Financial Impact of COVID-19 Pandemic on Endodontic Clinics in Egypt: A Questionnaire-Based Report.

OBJECTIVE: To evaluate the financial impact of the COVID-19 pandemic on endodontic clinics in Egypt.
METHODS: Two hundred Egyptian endodontists holding a minimum of a master's degree were invited to participate in an online survey in March 2021. Participants accessed the survey link shared on the social media group of the Egyptian Society of Endodontology. Participants read and signed an electronic informed consent before participating in this study. The questionnaire was designed exclusively by the authors. A draft was pilot tested on a sample of 15 endodontic masters' students at The British University in Egypt. Suggestions and comments to improve clarity, content, and validity were incorporated into the revised survey. The questionnaire was divided into five sections; the first section comprised of questions about the participants' demographic details. The second section targeted the current and future financial impact of COVID-19 on practices. The third section included information about the average patient flow and the introduction of teledentistry in clinical practice. The fourth section assessed the effect of COVID-19 on the staff in the dental clinics and the changes made in response to COVID-19. The last section estimated COVID-19 prevalence among endodontists and staff. Categorical data were presented as frequencies (n) and percentages (%) and were analysed using Fisher's exact test. Quantitative data were presented as mean and standard deviation values. P-values were adjusted for multiple comparisons utilising Bonferroni correction.
RESULTS: A total of 141 endodontists participated in the survey. The negative financial impact of COVID-19 was reported by 84.39% of the participants. Seventy-eight endodontists (55.3%) suffered from the increased cost of endodontic materials. Of the endodontist respondents, 90.8% suffered from the increased cost of PPE, 82.3% did not charge their patients more, and only 14.4% planned to charge more. A decrease in the number of referred cases for endodontic treatment has been noticed by 58.9%. About 47.5% noticed increased patient phone calls replacing patient visits. Only 12.8% have dismissed staff because of financial problems.
CONCLUSION: COVID-19 has negatively affected most endodontists financially and significantly affected their practices' strategies.

HIGHLIGHTS

Endodontic practices in Egypt suffered from enormous financial losses, with 37% reported more than a 50% drop in revenue.

The financial burden was exacerbated by the rising cost of PPE and the increase in the overhead costs and prices of endodontic materials.

Despite the numerous disadvantages caused by the COVID-19 pandemic, our survey shows that endodontists in Egypt have found ways to adapt to the new situation.

INTRODUCTION

On the 14th of February 2020, Egypt announced the first case of the severe acute respiratory syndrome coronavirus 2 disease (SARS-CoV-2) (COVID-19) in Africa (1). On the 11th of March 2020, COVID-19 was declared as a pandemic by WHO (2). Since then, most governments have imposed COVID-19 lockdown restrictions and several control measures to restrict the pandemic spread. For example, several measures were implemented by the Egyptian government on the 15th of March 2020, such as school and university closures, suspension of ritual activities and prayers in all mosques and churches, closing of all public areas (e.g., restaurants, cafes, clubs) throughout the country from 7 pm until 6 am, with a full lockdown during the weekends. In addition, all international flights were suspended till the 30th of June 2020. Furthermore, another semi-lockdown measures were announced from the 6th of May 2020 until the 21st of May 2020 (3).

Dental professionals are potentially at a higher risk of infection as the saliva acts as the primary reservoir of droplet transmission (4). Droplets, splash and spatter production are common during dental procedures using high- and low-speed handpieces, three-way syringes, and ultrasonic scalers (5). The virus may remain within the droplets for a few hours to days depending on the surface and may remain suspended in the air for a few hours depending on the surrounding atmosphere (6). The Occupational Safety and Health Administration classified dentists as a very high-risk group due to the potential exposure to SARS-CoV-2 through aerosol-generating procedures (7). Endodontists are in a unique situation as they are responsible for managing emergency cases; odontogenic pain, swelling, and dental alveolar trauma. About 50% of all patients attending emergency dental care are endodontic emergencies, with 53% being symptomatic irreversible pulpitis (8).

Many health regulatory bodies around the world (such as the American Dental Association, the National Health Service, and the Spanish Consejo General) have advised their licensed dentists to perform only emergency dental procedures and to refrain from performing all elective procedures like restorations, extractions of asymptomatic teeth, aesthetic dental procedures, orthodontic adjustments, and routine radiographs (6). Furthermore, certain preventative practices must be followed to limit the risk of infection during the pandemic. For example, pre-procedural mouth rinses should be used regularly, and dental instruments should be frequently disinfected (9). Additionally, high-volume saliva ejectors, anti-retraction handpieces, rubber dam isolation, and personal protective equipment (PPE) should be used (9).

These preventative precautions helped reduce COVID-19 spread; however, it has resulted in significant financial consequences for dental practices worldwide. General dental practices are currently suffering from enormous financial losses since they can only provide emergency dental care. According to a survey conducted by the Irish Dental Association involving 369 dentists, one-fifth of the dentists had closed their practices either temporarily or permanently (10). Furthermore, approximately three-quarters of the participants anticipate a financial loss of more than 70% throughout the COVID-19 outbreak period. The British Dental Association has stated the same, predicting that dental practices in the United Kingdom will suffer from severe losses due to deferring routine dental care (11). Similarly, the Irish Dental Association indicated that about 75% of the dental practitioners face financial losses of more than 70% during the outbreak (10).

This pandemic situation has grounded national and international economies to a halt. Almost all the sectors were affected by the economic recession brought forward by COVID-19. The reported global spillover of COVID-19 engulfed the travel industry, hospitality industry, sports industry, financial sector, financial market, entertainment industry, education sector, and health sector. Governments and dental associations in low- and middle-income countries did not support dental practices at this challenging time (11). During this COVID-19 surge between March and June 2020, some dental clinics in Egypt preferred to reduce their capacity and postpone elective procedures, while others preferred to remain completely closed. Patients' dental treatments have been disrupted due to the closure of dental clinics because of the COVID-19 outbreak.

In the present study, we aimed to evaluate the financial impact of the COVID-19 pandemic on endodontic clinics in Egypt by conducting an online questionnaire among members of the Egyptian Association of Endodontists.

MATERIALS AND METHODS

Ethical approval was obtained from the local Ethics Committee at Ain Shams University (Protocol no. 015-01-21). This study was designed as a cross-sectional descriptive online survey through Google Forms.

Sample size calculation

A power analysis was designed to have adequate power to apply a statistical test of the research question regarding the financial impact of COVID-19 on endodontic clinics in Egypt. According to the results of Ahmadi et al. (12), by adopting a confidence interval of (95%), a margin of error of (5%) with a finite population correction, the predicted sample size (n) was a total of (132) cases. Sample size calculation was performed using Epi info for windows version 7.2.

Participants recruitment

Recruitment of participants took place from the 1st of March 2021 till the 12th of March 2021. A total of 200 certified active members of the Egyptian Society of Endodontology holding a master's degree or a doctorate in endodontics were invited to the survey regardless of their city and workplace, whether in private practice, university, or hospital clinics. Masters students in endodontics were not invited.

The survey link was shared on the social media group of the Egyptian Society of Endodontology with a message explaining the study and inviting them to participate. The first page of the questionnaire assured that no personal information was required and data would be kept confidential. Participants were informed of the study objectives, and participation was purely voluntary. Participating endodontists read and signed an electronic informed consent before participating in this study.

Questionnaire production and validation

The questionnaire was not adopted from any previous study and was designed exclusively by the authors. The entire study team and a public health specialist reviewed an initial draft of the survey for critical feedback regarding the content, clarity, and presentation. We pilot tested the initial draft of the questionnaire on a sample of 15 endodontic masters' students at The British University in Egypt. Suggestions and comments to improve the clarity, content, and validity were incorporated into the revised survey.

Questionnaire composition

The questionnaire was divided into five sections. The first section comprised questions about the participants' demographic details, including years of experience and practice type. The second section targeted the current and future financial impact of COVID-19 on practices. Information about the average patient's flow and the introduction of teledentistry in practice were included in the third section. In the fourth section, questions assessed the effect of COVID-19 on the staff and the difficulty faced to pay salary to staff, followed by questions related to changes made in practice in response to COVID-19. The last section estimated the COVID-19 prevalence among endodontists and their staff.

Statistical analysis

Data were transferred into Microsoft Excel (Microsoft Corp, Redmond, WA). Categorical data were presented as frequencies (n) and percentages (%) and were analyzed using Fisher's exact test. Quantitative data were presented as mean and standard deviation values. P-values were adjusted for multiple comparisons utilizing Bonferroni correction. The significance level was set at P≤0.05 for all tests. Statistical analysis was performed with R statistical analysis software version 4.0.3 for Windows (R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

From the 200 endodontists targeted and invited, 147 participated in the survey. Six participants were excluded from the study because they did not hold any postgraduate qualification in endodontics. Participants' demographic data, including age, gender, years of practice, qualifications, nature of practice, and practice scope, are shown in Table 1.

TABLE 1

Frequency and percentage (%) for answers to the questions about the participants' demographic details

Question	Answers	n	%	P
1. Age (years)	56<	4c	2.8	<0.001*
	46-55	6c	4.3
	36-45	37b	26.2
	>35	94a	66.7
2. Gender	Male	73a	51.8	0.674ns
	Female	68a	48.2
3. How long have you been practicing?	Less than 5 years	17c	12.1	<0.001*
	6-10 years	51a	36.2
	11-15 years	44ab	31.2
	16 years or more	29bc	20.6
Currently, you are?	Holder of Master Degree of Endodontics	28a	19.9	<0.001*
	Holder of PhD Degree of Endodontics	41a	29.1
	Endodontic Master student	34a	24.1
	PhD Endodontic student	32a	22.7
	Other specialty master student	2b	1.4
	Holder of Master Degree of Other specialty	2b	1.4
	Holder of PhD Degree of Other specialty	1b	0.7
	PhD student other specialty	1b	0.7
4. What describes the nature of your practice?	Solo practice	29b	20.6	<0.001*
	Group endodontic practice	12c	8.5
	Multi- specialty practice	49a	34.8
	Faculty practice	39ab	27.7
	Outpatient clinic in private hospital	12c	8.5
5. Do you perform treatments other than endodontics?	Yes	97a	68.8	<0.001*
	No	44b	31.2

Different letters indicate a statistically significant difference within the same question. *: Significant (P≤0.05), ns: Non-significant (P>0.05)

Responses to sections 2-5 analyzing the financial impact of COVID-19 on practices, staff, patient patterns, and practice strategy are shown in Tables 2-5 with frequency, percentage, and statistical analysis. In addition, the medical status of participants and staff related to COVID-19 is shown in Figure 1.

TABLE 2

Frequency and percentage (%) for answers to the financial impact of COVID-19 questions

Question		Answers	n	%	P
1.	How did COVID-19 affect your practice financially?	Positively	4c	2.8	<0.001*
		Negatively	119a	84.4
		No effect	18b	12.8
2.	What has been the negative impact of the COVID-19	Less than 10%	15b	12.6	<0.001*
	on your income compared to what is typical at your	Over 10% but less than 25%	54a	45.4
	practice (only answer if the COVID-19 affected your	Over 50% but less than 75%	44a	37.0
	practice negatively)?	More than 75%	4c	3.4
		Total loss of business	2c	1.7
3.	Did the overhead costs increase per case?	Yes	76a	53.9	<0.001*
	(overhead refers to the ongoing costs to operate a	No	14c	9.9
	business but excludes the direct costs associated with	Unsure	51b	36.2
	creating a product or service)
4.	Did you notice an increase in the price of endodontic	Yes	78a	55.3	<0.001*
	materials?	No	32b	22.7
		Not sure	31b	22.0
5.	Did you face a problem with providing personal	Did not face any problems	13c	9.2	<0.001*
	protective equipment (PPE)	Rising in the price of PPE up to 25%	28ab	19.9
		Rising in price more between 25-75%	45a	31.9
		Rising in price between 75%-100%	23bc	16.3
		Rising in the price of PPE More than 100%	32ab	22.7
6.	Have you charged your patients for more?	Yes	25b	17.7	<0.001*
		No	116a	82.3
7.	Are you planning to charge your patients for more?	Yes	20b	14.2	<0.001*
		No	55a	39.0
		Maybe	66a	46.8
8.	Do you anticipate a decrease in income by continuing	Completely agree	27b	19.1	<0.001*
	the pandemic in the future?	Agree	63a	44.7
		Undecided	36b	25.5
		Disagree	13c	9.2
		Completely disagree	2d	1.4
9.	If the current situation lasts longer, I will	Find innovative ways to lower my operating costs	43a	30.5	<0.001*
		Borrow money to address financing shortfalls	4b	2.8
		Adjust staffing or salaries of my staff	2b	1.4
		I do not think I can sustain my practice	6b	4.3
		Do nothing	44a	31.2
		Charge the patients for more	42a	29.8

Different letters indicate a statistically significant difference within the same question. *: Significant (P≤0.05), ns: Non-significant (P>0.05)

TABLE 5

Frequency and percentage (%) for answers to changes in the practice strategy questions

Question		Answers	n	%	P
1.	What was your strategy during the first wave of the	Closed the clinic and did not see any patients	36b	25.5	<0.001*
	COVID-19 pandemic?	Closed the clinic but treated emergency cases only	58a	41.1
		Kept the clinic open but lowered the patient volume	43ab	30.5
		than usual
		Kept the clinic open, and nothing changed	4c	2.8
2.	Did you change the practice working time in	Yes	131a	92.9	<0.001*
	response to the COVID 19 pandemic (shortened	No	10b	7.1
	treatment time, reduced patient capacity)?
3.	Did you perform any non-emergency procedures	Yes, because of the patients' request	64a	45.4	<0.001*
	during the first wave of the COVID-19 pandemic?	Yes, because of financial problems	19b	13.5
		No	58a	41.1
4.	Did you install a Plexiglass aerosol shield for	Yes	21c	14.9	<0.001*
	microscope or Acetate sheets adapted to the	No	38b	27.0
	binocular as a protective barrier?	Do not have a microscope	82a	58.2
5.	Have you been using a rubber dam to minimize	Yes	114a	80.9	<0.001*
	saliva production- and blood-contaminated aerosol	No	27b	19.1
	or spatter in all of your dental treatment?
6.	If no, the reason for not using the Rubber dam is	Difficulties in its handling	12a	41.4	0.353ns
		Financial reason	17a	58.6
7.	For endodontic emergency, during the lockdown	No clinical intervention, only pharmacological	16c	11.3	<0.001*
	period, which endodontic intervention protocol	approach, i.e., recommended medications to
	represent your practice	manage severe dental pain
		Minimal clinical intervention (pulp capping,	39b	27.7
		pulpotomy, root canal debridement only) to
		control pain
		Single-visit endodontics to reduce the number of	76a	53.9
		treatment visits needed (when indicated)
		Multiple-visit treatments to reduce the treatment time	10c	7.1
8.	Currently, after the resumption of the clinical	Single-visit root canal treatment (when indicated)	104a	73.8	<0.001*
	practice, which endodontic intervention protocol	protects the patient, dentist, and staff from potential
	represent your practice during the pandemic	exposure to the virus during repeated visits
		Multiple-visit treatments to reduce the treatment time	37b	26.2
9.	Preferred restorative approach after endodontic	Direct permanent restoration to protect the patient,	105a	74.5	<0.001*
	treatment during the pandemic	dentist, and staff from potential exposure to the virus
		during repeated visits
		Temporary intra-coronal restorations to reduce the	36b	25.5
		treatment time
10.	What is your strategy of choice regarding the	Not going to reclose the clinic again	92a	65.2	<0.001*
	second wave of the COVID-19 pandemic?	Closing till the end of the alert phase	8c	5.7
		Closing until the end of the COVID-19 pandemic	1d	0.7
		Uncertain	40b	28.4

Different letters indicate a statistically significant difference within the same question. *: Significant (P≤0.05), ns: Non-significant (P>0.05)

Figure 1

Clustered column chart showing participants' response in percentage to questions related to their medical status and their staff related to COVID-19

DISCUSSION

More than 175 countries worldwide have reported cases of COVID-19 (13). As of the 9th of August 2021, nearly 202,296,216 confirmed cases of COVID-19, including 4,288,134 deaths (14). In Egypt, the current announced numbers are 284,641 confirmed cases of COVID-19 and 16,566 deaths (Figs. 2, 3) (13).

Figure 2

Report by the Ministry of Health and Population in Egypt during April 2020 to –July 2021 on the number of confirmed COVID-19 cases

Report by the Ministry of Health and Population in Egypt during April 2020 to –July 2021 on the number of confirmed COVID-19 deaths

This pandemic and the consequently employed strategies worldwide are unmatched in contemporary times. Mitigation and suppression essential to contain the spread have influenced the economy with disastrous results for small- and medium-sized businesses.

Dental practices are primarily small- to medium-sized businesses operated privately. Governments worldwide are working to stop the pandemic from spreading and lessen the economic impact of COVID-19. Scotland, Wales and Northern Ireland offered capital funding to help dental practices secure new equipment to expand patient numbers (15). So far in Egypt, dental practices have not been included in any specific governmental support or protection schemes. We aimed to analyse the financial impact of COVID-19 on endodontic practices in Egypt.

One year after the initial lockdown in March 2020, the COVID-19 pandemic had an enormous impact on the dental clinics. According to our results, 77.3% reported the pandemic's negative financial impact on their endodontic practices, with 44% reporting a more than 50% drop in revenue. Endodontists were unable to practice during the initial lockdown. The COVID-19 period clearly affected the number of endodontic patients. The number was lower for 66% of the respondents. Moreover, 90% anticipated a decrease in income by continuing the pandemic. Only 20.3% of respondents reported “business as usual” regarding patient numbers. According to a survey conducted on 180 dental clinics in Japan, 46.7% of the dental clinics reported a decrease in the number of patients, in agreement with the current study results (16).

Patients avoided elective dental treatment either for financial reasons or for fear of infection. However, it has been proven that dentistry is an essential service, and practices have been able to remain open despite additional lockdowns across the country, with only 1.7% (n=2) suffering from total loss of their businesses.

When practices have experienced unprecedented declines in revenue, the rising cost of PPE has exacerbated the financial burden. The increased cost of PPE has worsened the financial burden for practices that have suffered from unprecedented declines in revenue. Only 9.2 % (n=13) did not face any problem in providing PPE, while the rest disclosed a substantial increase in PPE price with different percentages. The difference in the increased cost reported could be explained by the surge in demand in rural versus urban areas. A recent report estimated a 1000% increase in PPE cost than the pre- COVID-19 period (17). The Irish Dental Association reported similar findings where 70% of the dentists did not have access to gowns and 30% did not have unimpeded access to face masks (18). Surprisingly, more than 50% of the respondents faced an increase in overhead costs and an increase in the price of endodontic materials.

Most dental practice employers in Egypt paid full salaries to their staff (82.3%) despite the closure of the clinics, in agreement with the results of a cross-sectional study conducted in Iran (12). Only 22% (n=31) decreased the staff's salary due to the reduction in the working hours. In contrast, in a US study, only 27% paid the full salary to staff, 45% paid half the salary, and 28% did not pay salaries (19). It is worth mentioning that 56.7% of the dental practices in Egypt reported that one or more of their staff decided not to work during the COVID-19 pandemic.

The infection rate among Egyptian endodontists was 16.3% (n=23), and 31.9% (n=45) reported developing symptoms of COVID-19. This percentage is higher than the reported percentage of US dentists of 0.9% in June 2020 (20) and the infection rates reported in health care professionals was 0.9% in the Netherlands and 1.1% in China (21, 22). Currently, there are no official numbers of infection rates reported among Egypt's healthcare workers. It must be emphasised that this survey targeted Egyptian endodontists only, which could affect the generalisability of these results. Respondents might also have had restricted access to COVID-19 testing and might have had undiagnosed infections.

Our data showed higher infection rates reported by the staff/assistants in endodontic clinics, where 39% suffered from COVID-19 symptoms and 24.8% tested positive. However, it is unclear whether these infections were due to community transmission or transmission associated with oral health care delivery (6). This raises concerns regarding the transmission of virus-containing airborne particles in the dental office. It has been suggested that additional potential for COVID-19 transmission exists in dental settings during the delivery of aerosol-generating dental procedures. The Occupational Safety and Health Administration classified dentists as a very high-risk group due to the potential for exposure to COVID-19 through aerosol-generating procedures (5, 7). The current understanding is that COVID-19 has sustained infectivity in aerosol with a half-life of 90 minutes (23).

Previous studies (26, 27) have stressed the necessity of rubber dam isolation in reducing saliva production and blood-contaminated aerosol or spatter, which has been concurred by most of the respondents in the current study. About 80% of the respondents from this study have been using a dental dam in all dental treatments. As endodontists are on the front lines of the pandemic, the dental emergency can be a devastating experience resulting in systemic infection. Therefore, emergency dental care poses a challenge in balancing patient care with personnel safety (24).

Despite the numerous setbacks caused by the COVID-19 pandemic, our survey shows that endodontists have found ways to adapt to the new situation. More than 90% have changed the practice working time in response to the COVID-19 pandemic. Changes implemented to dental practices included shortening treatment time and reducing patients' capacity. Single-visit endodontics was preferred by 53.9% of the endodontists to reduce the number of treatment visits needed whenever indicated. About 74.5% chose to place direct permanent restorations after endodontic treatment to protect the patient, dentist, and staff from potential exposure to the virus during repeated visits. About 11% (n=16) chose to stop performing aerosol-producing procedures where no clinical intervention was preferred and only prescribed medications to manage severe dental pain, i.e., a pharmacological approach. A recent international (multi-country) survey showed that only 19.2% of the endodontists had closed their practice, 78.1% (n=350) of the endodontic practitioners limited the provision of endodontic treatment to emergency cases only, and 2.7% (n=12) continued with normal operations (25). In Egypt, a higher percentage of endodontists 25.5% (n=36) reported shutting down their entire practice, 41.1% (n=58) treated only emergency cases, 30.5% (n=43) chose to decrease the number of patients per day, and 2.8% (n=4) kept the clinic open, unchanged practice.

Teledentistry could be described as one of the adaptive responses applied by patients. About 47% of the endodontists reported an increase in the demand for remote dental consultations through phone calls. About 50% implied that phone calls replaced some in-office visits. While patients' continuity of care was severely disrupted for more than 50% of the respondents, about 63.8% of the respondents indicated that their patients were apprehensive about visiting the dental practice after re-opening. The significant disruption of care and patients' dental treatment concerns justifies the increase in teledentistry demand. However, advanced technologies and platforms that can virtually deliver dental consultations are still required.

To our knowledge, this is the first survey to investigate the impact of the COVID-19 pandemic on the status of endodontic practices in Egypt. There are, however, some limitations to these findings. There might be recall bias in the questions asked about the modifications implemented in the practice strategy in response to the COVID-19 pandemic. Although participants were assured of their anonymity, concerns about being identified may have affected their answers. Respondents likely reported higher levels of infection prevention and control compliance due to social desirability bias and unrecognized lapses in PPE usage.

CONCLUSION

COVID-19 has negatively affected most endodontists financially and significantly affected their practice strategies.

TABLE 3

Frequency and percentage (%) for answers to patient pattern questions

Question		Answers	n	%	P
1.	Did you notice a change in the number of referred cases?	Increased	4c	2.8	<0.001*
		Decreased	83a	58.9
		No change	30b	21.3
		Unsure	24b	17.0
2.	How does the number of endodontic patients per month	Increased	6c	4.3	<0.001*
	compare to this same period last year?	Decreased	93a	66.0
		Almost the same	42b	29.8
3.	Did you notice a rise in phone calls from patients? (Teledentistry)	Yes	67a	47.5	<0.001*
		No	42b	29.8
		Maybe	32b	22.7
4.	Have some calls replaced visits?	Yes	71a	50.4	0.933ns
		No	70a	49.6
5.	Have you been treating high-risk patients (close contacts of	Yes	50b	35.5	<0.001*
	confirmed or probable COVID-19 patients)?	No	91a	64.5
6.	Have your patients expressed any apprehensions in visiting	Yes	90a	63.8	<0.001*
	the dental practice after you have re-opened for elective dental care?	No	29b	20.6
		Unsure	22b	15.6
7.	The COVID-19 pandemic significantly disrupted patient continuity of care	Strongly Agree	42b	29.8	<0.001*
		Agree	81a	57.4
		Undecided	13c	9.2
		Disagree	5c	3.5
		Strongly disagree	0	0

Different letters indicate a statistically significant difference within the same question. *: Significant (P≤0.05), ns: Non-significant (P>0.05)

TABLE 4

Frequency and percentage (%) for answers to the effect of the COVID-19 on the staff questions

Question		Answers	n	%	P
1.	Did you dismiss any of the staff because of financial problems?	Yes	18b	12.8	<0.001*
		No	123a	87.2
2.	Did you pay the staff their full salaries regardless of the closure of dental	Yes	116a	82.3	<0.001*
	clinics?	No	25b	17.7
3.	Did you decrease the salary of the staff due to the reduction in the	Yes	31b	22.0	<0.001*
	working hours?	No	110a	78.0
4.	Did any of the staff decide not to work during the COVID-19 pandemic?	Yes	80a	56.7	0.110ns
		No	61b	43.3

Different letters indicate a statistically significant difference within the same question. *: Significant (P≤0.05), ns: Non-significant (P>0.05)