female from urban Dharan. "Didn't come due to fear of transmission in hospital" was response from adult man from urban Dharan. A participant from rural area seemed to be more aware regarding his concerns on COVID 19 as she stated: "had visited a local clinic; there was no social distancing; got afraid and didn't seek for treatment". An elderly housewife reported: "Didn't want to crowd at hospital; telemedicine was not worthy".

Deferring of treatment services
Some even reported to have had a visit in past few days but the suggestions or treatment provided didn't help ease their complaint. An adult man reported "(I) had come for treatment; doctor gave me medications that subsided the swelling but pain still persists; didn't want to come to the hospital due to fear". Another older male responded with more displeasure: "Only emergency services were available; they didn't attend my problem".

Unavailability of hospital services
Few individuals reported having tried seeking dental care but couldn't reach to one as all services were closed. An elderly housewife reported: "hospital services were not available in the city; tried searching for one that was open but everything was closed" The illustrative quotes from participant interviews regarding reasons for failing to seek dental care during the COVID-19 outbreak is given in Table 3 in additional le [Additional le 2].

Discussion
This study attempted to identify dimensions on dental care seeking pattern during the COVID-19 outbreak. Studies have highlighted on the need for development of outbreak-ready research capacity in both high-and low-resource settings. (14) Identi cation of knowledge gaps, without disrupting the critical work of saving lives, in order to generate research questions for high-priority study through surveys is considered as an integral component of the immediate response and of longer-term follow-up. (15) Qualitative research has been used in dental public health to explore emerging ideas and answer important research questions that are di cult to address satisfactorily using quantitative methods alone. (16,17) Moreover, use of mixed methods in addressing population oral health outcomes has been identi ed for recognizing the determinants of oral disease. (18) The most important nding that emerged from this study was pain seemingly being the leading problem faced by the participants during this outbreak. Toothache has been identi ed as the major reason for care seeking behavior. (19,20) Though individuals also expressed other problems faced during this duration, pain could have driven the participants to the hospital this time. It has been understood that manifestation of other clinical conditions as toothache ultimately plays an important role in care-seeking patterns. (21) Patients are thought to undertake for desperate measure at times of emergency. Few participants in our study reported to have taken some forms of medication for their symptoms. They turned up for the visit only after the medications were no longer effective. Pain sufferers often use a combination of self-care and formal care strategies. Self-care strategies mainly focuses on nonprescription remedies. (22) This was evident in our study where a number of participants responded taking self-prescribed medication for pain relief. Episodes of pain may propel an individual to seek lay consultations especially when formal care strategies are not available. (23,24) Our participants response also suggested similar pattern as the need for seeking care led them to communicate with non-health professionals (relatives and neighbours) and hence some were misled into inappropriate behaviour. Moreover, misinformation resulting from information overload in social media may well be an unintended consequence of the COVID-19 crisis which exacerbated the problems. (25) As highlighted by our study few participants were misinformed about hospital services. Meanwhile, lack of proper communication about availability of urgent care services can be contributed to the reason for patient's inability to receive care. Many seemed not having any knowledge of urgent care services like telemedicine and telephone helpline services that were provided by the institute. Use of appropriate risk communication in social media channels and ensuring a consistent media presence by including all stakeholders in public health messaging can help guide the communication channel. (26) The participants in our study reported having a range of functional discomforts resulting from pain. This was consistent with ndings from other researches. (27,28) Fox et al have highlighted change in symptoms, persistent of symptoms, worry/concern about symptoms and dislike of symptoms as the major triggers for seeking help. Moreover, beliefs about symptoms, health care professionals and individual circumstances were considered as the major barrier. (29) It is imperative to explore that whether this COVID 19 situation made them reluctant to seek for dental care and wait till symptoms progressed and became unbearable. Besides, an array of patterns of careseeking were identi ed. Situational factors play a role in determining their behaviour. Among individuals who perceive themselves to be in poor health, those who develop fewer urgent symptoms, less di cult life situation, and lack of faith in the medical care system would be least likely to seek medical attention. Quantitative assessment of the study participants in our study failed to show if inability to seek care during COVID 19 was related to past dental visits. This could be attributed to our study population who were included from hospitals. The response from surveys conducted in community could prove otherwise. The hazards associated with this pandemic limited the investigators attempt to plan a comprehensive community-based study. None the less majority of the participants reported not being able to receive dental care during the outbreak. Moreover, the de nition of perceived unmet need used in this study should be taken with caution as it encompasses a wider multidimensional de nition depending on who is de ning the concept. (33) The generalizability of study ndings should be done with caution. A more robust sampling strategy could ensure external validity of the study. Participants, despite agreeing to participate, may have been wary of prolonging the interview for too long due to fear and resorted to simple short responses. Social desirable bias may have occurred due to participants tendency for answering answers considered favourably by others. Obviously signi cant changes in service provision for dentistry is in place worldwide. (34) Evidences have been published regarding the concerns in dental service during the pandemic and recommendations have been suggested. (4,6,(35)(36)(37) The rapid reorganization of clinical services may not be straightforward and might require considerable moral decision making from the dental professionals to commence regular services. (38) This might be the reason few participants despite being able to reach to the hospital were not provided with the desired treatment. Besides, the utilization of dental services has been traditionally low especially in our part of the world. (39,40) It was similar in our study in which only 40 of the 108 participants reported having had a dental visit in the past year. It should also be noted that for the rst time since world war, the reversal of casualties by disease pandemic is noted in developed part of the world.(41) So, evidence regarding potential impact on oral health and necessary measures are yet to come from the developed world. (42) This could then guide the more resource restraint part of the world to undertake necessary responses.
Meanwhile these studies can serve as body of literature in times when necessary evidence is lacking from developed countries. (43) COVID 19 has again highlighted the issue of pandemic preparedness. Strengthening core capabilities along with public health and clinical infrastructure of developing countries is an important step. (44) The results from this study suggest that more studies should be undertaken to explore the impact of this outbreak on dental service utilization and preparedness for future scenarios should be well planned. A detailed impact of this pandemic on dental service utilization is yet to be obtained at community level. However, this study can serve as a framework in devising and planning further studies. Figure 1 shows a conceptual framework which can serve as a guide for future research on perceived unmet dental care need during COVD 19 outbreak. [ Figure 1 here; Conceptual framework which can serve as a guide for future research on perceived unmet dental care need during COVD 19 outbreak] The actions now should aim towards generating more evidence and focus on preparedness in providing urgent dental care services for the consequences that may arise in the light of rapid increase of infection or subsequent wave of reinfection. Participants were required to fully understand the research purpose and risks involved (if any) before consenting to participate. The questionnaire form included information sheet and consent form. Con dentiality was assured and only those agreeing to consent were allowed to participate.

Consent for Publication
Written consent agreeing on publication of scienti c data from the study was obtained from each participant.

Availability of Data and Materials
The dataset for the study can be obtained from principal author on reasonable request.

Competing Interests
The authors declare that they have no competing interests. The reports made by participants are not included in any other submitted manuscrpits.