Sensitivity to change of the COVID-19 Anxiety Syndrome Scale among Canadian dentists

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Madathil, Walter L. Siqueira, Mary McNally, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4605107/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Oct, 2025 Read the published version in BMC Psychology → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: There is a need to further validate the COVID-19 Anxiety Syndrome Scale (C-19ASS) by evaluating its sensitivity to change over time. Aim To estimate the sensitivity to change over time of the C-19ASS in a sample of Canadian dentists. To estimate the effect of age, sex, practice type and vaccination on the anxiety levels of dentists in Canada. Methods Longitudinal data were used from a prospective cohort study conducted to estimate the incidence of COVID-19 among dentists practising in Canada. Mixed effects ordinal logistic regression models were used to estimate the association between total C-19ASS scores and follow-up time in the study and COVID-19 case counts in the province of practice of the participants during the 14 days prior to completing the C-19ASS questionnaire. Mixed effects models were utilized to identify the factors associated with COVID-19 related anxiety. Results The odds of being in a more severe category of anxiety were reduced by 26% (OR 0.74, 95% C.I. 0.72–0.76) with every 30-day increase in the follow-up time. The odds of being in a more severe category of anxiety increased by 20% (Odds Ratio = 1.20, 95% C.I.= 1.12–1.27) with each 10,000 COVID-19 case increase in the dentists’ work province during the 14 days prior to data collection. Age, sex and practice type were significantly associated with COVID-19 related anxiety in dentists. Conclusion The C-19ASS is sensitive to change over time and with external anxiety stimuli. COVID-19 related anxiety among dentists was associated with age, sex and practice type. C-19ASS dentists responsiveness anxiety longitudinal vaccination Figures Figure 1 INTRODUCTION The COVID-19 pandemic led to increases in anxiety, depression and overall psychological distress. 1 There were adverse psychosocial impacts on various sociocultural groups in Canada. 2 There are reports of lasting anxiety following COVID-19 infection 3 and this experience evolved over time as the pandemic progressed. A recent review of longitudinal studies examining changes in mental health and lifestyle among college students during the COVID-19 pandemic revealed increases in anxiety, mood disorders, alcohol use, sedentary behaviour, internet use and a decrease in physical activity. 4 Healthcare workers also experienced significant levels of anxiety, especially those on the frontline and nurses because they were responsible for the care of patients with COVID-19 and more mentally overwhelmed by the lack of specific treatment guidelines or support. 5 A rapid review of the impact of COVID-19 on the mental health of healthcare workers identified underlying organic illness, female gender, concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19 as risk factors associated with adverse mental health outcomes. 6 There was considerable psychological impact of the pandemic on the mental health outcomes of dentists worldwide as well. 7 Prior to the COVID-19 pandemic, literature has reported high rates of suicidality, burnout, stress, anxiety and depression among dentists. 8,9 Dental settings present a potentially high risk of COVID-19 cross-infection as dental care workers work in closed environments and conduct aerosol-generating procedures. 5 Many dentists in Canada reported increased work-related stress as their tasks increased significantly during the pandemic. 10 The early months of the pandemic were complicated by personal protective equipment (PPE) shortages and heightened anxieties among patients and dental staff. 11 Despite that COVID-19 vaccines were rapidly administered, starting in December 2020 and public health restrictions were progressively lifted thereafter, authorities continued urging dentists to remain vigilant. 12 Anxiety and depression in US dental healthcare workers during the pandemic were associated with demographic and professional characteristics as well as perceived risk of COVID-19. 13 In China, the frontline dental staff were more likely to suffer from anxiety disorders than the general public. 14 Older age, sufficient personal protective measures and good relationships with colleagues and patients were factors associated with decreased anxiety among them during the pandemic. 14 Furthermore, vaccination against COVID-19 is an effective tool to control the spread of this infectious disease 15 and studies have shown that the anxiety levels of vaccinated healthcare providers were lower compared to the non-vaccinated healthcare providers. 15 Elevated levels of stress, anxiety and depression could have long-term psychological implications on all healthcare workers, 16 therefore it is of paramount importance to identify the risk and protective factors associated with COVID-19 related and generalized anxiety in dentists for their long-term psychological well-being. A number of instruments have been developed and validated for assessing fear, anxiety and stress related to COVID-19 (e.g., the Fear of COVID-19 Scale 17 , Multidimensional Assessment of COVID-19 related fears 18 , Coronavirus Anxiety Scale 19 , COVID-19 Anxiety Scale 20 , COVID Stress Scales 21 , Perceived Coronavirus Threat Questionnaire 22 ). A widely used instrument, the COVID-19 Anxiety Syndrome Scale 23 was initially developed to reliably assess the presence of COVID-19 anxiety syndrome features in a general US adult population. Later, it was validated in several countries including Iran, 24 Italy, 25 Indonesia, 26 Brazil, 27 Saudi Arabia 28 , Canada 29 and Greece. 30 A previous study in Canada has evaluated the validity and reliability of the C-19ASS in English and French among Canadian dentists and it can be used to evaluate COVID-19 related anxiety in this population. 29 As a follow-up to this, further validation of this anxiety measure in Canadian dentists can be done by assessment of a longitudinal measurement aspect, responsiveness (sensitivity to change) which is an important psychometric property of a measure. Responsiveness is the ability of a measure to detect a real change in the true value of an underlying construct. 31 Due to heightened interest in the impact of the COVID-19 pandemic on the psychological health of dentists, numerous cross-sectional studies have been conducted during this epidemiological crisis 32–36 , however, they have not reported how COVID-19 related anxiety changed over time among dentists as the pandemic evolved. There is a pressing need for further longitudinal studies to improve our knowledge on this subject. Previously, studies have tested whether COVID-19 risk was positively correlated with mental health concerns among dental healthcare workers. 13 For this purpose, COVID-19 case rate per 100,000 people in each US state and territory from the Centers for Disease Control and Prevention (CDC) for the 7 days before each survey were obtained. 13 Data on the count of COVID-19 cases reported in Canada was extracted from https://health-infobase.canada.ca/covid-19/ to estimate the extent to which COVID-19 disease burden is associated with salivary cortisol levels in dentists during 1 year. 11 To our knowledge, the responsiveness (sensitivity to change over time) of the C-19ASS among this population during the COVID-19 pandemic has not been reported by any studies. There is a need to further validate the C-19ASS among Canadian dentists by investigating its responsiveness (sensitivity to change over time) using longitudinal data. Further research regarding risk factors associated with COVID-19 related anxiety in dentists practising in Canada is warranted in order to build a resilient workforce. Adequate evidence is required about particularly vulnerable groups among dentists practising in Canada to provide targeted psychological support to them. Therefore, the objectives of the present study were 1) to estimate the sensitivity to change over time of the C-19ASS among a sample of Canadian dentists; 2) to identify factors associated with COVID-19 related anxiety in Canadian dentists over time and 3) to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2. We tested the following hypotheses: 1) With increased time during the COVID-19 pandemic, the anxiety levels of the dentists decreased; 2) With increases and decreases in the COVID-19 disease prevalence in the province in which the dentists were working, their anxiety levels similarly increased and decreased. METHODS The study protocol was approved by the Institutional Review Board of McGill University, Montreal – IRB Review Number A06-M49-20A (20-06-018). To address the aims of this study, data were used from a prospective cohort study conducted with the aim of estimating the incidence rate of COVID-19 among licensed dentists in Canada over a 6-month study period. 37 A convenient non-probability sampling strategy was used to maximize participation and retention. In August 2020, 644 dentists were recruited through email invitations sent to all registered members in the rosters of the collaborating organisations, which included dental regulatory authorities, dental associations and dental schools covering provinces and territories across Canada. After providing informed consent, participants were invited to complete an online baseline survey where detailed information including sociodemographic information, type, province of practice and number of years of practice were collected. Every 4 weeks after baseline, participants completed an online questionnaire through a LimeSurvey 22 platform until October 2021. For every follow-up data collection point starting from November 2020, participants completed the C-19ASS (see Appendix A ): a 9-item instrument that assesses the presence of perseverate thinking (6 items) and avoidance (3 items) jointly defined as COVID-19 anxiety syndrome. To aid interpretation, we categorized the continuous total C-19ASS scores into mild (0–12), moderate ( 13 – 24 ) and severe ( 25 – 36 ) levels of anxiety. Those who provided questionnaire responses (N = 632) were analyzed in the present study. To account for the change in the pandemic situation in Canada, we identified the total count of COVID-19 cases reported in the province of primary practice of the participant during the 14-day period prior to the date of follow-up survey completion, from https://health-infobase.canada.ca/covid-19/ . We used mixed-effect ordered logistic regression models with random intercept to estimate the association between COVID-19 case counts, follow-up time and the C-19ASS scores. The mixed effect model allowed us to consider the correlation due to repeated measures within a participant by including a random intercept. These association estimates aid in describing how strongly the C-19ASS scores of the participants change in relation to chronological time (November 2020 to October 2021) and with the change of the epidemiological situation of COVID-19 pandemic in their province. Mixed effects ordinal logistic regression models were utilized to identify factors associated with COVID-19 related anxiety and to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2. RESULTS Demographic and dental practice characteristics of the study cohort are presented in Table 1 . The mean age of the dentists was 47.3 years (standard deviation 11.4 years). There was a higher proportion of female participants (56.8%) in our sample. Table 1 Demographic and Dental Practice Characteristics of the Study Cohort (N = 632) Characteristic n % Sex Female 359 (56.8%) Male 273 (43.2%) Age (Years) 20–30 43 (6.8%) 31–40 158 (25.0%) 41–50 172 (27.2%) 51–60 177 (28.0%) 61–70 69 (10.9%) 71–80 13 (2.1%) Dental License Type Generalist 575 (91.0%) Specialist 57 (9.0%) Location of primary dental practice Alberta 27 (4.3%) British Columbia 107 (16.9%) Manitoba 26 (4.1%) Newfoundland and Labrador 2 (0.3%) Nova Scotia 33 (5.2%) Ontario 236 (37.3%) Prince Edward Island 11 (1.7%) Quebec 160 (25.3%) Saskatchewan 29 (4.6%) Yukon 1 (0.2%) The average trajectory of the total C-19ASS scores showed a progressive decrease from November 2020 to October 2021 (Fig. 1 ). Ordinal mixed-effects regression analysis revealed that the mean C-19ASS scores of the dentists decreased over time. The output for the cumulative link mixed model fitted to the data is shown in Table 3 . The odds of being in a more severe category of anxiety for the dentists reduced by 26% with every 30-day increase in follow-up time during the study (O.R.= 0.74, 95% C.I. 0.72–0.76). However, the odds of being in a more severe category of anxiety increased by 20% (O.R.= 1.20, 95% C.I.= 1.12–1.27) with every increase of 10,000 in the total count of COVID-19 cases in the province of primary practice of the dentists during the last 14 days from the date on which they completed the C-19ASS questionnaire. Table 2 Participant COVID-19 vaccination status by follow-up visit Follow-up 4 n (%) Follow-up 5 n (%) Follow-up 6 n (%) Follow-up 7 n (%) Follow-up 8 n (%) Follow-up 9 n (%) Follow-up 10 n (%) Follow-up 11 n (%) Not vaccinated 611 (98.5) 574 (94.6) 348 (58.2) 95 (16.6) 21 (3.8) 13 (2.4) 18 (3.2) 13 (2.3) Vaccinated 9 (1.5) 33 (5.4) 250 (41.8) 479 (83.4) 531 (96.2) 526 (97.6) 538 (96.8) 553 (97.7) Table 3 Association between the state of the COVID-19 pandemic, chronological time and C-19ASS scores Odds Ratios 95% C.I. Variable name Follow-up time COVID-19 case burden 0.74 1.20 0.72–0.76 1.12–1.27 C.I. confidence interval, COVID-19 case burden refers to the number of COVID-19 cases in the province of primary practice of the dentists in the last 14 days prior to completing the C-19ASS questionnaire Ordinal mixed-effects regression analysis to identify factors associated with COVID-19 related anxiety in Canadian dentists showed that with every increase of 11 years in the age of the dentists, the odds of the dentists being in a more severe category of anxiety reduced by 15% (OR 0.85, 95% CI 0.84 − 0.85) (Table 4 ). The odds for male dentists being in a more severe category of anxiety were reduced by 11% (OR 0.89, 95% CI 0.89–0.90). Controlling for age, sex, follow-up time, province of primary practice and ethnicity of the dentists, the odds for specialists being in a more severe category of anxiety were increased by 48% (OR 1.48, 95% CI 0.61–3.59). Table 4 Association between age, sex, practice type and C-19ASS scores Odds Ratios 95% C.I. Age 0.85 0.84–0.85 Sex Males Reference category- Females 0.89 0.89–0.90 Practice type Specialist Reference category-generalist 1.48 0.61–3.59 Model adjusted for follow-up time, province of primary practice and ethnicity of the dentists At the time of the baseline survey (August 2020), COVID-19 vaccines were not yet available to dentists in Canada. In the fourth follow-up period (January 2021 to February 2021) only 1.5% of respondents indicated that they had received at least one dose of the COVID-19 vaccine (Table 2 ). The proportion of participants who received at least one dose of the COVID-19 vaccine increased sharply between follow-up 4 and 6. At follow-up 6 in March 2021, 41.8% of respondents indicated that they had received one dose of the COVID-19 vaccine. At the last follow-up in October 2021, 97.7% of participants self-reported that they had received at least one dose of a COVID-19 vaccine. Compared with unvaccinated dentists, those vaccinated against SARS CoV2, had no reduction in odds of being in a more severe category of anxiety (OR 0.98, 95% CI 0.77–1.24) (Table 5 ). Table 5 Association between vaccination against SARS-CoV2 and C-19ASS score Odds Ratios 95% C.I. Vaccinated dentists 0.98 0.77–1.24 Model adjusted for follow-up time, age, sex, practice type, province of primary practice and ethnicity of the dentists. DISCUSSION We have previously investigated and reported the internal, convergent and cross-cultural validity of the C-19ASS, demonstrating the instrument works well with Canadian dentists. 29 Given the longitudinal nature of our work we wanted to also investigate the instrument’s responsiveness to change during the COVID-19 pandemic. This study has built on our previous work by demonstrating the instrument’s sensitivity to change, which is necessary for instruments to be used in longitudinal studies, particularly given the cross-sectional nature of previous psychometric validation studies. 23–25,30 The objectives of our study were 1) to estimate the sensitivity to change over time of the C-19ASS among a sample of Canadian dentists; 2) to identify factors associated with COVID-19 related anxiety in Canadian dentists over time and 3) to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2. Assessment of responsiveness requires a longitudinal study design. 38 Methods to evaluate responsiveness usually involve an anchor-based method to explore the relationship between change over time in scores of the measure and change over time in an anchor. Responsiveness reflects the extent to which changes in a measure over a specified time frame relate to corresponding changes in a reference measure of health status. 39 It is commonly reported through minimally important difference (MID) estimate, whereby a change score on a measure should equal or exceed its MID estimate to be considered important. 40 A limitation in our study was that we did not have longitudinal data from a ‘gold-standard’ measure of anxiety. Having acknowledged this potential limitation in our study, we chose the approach of testing the changes in C-19ASS scores over time against two hypotheses: i) that anxiety ratings would decrease with time as dentists became used to the pandemic; and ii) that their ratings would increase and decrease as local provincial COVID-19 case numbers also increased and decreased. Our analyses supported these hypotheses and so we conclude that the C-19ASS can be used to detect change over time in COVID-19 related anxiety ratings among French and English-speaking Canadian dentists. A similar approach was utilised in a study using data from the same prospective study which aimed to estimate the extent to which COVID-19 disease burden is associated with salivary cortisol levels of a cohort of Canadian dentists. 11 Data on the count of COVID-19 cases reported in Canada was extracted from https://health-infobase.canada.ca/covid-19/ and the results indicated a modest positive association between the dentists’ salivary cortisol levels and the count of COVID-19 cases in Canada. 11 It also strongly suggested a link between COVID-19 related anxiety as measured with the C-19ASS and salivary cortisol levels in Canadian dentists during the COVID-19 pandemic. A similar method was utilized in a study to test whether COVID-19 risk was positively correlated with mental health concerns among US dental healthcare workers (DHCWs). 13 The results in that study showed that DHCWs living in states and during periods with high levels of COVID-19 community transmission had significantly higher odds of anxiety and depression symptoms than those living with lower transmission. 13 We identified the following pivotal factors associated with COVID-19 related anxiety in Canadian dentists over time. Our findings show that dentists in older age groups had reduced levels of anxiety during the COVID-19 pandemic. These are consistent with previous reports about DHCWs in the US 13 and surveys that showed an increased prevalence of mental health symptoms among young adults. 41 A recent systematic review of dentists’ psychological well-being during the COVID-19 pandemic identified age as a risk factor for adverse mental health outcomes in this group. 7 Gasparro et al postulated that younger, less experienced dentists were more likely to develop psychological symptoms of anxiety and depression. 42 Zhao et al concluded that with increase in age, the frontline dental staff were less likely to suffer from anxiety disorders. 14 As has been commonly found, 4,41 female dentists reported higher levels of anxiety than male dentists. A cross-sectional study on dental professionals in India reported that female dental professionals had more anxiety and depression. 43 This might be due to the fact that females are more vulnerable to mood and anxiety disorders. 44 Rates of depression and some anxiety disorders are higher in adult women. 44 The specialists in our study had higher levels of anxiety as compared to the general dentists. This differs from a study investigating the prevalence of COVID-19 related anxiety among Iranian dentists in which there were no significant differences in the anxiety of general dentists and specialists. 45 There were no differences in mental health concerns between these groups of DHCWs in the US as well. 13 In our study, we found that vaccination against COVID-19 did not have an effect on the anxiety levels in dentists. Uptake of COVID-19 vaccination contributes to low infection rates among oral-healthcare professionals but since they are a high-risk group for exposure to the SARS-CoV2-virus, 46–48 vaccinated dentists still experienced some level of anxiety. Contrary to our findings, vaccination against COVID-19 had positive effects on the anxiety levels of Turkish dental professionals. 49 The DHCWs in US who were unvaccinated experienced significantly higher rates of anxiety and depression symptoms than those who were vaccinated. 13 These findings imply that if dentists have the resources to safely practice dentistry, including vaccination then psychological distress may be reduced. Previous research regarding potential factors associated with the anxiety of frontline dental staff during the COVID-19 pandemic showed that personal protective measures could ease the anxiety of frontline dental staff, having less conflicts and good communication with colleagues and patients could help them. 14 The results of our study must be interpreted with caution since it has some limitations. This study may have enabled self-selection bias because email invitations were sent to the majority of dentists practising in Canada during the pandemic but similar to other studies conducted during the COVID-19 pandemic, our response rate was low. Furthermore, to our knowledge there are no other prospective cohort studies that gathered self-reported measurements of anxiety among our population of interest during the COVID-19 pandemic. Notwithstanding the limitations of the present study, the results are important because responsiveness is a necessary aspect of psychometric evaluation of outcome measures in mental health care. 50 Some further recommendations for future research about C-19ASS among dentists include the following: a longitudinal study design including a global measure of anxiety can be utilised to evaluate the longitudinal construct validity of the C-19ASS in a sample of Canadian dentists. These would strengthen our findings about sensitivity to change over time of this COVID-19 anxiety measure in this population. Conclusion In summary, our project demonstrates the sensitivity to change over time of the C-19ASS among dentists in Canada over the course of 1 year during the COVID-19 pandemic. COVID-19 related anxiety in dentists in Canada was associated with demographic and professional characteristics. This is an important step in supporting the validity of this measure and will enable documentation of changes in COVID-19 related anxiety ratings among dentists in Canada in relation to the COVID-19 pandemic. Declarations Human Ethics and Consent to participate declaration: This study protocol was approved by the Institutional Review Board of McGill University, Montreal– IRB Review Number A06-M49-20A (20-06-018). Participants provided informed consent by email and then completed the surveys. Consent for publication: Not applicable Availability of data and materials: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Competing interests: The authors declare that they have no competing interests to disclose. A funding statement: This project was supported by funding from the Government of Canada, through the Canadian Institutes of Health Research [VR4-172757] and the COVID-19 Immunity Task Force. /Ce projet a été soutenu par un financement du Gouvernement du Canada, par le biasis des Instituts de recherche en sante du Canada et du Secrétariat du groupe de travail sur l’immunité COVID-19. S. Madathil is a recipient of a Career award from the Fonds de Recherche du Québec Santé. Author’s contributions: R.S., P.A. and S.M. contributed to the conception, design of the work; analysis and interpretation of the data; drafted the manuscript. P.A., S.M. W.S., M.M., C.Q., M.G. contributed to the acquisition of the data. All authors reviewed the manuscript. Acknowledgements: The authors would like to acknowledge the following organizations for their support: Canadian Dental Association, Provincial Dental Board of Nova Scotia, Dental Association of Prince Edward Island, Association des chirugiens dentists du Quebec, Ontario Dental Association, Manitoba Dental Association, College of Dental Surgeons of Saskatchewan, School of Dentistry University of Alberta, College of Dental Surgeons of British Columbia and Newfoundland and Labrador Dental Association. References Emmelkamp PMG. Psychological consequences of COVID-19. Clin Psychol Psychother. Nov 2021;28(6):1315-1316. doi:10.1002/cpp.2701 Généreux M, Roy M, David MD, et al. Psychological response to the COVID-19 pandemic in Canada: main stressors and assets. Glob Health Promot. Mar 2022;29(1):23-32. doi:10.1177/17579759211023671 Rogers JP, Chesney E, Oliver D, et al. 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Clin Psychol Psychother. Nov 2022;29(6):1972-1990. doi:10.1002/cpp.2767 Muthiah AG, Yanuar A, Amanta AG, et al. The Adaptation of COVID-19 Anxiety Syndrome Scale (C-19ASS) Measurement Tool in Indonesian Language. Atlantis Press; 2022:1645-1650. Coelho GLH, Monteiro R, de Queiroz KKR, Dianni NVR, Nakamura PM, Diniz TN. Is There a Better Way to Assess COVID-19 Anxiety? Comparing Structure and Item Parameters Across Multiple Measures. PsyArXiv; 2022. Alhakami A, Salem V, Alateeq D, et al. The Arab COVID-19 Anxiety Syndrome Scale (C-19ASS): COVID-19 anxiety syndrome and psychological symptoms in the Saudi Arabian population. Clin Psychol Psychother. 2023;30(5):1083-1094. doi:10.1002/cpp.2860 Seth R, Madathil SA, Siqueira WL, et al. Validity and reliability of the COVID-19 Anxiety Syndrome Scale in Canadian dentists. Clin Psychol Psychother. 2023;30(6):1349-1356. doi: 10.1002/cpp.2877 Seydavi M, Troulli MD, Akbari M, Nikčević AV, Spada MM. An assessment of the psychometric properties and psychological correlates of the Greek COVID-19 Anxiety Syndrome Scale (C-19ASS). Clin Psychol Psychother. Published online Aug 16, 2023. doi:10.1002/cpp.2895 Terwee CB, Dekker FW, Wiersinga WM, Prummel MF, Bossuyt PM. On assessing responsiveness of health-related quality of life instruments: guidelines for instrument evaluation. Qual Life Res. 2003;12(4):349-62. doi:10.1023/a:1023499322593 Alencar CdM, Silva AM, Jural LA, et al. Factors associated with depression, anxiety and stress among dentists during the COVID-19 pandemic. Brazilian oral research. 2021;35 Cimilluca JJ, Lee KC, Halepas S, Ferguson B. COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists. J Contemp Dent Pract. 2021;22(5):473-478. Gohil DA, Nair RD, Mohammadnezhad M, Raman Reddy KV. Impact of COVID–19 on the psychological health of dental professionals: a systematic review. Global J Health Sci. 2021;13(7):1. doi:10.5539/gjhs.v13n7p1 Ismail N, Oweis Y, Alasmar A et al. The change in stress and anxiety level caused by practicing dentistry during COVID-19 pandemic. Jordan Med J. 2021;55(1) Özarslan M, Caliskan S. Attitudes and predictive factors of psychological distress and occupational burnout among dentists during COVID-19 pandemic in Turkey. Curr Psychol. 2021;40(7):3113-3124. doi:10.1007/s12144-021-01764-x Madathil S, Siqueira WL, Marin LM, et al. The incidence of COVID-19 among dentists practicing in the community in Canada: A prospective cohort study over a 6-month period. J of the Am Dent Ass. 2022;153(5):450-459.e1. doi:10.1016/j.adaj.2021.10.006 Polit DF. Assessing measurement in health: Beyond reliability and validity. Int J Nurs Stud. Nov 2015;52(11):1746-53. doi:10.1016/j.ijnurstu.2015.07.002 Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol. May 2000;53(5):459-68. doi:10.1016/s0895-4356(99)00206-1 Revicki D, Hays RD, Cella D, Sloan J. Recommended methods for determining responsiveness and minimally important differences for patient-reported outcomes. J Clin Epidemiol. Feb 2008;61(2):102-9. doi:10.1016/j.jclinepi.2007.03.012 Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic - United States, August 2020-February 2021. MMWR Morb Mortal Wkly Rep. Apr 2 2021;70(13):490-494. doi:10.15585/mmwr.mm7013e2 Gasparro R, Scandurra C, Maldonato NM, et al. Perceived Job Insecurity and Depressive Symptoms among Italian Dentists: The Moderating Role of Fear of COVID-19. Int J Environ Res Public Health. 2020;17(15). doi:10.3390/ijerph17155338 Jyoti B, Kiran M, Srivastava R, Jaiswal V, Kumari S, Sinha AK. Psychological consequences of lockdown on dental professionals during the early phase of the COVID-19 pandemic. J Educ Health Promot. 2021;10:472. doi:10.4103/jehp.jehp_1388_20 Altemus M, Sarvaiya N, Neill Epperson C. Sex differences in anxiety and depression clinical perspectives. Front Neuroendocrinol. 2014;35(3):320-30. doi:10.1016/j.yfrne.2014.05.004 Salehiniya H, Abbaszadeh H. Prevalence of corona-associated anxiety and mental health disorder among dentists during the COVID-19 pandemic. Neuropsychopharmacol Rep. 2021;41(2):223-229. doi:10.1002/npr2.12179 United States Department of Labor OSaHA. COVID-19 Control and Prevention: Dentistry Workers and Employers [Internet]. Banakar M, Bagheri Lankarani K, Jafarpour D, Moayedi S, Banakar MH, Mohammad Sadeghi A. COVID-19 transmission risk and protective protocols in dentistry: a systematic review. BMC Oral Health. Oct 8 2020;20(1):275. doi:10.1186/s12903-020-01270-9 Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 Outbreak: An Overview on Dentistry. Int J Environ Res Public Health. Mar 22 2020;17(6)doi:10.3390/ijerph17062094 Karayürek F, Çebi AT, Gülses A, Ayna M. The Impact of COVID-19 Vaccination on Anxiety Levels of Turkish Dental Professionals and Their Attitude in Clinical Care: A Cross-Sectional Study. Int J Environ Res Public Health. Oct 1 2021;18(19)doi:10.3390/ijerph181910373 Pardasaney PK, Latham NK, Jette AM, et al. Sensitivity to change and responsiveness of four balance measures for community-dwelling older adults. Phys Ther . Mar 2012;92(3):388-97. doi:10.2522/ptj.20100398 Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.docx Cite Share Download PDF Status: Published Journal Publication published 13 Oct, 2025 Read the published version in BMC Psychology → Version 1 posted Editorial decision: Revision requested 03 Jul, 2025 Reviews received at journal 24 Jun, 2025 Reviewers agreed at journal 16 Jun, 2025 Reviews received at journal 23 Aug, 2024 Reviewers agreed at journal 14 Aug, 2024 Reviewers invited by journal 14 Aug, 2024 Editor invited by journal 27 Jun, 2024 Editor assigned by journal 25 Jun, 2024 Submission checks completed at journal 25 Jun, 2024 First submitted to journal 19 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4605107","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327522341,"identity":"5af490f0-10a9-4e16-ae8d-2bcd0102bf50","order_by":0,"name":"Rachita Seth","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"prefix":"","firstName":"Rachita","middleName":"","lastName":"Seth","suffix":""},{"id":327522342,"identity":"170e61e9-eba8-46d4-ae96-351ec424210c","order_by":1,"name":"Sreenath A. Madathil","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"prefix":"","firstName":"Sreenath","middleName":"A.","lastName":"Madathil","suffix":""},{"id":327522343,"identity":"e388c4e4-cad7-4895-818a-5036928ff0a4","order_by":2,"name":"Walter L. Siqueira","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Walter","middleName":"L.","lastName":"Siqueira","suffix":""},{"id":327522344,"identity":"2f0eb0ca-1c49-4cc0-b3ae-3278023095c6","order_by":3,"name":"Mary McNally","email":"","orcid":"","institution":"Dalhousie University","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"McNally","suffix":""},{"id":327522345,"identity":"f4e01c41-9fa6-43f3-b8aa-f99db3b9c8a1","order_by":4,"name":"Carlos R. Quinonez","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"R.","lastName":"Quinonez","suffix":""},{"id":327522346,"identity":"383ff68f-873d-45dc-a4b4-dac3d41e1c6f","order_by":5,"name":"Michael Glogauer","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Glogauer","suffix":""},{"id":327522347,"identity":"9c650d75-9c5d-45f7-a434-fca4ea340b8e","order_by":6,"name":"Paul Allison","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHACxgMMDBYybCDmByBmY2duIKgHqEWCB6SFcQZICzMjkVpADGYISUCLOfsZgwMMNRI8fPyHjz22zbGz6wNp+VGDW4tlTw5QyzGgwyTS0o1ztyUntwG1MPYcw63F4ABICxtIC4+ZdO62A8kgvzAzsOHRcv4NUMs/oBb+M2bSlnAt//BouQG0hbENFGI5ZtKM2w7YgbUwtuHxy4xnBQcS+8B+SZPs3ZacANJysLcPtxZz/uSNDz58s5GT7z98TOLnNjt7+fbmgw9+fMPjMBCRgCSQ2MAAjikCWpCBPT7Vo2AUjIJRMDIBAO02RkQAI+VUAAAAAElFTkSuQmCC","orcid":"","institution":"McGill University","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Allison","suffix":""}],"badges":[],"createdAt":"2024-06-19 10:15:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4605107/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4605107/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-025-03491-5","type":"published","date":"2025-10-13T15:58:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60630811,"identity":"ba33354e-5fce-491e-9f24-9c8a4f69181b","added_by":"auto","created_at":"2024-07-19 00:48:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160650,"visible":true,"origin":"","legend":"\u003cp\u003eAverage trajectory of the total C-19ASS scores\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4605107/v1/28419e06132b8a3cc8e339ea.jpg"},{"id":93957168,"identity":"91295f23-ec5c-463e-abbd-8132375bc8ca","added_by":"auto","created_at":"2025-10-20 16:13:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":814808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4605107/v1/f9edd045-0a3b-43d9-b6a8-1245b3421a69.pdf"},{"id":60630812,"identity":"5c928b82-0f0d-43b5-956a-6ce375825488","added_by":"auto","created_at":"2024-07-19 00:48:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17763,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4605107/v1/8993feddbec169dacbc388b2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sensitivity to change of the COVID-19 Anxiety Syndrome Scale among Canadian dentists","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe COVID-19 pandemic led to increases in anxiety, depression and overall psychological distress. \u003csup\u003e1\u003c/sup\u003e There were adverse psychosocial impacts on various sociocultural groups in Canada. \u003csup\u003e2\u003c/sup\u003e There are reports of lasting anxiety following COVID-19 infection\u003csup\u003e3\u003c/sup\u003e and this experience evolved over time as the pandemic progressed. A recent review of longitudinal studies examining changes in mental health and lifestyle among college students during the COVID-19 pandemic revealed increases in anxiety, mood disorders, alcohol use, sedentary behaviour, internet use and a decrease in physical activity. \u003csup\u003e4\u003c/sup\u003e Healthcare workers also experienced significant levels of anxiety, especially those on the frontline and nurses because they were responsible for the care of patients with COVID-19 and more mentally overwhelmed by the lack of specific treatment guidelines or support. \u003csup\u003e5\u003c/sup\u003e A rapid review of the impact of COVID-19 on the mental health of healthcare workers identified underlying organic illness, female gender, concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19 as risk factors associated with adverse mental health outcomes. \u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere was considerable psychological impact of the pandemic on the mental health outcomes of dentists worldwide as well. \u003csup\u003e7\u003c/sup\u003e Prior to the COVID-19 pandemic, literature has reported high rates of suicidality, burnout, stress, anxiety and depression among dentists. \u003csup\u003e8,9\u003c/sup\u003e Dental settings present a potentially high risk of COVID-19 cross-infection as dental care workers work in closed environments and conduct aerosol-generating procedures.\u003csup\u003e5\u003c/sup\u003e Many dentists in Canada reported increased work-related stress as their tasks increased significantly during the pandemic. \u003csup\u003e10\u003c/sup\u003e The early months of the pandemic were complicated by personal protective equipment (PPE) shortages and heightened anxieties among patients and dental staff. \u003csup\u003e11\u003c/sup\u003e Despite that COVID-19 vaccines were rapidly administered, starting in December 2020 and public health restrictions were progressively lifted thereafter, authorities continued urging dentists to remain vigilant. \u003csup\u003e12\u003c/sup\u003e Anxiety and depression in US dental healthcare workers during the pandemic were associated with demographic and professional characteristics as well as perceived risk of COVID-19. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn China, the frontline dental staff were more likely to suffer from anxiety disorders than the general public. \u003csup\u003e14\u003c/sup\u003e Older age, sufficient personal protective measures and good relationships with colleagues and patients were factors associated with decreased anxiety among them during the pandemic. \u003csup\u003e14\u003c/sup\u003e Furthermore, vaccination against COVID-19 is an effective tool to control the spread of this infectious disease\u003csup\u003e15\u003c/sup\u003e and studies have shown that the anxiety levels of vaccinated healthcare providers were lower compared to the non-vaccinated healthcare providers. \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eElevated levels of stress, anxiety and depression could have long-term psychological implications on all healthcare workers, \u003csup\u003e16\u003c/sup\u003e therefore it is of paramount importance to identify the risk and protective factors associated with COVID-19 related and generalized anxiety in dentists for their long-term psychological well-being.\u003c/p\u003e \u003cp\u003eA number of instruments have been developed and validated for assessing fear, anxiety and stress related to COVID-19 (e.g., the Fear of COVID-19 Scale\u003csup\u003e17\u003c/sup\u003e, Multidimensional Assessment of COVID-19 related fears\u003csup\u003e18\u003c/sup\u003e, Coronavirus Anxiety Scale\u003csup\u003e19\u003c/sup\u003e, COVID-19 Anxiety Scale\u003csup\u003e20\u003c/sup\u003e, COVID Stress Scales\u003csup\u003e21\u003c/sup\u003e, Perceived Coronavirus Threat Questionnaire\u003csup\u003e22\u003c/sup\u003e). A widely used instrument, the COVID-19 Anxiety Syndrome Scale\u003csup\u003e23\u003c/sup\u003e was initially developed to reliably assess the presence of COVID-19 anxiety syndrome features in a general US adult population. Later, it was validated in several countries including Iran, \u003csup\u003e24\u003c/sup\u003e Italy, \u003csup\u003e25\u003c/sup\u003e Indonesia, \u003csup\u003e26\u003c/sup\u003e Brazil, \u003csup\u003e27\u003c/sup\u003e Saudi Arabia\u003csup\u003e28\u003c/sup\u003e, Canada\u003csup\u003e29\u003c/sup\u003e and Greece. \u003csup\u003e30\u003c/sup\u003e A previous study in Canada has evaluated the validity and reliability of the C-19ASS in English and French among Canadian dentists and it can be used to evaluate COVID-19 related anxiety in this population. \u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs a follow-up to this, further validation of this anxiety measure in Canadian dentists can be done by assessment of a longitudinal measurement aspect, responsiveness (sensitivity to change) which is an important psychometric property of a measure. Responsiveness is the ability of a measure to detect a real change in the true value of an underlying construct. \u003csup\u003e31\u003c/sup\u003e Due to heightened interest in the impact of the COVID-19 pandemic on the psychological health of dentists, numerous cross-sectional studies have been conducted during this epidemiological crisis\u003csup\u003e32\u0026ndash;36\u003c/sup\u003e, however, they have not reported how COVID-19 related anxiety changed over time among dentists as the pandemic evolved. There is a pressing need for further longitudinal studies to improve our knowledge on this subject.\u003c/p\u003e \u003cp\u003ePreviously, studies have tested whether COVID-19 risk was positively correlated with mental health concerns among dental healthcare workers. \u003csup\u003e13\u003c/sup\u003e For this purpose, COVID-19 case rate per 100,000 people in each US state and territory from the Centers for Disease Control and Prevention (CDC) for the 7 days before each survey were obtained. \u003csup\u003e13\u003c/sup\u003e Data on the count of COVID-19 cases reported in Canada was extracted from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://health-infobase.canada.ca/covid-19/\u003c/span\u003e\u003cspan address=\"https://health-infobase.canada.ca/covid-19/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e to estimate the extent to which COVID-19 disease burden is associated with salivary cortisol levels in dentists during 1 year. \u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo our knowledge, the responsiveness (sensitivity to change over time) of the C-19ASS among this population during the COVID-19 pandemic has not been reported by any studies. There is a need to further validate the C-19ASS among Canadian dentists by investigating its responsiveness (sensitivity to change over time) using longitudinal data. Further research regarding risk factors associated with COVID-19 related anxiety in dentists practising in Canada is warranted in order to build a resilient workforce. Adequate evidence is required about particularly vulnerable groups among dentists practising in Canada to provide targeted psychological support to them.\u003c/p\u003e \u003cp\u003eTherefore, the objectives of the present study were 1) to estimate the sensitivity to change over time of the C-19ASS among a sample of Canadian dentists; 2) to identify factors associated with COVID-19 related anxiety in Canadian dentists over time and 3) to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2. We tested the following hypotheses: 1) With increased time during the COVID-19 pandemic, the anxiety levels of the dentists decreased; 2) With increases and decreases in the COVID-19 disease prevalence in the province in which the dentists were working, their anxiety levels similarly increased and decreased.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e The study protocol was approved by the Institutional Review Board of McGill University, Montreal \u0026ndash; IRB Review Number A06-M49-20A (20-06-018). To address the aims of this study, data were used from a prospective cohort study conducted with the aim of estimating the incidence rate of COVID-19 among licensed dentists in Canada over a 6-month study period. \u003csup\u003e37\u003c/sup\u003e A convenient non-probability sampling strategy was used to maximize participation and retention.\u003c/p\u003e \u003cp\u003eIn August 2020, 644 dentists were recruited through email invitations sent to all registered members in the rosters of the collaborating organisations, which included dental regulatory authorities, dental associations and dental schools covering provinces and territories across Canada.\u003c/p\u003e \u003cp\u003e After providing informed consent, participants were invited to complete an online baseline survey where detailed information including sociodemographic information, type, province of practice and number of years of practice were collected. Every 4 weeks after baseline, participants completed an online questionnaire through a LimeSurvey \u003csup\u003e22\u003c/sup\u003e platform until October 2021. For every follow-up data collection point starting from November 2020, participants completed the C-19ASS (see Appendix \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eA\u003c/span\u003e): a 9-item instrument that assesses the presence of perseverate thinking (6 items) and avoidance (3 items) jointly defined as COVID-19 anxiety syndrome. To aid interpretation, we categorized the continuous total C-19ASS scores into mild (0\u0026ndash;12), moderate (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and severe (\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) levels of anxiety. Those who provided questionnaire responses (N\u0026thinsp;=\u0026thinsp;632) were analyzed in the present study. To account for the change in the pandemic situation in Canada, we identified the total count of COVID-19 cases reported in the province of primary practice of the participant during the 14-day period prior to the date of follow-up survey completion, from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://health-infobase.canada.ca/covid-19/\u003c/span\u003e\u003cspan address=\"https://health-infobase.canada.ca/covid-19/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. We used mixed-effect ordered logistic regression models with random intercept to estimate the association between COVID-19 case counts, follow-up time and the C-19ASS scores. The mixed effect model allowed us to consider the correlation due to repeated measures within a participant by including a random intercept. These association estimates aid in describing how strongly the C-19ASS scores of the participants change in relation to chronological time (November 2020 to October 2021) and with the change of the epidemiological situation of COVID-19 pandemic in their province.\u003c/p\u003e \u003cp\u003eMixed effects ordinal logistic regression models were utilized to identify factors associated with COVID-19 related anxiety and to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDemographic and dental practice characteristics of the study cohort are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the dentists was 47.3 years (standard deviation 11.4 years). There was a higher proportion of female participants (56.8%) in our sample.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Dental Practice Characteristics of the Study Cohort (N\u0026thinsp;=\u0026thinsp;632)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e359 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e273 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e158 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e172 (27.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e177 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e71\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDental License Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e575 (91.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of primary dental practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlberta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBritish Columbia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e107 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManitoba\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewfoundland and Labrador\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNova Scotia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOntario\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e236 (37.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrince Edward Island\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuebec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e160 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaskatchewan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYukon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average trajectory of the total C-19ASS scores showed a progressive decrease from November 2020 to October 2021 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Ordinal mixed-effects regression analysis revealed that the mean C-19ASS scores of the dentists decreased over time. The output for the cumulative link mixed model fitted to the data is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The odds of being in a more severe category of anxiety for the dentists reduced by 26% with every 30-day increase in follow-up time during the study (O.R.= 0.74, 95% C.I. 0.72\u0026ndash;0.76). However, the odds of being in a more severe category of anxiety increased by 20% (O.R.= 1.20, 95% C.I.= 1.12\u0026ndash;1.27) with every increase of 10,000 in the total count of COVID-19 cases in the province of primary practice of the dentists during the last 14 days from the date on which they completed the C-19ASS questionnaire.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant COVID-19 vaccination status by follow-up visit\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow-up 4\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up 5 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFollow-up 6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFollow-up 7 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow-up 8 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFollow-up 9 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFollow-up 10 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow-up 11 n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e611 (98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e574 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e348 (58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e95 (16.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e250 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e479 (83.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e531 (96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e526 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e538 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e553 (97.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between the state of the COVID-19 pandemic, chronological time and C-19ASS scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eOdds Ratios 95% C.I.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable name\u003c/p\u003e \u003cp\u003eFollow-up time\u003c/p\u003e \u003cp\u003eCOVID-19 case\u003c/p\u003e \u003cp\u003eburden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e0.74\u003c/p\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e0.72\u0026ndash;0.76\u003c/p\u003e \u003cp\u003e1.12\u0026ndash;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eC.I. confidence interval, COVID-19 case burden refers to the number of COVID-19 cases in the province of primary practice of the dentists in the last 14 days prior to completing the C-19ASS questionnaire\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOrdinal mixed-effects regression analysis to identify factors associated with COVID-19 related anxiety in Canadian dentists showed that with every increase of 11 years in the age of the dentists, the odds of the dentists being in a more severe category of anxiety reduced by 15% (OR 0.85, 95% CI 0.84 \u0026minus;\u0026thinsp;0.85) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The odds for male dentists being in a more severe category of anxiety were reduced by 11% (OR 0.89, 95% CI 0.89\u0026ndash;0.90). Controlling for age, sex, follow-up time, province of primary practice and ethnicity of the dentists, the odds for specialists being in a more severe category of anxiety were increased by 48% (OR 1.48, 95% CI 0.61\u0026ndash;3.59).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between age, sex, practice type and C-19ASS scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratios\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% C.I.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84\u0026ndash;0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMales\u003c/p\u003e \u003cp\u003eReference category- Females\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.89\u0026ndash;0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice type\u003c/p\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003cp\u003eReference category-generalist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u0026ndash;3.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel adjusted for follow-up time, province of primary practice and ethnicity of the dentists\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAt the time of the baseline survey (August 2020), COVID-19 vaccines were not yet available to dentists in Canada. In the fourth follow-up period (January 2021 to February 2021) only 1.5% of respondents indicated that they had received at least one dose of the COVID-19 vaccine (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The proportion of participants who received at least one dose of the COVID-19 vaccine increased sharply between follow-up 4 and 6. At follow-up 6 in March 2021, 41.8% of respondents indicated that they had received one dose of the COVID-19 vaccine. At the last follow-up in October 2021, 97.7% of participants self-reported that they had received at least one dose of a COVID-19 vaccine. Compared with unvaccinated dentists, those vaccinated against SARS CoV2, had no reduction in odds of being in a more severe category of anxiety (OR 0.98, 95% CI 0.77\u0026ndash;1.24) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between vaccination against SARS-CoV2 and C-19ASS score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratios\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% C.I.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccinated dentists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77\u0026ndash;1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel adjusted for follow-up time, age, sex, practice type, province of primary practice and ethnicity of the dentists.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe have previously investigated and reported the internal, convergent and cross-cultural validity of the C-19ASS, demonstrating the instrument works well with Canadian dentists. \u003csup\u003e29\u003c/sup\u003e Given the longitudinal nature of our work we wanted to also investigate the instrument\u0026rsquo;s responsiveness to change during the COVID-19 pandemic. This study has built on our previous work by demonstrating the instrument\u0026rsquo;s sensitivity to change, which is necessary for instruments to be used in longitudinal studies, particularly given the cross-sectional nature of previous psychometric validation studies. \u003csup\u003e23\u0026ndash;25,30\u003c/sup\u003e The objectives of our study were 1) to estimate the sensitivity to change over time of the C-19ASS among a sample of Canadian dentists; 2) to identify factors associated with COVID-19 related anxiety in Canadian dentists over time and 3) to estimate the differences in the anxiety levels in dentists in Canada following vaccination against SARS-CoV2.\u003c/p\u003e \u003cp\u003eAssessment of responsiveness requires a longitudinal study design. \u003csup\u003e38\u003c/sup\u003e Methods to evaluate responsiveness usually involve an anchor-based method to explore the relationship between change over time in scores of the measure and change over time in an anchor. Responsiveness reflects the extent to which changes in a measure over a specified time frame relate to corresponding changes in a reference measure of health status. \u003csup\u003e39\u003c/sup\u003e It is commonly reported through minimally important difference (MID) estimate, whereby a change score on a measure should equal or exceed its MID estimate to be considered important. \u003csup\u003e40\u003c/sup\u003eA limitation in our study was that we did not have longitudinal data from a \u0026lsquo;gold-standard\u0026rsquo; measure of anxiety. Having acknowledged this potential limitation in our study, we chose the approach of testing the changes in C-19ASS scores over time against two hypotheses: i) that anxiety ratings would decrease with time as dentists became used to the pandemic; and ii) that their ratings would increase and decrease as local provincial COVID-19 case numbers also increased and decreased. Our analyses supported these hypotheses and so we conclude that the C-19ASS can be used to detect change over time in COVID-19 related anxiety ratings among French and English-speaking Canadian dentists. A similar approach was utilised in a study using data from the same prospective study which aimed to estimate the extent to which COVID-19 disease burden is associated with salivary cortisol levels of a cohort of Canadian dentists. \u003csup\u003e11\u003c/sup\u003e Data on the count of COVID-19 cases reported in Canada was extracted from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://health-infobase.canada.ca/covid-19/\u003c/span\u003e\u003cspan address=\"https://health-infobase.canada.ca/covid-19/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e and the results indicated a modest positive association between the dentists\u0026rsquo; salivary cortisol levels and the count of COVID-19 cases in Canada. \u003csup\u003e11\u003c/sup\u003e It also strongly suggested a link between COVID-19 related anxiety as measured with the C-19ASS and salivary cortisol levels in Canadian dentists during the COVID-19 pandemic. A similar method was utilized in a study to test whether COVID-19 risk was positively correlated with mental health concerns among US dental healthcare workers (DHCWs). \u003csup\u003e13\u003c/sup\u003e The results in that study showed that DHCWs living in states and during periods with high levels of COVID-19 community transmission had significantly higher odds of anxiety and depression symptoms than those living with lower transmission. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe identified the following pivotal factors associated with COVID-19 related anxiety in Canadian dentists over time. Our findings show that dentists in older age groups had reduced levels of anxiety during the COVID-19 pandemic. These are consistent with previous reports about DHCWs in the US\u003csup\u003e13\u003c/sup\u003eand surveys that showed an increased prevalence of mental health symptoms among young adults. \u003csup\u003e41\u003c/sup\u003e A recent systematic review of dentists\u0026rsquo; psychological well-being during the COVID-19 pandemic identified age as a risk factor for adverse mental health outcomes in this group. \u003csup\u003e7\u003c/sup\u003e Gasparro et al postulated that younger, less experienced dentists were more likely to develop psychological symptoms of anxiety and depression. \u003csup\u003e42\u003c/sup\u003e Zhao et al concluded that with increase in age, the frontline dental staff were less likely to suffer from anxiety disorders. \u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs has been commonly found, \u003csup\u003e4,41\u003c/sup\u003e female dentists reported higher levels of anxiety than male dentists. A cross-sectional study on dental professionals in India reported that female dental professionals had more anxiety and depression. \u003csup\u003e43\u003c/sup\u003e This might be due to the fact that females are more vulnerable to mood and anxiety disorders. \u003csup\u003e44\u003c/sup\u003e Rates of depression and some anxiety disorders are higher in adult women. \u003csup\u003e44\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe specialists in our study had higher levels of anxiety as compared to the general dentists. This differs from a study investigating the prevalence of COVID-19 related anxiety among Iranian dentists in which there were no significant differences in the anxiety of general dentists and specialists. \u003csup\u003e45\u003c/sup\u003e There were no differences in mental health concerns between these groups of DHCWs in the US as well. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our study, we found that vaccination against COVID-19 did not have an effect on the anxiety levels in dentists. Uptake of COVID-19 vaccination contributes to low infection rates among oral-healthcare professionals but since they are a high-risk group for exposure to the SARS-CoV2-virus, \u003csup\u003e46\u0026ndash;48\u003c/sup\u003e vaccinated dentists still experienced some level of anxiety. Contrary to our findings, vaccination against COVID-19 had positive effects on the anxiety levels of Turkish dental professionals. \u003csup\u003e49\u003c/sup\u003e The DHCWs in US who were unvaccinated experienced significantly higher rates of anxiety and depression symptoms than those who were vaccinated. \u003csup\u003e13\u003c/sup\u003e These findings imply that if dentists have the resources to safely practice dentistry, including vaccination then psychological distress may be reduced.\u003c/p\u003e \u003cp\u003ePrevious research regarding potential factors associated with the anxiety of frontline dental staff during the COVID-19 pandemic showed that personal protective measures could ease the anxiety of frontline dental staff, having less conflicts and good communication with colleagues and patients could help them. \u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe results of our study must be interpreted with caution since it has some limitations. This study may have enabled self-selection bias because email invitations were sent to the majority of dentists practising in Canada during the pandemic but similar to other studies conducted during the COVID-19 pandemic, our response rate was low. Furthermore, to our knowledge there are no other prospective cohort studies that gathered self-reported measurements of anxiety among our population of interest during the COVID-19 pandemic. Notwithstanding the limitations of the present study, the results are important because responsiveness is a necessary aspect of psychometric evaluation of outcome measures in mental health care. \u003csup\u003e50\u003c/sup\u003e Some further recommendations for future research about C-19ASS among dentists include the following: a longitudinal study design including a global measure of anxiety can be utilised to evaluate the longitudinal construct validity of the C-19ASS in a sample of Canadian dentists. These would strengthen our findings about sensitivity to change over time of this COVID-19 anxiety measure in this population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, our project demonstrates the sensitivity to change over time of the C-19ASS among dentists in Canada over the course of 1 year during the COVID-19 pandemic. COVID-19 related anxiety in dentists in Canada was associated with demographic and professional characteristics.\u003c/p\u003e \u003cp\u003eThis is an important step in supporting the validity of this measure and will enable documentation of changes in COVID-19 related anxiety ratings among dentists in Canada in relation to the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to participate declaration:\u003c/strong\u003e This study protocol was approved by the Institutional Review Board of McGill University, Montreal– IRB Review Number A06-M49-20A (20-06-018). \u0026nbsp;Participants provided informed consent by email and then completed the surveys.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA funding statement:\u003c/strong\u003e This project was supported by funding from the Government of Canada, through the Canadian Institutes of Health Research [VR4-172757] and the COVID-19 Immunity Task Force. /Ce projet a été soutenu par un financement du Gouvernement du Canada, par le biasis des Instituts de recherche en sante du Canada et du Secrétariat du groupe de travail sur l’immunité COVID-19. S. Madathil is a recipient of a Career award from the Fonds de Recherche du Québec Santé.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions:\u0026nbsp;\u003c/strong\u003eR.S., P.A. and S.M. contributed to the conception, design of the work; analysis and interpretation of the data; drafted the manuscript. P.A., S.M. W.S., M.M., C.Q., M.G. contributed to the acquisition of the data. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge the following organizations for their support: Canadian Dental Association, Provincial Dental Board of Nova Scotia, Dental Association of Prince Edward Island, Association des chirugiens dentists du Quebec, Ontario\u003c/p\u003e\n\u003cp\u003eDental Association, Manitoba Dental Association, College of Dental Surgeons of Saskatchewan, School of Dentistry University of Alberta, College of Dental Surgeons of British Columbia and Newfoundland and Labrador Dental Association.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEmmelkamp PMG. Psychological consequences of COVID-19. Clin Psychol Psychother. Nov 2021;28(6):1315-1316. doi:10.1002/cpp.2701\u003c/li\u003e\n\u003cli\u003eG\u0026eacute;n\u0026eacute;reux M, Roy M, David MD, et al. 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Nov 2022;29(6):1972-1990. doi:10.1002/cpp.2767\u003c/li\u003e\n\u003cli\u003eMuthiah AG, Yanuar A, Amanta AG, et al. The Adaptation of COVID-19 Anxiety Syndrome Scale (C-19ASS) Measurement Tool in Indonesian Language. Atlantis Press; 2022:1645-1650.\u003c/li\u003e\n\u003cli\u003eCoelho GLH, Monteiro R, de Queiroz KKR, Dianni NVR, Nakamura PM, Diniz TN. Is There a Better Way to Assess COVID-19 Anxiety? Comparing Structure and Item Parameters Across Multiple Measures. PsyArXiv; 2022.\u003c/li\u003e\n\u003cli\u003eAlhakami A, Salem V, Alateeq D, et al. The Arab COVID-19 Anxiety Syndrome Scale (C-19ASS): COVID-19 anxiety syndrome and psychological symptoms in the Saudi Arabian population. Clin Psychol Psychother. 2023;30(5):1083-1094. doi:10.1002/cpp.2860\u003c/li\u003e\n\u003cli\u003eSeth R, Madathil SA, Siqueira WL, et al. Validity and reliability of the COVID-19 Anxiety Syndrome Scale in Canadian dentists. Clin Psychol Psychother. 2023;30(6):1349-1356. doi: 10.1002/cpp.2877\u003c/li\u003e\n\u003cli\u003eSeydavi M, Troulli MD, Akbari M, Nikčević AV, Spada MM. An assessment of the psychometric properties and psychological correlates of the Greek COVID-19 Anxiety Syndrome Scale (C-19ASS). Clin Psychol Psychother. Published online Aug 16, 2023. doi:10.1002/cpp.2895\u003c/li\u003e\n\u003cli\u003eTerwee CB, Dekker FW, Wiersinga WM, Prummel MF, Bossuyt PM. On assessing responsiveness of health-related quality of life instruments: guidelines for instrument evaluation. Qual Life Res. 2003;12(4):349-62. doi:10.1023/a:1023499322593\u003c/li\u003e\n\u003cli\u003eAlencar CdM, Silva AM, Jural LA, et al. Factors associated with depression, anxiety and stress among dentists during the COVID-19 pandemic. Brazilian oral research. 2021;35\u003c/li\u003e\n\u003cli\u003eCimilluca JJ, Lee KC, Halepas S, Ferguson B. COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists. J Contemp Dent Pract. 2021;22(5):473-478. \u003c/li\u003e\n\u003cli\u003eGohil DA, Nair RD, Mohammadnezhad M, Raman Reddy KV. Impact of COVID\u0026ndash;19 on the psychological health of dental professionals: a systematic review. Global J Health Sci. 2021;13(7):1. doi:10.5539/gjhs.v13n7p1\u003c/li\u003e\n\u003cli\u003eIsmail N, Oweis Y, Alasmar A et al. The change in stress and anxiety level caused by practicing dentistry during COVID-19 pandemic. Jordan Med J. 2021;55(1)\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zarslan M, Caliskan S. Attitudes and predictive factors of psychological distress and occupational burnout among dentists during COVID-19 pandemic in Turkey. Curr Psychol. 2021;40(7):3113-3124. doi:10.1007/s12144-021-01764-x\u003c/li\u003e\n\u003cli\u003eMadathil S, Siqueira WL, Marin LM, et al. The incidence of COVID-19 among dentists practicing in the community in Canada: A prospective cohort study over a 6-month period. J of the Am Dent Ass. 2022;153(5):450-459.e1. doi:10.1016/j.adaj.2021.10.006\u003c/li\u003e\n\u003cli\u003ePolit DF. Assessing measurement in health: Beyond reliability and validity. Int J Nurs Stud. Nov 2015;52(11):1746-53. doi:10.1016/j.ijnurstu.2015.07.002\u003c/li\u003e\n\u003cli\u003eHusted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol. May 2000;53(5):459-68. doi:10.1016/s0895-4356(99)00206-1\u003c/li\u003e\n\u003cli\u003eRevicki D, Hays RD, Cella D, Sloan J. Recommended methods for determining responsiveness and minimally important differences for patient-reported outcomes. J Clin Epidemiol. Feb 2008;61(2):102-9. doi:10.1016/j.jclinepi.2007.03.012\u003c/li\u003e\n\u003cli\u003eVahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic - United States, August 2020-February 2021. MMWR Morb Mortal Wkly Rep. Apr 2 2021;70(13):490-494. doi:10.15585/mmwr.mm7013e2\u003c/li\u003e\n\u003cli\u003eGasparro R, Scandurra C, Maldonato NM, et al. Perceived Job Insecurity and Depressive Symptoms among Italian Dentists: The Moderating Role of Fear of COVID-19. Int J Environ Res Public Health. 2020;17(15). doi:10.3390/ijerph17155338\u003c/li\u003e\n\u003cli\u003eJyoti B, Kiran M, Srivastava R, Jaiswal V, Kumari S, Sinha AK. Psychological consequences of lockdown on dental professionals during the early phase of the COVID-19 pandemic. J Educ Health Promot. 2021;10:472. doi:10.4103/jehp.jehp_1388_20\u003c/li\u003e\n\u003cli\u003eAltemus M, Sarvaiya N, Neill Epperson C. Sex differences in anxiety and depression clinical perspectives. Front Neuroendocrinol. 2014;35(3):320-30. doi:10.1016/j.yfrne.2014.05.004\u003c/li\u003e\n\u003cli\u003eSalehiniya H, Abbaszadeh H. Prevalence of corona-associated anxiety and mental health disorder among dentists during the COVID-19 pandemic. Neuropsychopharmacol Rep. 2021;41(2):223-229. doi:10.1002/npr2.12179\u003c/li\u003e\n\u003cli\u003eUnited States Department of Labor OSaHA. COVID-19 Control and Prevention: Dentistry Workers and Employers [Internet]. \u003c/li\u003e\n\u003cli\u003eBanakar M, Bagheri Lankarani K, Jafarpour D, Moayedi S, Banakar MH, Mohammad Sadeghi A. COVID-19 transmission risk and protective protocols in dentistry: a systematic review. BMC Oral Health. Oct 8 2020;20(1):275. doi:10.1186/s12903-020-01270-9\u003c/li\u003e\n\u003cli\u003eSpagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 Outbreak: An Overview on Dentistry. Int J Environ Res Public Health. Mar 22 2020;17(6)doi:10.3390/ijerph17062094\u003c/li\u003e\n\u003cli\u003eKaray\u0026uuml;rek F, \u0026Ccedil;ebi AT, G\u0026uuml;lses A, Ayna M. The Impact of COVID-19 Vaccination on Anxiety Levels of Turkish Dental Professionals and Their Attitude in Clinical Care: A Cross-Sectional Study. Int J Environ Res Public Health. Oct 1 2021;18(19)doi:10.3390/ijerph181910373\u003c/li\u003e\n\u003cli\u003ePardasaney PK, Latham NK, Jette AM, et al. Sensitivity to change and responsiveness of four balance measures for community-dwelling older adults. \u003cem\u003ePhys Ther\u003c/em\u003e. Mar 2012;92(3):388-97. doi:10.2522/ptj.20100398\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"C-19ASS, dentists, responsiveness, anxiety, longitudinal, vaccination","lastPublishedDoi":"10.21203/rs.3.rs-4605107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4605107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThere is a need to further validate the COVID-19 Anxiety Syndrome Scale (C-19ASS) by evaluating its sensitivity to change over time.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo estimate the sensitivity to change over time of the C-19ASS in a sample of Canadian dentists. To estimate the effect of age, sex, practice type and vaccination on the anxiety levels of dentists in Canada.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eLongitudinal data were used from a prospective cohort study conducted to estimate the incidence of COVID-19 among dentists practising in Canada. Mixed effects ordinal logistic regression models were used to estimate the association between total C-19ASS scores and follow-up time in the study and COVID-19 case counts in the province of practice of the participants during the 14 days prior to completing the C-19ASS questionnaire. Mixed effects models were utilized to identify the factors associated with COVID-19 related anxiety.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe odds of being in a more severe category of anxiety were reduced by 26% (OR 0.74, 95% C.I. 0.72\u0026ndash;0.76) with every 30-day increase in the follow-up time. The odds of being in a more severe category of anxiety increased by 20% (Odds Ratio\u0026thinsp;=\u0026thinsp;1.20, 95% C.I.= 1.12\u0026ndash;1.27) with each 10,000 COVID-19 case increase in the dentists\u0026rsquo; work province during the 14 days prior to data collection. Age, sex and practice type were significantly associated with COVID-19 related anxiety in dentists.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe C-19ASS is sensitive to change over time and with external anxiety stimuli. 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