Abstract

This study aimed to reconstruct and analyze the discourses of the pandemic in the post-COVID-19 era. The methodology was based on a critical review of the scientific literature on the pandemic, selecting 80 non-biomedical, clinical, or pharmacological articles published in journals indexed in Scopus or Web of Science from a sample of the 500 most cited scientific articles on the pandemic in Google Scholar. The theoretical approach was based on the debates on predictability, unpredictability, determination, and indeterminacy in the health and social sciences. As a result, six theses on the pandemic were identified and analyzed: a) the thesis of the unpredictability of pandemics; b) the thesis of pandemic denial; c) the thesis of the pandemic as a failure in predictability systems; d) the thesis of the prevention of catastrophic events with timely interventions; e) the thesis of the structural postponement of predictive care by non-developed countries; and f) the environmentalist-health thesis, of foreseeing a critical phase for the planet and humanity. We concluded on the limits of resilience as the center in preparing Latin American health systems in the post-pandemic.

Key words:
Health surveillance; Disaster management; Pandemic; COVID-19; Health discourses

Introduction

COVID-19 caused irreparable damage to various sectors of society and is considered the greatest health challenge of the past 100 years¹1 COVID-19 Data Explorer [Internet] 2022. England: Our World in Data; c2020-2022 [citado el 15 de agosto de 2022.] Disponible en: https://ourworldindata.org/grapher/daily-cases-covid-19
https://ourworldindata.org/grapher/daily... . Furthermore, the high capacity for adaptive mutations of the etiologic agent, the Sars-CoV-2 virus, and the emergence of new variants heighten the uncertainties regarding vaccine coverage and the end stage of the pandemic²2 Taleb NN. El Cisne Negro: El impacto de lo altamente improbable. Barcelona: Paidós; 2008..

In 2020, the first year of the pandemic, guidelines issued by Brazil’s national health surveillance agency (Agência Nacional de Vigilância Sanitária, ANVISA)³3 Schwabe CW. Veterinary Medicine and Human Health. Baltimore: Williams & Wilkins; 1984. recommended that the main measures to be taken in dental services include suspending elective care, placing restrictions on emergency care, applying new biosecurity protocols and acquiring personal protective equipment (PPE), such as face shields and N95 or similar masks, as well as encouraging teleworking, distancing in waiting rooms and others³3 Schwabe CW. Veterinary Medicine and Human Health. Baltimore: Williams & Wilkins; 1984..

In private dental practice, it is up to the dental employer or employee to make organisational decisions and changes, and to purchase the necessary PPE for safe care. These professionals were directly affected by the suspension of elective treatment: their earnings depend daily on their performance in carrying out procedures to maintain the profitability of their establishments⁴4 Dente MG, Riccardo F, Declich S, Milano A, Robbiati C, Agrimi U, Mantovani A, Morabito S, Scavia G, Cubadda F, Villa L, Monaco M, Mancini L, Carere M, Marcheggiani S, Lavazza A, Farina M, Dar O, Villa M, Testori Coggi P, Brusaferro S. Strengthening preparedness against global health threats: a paradigm shift. One Health 2022; 14:100396.. The biosafety measures to be taken⁵5 Kahneman D. Pensar rápido, pensar despacio. Barcelona: Penguin Random House; 2014. entailed higher expenses and economic consequences of major concern to the profession⁶6 Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. London: Yale University Press; 2009.

7 Akerlof G, Shiller R. Animal Spirits: How Human Psychology Drives the Economy, and Why It Matters for Global Capitalism. New Jersey: Princeton University Press; 2009.^-88 Maxmen A. Wuhan market was epicentre of pandemic's start, studies suggest. Nature 2022; 603(7899):15-16..

COVID-19 brought diverse changes to the global scenario and had strong impact on dental practice, especially during the first year of the pandemic⁹9 Worobey M, Levy JI, Malpica Serrano L, Crits-Christoph A, Pekar JE, Goldstein SA, Rasmussen AL, Kraemer MUG, Newman C, Koopmans MPG, Suchard MA, Wertheim JO, Lemey P, Robertson DL, Garry RF, Holmes EC, Rambaut A, Andersen KG. The Huanan Seafood Wholesale Market in Wuhan was the early epicenter of the COVID-19 pandemic. Science 2022; 377(6609):951-959.. Also, private sector dentists¹⁰10 Ashton J. COVID-19 and herd immunity. JRSM 2022; 115(2):76-77. have shown greater emotional impairment than those in the public sector⁹9 Worobey M, Levy JI, Malpica Serrano L, Crits-Christoph A, Pekar JE, Goldstein SA, Rasmussen AL, Kraemer MUG, Newman C, Koopmans MPG, Suchard MA, Wertheim JO, Lemey P, Robertson DL, Garry RF, Holmes EC, Rambaut A, Andersen KG. The Huanan Seafood Wholesale Market in Wuhan was the early epicenter of the COVID-19 pandemic. Science 2022; 377(6609):951-959.

10 Ashton J. COVID-19 and herd immunity. JRSM 2022; 115(2):76-77.^-1111 Jung F, Krieger V, Hufert FT, Küpper JH. Herd immunity or suppression strategy to combat COVID-19. Clin Hemorheol Microcirc 2020; 75(1):13-17., possibly due to the numerous uncertainties and insecurity of employment in the private sector.

In view of the atypical problems experienced by these professionals and the concept of occupational stress (which can be defined as a physiological and psychological response to pressures and demands unrelated to workers’ knowledge and skills¹²12 Bourgeron T. 'Let the virus spread'. A doctrine of pandemic management for the libertarian-authoritarian capital accumulation regime. Organization 2021; 29(3):401-413.), it became important to identify possible factors causing job stress in the private sector during the pandemic period. Accordingly, this study examined for individual and organisational factors associated with occupational stress among dentists working in the private sector in the first year of the COVID-19 pandemic in Brazil.

Methods

This cross-sectional study used data from a multicentre, observational, cross-sectional study to evaluate the COVID-19 prevention and control measures adopted by dental surgeons, technicians and oral health assistants in Brazil’s southern states (Paraná, Santa Catarina and Rio Grande do Sul) in response to the ANVISA recommendations for health services. Data for Paraná were obtained under the responsibility of the Universidade Estadual de Ponta Grossa and the Universidade Federal do Paraná. The study was approved by the research ethics committees of the Universidade Estadual de Ponta Grossa (CAAE certificate: 31720920.5.1001.0105, opinion 4,024,593) and the Universidade Federal do Paraná (CAAE certificate: 31720920.5.3001.0102, opinion 4,312,933).

The design followed a methodological framework for online studies (websurveys), within the limitations of a non-probabilistic, convenience sample. The research and reporting of results were guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)¹³13 Bustamente T, Hübner Mendes C. Freedom without responsibility: the promise of Bolsonaro's COVID-19 denial. Jus Cogens 2021; 3:181-207..

A research form of open and closed questions was drawn up, subjected to face and content validation, assessment by eight experts in the field and a pilot study with oral health professionals from states not participating in the research. The construction and validation of the data collection instrument used for this research are described in detail in another publication¹⁴14 Douglass K. Covid-19 conspiracy theories. Group Process Intergroup Relat 2021; 24(2):270-275,.

The questionnaire was organised on the Google Forms platform and the link to participate was sent out by email by the regional boards of dentistry (Conselhos Regionais de Odontologia, CROs). The CROs resent the email 14 and 45 days after the first sending, totalling three attempts. In the same period, a wide-ranging dissemination strategy was pursued through social media. Responses to the form were monitored at all times and further dissemination strategies were implemented as needed¹⁵15 Uscinski JE, Klofstad C, Funchion J, Wuchty S, Murthi M, Enders AM, Seelig M, Everett C, Premaratne K. Why do people believe COVID-19 conspiracy theories? Harv Kennedy Sch Misinformaton Rev 2020; 1(spe.):1-12..

The population of the multicentre study comprised 81,531 oral health professionals working in the three southern states in May 2020. With the study population size given by the number registered with the CROs, a non-probabilistic, convenience sample of 2,560 participants was obtained, representing a 3.1% response rate.

Participants from Paraná comprised 1,127 oral health professionals, of whom 435 worked in private dental clinics and surgeries. The sample selected for this study comprised the 384 dental surgeons in Paraná who responded with regard to their work process in these establishments.

The survey form addressed: sociodemographic characteristics; academic background and work; biosafety and COVID-19-related work process; access to information; and perceptions regarding anxiety, worry and emotional aspects of work. Response options for questions on biosafety and work process were organised on a five-point Likert frequency scale: (1) never, (2) almost never, (3) sometimes, (4) almost always and (5) always. There was also an ‘I don’t know’ option.

In this study, the two outcome items selected as proxy for occupational stress related to perceived anxiety and emotional aspects of work during the pandemic: (1) I feel informed and secure enough to practice dentistry properly during the COVID-19 pandemic and (2) I feel anxious and worried about working properly in my dental practice during the COVID-19 pandemic. Both offered response options on a five-point Likert scale of agreement: (1) strongly disagree, (2) partly disagree, (3) neither agree nor disagree, (4) partly agree and (5) strongly agree. They also offered the ‘I don’t know’ response option.

For purposes of analysis, in addition to the ordinal measure, responses to the two items were dichotomised and categorised as: a) ‘No’ - negative and neutral responses (completely disagree, partly disagree, neither agree nor disagree); and b) ‘Yes’ - positive responses (partly agree and totally agree). ‘I don’t know’ responses were considered missing (lost data). The outcomes of interest were the ‘No’ responses to feeling prepared and safe, and ‘Yes’ to feeling anxious and worried about working during the COVID-19 pandemic. These were considered proxy variables for stress symptoms.

This study is based on self-perceived stress assessment¹⁶16 Herrera-Peco I, Jiménez-Gómez B, Romero Magdalena CS, Deudero JJ, García-Puente MG, Benítez de Gracia E, Ruiz Núñez C. Antivaccine movement and COVID-19 negationism: a content analysis of Spanish-written messages on Twitter. Vaccines (Basel) 2021; 9(6):656., and the choice of dependent and independent variables followed the explanatory theoretical model of occupational stress proposed by the World Health Organization (WHO)¹⁷17 Paviotti A. God and COVID-19 in Burundian social media: the political fight for the control of the narrative. J African Media Studies 2021; 13(3):385-397. and adapted to dental surgeons working during the pandemic (Figure 1). The proxy variables for stress symptoms include psychological and emotional factors (anxiety and worry) and cognitive and behavioural factors (secure and knowledge). The independent variables identified from the answers were listed as individual factors and extra-organisational and organisational sources of stress connected with the work process, biosafety and access to personal protective equipment (PPE).

The theoretical model described here rests on three explanatory pillars:

1) Individual characteristics: intrinsically individual possible sources of stress represented by the variables: age (dichotomised at the median into less than 39 years old and 39 years old or more), gender (male/female), time since professional qualification (10 years or less/11 to 20 years/more than 20 years), existence of a risk condition for severe COVID-19 (No/Yes) and whether COVID-19 tested (No/Yes);

2) Extra-organisational sources of stress indirectly related to the service as such and represented here by: withdrawal from practice in the pandemic (No/Yes) and access to information guidelines on dental care in health services (No/Yes); and

3) Organisational sources of stress, that is, directly work-related possible causes of stress, such as: type of work relationship (dichotomised into self-employed and other relationships), having received workplace guidance on measures to be taken during the COVID-19 pandemic (No/Yes) and a set of questions about work process organisation (suspension of elective care, participation in decision-making, reduction of workload, investigation for symptoms of respiratory infection when scheduling appointments, specification of urgency following prior clinical protocols, COVID-19 guidance from dentist to patients, use of digital tele-guidance and tele-monitoring tools), which were categorised into ‘always/almost always’, ‘sometimes ‘ and ‘almost never/never’. The same went for dental clinic biosafety factors (cleaning and disinfection of the environment and suction hoses at each appointment, use of sterile handpieces at each appointment, four-handed dentistry, use of the rubber dam in high-speed procedures, avoidance of aerosol-generating procedures, doffing in correct sequence at each appointment) and access to, and use of, PPE (N95/PFF2 masks and waterproof aprons in sufficient quantity, use of face shield during patient care and N95/PFF2 mask reuse in accordance with safety criteria) (Figure 1).

Lastly, the responses identified as proxy for occupational stress constituted the study outcome were the resultant of, on the one hand, sources of stress which can foster anxiety and concern and, on the other, information and conditions for safe clinical care during the pandemic (Figure 1).

The data were organised in a Microsoft Excel spreadsheet and analysed using the SPSS for Windows (version 16.0) Package for the Social Sciences statistics programme. The sample’s sociodemographic, education, work and health characteristics were analysed using descriptive statistics. Absolute and percentage frequencies were measured for categorical variables, and medians (± interquartile intervals), for numeric variables.

Associations between outcome variables were quantified using Spearman’s correlation test. Bivariate associations between outcomes (proxy for occupational stress) and explanatory variables (individual, extra-organisational and organisational factors) were measured using Pearson’s chi-square test, to a 5% level of statistical significance. Variables associated with each outcome with p-value ≤ 0.20 were eligible for multivariate analysis, which was performed by binary logistic regression. Results for the variables included in the multivariate explanatory model are displayed by crude and adjusted odds ratio with respective 95% confidence intervals. Years since completion of undergraduate course showed multicollinearity with age and was excluded from the analysis. Variables were included in the regression analysis by the enter method. Goodness of fit of the final model was assessed using the Hosmer and Lemershow test, with p ≥ 0.05 indicating fit.

Results

The sample characterisation (Table 1) revealed that participants were predominantly female (74.7%) and 39 years old or less (51.0%). Most reported no risk factors for the development of severe forms of COVID-19 (90.9%) and had not yet been tested for COVID-19 (71.6%). On the other hand, most participants declared having left off working in a dental clinic during the pandemic (84.4%), having had access to official COVID-19 prevention and control guidelines (84.4%) and having received workplace guidance on measures to be taken during the COVID-19 pandemic (77.5%). Table 1 also shows that, despite the high frequency of reports of feeling prepared and safe to work properly in dentistry during the COVID-19 pandemic (78.1%), most participants reported feeling anxious and worried (64.8%).

The measure most often adopted to prevent and control the spread of COVID-19, as reflected in the response ‘always/almost always’, was to investigate for symptoms of respiratory infection when scheduling appointments (83.4%) and the measure least applied was to suspend elective procedures and restrict care to emergencies (29.7%) (Table 2).

The biosafety measure most often taken in dental clinics, as given by ‘always/almost always’ responses, was for a trained professional, with appropriate PPE, to clean and disinfect the environment (80.5%), while the least applied was to avoid aerosol-generating procedures (26.6%), to use a rubber dam in high-speed treatments (32.0%), four-hand dentistry (40.1%) and to use sterile handpieces at each appointment (42.7%) (Table 2).

The PPE most commonly available and used was the face shield (85.4%) and N95/PFF2 masks were available in sufficient quantity for most participants (76.6%) (Table 2).

Table 3 shows the bivariate associations between explanatory factors of the theoretical model and the dichotomised outcome variables. As regards the individual factors, participants who felt prepared and confident were mostly male (p = 0.018), over 39 years old (p < 0.001), trained more than 20 years ago (p < 0.001) and had some risk factor for severe forms of COVID-19 (p = 0.044). Women (p = 0.015), younger participants (up to 39 years old) (p < 0.001) and more recent graduates (qualified up to 10 years previously) (p = 0.055) reported greater anxiety and concern (Table 3).

In the block of extra-organisational work-related factors, professionals who stopped working during the pandemic were more anxious and concerned (p = 0.020), while those who had access to official COVID-19 prevention and control guidelines were more prepared and confident (p = 0.050) (Table 3).

With regard to organisational factors, participants who declared they were more prepared and confident reported receiving workplace guidance on measures to be taken during the pandemic (p < 0.001), always or almost always suspending elective care (p = 0.035) and participating in decision-making (p < 0.001), as well as those who reported ‘always/almost always’ investigating for respiratory infection symptoms when scheduling appointments (p < 0.001), specifying emergencies on the basis of established protocols (p < 0.001) and using digital tele-guidance and tele-monitoring tools (p < 0.001). As regards workplace biosafety measures, participants who reported feeling better prepared and safer responded that ‘always/almost always’: a) the environment was cleaned and disinfected by a trained professional with appropriate PPE (p < 0.001); b) suction hoses were cleaned at each appointment (p < 0.001); c) sterile pens and handpieces were used at each appointment (p < 0.001); d) four-hand dentistry was performed (p = 0.002); e) aerosol-generating procedures were avoided (p = 0.005); f) doffing followed the recommended sequence (p < 0.001); g) enough N95/PFF2 masks were available (p = 0.018); and h) enough waterproof aprons were available (p = 0.046) (Table 3).

The most anxious and concerned were women (p = 0.015), young people (up to 39 years old) (p < 0.001), participants who had completed their professional training within 10 years earlier (p = 0.055), who withdrew from clinical work during the pandemic (p = 0.020) and who “always/almost always” suspended elective care (p = 0.037) and used a face shield (p = 0.001). The most anxious and concerned declared that they “never/almost never” took part in decision making (p = 0.010). Also more anxious and worried were those who answered “sometimes” with regard to a trained professional’s cleaning and disinfecting the environment (p = 0.009) and four-hand dental care (p < 0.001) (Table 3).

Table 4 shows the results of multivariate analysis for feeling individually prepared and safe with regard to, and anxious and concerned about, working in a clinic during the pandemic. The final model revealed that the preparedness and safety outcome was associated with individual and organisational biosafety-related factors. Participants were less likely to feel prepared and safe regarding clinical care because of individual factors (being female and younger) and organisational factors (not receiving workplace guidance on measures to be taken during the pandemic and “almost never/never” doffing in the recommended sequence). COVID-19-related factors, such as risk factors for severe forms of the disease and laboratory testing to detect COVID-19, were of borderline statistical significance and adjusted the explanatory model.

In the multivariate model, feelings of anxiety and concern about working were found to be associated with only one individual factor - age - and with factors relating to work process organisation and biosafety in the clinic. Younger dentists, those who “almost never/never” participated in decision-making and who “sometimes” performed four-handed dental procedures were more likely to feel anxious and worried. Less likely to be anxious and worried were those who “almost never/never” suspended elective care and who “sometimes” used a face shield (Table 4).

Discussion

This study showed that most dentists reported feeling anxiety and concern about working during the COVID-19 pandemic, and that individual and organisational factors were associated with occupational stress among dentists in the private sector in the state of Paraná during the COVID-19 pandemic. Studies have shown that the pandemic affected mental health adversely in the population at large¹⁸18 Hannon E, Hanbali L, Lehtimaki S, Schwalbe N. Why we still need a pandemic treaty. Lancet Glob Health 2022; 10(9):E1232-E1233., and especially among health personnel¹⁹19 Garret L. The coming plague: newly emerging diseases in a world out of balance. New York: Farrar Straus Giroux; 1994. , including private-sector dentists¹⁰10 Ashton J. COVID-19 and herd immunity. JRSM 2022; 115(2):76-77., who were more affected as compared with the emotional state of public-sector dentists¹⁰10 Ashton J. COVID-19 and herd immunity. JRSM 2022; 115(2):76-77.^,1111 Jung F, Krieger V, Hufert FT, Küpper JH. Herd immunity or suppression strategy to combat COVID-19. Clin Hemorheol Microcirc 2020; 75(1):13-17., possibly because of the unpredictability inherent to economic and work conditions in the former sector.

Women are a majority among dental professionals in southern Brazil and the mostly-female sample was similar to those of most studies of dentists there, corroborating the feminisation of the profession²⁰20 Osterholm M. Preparing for the next pandemic. Foreing Affairs 2005; 84(4):24-37.^,2121 Webster RG. Flu Hunter: unlocking the secrets of a virus. Dunedin: Otago University Press; 2018.. Although studies have shown women to be more perceptive of mental health, the only outcomes with which gender was found to associate in this study were preparedness for, and safety at, work: more women reported feeling less prepared and safe. Although, in this study, gender was not retained in the multivariate analysis as a factor associated with anxiety, in the literature, women have been found at greater risk of anxiety during the COVID-19 pandemic¹⁹19 Garret L. The coming plague: newly emerging diseases in a world out of balance. New York: Farrar Straus Giroux; 1994.^,2222 Soucheray S. Experts review 1918 pandemic, warn flu is global threat [Internet]. 2018. [citado 2022 ago 3] Disponible en: https://www.cidrap.umn.edu/news-perspective/2018/05/experts-review-1918-pandemic-warn-flu-global-threat
https://www.cidrap.umn.edu/news-perspect... . That age showed greater impact than gender may be explained by the professional experience gained with age’s fostering feelings of being informed and safe in clinical practice and, consequently, resulting in less anxiety and concern at work and mitigating the influence of gender.

In this study, most participants were in the younger age groups (median age, 39; 75% percentile, 47 years). Younger people tend to use social networks more and are more likely to respond to online surveys. With social isolation, however, the population as a whole began to make more use of these tools²³23 Arroyo J. La revancha de Higea. Crónica de una pelea en desventaja. In: Tanaka M, compilador. El desafío del buen gobierno. Intersecciones entre academia, política y gestión pública. Lima: Fondo Editorial PUCP; 2022. p. 135-156., which may justify the similar participation by different age groups. Age was the only individual factor retained in the theoretical model in both outcomes, in which younger professionals felt less prepared and safe, and more anxious and concerned about working during the pandemic. In Turkey, recent dentistry graduates seemed to be the most affected during the pandemic²⁴24 PNUD América Latina. Cronología de la respuesta de política durante la pandemia del COVID-19 en América Latina y el Caribe. Panamá: PNUD; 2022. and a study in Paraíba State in Brazil showed greater confidence in working during the pandemic among older dentists, which can be explained by their being longer in practice and more stably established in the profession²⁵25 Lupien P, Rincón A, Carrera F, Lagos G. Early COVID-19 policy responses in Latin America: a comparative analysis of social protection and health policy. Can J Lat Am Caribb Stud 2021; 46(2):297-317..

As regards the organisational factors, participants who received workplace guidance on COVID-19 reported greater confidence and preparedness for work, highlighting the importance of continuing health education for practitioners. A study in São Paulo state showed that more than 80% of dentists received no specific training to control COVID-19 transmission in the healthcare environment, although several courses were available and widely publicised¹¹11 Jung F, Krieger V, Hufert FT, Küpper JH. Herd immunity or suppression strategy to combat COVID-19. Clin Hemorheol Microcirc 2020; 75(1):13-17..

Participants who did not follow the recommended sequence for doffing PPE felt unprepared and more insecure in providing care during the pandemic. Given that doffing is one of the main routes for contamination of health personnel, this procedure is as important as donning³3 Schwabe CW. Veterinary Medicine and Human Health. Baltimore: Williams & Wilkins; 1984.. Adequate access to, and proper use of, PPE have been associated with not only physical health protection, but greater job satisfaction and lesser emotional distress²⁶26 Acosta LD. Capacidad de respuesta frente a la pandemia de COVID-19 en América Latina y el Caribe. Pan Am J Public Health 2020; 44:e109..

Organisational factors relating to adherence to COVID-19 protocols were associated with anxiety and concern about working. Lack of participation in decision-making was associated with a greater likelihood of participants’ being anxious and worried, suggesting that those employed in clinics, with fragile employment relationships, were adversely affected. This underlines the importance of team dialogue, as well as managers’ role in guiding targeted measures.

Professionals who understood the importance of the adjustments were more affected emotionally, as they were more aware of the risk of infection and possibly more concerned about the consequences of contamination, as evidenced in the association between use of face shield and anxiety and concern. Lax adherence to protective measures, reflected in the “sometimes” responses with regard to four-hand care, showed that uncertainty regarding the workplace support structure can generate anxiety and concern among health personnel. Private sector care teams do not always include oral health assistants and technicians, although this can optimise the work, possibly because they represent an additional financial burden for the clinics. Nonetheless, four-hand dentistry is highly recommended and stressed during pandemics because it helps reduce the generation of aerosols, speeds up care and, consequently, reduces the risk of contamination²⁷27 García PJ, Alarcón A, Bayer A, Buss P, Guerra G, Ribeiro H. COVID-19 response in Latin America. Am J Trop Med Hyg 2020; 103(5):1765-1772..

On the other hand, participants who did not suspend elective care were less anxious and worried. With time, they had possibly grown used to the inappropriate conditions or this may even suggest carelessness and denial of the severity of the pandemic, both of which are associated with a lesser likelihood of occupational stress. A study in Poland showed that dentists who suspended their clinical work reported greater anxiety than those who continued their practice without interruption²²22 Soucheray S. Experts review 1918 pandemic, warn flu is global threat [Internet]. 2018. [citado 2022 ago 3] Disponible en: https://www.cidrap.umn.edu/news-perspective/2018/05/experts-review-1918-pandemic-warn-flu-global-threat
https://www.cidrap.umn.edu/news-perspect... . In general, however, dentists seem to have a good command of knowledge of COVID-19 and the adjustments necessary in services to minimise the risk of contamination²⁸28 Schwalb A, Armyra E, Méndez-Aranda M, Ugarte-Gil C. COVID-19 in Latin America and the Caribbean: two years of the pandemic. J Intern Med 2022; 292(3):409-427..

Patient flow, in both urgent and elective care²⁹29 Cid C, Marinho ML. Dos años de pandemia de COVID-19 en América Latina y el Caribe: reflexiones para avanzar hacia sistemas de salud y de protección social universales, integrales, sostenibles y resilientes. Santiago: CEPAL; 2022., has been seen to decrease in private dental services worldwide, entailing financial losses for practitioners. Also, the impact of COVID-19 on dentists’ financial situation is determined by factors beyond those inherent to suspending care during a critical period of the pandemic, because the economic situation of patients who attend private dental clinics is intrinsically bound up with the country’s economic situation. Accordingly, the current economic crisis in Brazil, which involves reduced purchasing power, high rates of unemployment and food insecurity, has heightened the impacts of the pandemic and aggravated this problem³⁰30 Holland AC. Forbearance. Am Polit Sci Rev 2016; 110(2):232-246..

The findings of this study, in which participants under most occupational stress were younger, women and more recent graduates, demonstrate the existence of precarious work relations in the private dental sector. In practice, it is increasingly common for employment situations not to assure favourable conditions of care and adequate PPE, but subject dental workers’ wage gains to their quantitative performance of procedures, which diminished or were abruptly stopped during the pandemic period. This thus resulted in substantial financial losses and, consequently, affected these workers’ emotional health. Also, informal employment lacking guarantees has devalued and impaired working conditions. That dental practice in the supplementary health market is precarious is recognised in the literature³¹31 McConnell A, Hart Paul't. Inaction and public policy: understanding why policymakers 'do nothing'. Policy Sci 2019; 52:645-661., and in Brazil, it has to be acknowledged that the labour market is over-supplied with dental surgeons, as a result of the excessive number of schools of dentistry across the country, plus a lack of market regulation and State control³¹31 McConnell A, Hart Paul't. Inaction and public policy: understanding why policymakers 'do nothing'. Policy Sci 2019; 52:645-661..

The findings of this study may thus be reflecting the effects of problems existing in the dental sector labour market prior to the pandemic, especially in southern Brazil, where this study took place and where, after the southeast, most of Brazil’s dentists are concentrated³²32 Cecchini S. Protección social universal en América Latina y el Caribe. Santiago de Chile: ONU; 2019.. The findings, which are grounded in the concepts of the theoretical models applied³³33 Bizberg I. Latin American health regimes in the face of the pandemic. Revue Interventions Économiques 2022; 67:478-507.^,3434 Mazzucato M, Ghosh J. An effective pandemic response must be truly global [Internet]. 2022. [citado 2022 ago 22]. Disponible en: https://www.project-syndicate.org/commentary/g20-world-bank-ineffective-approach-to-pandemic-preparedness-by-mariana-mazzucato-and-jayati-ghosh-2022-07
https://www.project-syndicate.org/commen... , help to explain, in part, socioeconomic points of view on occupational stress among dentists, which was aggravated during COVID-19.

Having been tested for COVID-19, although not associated at the 5% level, was an important variable in fitting the final explanatory model. This finding may be connected with uncertainty about possible infection by the disease, which would affect dentists emotionally, especially at a time when there were no proven effective drugs nor vaccines available for the disease. The sample comprised liberal professionals from the private sector, most of whom had only one job and were thus not only concerned over their own health with regard to this newly-arrived installed infectious disease, but were suffering direct impact on their financial situation from the necessary period of isolation, quarantine and resulting absence from work, which left them apprehensive and worried about the future of the profession³⁵35 Arena de Mesa A. Las debilidades estructurales de los sistemas de salud de América Latina a la luz de la pandemia: la urgencia de avanzar hacia sistemas de salud universales, integrales y sostenibles [Internet]. 2022. [citado 2022 ago 3]. Disponible en: https://www.cepal.org/sites/default/files/presentations/presentacion_alberto_arenas_de_mesa.pdf
https://www.cepal.org/sites/default/file... ^,3636 Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, Chua A, Verma M, Shrestha P, Singh S, Perez T, Tan SM, Bartos M, Mabuchi S, Bonk M, McNab C, Werner GK, Panjabi R, Nordström A, Legido-Quigley H. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 2021; 27(5):964-980..

Vaccination has been highly effective in controlling COVID-19³⁷37 Forman R, Azzopardi-Muscat N, Kirkby V, Lessof S, Limaro Nathan N, Pastorino G, Permanand G, van Schalkwyk MC, Torbica A, Busse R, Figueras J, McKee M, Mossialos E. Drawing light from the pandemic: rethinking strategies for health policy and beyond. Health Policy 2022; 126(1):1-6. and may impact the responses of participants who answered the questionnaire early in the pandemic. Accordingly, the multicentre research team plans to conduct a further wave of data collection. Although the instrument used to measure occupational stress was a proxy for occupational stress and the validation of the research instrument has yet to be published, the data obtained here are consistent with findings in the literature on the subject¹⁹19 Garret L. The coming plague: newly emerging diseases in a world out of balance. New York: Farrar Straus Giroux; 1994.^,2424 PNUD América Latina. Cronología de la respuesta de política durante la pandemia del COVID-19 en América Latina y el Caribe. Panamá: PNUD; 2022.. Note that the data were collected between August 10 and October 7, 2020 and, given the spread of the pandemic into new phases, accentuated by the emergence of new variants of the virus, the findings should be interpreted with caution, as they may not be representative of the whole pandemic period. One limitation of this study is the bias inherent to participation in an online questionnaire by a convenience sample. However, sample calculation found that the study sample was of sufficient sise to represent the state of Paraná.

The findings of this study underline the need to build strategies to minimise the emotional impacts suffered by private sector dentists during the COVID-19 pandemic. It is the job of Brazil’s federal and regional boards of dentistry to enable and encourage dental caregivers to qualify through permanent health education to afford them effective preparation and safety for working in clinical practice. It is the function of the regulatory bodies to supervise and seek to improve labour relations and working conditions in the private dental sector, so as to guarantee dentists’ rights, given that these conditions are intrinsically related to the occupational stress suffered by workers, which may potentially affect their mental health.

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