Behavior change due to COVID-19 among dental academics-The theory of planned behavior: Stresses, worries, training, and pandemic severity.

OBJECTIVE: COVID-19 pandemic led to major life changes. We assessed the psychological impact of COVID-19 on dental academics globally and on changes in their behaviors.
METHODS: We invited dental academics to complete a cross-sectional, online survey from March to May 2020. The survey was based on the Theory of Planned Behavior (TPB). The survey collected data on participants' stress levels (using the Impact of Event Scale), attitude (fears, and worries because of COVID-19 extracted by Principal Component Analysis (PCA), perceived control (resulting from training on public health emergencies), norms (country-level COVID-19 fatality rate), and personal and professional backgrounds. We used multilevel regression models to assess the association between the study outcome variables (frequent handwashing and avoidance of crowded places) and explanatory variables (stress, attitude, perceived control and norms).
RESULTS: 1862 academics from 28 countries participated in the survey (response rate = 11.3%). Of those, 53.4% were female, 32.9% were <46 years old and 9.9% had severe stress. PCA extracted three main factors: fear of infection, worries because of professional responsibilities, and worries because of restricted mobility. These factors had significant dose-dependent association with stress and were significantly associated with more frequent handwashing by dental academics (B = 0.56, 0.33, and 0.34) and avoiding crowded places (B = 0.55, 0.30, and 0.28). Low country fatality rates were significantly associated with more handwashing (B = -2.82) and avoiding crowded places (B = -6.61). Training on public health emergencies was not significantly associated with behavior change (B = -0.01 and -0.11).
CONCLUSIONS: COVID-19 had a considerable psychological impact on dental academics. There was a direct, dose-dependent association between change in behaviors and worries but no association between these changes and training on public health emergencies. More change in behaviors was associated with lower country COVID-19 fatality rates. Fears and stresses were associated with greater adoption of preventive measures against the pandemic.

Introduction

The novel coronavirus (COVID-19) pandemic has influenced all life aspects. The highly contagious nature of the disease and its fatal outcomes led to changes in lifestyle for many people [1]. These lifestyle changes included social distancing, avoiding public places, more frequent hand washing, and wearing face masks in public [2]. These changes were sometimes associated with stress-inducing factors such as temporary unemployment, working from home, home-schooling of children, lack of physical contact with other family members, friends, and colleagues, and worrying that loved ones and important others may be infected [3, 4].

Researchers and academics also face the psychological impact of the COVID-19 pandemic. The sudden closure of schools mandated the adoption of e-learning technologies. This, coupled with the suspension of several research projects [5] and unemployment threats [6] may have created new stresses and added to already existing mental health conditions associated with work-life conflict [7-9].

Healthcare workers are at greater risk of COVID-19 infection than the general population because of their frequent contact with affected individuals. Dental professionals are especially vulnerable to infections during pandemics [8]. Dental academics—educators who train dental students—face high levels of stress resulting from heavy work overload and incompatibility between their ability to act and what is expected from them [10]. They are also liable to anxiety and fear attributed to the greater risk of infection during treatment provision in the dental office, especially during pandemics [11]. Mild anxiety helps people perform goal-directed tasks, is natural and may foster preventive behaviors during pandemics [12]. Severe anxiety, on the other hand, is associated with physical symptoms such as muscle tightening, hyperventilation, increased heart rate, sweating, trembling, fatigue, troubled sleeping, gastrointestinal disorders in addition to impaired cognitive skills [13]. Persistent severe anxiety may affect physical and mental well-being [14, 15].

The theory of planned behavior (TPB) posits that behaviors can be predicted by intentions to engage in these behaviors [16]. These intentions, in turn, are affected by the control that people perceive they have over their actions, by their attitude toward the behavior and whether they think it is useful, important or desirable, and by the norms they perceive to be prevailing around them. The TPB was previously used to explain dentists’ behaviors including delivering prevention [17], reporting suspected violence [18], and managing drug users [19]. The change in behaviors among dentists due to the COVID-19 pandemic may be explained by the TPB including the control they perceive they have over avoiding infection by the disease because of previous training they received, worries because of the pandemic which may affect their attitudes and the importance they attach to adopting preventive behaviors, and the prevailing norms around them regarding the seriousness of the pandemic based on the fatalities it causes. Adopting preventive measures to avoid infection protects health care professionals, their families, patients, and the public. It is important to understand the factors associated with these behaviors and if they are impaired by the levels of stress these professionals have. A number of studies have assessed the psychological outcomes of the pandemic on health care workers [20-22] and the general population [23-26] but not on dental academics.

This study aimed to assess the psychological impact of the COVID-19 pandemic on dental academics and on changes in their behaviors as a result of the pandemic in several countries. The hypothesis of the study was that the TPB components are associated with change in dental academics’ behaviors due to the pandemic.

Methods

Design

This was a cross-sectional study that used an online, multi-country survey to collect data from dental academics in several countries around the world between March 2020 and May 2020. Ethical approvals for the study were obtained from Alexandria University, Egypt (IRB 00010556)-(IORG 0008839)/6-11-2016) and other institutions in participating countries.

Participants and sampling

The study participants were a convenience sample of dental academics identified and contacted through their emails that were publicly available on the academics’ institutional affiliation websites, in addition to direct personal invitation from local dental academics (collaborators) in the country, who reached them through professional social media groups or email lists. Participants were recruited and invited to complete the online survey if they were dental academics training and/or educating dental students in universities or institutions at the time of the study, regardless of their degree (BDS or higher) or their title (professor or lower) including clinical instructors, and if they consented to participate. Undergraduate and postgraduate students were not invited to participate, nor were private dentists.

Countries from which participants were recruited are listed in S1 Appendix. Sample size was based on assuming a 95% confidence level, 5% margin of error, and prevalence of severe stress = 10% [27, 28]. The calculated number of participants also ensured adequate power for Principal Component Analysis (PCA) which requires at least 100 participants [29].

Study questionnaire

An anonymous, close-ended questionnaire was developed for the study. The questionnaire consisted of four sections; section 1 included the 15-item Impact of Event Scale (IES) [30, 31] which assessed post-traumatic responses to certain events- in this case, COVID-19. Its internal consistency and validity were previously demonstrated [30]. In the present study, its Cronbach alpha was 0.83 indicating high internal consistency. Items were scored on a 4-point Likert scale; 0 = not at all, 1 = rarely, 3 = sometimes, and 5 = often. Adding the scores of all items gave the total score which was categorized into subclinical, mild stress, moderate stress, and severe stress using cutoff points of 0–8, 9–25, 26–43, and 44+ [31]. Section 2 included 16 items assessing participants’ attitudes toward the impact of the COVID-19. Participants indicated how much these items caused them worry on a scale from 1 (not worried at all) to 10 (extremely worried). Section 3 assessed participants’ agreement with two statements describing change in behavior because of the COVID-19 pandemic (frequent handwashing and avoiding crowded places) on a scale from 1 (strongly disagree) to 10 (strongly agree). Section 4 was a 9 item close-ended questionnaire about participants’ personal and professional background including sex, age, country, living arrangements, highest academic degree obtained, whether the participants coordinate courses, have clinical responsibilities, hold administrative positions, and whether they received training on public health emergencies, the full survey can be found in the S2 Appendix.

The questionnaire was uploaded to SurveyMonkey. Participants were asked to select only one response per question and they were allowed to make one submission. No IPs or emails were collected to ensure confidentiality. The questionnaire was preceded by a brief introduction explaining the purpose of the study, assuring participants of the confidentiality of their responses, and emphasizing that their participation was voluntary. After SurveyMonkey settings were modified, the survey was tested for face and content validity by five academics who were not involved in the study to ensure clarity and relevance of the questionnaire. The questionnaire was developed in English. In addition, two versions were prepared for use in Iran and Brazil where it was translated by collaborators/ dentists into Farsi and Portuguese followed by back translation to ensure accuracy.

Data collection

Survey links were sent to collaborators for distribution to participants who received the links on their emails or social media groups. Reminders were sent two weeks after the first invitation email to encourage participation.

Analysis

After the survey closure, the Excel sheets were downloaded, cleaned, and imported to SPSS version 23.0 for analysis (IBM Corp., Armonk, N.Y., USA). Frequencies, percentages, means, and standard deviations were calculated for descriptive statistics.

Prior to PCA, the suitability of data for this analysis was assessed. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.91 which is above the recommended value of 0.6. The P-value of Bartlett’s test of Sphericity [32] was statistically significant (P< 0.0001), supporting the use of PCA. Major attitude components were, therefore, extracted from the 16 items in section 2 of the survey. Extraction was based on eigenvalues >1. Varimax rotation with Kaiser normalization was used and loading coefficients < 0.4 were suppressed to facilitate interpretation of factor loading. Regression coefficients of the factors extracted from the PCA were saved to the dataset and used as explanatory variables for further analysis.

Two types of outcomes were assessed. The first was the stress levels based on the categories of IES. These were included in a multilevel ordinal logistic regression where the explanatory variables were the major worries/ attitudes derived from the PCA, the ratio between the number of COVID-19 deaths to cases per million at country level (fatality rate) [33] and whether the participant received training to manage public health emergencies. The model controlled for confounders (personal and professional background factors) which were introduced as fixed effects and country was included in the model as a random effect factor. The second set of outcomes was the scores indicating change in behaviors due to the COVID-19 pandemic (frequent handwashing and avoiding crowded places). These were included in two multilevel linear regression models with the same explanatory variables representing the TPB components (major attitude/ worries, fatality rate at country level, and receiving training) in addition to stress levels. These models also controlled for the confounders (personal and professional background variables) and included country as a random effect factor. Regression coefficients (and odds ratios for the ordinal logistic regression model) and 95% confidence intervals were calculated. Significance was set at 5%.

Results

Responses were received from 1862 participants from 28 countries with an overall response rate = 11.3%. Almost half the participants (53.8%) were from Iran, USA, India, Germany and, Indonesia (Appendix 1). About 53.4% were females, 32.9% were >35–45 years old, 87.4% had clinical responsibilities and 52.9% had administrative positions. The mean (SD) fatality rate at country-level as of May 25th, 2020 was 0.06 (0.04). Also, 9.9% had severe stress, 37.5% had moderate stress and 39.6% had mild stress Table 1.

Table 1

Personal and professional background of dental academics and their levels of COVID-19- related stress (n = 1862).

Factors		N (%)
Sex	Male	869 (46.6)
	Female	996 (53.4)
Age in years	25–35	519 (27.8)
	>35–45	614 (32.9)
	>45–55	376 (20.2)
	>55–65	256 (13.7)
	>65	100 (5.4)
Living arrangements	Alone	198 (10.6)
	With parents	281 (15.1)
	With partner/ spouse	1236 (66.3)
	Shared accommodation	68 (3.6)
	Other	82 (4.4)
Highest academic degree obtained	BDS	337 (18.1)
	MSc	619 (33.2)
	PhD	909 (48.7)
Coordinates courses	No	269 (14.4)
	Yes	1596 (85.6)
Has clinical responsibilities	No	235 (12.6)
	Yes	1630 (87.4)
Has administrative position	No	878 (47.1)
	Yes	987 (52.9)
Received training for public health emergencies	No	964 (51.7)
	Yes	901 (48.3)
Stress levels	Subclinical	242 (13.0)
	Mild	739 (39.6)
	Moderate	700 (37.5)
	Severe	184 (9.9)

Table 2 highlights the PCA and factor loadings for major worries and attitudes related to the COVID-19 pandemic. Three components explaining 67.3% of the variance were extracted by PCA from the 16 items with factor loadings ranging from 0.735 to 0.823. In the first component, seven items had loadings ≥ 0.735 and were related to fear of infection. In the second component, five items had loadings ≥ 0.737 and were related to worries from professional responsibilities. The last component included four items with factor loadings ≥ 0.754 and it was about worries from restricted mobility. The greatest fear of infection was that important others would get COVID-19 infection because of the participant (mean = 7.66). The greatest worry about professional responsibilities was related to the required material during the pandemic (mean = 6.48). The greatest worry because of restricted mobility was caused by restricted mobility within the country (mean = 6.70).

Table 2

Principal component analysis and factor loadings for major worries and attitudes related to COVID-19 pandemic.

	Mean (SD)	Factor loadings
		Fear of infection	Professional responsibilities	Restricted mobility
Catching COVID-19 infection from a colleague	5.83 (2.74)	0.768
Catching COVID-19 infection from a patient	7.20 (2.80)	0.786
Catching COVID-19 infection from a student	5.61 (2.96)	0.777
Catching COVID-19 infection from a source not related to work	6.41 (2.61)	0.735
Important others getting infected with COVID-19 because of me	7.66 (2.76)	0.750
Important others getting infected with COVID-19 because of another source	7.64 (2.48)	0.747
Patients getting infected with COVID-19	7.15 (2.63)	0.755
Finishing open courses satisfactorily because of the COVID-19 outbreak	6.18 (2.73)		0.774
Teaching students required material because of the COVID-19 outbreak	6.48 (2.68)		0.823
Supporting students psychologically during the COVID-19 outbreak	6.44 (2.67)		0.737
Managing online learning during the COVID-19 outbreak	6.45 (2.75)		0.783
Finishing required reports/ assignments during the COVID-19 outbreak	6.23 (2.76)		0.749
Restricted mobility in my country because of the COVID-19 outbreak	6.70 (2.91)			0.769
Restricted mobility from/ to my country because of the COVID-19 outbreak	6.13 (3.24)			0.817
Restricted mobility affecting sports and social activities because of COVID-19	6.33 (2.85)			0.790
Missing events important to my career because of the COVID-19 outbreak	5.96 (2.94)			0.754

KMO = 0.91, P value of Bartlett’s test< 0.0001

Table 3 highlights the factors associated with stress levels among dental academics. Fear of infection, worries about professional responsibilities and restricted mobility, country-level fatality rate, and previous training on public health emergencies were significantly associated with severe, moderate, and mild stress (P< 0.0001). Fear of infection had a significant, direct, and dose-dependent association with stress with higher scores of fear associated in a gradient with mild (OR = 1.186), moderate (OR = 1.465), and severe stress (OR = 1.483).

Table 3

Factors associated with stress levels among dental academics (n = 1862).

Stressors	OR (95% CI): vs subclinical stress
	Severe	Moderate	Mild
Fear of infection	1.483 (1.481, 1.484)*	1.465 (1.464, 1.466)*	1.186 (1.184, 1.188)*
Worries about professional issues	1.369 (1.368, 1.369)*	1.317 (1.316, 1.318)*	1.209 (1.208, 1.210)*
Worries about restricted mobility	1.379 (1.378, 1.380)*	1.302 (1.300, 1.305)*	1.010 (1.008, 1.012)*
COVID-19 fatality rate	6.893 (6.891, 6.893)*	1.539 (1.539, 1.540)*	0.947 (0.935, 0.939)*
Received training vs not	1.040 (1.038, 1.042)*	0.973 (0.971, 0.974)*	1.084 (1.083, 1.086)*

Similarly, there was a significant, direct, and dose-dependent association between worries due to professional responsibilities and higher levels of stress: worries were associated in a gradient with mild (OR = 1.209), moderate (OR = 1.317) and severe stress (OR = 1.369). The direct, dose-dependent association between worries due to restricted mobility and stresses also followed a gradient with mild (OR = 1.010), moderate (OR = 1.302), and severe stress (OR = 1.379).

A stronger dose-dependent relationship was observed in the association between country-level fatality rate and severe (OR = 6.893), moderate (OR = 1.539), and mild stresses (OR = 0.947); higher fatality rate was associated with higher odds of severe and moderate stress but lower odds of mild stress. The association between stress levels and receiving training was U shaped; training was associated with higher odds of severe (OR = 1.040) and mild stress (OR = 1.084) and lower odds of moderate stress (OR = 0.971).

Multilevel ordinal logistic regression controlling for sex, age, living arrangements, highest academic degree obtained, course coordination, having clinical responsibilities, having administrative positions as fixed factors and country included as a random factor; 48.7% correctly classified. OR: odds ratio, CI: confidence interval, *: statistically significant at P< 0.05.

Table 4 shows the factors associated with behavior change as a result of the COVID-19 pandemic in multilevel linear regression analysis. Participants agreed that they avoided crowded places (mean = 8.14) and washed their hands frequently (mean = 8.06). Compared to subclinical stress, severe stress was significantly and directly associated with more frequent handwashing (B = 0.93) and avoiding crowded places (B = 0.62). Also, compared to subclinical stress, moderate and mild stresses were significantly associated with more frequent handwashing (B = 0.83 and B = 0.67) but had no significant association with avoiding crowded places. The dose-dependent associations between stress severity and change in each behavior followed a gradient with greater changes reported by participants with higher levels of stress.

Table 4

Association between change in behaviors due to COVID-19 and stresses, worries, COVID-19 fatality rate, and training among dental academics (n = 1862).

Factors	B (95% CI)
	Frequent handwashing	Avoiding crowded places
Change in behavior scale: Mean (SD)	8.06 (2.40)	8.14 (2.41)
Severe vs subclinical stress	0.93 (0.46, 1.40)*	0.62 (0.15, 1.10)*
Moderate vs subclinical stress	0.83 (0.48, 1.19)*	0.33 (-0.03, 0.68)
Mild vs subclinical stress	0.67 (0.33, 1.01)*	0.26 (-0.08, 0.60)
Fear of infection	0.56 (0.45, 0.67)*	0.55 (0.44, 0.66)*
Worries about professional responsibilities	0.33 (0.23, 0.44)*	0.30 (0.19, 0.40)*
Worries about restricted mobility	0.34 (0.24, 0.45)*	0.28 (0.18, 0.39)*
COVID-19 fatality rate	-2.82 (-5.32, -0.32)*	-6.61 (-9.13, -4.08)*
Received training vs not	-0.01 (-0.21, 0.20)	-0.11 (-0.32, 0.10)

Multilevel linear regression controlling for sex, age, living arrangements, highest academic degree obtained, course coordination, clinical responsibilities, having administrative positions as fixed factors and country as random factor, B: regression coefficient, CI: confidence interval,

*: statistically significant at P< 0.05.

Greater fear of infection, worries about professional responsibilities and worries because of restricted mobility were associated with more frequent handwashing (B = 0.56, 0.33 and 0.34) and more avoidance of crowded places (B = 0.55, 0.30 and 0.28).

Higher COVID-19 fatality rates were associated with less frequent handwashing (B = -2.82) and less avoidance of crowded places (B = -6.61). The associations between receiving training and changes in the two behaviors were not statistically significant (P< 0.05).

Discussion

The findings indicated that the COVID-19 pandemic was a stress inducer for dental academics, with approximately 10% having severe COVID-19-related traumatic stress. The main sources of stress were fear of contracting infection, restricted mobility due to the lockdown enforced in most countries to control the spread of the pandemic and worries because of professional responsibilities related to teaching and research. Measures taken by individuals to contain the infection included avoidance of crowded places and washing hands more frequently. Training on public health emergencies was significantly associated with stresses but not with change in behaviors due to the pandemic. A dose-dependent relationship existed between severity of stresses and worries related to fear of infection, teaching and research responsibilities and restricted mobility. A direct, dose-dependent relationship also existed between stress levels and change in behaviors due to the pandemic. Dose-dependent associations were suggested by Hill among the criteria supporting causality in observational studies when clinical trials cannot be conducted [34]. However, dose-dependent associations are not proof of causality on their own and the most important criterion of causality; time sequence where exposure precedes outcome, can only be ascertained in a longitudinal study. The study hypothesis was, thus, partly supported: not all components of the TPB were significantly associated with change in behaviors due to COVID-19.

One of the strengths of the study was the diversity of countries represented by the study participants. This enabled the study to generate data representing different educational systems and backgrounds thereby increasing the generalizability of the findings. Also, the study used validated tools with high internal consistency and/ or factor loadings. In addition, the study captured the psychological impact of the pandemic at its early stages thus providing important and valuable information that can be used in designing support systems for dental academics.

The study, however, had some limitations. First, data were collected at different stages of the pandemic in various countries and this may have confounded the assessment of the level of stress. In addition, the study was cross-sectional and thus, cannot prove causality. Also, the response rate was low similar to previous research [35] and this may be attributed to the psychological impact of the pandemic with resulting possible underestimation of the level of stress reported in the study since those with higher levels of stress may be more likely to ignore the survey. The academics were selected in the present study using convenience sampling. Thus, strict statistical representativeness cannot be claimed. However, in the absence of a sampling framework including dental academics in educational institutions all over the world, random sampling may not be possible. Thus, the wide geographic coverage and range of professional attributes represented in the study indicate representativeness of a large segment of the dental academic community worldwide. The study highlights the psychological impact of the pandemic on dental educators who are critical stakeholders in the education and healthcare sectors. As countries pass through the first wave of the pandemic, more attention will need to be paid to the psychological impact of the pandemic on people’s lives because of its possible effect on productivity, wellbeing, health, and quality of life [36].

We found a direct association between fears and worries and behavior changes in agreement with previous studies including British adults [37], a nationally representative sample of Americans [38] and lay persons from ten countries in Europe, America and Asia. [39] These studies reported an association between perceived risk of infection, fatality risk or negative emotions such as fear and anxiety and greater adoption of COVID-19 preventive behaviors such as hand hygiene and social distancing. Our findings and those of other studies suggest that fear may trigger a protective reaction through the adoption of preventive measures to reduce risks.

Lower COVID-19 fatality rates were observed in countries where dental academics reported more frequent handwashing and more avoidance of crowded places. Dental academics’ COVID-19-related behaviors reflect the behaviors of the general populations. Risk reduction communication undertaken as part of the public health response might have led to the adoption of COVID-19 preventive measures resulting in lower rates of COVID-19 spread and fatality. However, the cross-sectional design of the study does not show time sequence and the direction of the relationship between fatality rates and adoption of preventive measures cannot be elucidated. Future longitudinal studies are needed to establish cause and effect and allow the disentanglement of these complex associations.

The present study showed a 10% prevalence of severe COVID-19-induced stress among dental academics; a higher level than the 7% reported among the general public in Wuhan, China [27] and 8.7% general anxiety reported among Italian dentists [28] and similar to the 11.5% among Israeli dentists and dental hygienists [40]. This indicates a need to provide support for dental academics’ mental health. In addition, fear and anxiety among the educators may have a detrimental effect on dental students with long-lasting consequences on the profession. Few universities have instituted mental health support programs for their staff and students to cope with stresses even before the pandemic crisis [41] and this should assume greater importance as the duration of the pandemic becomes longer and its impact becomes greater.

In the present study, COVID-19 was associated with severe stresses because of restricted mobility caused by isolation and quarantine [42], as observed in past epidemics like the Ebola [43] and MERS [44]. The fear of transmitting infections to important others and loved ones was another COVID-19-related stress inducing factor observed in the present study similar to that reported by dentists from 30 countries in a previous study [4], and it had a dose-dependent association similar to what was observed among Israeli dentists [40].

At the present time when the pandemic spreads and death toll rises, it was hoped that training would prepare dental academics to adopt preventive measures. Our results, however, showed no significant effect of previous training on changing behaviors. Training on public health emergencies was associated with less stress up to a certain level beyond which the higher awareness of risks brought about by training was associated with more rather than less stress. Thus, whether in relation to change in behavior or reducing stresses, training was not associated with greater perceived control. This may be attributed to the generic nature training the academics received which did not address the specific needs related to COVID-19 prevention. This implies that appropriate responses to COVID-19 will require specific and tailored training different from the standard training for public health emergencies. Targeted training programs developed by international organizations such as the World Health Organization may help provide the required skills to deal with this pandemic.

Conclusion

The present study showed a considerable psychological impact of the COVID-19 pandemic on dental academics that was directly associated with fear of infection and worries because of professional responsibilities and restricted mobility. Changes in behaviors due to the pandemic and greater adoption of preventive measures were associated with stresses and worries in a direct and dose-dependent relationship but were not associated with training. Greater adoption of preventive measures was inversely related to COVID-19 fatality rates at country level.

Countries participating in the study and number of participants.

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Survey for dental academics’ stresses at the time of the COVID-19 outbreak (English, Portuguese, and Farsi versions).

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19 Aug 2020

PONE-D-20-20341

Behavior change due to COVID-19 among dental academics - The theory of planned behavior: stresses, worries, training, and pandemic severity

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Author, your manuscript is well written and relevant. please explain how your questionair was validated. It is not possible in my opinion to place such a long list of authors on one article of this kind; in my opinion you should select a maximum of 6 authors who gave the major contribute to this work and Aknowledge the others. You should add to the reference list an important reference specifically to this work and is the following:

Subjective Overload and Psychological Distress among Dentists during COVID-19.

Mijiritsky E, Hamama-Raz Y, Liu F, Datarkar AN, Mangani L, Caplan J, Shacham A, Kolerman R, Mijiritsky O, Ben-Ezra M, Shacham M.

Int J Environ Res Public Health. 2020 Jul 14;17(14):E5074. doi: 10.3390/ijerph17145074

Reviewer #2: I would like to take the chance and congratulate the authors for accomplishment of this work. As a dental academic I am happy with the way it was designed with likert scale questionnaire and conducted during the lockdown and limitation caused by COVID19 outbreak.

Reviewer #3: Typographical or grammatical: line 84 only one bracket needed; line 101 word psychological; line 145 suggest word 'these professionals' instead of 'the'; line 161 suggest adding a comma between 'websites' and 'in addition'; line 397 word psychological

Reference: line 211, in different format

Introduction: in general I would have liked to see a clear separation between academics who just teach, and those who also treat patients, or have any other additional duties (admin, etc). Reason for this is related to stress levels proven to increase with workload.

Line 129: Rutter et al. report higher levels of stress in healthcare workers due to a number of factors including low autonomy, work overload, and lack of congruence between power and responsibility. However, there is also evidence that taking on a teaching role in addition to their clinical role reduce job‐related stress. Also, there is no mention in this paper of pandemic-related issues. I suggest revising the text and separating the information pertaining to Rutter et al. and the information related to the other reference.

I would also like to read a bit more about a separation between mild and severe anxiety, and their impact on dentists' health. What is mild anxiety... and severe? What are the conditions that severe anxiety can cause to dentists' health... cardiovascular, digestive, etc? For example, line 129 'mild anxiety with symptoms of... is natural, and may foster preventative behaviors such as... However, severe and persistent anxiety as observed by symptoms of..., may cause the following conditions...'

Results paragraph - lines 239 to 246. Difficult to read as flow is impacted by % quoted... I suggest picking a small number of characteristics that generally describe the participant population, such as gender, age, highest education, clinical responsibilities and training for emergencies but not all % as these are already in the table. Clinical responsibilities will help separate those who just teach from those who teach and also treat patients (as above).

Stress scale used - I am curious as to why this scale was used. The study appears to be unclear in what stress they are discussing... personal or occupational?

Clarity with this could help determine which scale to use.

IES - there is a revised version of this scale, but it appears that the original scale was used. If this was to be used for a PTSD study I would be concerned, otherwise it should be ok.

However, the results for this scale do not seem right. This scale requires reporting mean scores for total score, and for intrusion, and avoidance subscales.

Also the test-retest reliability of this scale has been widely criticised (see for example Joseph, 2000).

I suggest the use of a pandemic-specific measure of stress such as the COVID-19 Pandemic Mental Health Questionnaire (CoPaQ), or COVID Stress Scales (CSS).

Final note - well done for studying this important topic, during these unprecedented times and the enormous impact of COVID-19. I wish you all the best!

Reviewer #4: This multinational cross-sectional study demonstrated a psychological impact of the COVID-19 pandemic on dental academics that was directly associated with fear of infection and worries related to professional responsibilities and restricted mobility. Training level was not significantly associated with behaviour change (according to theory of planned behaviour). Of interest, greater adoption of preventive measures (handwashing and crowd avoidance) was inversely related to COVID-19 national fatality rates. The study finds similar levels of anxiety as previously reported in the general populous and other dental professionals.

The study is well conducted and written, and appropriately highlights limitations of the research and its interpretation based on its cross-sectional and multinational nature.

I only have very minor comments:

1. Table 2 is cumbersome and would be better broken down into three separate tables based on factor loadings.

2. A literature search for similar psychological studies on other high-risk professional groups, e.g., ear, nose and throat specialists, should be conducted prior to any response to the editor, as the literature on COVID-19 is rapidly evolving. Similarly, any further comparisons that can be made with general populations may be beneficial.

Reviewer #5: This is a very well written, comprehensive analysis of the psychological impact of COVID-19 on dental academics. It is interesting to see how Theory of Planned Behavior has influenced academics across the world , irrespective of their differences. What is the direction the authors propose based on their study?

What other additional training would the academics require to overcome their fear/ stress of COVID-19 infection?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Dr. Parvati Iyer

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Submitted filename: PONE-D-20-20341_reviewer (1) Comments.pdf

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2 Sep 2020

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• The ‘Revised Manuscript with Track Changes’ file has been revised and is compliant with the PLOS ONE style requirements, the files submitted have been renamed according to the instructions provided in the email for resubmitting the revised manuscript.

2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

a) the recruitment date range (month and year),

b) a description of any inclusion/exclusion criteria that were applied to participant recruitment,

c) a table of relevant demographic details,

d) a statement as to whether your sample can be considered representative of a larger population,

e) a description of how participants were recruited,

f) descriptions of where participants were recruited and where the research took place.

• We clarified the recruitment date (MS with track changes, L170-171) and the inclusion criteria (MS with track changes, L181-185). Table 1 includes the relevant demographic details. In MS with track changes, L176, we mentioned that we used convenience sampling. Later, in Discussion, MS with track changes, L368-373, we explain our point of view regarding representativeness. Details about recruitment of participants were added to Methods, MS with track changes, L169 -185 and 223-225.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and translated, and whether it was validated.

• A copy of the questionnaire used has been submitted as the “S2 Appendix 2.pdf” supporting file, including the English, Farsi and Portuguese versions. Details on how the questionnaire was pre-tested and validated is highlighted in the “study questionnaire” subsection of Methods. Please check MS with track changes, L196 -197 and 216 -220.

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere.

"We do not have a dual publication issue. We applied another survey to the same target group to address another research point. What is shared is only the sample profile. The dependent and independent variables are different. We are attaching the related paper which is submitted elsewhere for your review. "

Please clarify whether this publication was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

• The other publication is still under review and we have not yet received Reviewers’ comments. We targeted the same group (dental academics) using three different surveys with three different links. This means that one academic could have completed the three surveys or- for example- only one of them. The surveys were anonymous and therefore we cannot combine responses from the three surveys even if we wanted to do that. Thus, each survey must be included in a different paper. The present one in this paper was about stresses. The other one under review was about knowledge of various aspect of the pandemic: methods of transmission, diagnosis, manifestations, treatment and so on. Both topics are not related and cannot be combined they have different respondents/ samples of the same target group. The details of the other paper clarify this.

5. We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data.

• We meant that the values for this particular variable were not in the table. They are already included in the data set we submitted as Excel file with the paper (column AZ: RatioDCases). We removed this part from the text to avoid misunderstanding.

Reviewers' comments

Reviewer #1

Dear Author, your manuscript is well written and relevant. please explain how your questionnaire was validated.

• Response: We thank the Reviewer for this comment. We highlighted in Methods section (MS with track changes, L196-197 and 215-220) how we assessed the internal consistency of relevant sections of the questionnaire and how we assessed its content validity by the help of some experts whose responses were not included in the final analysis.

It is not possible in my opinion to place such a long list of authors on one article of this kind; in my opinion you should select a maximum of 6 authors who gave the major contribute to this work and acknowledge the others.

• Response: We understand and thank the Reviewer for this concern. We followed the recommendations of the ICMJE (http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html) for defining authorship. Because many countries were included in the study, we needed country-experts to be involved since they would be more able to represent their countries during sampling and to ensure the cultural appropriateness of the survey tool. Thus, the first criterion of authorship was fulfilled. During drafting and submission of the paper, the three other criteria were fulfilled. Selecting some authors and leaving out others for acknowledgement would have impinged on their rights. The number of authors, therefore, corresponds to the geographic coverage of the study and the input of collaborators. In addition, the journal did not require a maximum number of authors.

You should add to the reference list an important reference specifically to this work and is the following:

Subjective Overload and Psychological Distress among Dentists during COVID-19.

Mijiritsky E, Hamama-Raz Y, Liu F, Datarkar AN, Mangani L, Caplan J, Shacham A, Kolerman R, Mijiritsky O, Ben-Ezra M, Shacham M.

Int J Environ Res Public Health. 2020 Jul 14;17(14):E5074. doi: 10.3390/ijerph17145074

• Response: we thank the Reviewer for drawing our attention to the reference. We added it (reference #9).

Reviewer #2

I would like to take the chance and congratulate the authors for accomplishment of this work. As a dental academic I am happy with the way it was designed with likert scale questionnaire and conducted during the lockdown and limitation caused by COVID19 outbreak.

• Response: we are very thankful for the Reviewer’s kind feedback.

Reviewer #3

Typographical or grammatical: line 84 only one bracket needed;

• Response: we thank the Reviewer for catching this error. We removed the extra bracket.

Line 101 word psychological;

• Response: we corrected this word as instructed.

Line 145 suggest word 'these professionals' instead of 'the';

• Response: modified as suggested.

Line 161 suggest adding a comma between 'websites' and 'in addition';

• Response: we added the comma.

Line 397 word psychological

• Response: corrected as indicated.

Reference: line 211, in different format

• Response: We provided the information in between brackets because we considered the software as a product rather than a scientific publication that needs a reference to be cited.

Introduction: in general I would have liked to see a clear separation between academics who just teach, and those who also treat patients, or have any other additional duties (admin, etc). Reason for this is related to stress levels proven to increase with workload.

• Response: we understand the Reviewer’s point of view and agree with it. We included item/s in the survey to assess patient care load of the academics, the number of courses they manage and whether they had administrative role. We controlled for all these factors in the analysis as confounders. We did not focus on them in Introduction since they were treated as confounders in addition to other confounders and because covering them all would have increased to the length of the Introduction and distracted the readers from the main aims of the study.

Line 129: Rutter et al. report higher levels of stress in healthcare workers due to a number of factors including low autonomy, work overload, and lack of congruence between power and responsibility. However, there is also evidence that taking on a teaching role in addition to their clinical role reduce job‐related stress. Also, there is no mention in this paper of pandemic-related issues. I suggest revising the text and separating the information pertaining to Rutter et al. and the information related to the other reference.

• Response: We rephrased to differentiate between the information supported by each of the two references following the Reviewer’s suggestion.

I would also like to read a bit more about a separation between mild and severe anxiety, and their impact on dentists' health. What is mild anxiety... and severe? What are the conditions that severe anxiety can cause to dentists' health... cardiovascular, digestive, etc? For example, line 129 'mild anxiety with symptoms of... is natural, and may foster preventative behaviors such as... However, severe and persistent anxiety as observed by symptoms of..., may cause the following conditions...'

• Response: Following the Reviewer’s suggestion, we clarified the difference between mild and severe anxiety, the manifestations of the latter and how they affect the person’s ability to function. We supported this by a new reference (#13) that was added to the references list.

Results paragraph - lines 239 to 246. Difficult to read as flow is impacted by % quoted... I suggest picking a small number of characteristics that generally describe the participant population, such as gender, age, highest education, clinical responsibilities and training for emergencies but not all % as these are already in the table. Clinical responsibilities will help separate those who just teach from those who teach and also treat patients (as above).

• Response: We edited to focus on the important variables that describe the profile of the participants based on the Reviewer’s suggestion.

Stress scale used - I am curious as to why this scale was used. The study appears to be unclear in what stress they are discussing... personal or occupational? Clarity with this could help determine which scale to use. IES - there is a revised version of this scale, but it appears that the original scale was used. If this was to be used for a PTSD study I would be concerned, otherwise it should be ok. However, the results for this scale do not seem right. This scale requires reporting mean scores for total score, and for intrusion, and avoidance subscales. Also the test-retest reliability of this scale has been widely criticised (see for example Joseph, 2000). I suggest the use of a pandemic-specific measure of stress such as the COVID-19 Pandemic Mental Health Questionnaire (CoPaQ), or COVID Stress Scales (CSS).

• Response: the scale is used to measure the stress that dental academics report because of the pandemic; their subjective stress. We did not use it to assess PTSD (https://link.springer.com/referenceworkentry/10.1007%2F978-94-007-0753-5_1377) and therefore opted to use the shorter 15-items original version to avoid respondent fatigue that is likely to occur because of the number of questions we used in the survey. This fatigue would have further reduced the response rate of the participants who are already burdened by their academic responsibilities at a difficult time. The IES in general was used in previous studies assessing the impact of COVID-19 on health care workers and/ or the general population. We followed the method of reporting the scale used in these studies where categories (mild to severe) were reported such as Shacham et al (https://pubmed.ncbi.nlm.nih.gov/32331401/), Bohlken et al (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295275/), or total score was reported (Sun et al: https://pubmed.ncbi.nlm.nih.gov/32430086/, El-Zoghby et al: https://pubmed.ncbi.nlm.nih.gov/32468155/).

• We agree with the Reviewer that using pandemic-specific inventories would generate useful information about the psychologic impact of COVID-19. However, both scales that the Reviewer kindly suggested were not available at the time we planned our study; we began data collection in March 2020.

Final note - well done for studying this important topic, during these unprecedented times and the enormous impact of COVID-19. I wish you all the best!

• Response: we thank the Reviewer for the kind feedback and this appreciation of our work.

Reviewer #4

This multinational cross-sectional study demonstrated a psychological impact of the COVID-19 pandemic on dental academics that was directly associated with fear of infection and worries related to professional responsibilities and restricted mobility. Training level was not significantly associated with behaviour change (according to theory of planned behaviour). Of interest, greater adoption of preventive measures (handwashing and crowd avoidance) was inversely related to COVID-19 national fatality rates. The study finds similar levels of anxiety as previously reported in the general populous and other dental professionals.

The study is well conducted and written, and appropriately highlights limitations of the research and its interpretation based on its cross-sectional and multinational nature.

• Response: we appreciate the Reviewer’s positive feedback on our work.

I only have very minor comments:

1. Table 2 is cumbersome and would be better broken down into three separate tables based on factor loadings.

• Response: we understand the Reviewer’s concern. There are two reasons that we had for using one instead of three tables: 1) to avoid increasing the total number of tables to 6 which may be too many for readers to follow and 2) to follow the method of reporting the results of principal component analysis adopted in literature where the various factors to be reduced are displayed in one table showing the loadings into different components similar to, for example, these papers:

o https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2020000100472&lng=en&nrm=iso&tlng=en

o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384865/

o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395981/

o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372913/

2. A literature search for similar psychological studies on other high-risk professional groups, e.g., ear, nose and throat specialists, should be conducted prior to any response to the editor, as the literature on COVID-19 is rapidly evolving. Similarly, any further comparisons that can be made with general populations may be beneficial.

• Response: After a review of literature based on the Reviewer’s suggestion, we added a number of references in Introduction assessing the psychological impact of the pandemic on health care workers and the general population.

Reviewer #5

This is a very well written, comprehensive analysis of the psychological impact of COVID-19 on dental academics. It is interesting to see how Theory of Planned Behavior has influenced academics across the world, irrespective of their differences. What is the direction the authors propose based on their study?

• Response: We highlighted in yellow the part of the Discussion where we emphasized the importance of paying attention to people’s psychologic health during the pandemic because of its importance for general wellbeing and the part where we indicated the responsibility of universities to stablish mental health support services for their teaching staff and students.

What other additional training would the academics require to overcome their fear/ stress of COVID-19 infection?

• Response: We clarified this part at the end of the Discussion by indicating that programs designed specially to deal with COVID-19 -such as those developed by the WHO- may be helpful.

Submitted filename: Response to Reviewers (+ Journal requirements) 28082020.docx

Click here for additional data file.

17 Sep 2020

Behavior change due to COVID-19 among dental academics - The theory of planned behavior: stresses, worries, training, and pandemic severity

PONE-D-20-20341R1

Dear Dr. El Tantawi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed and the manuscript is well written.

This topic is of great current importance.

Thank you for addressing the reviewers' comments.

Great work on this study!

Reviewer #4: The authors have satisfactorily addressed my comments on data presentation and the need for comparison to similar research in other health care workers and the general population.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Eitan Mijiritsky

Reviewer #3: No

Reviewer #4: No

21 Sep 2020

PONE-D-20-20341R1

Behavior change due to COVID-19 among dental academics - The theory of planned behavior: stresses, worries, training, and pandemic severity

Dear Dr. El Tantawi:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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