Introduction
The COVID-19 pandemic has exposed preparedness challenges to healthcare systems worldwide, particularly in dental clinics. Dental professionals are the most susceptible healthcare workers because of the nature of their work. The proximity of the dental team to patients could readily lead to the spread of the disease from infected patients to the dental team, or from the infected dental team to the patient in cases where appropriate protective procedures are not undertaken (Banakar et al., 2020). This led to the recommendation by government bodies and oral healthcare institutions to close the dental care system as one of the response measures to minimize in-person transmission (Barnett et al., 2020). In a study by Iurcov et al. (2021), 65.51% of dentists registered a decrease in the number of patients at the beginning of the pandemic, leading to over 70% loss in financial income, with over 70% unable to sustain their employees for up to 3 months. The financial implications of the pandemic for dental facilities were multivariable in nature. Revenue loss occurs due to the temporary closure of dental facilities and the perspective that dental care is not an emergency or a necessary service (WHO, 2023). Only emergency treatment is available in hospitals prioritizing emergency conditions over preventive dental health procedures, leading to a financial crisis for dental health departments (Chamorro-Petronacci et al., 2020).
Additionally, due to disruption of the supply chain, the cost of procuring personal protective equipment (PPE) and environmental disinfection supplies has increased, adding another layer of financial stress for dental facilities (Guner et al., 2022). A crucial part of the recommendations was the use of personal protective equipment (PPE) which serves as a nontherapeutic measure to help curb the spread of the disease. However, the success of these recommendations depends on the supply and availability of PPEs and sterilization of equipment and disinfectants. According to Iurcov et al. (2021), 65.1% of doctors in the northern parts of Italy encountered difficulties in purchasing protective suits and medical supplies, with a majority focusing on the quality and cost of purchasing protective suits.
The lack of PPE, fear and stigmatization of health workers, and lack of training of dental healthcare personnel have affected human resource preparedness. According to a study conducted in Poland, unpreparedness, anxiety, and phobia associated with COVID-19 in public and private settings and dental facilities compelled 71.2% of dentists to willingly suspend their practice (Tysiąc-Miśta & Dziedzic, 2020). This study concurs with the need to rethink healthcare systems, particularly in developing countries, to address future emergencies and mitigate the negative effects that may arise during emergencies.
Methods
Study site
The study area was Nairobi County with an estimated population of 4.3m people (2019 Census). It also comprises 221 public facilities and two to six private dental facilities. The dental services offered in these facilities include but are not limited to oral diagnosis, extraction, fillings, root canal treatment, disimpassion, crowns and bridges, prosthodontics, full-mouth scaling and prophylaxis, dry socket management, and referral services. Nairobi County was selected because of the high prevalence of COVID 19 cases in Kenya. It also has the highest percentage of facilities offering dental services in Kenya (Ogira et al., 2022).
Study design
This study adopted a cross-sectional design. The mixed-method approach was used to gather both quantitative and qualitative data for the broad purposes of breadth and depth of understanding and collaboration (Salahshoori et al., 2021).
Study population
The study population included 221 dental facilities across Nairobi County categorized as either public (13) or private and mission-based (208).
Inclusion criteria. A total of 221 facilities were included in this study. The study engaged the heads of the dental facilities or their equivalents in the facility (questionnaire) and selected four key informants, those informed on county dental health delivery (interview).
Exclusion criteria. The study excluded the heads of facilities who were not willing to take part and officials who were not in session.
Sampling and sample size
Census sampling was used in this study. Therefore, the heads of each of the 221 dental facilities in Nairobi were included in this study.
Study variables
The dependent variable was the COVID-19 emergency preparedness. The independent variables are the main factors associated with dental facility preparedness, such as finance, supplies, and human resources, including (emergency response kitts, budgetary allocation emergencies, main source of funding, Adequacy of the IPC supplies, and flexibility of resources).
Data collection tools
A semi-structured questionnaire was the main tool used to collect the data. Considering the educational level of the respondents, the questionnaires were self-administered. The study also used a key informant interview (KII) guide to the four key informants. Purposive sampling was used to identify key informants.
Data collection procedure
Quantitative data were collected using the KoboCollect Application. It was estimated 15-minute period to complete the questionnaire. Upon completion of the survey tool, participants submitted their responses using the KoboCollect Application. Qualitative data were collected through interviews done using in-person interviews with an estimated maximum duration of 15 minutes. Once the interview was completed, the recorded data were saved in a password-protected gadget before being shared with the data analyst for verbatim transcription and analysis.
Data analysis and management
The data were coded and organized in Excel 365 and exported to SPSS for analysis. This was followed by a descriptive analysis of the facility to determine financial, supply, and human resource factors in preparedness for the management of the COVID 19 pandemic. Chi-square tests for proportions were used for bivariate analysis. Multivariate logistic regression was used to determine factors associated with dental facility preparedness for covid-19. The results of these analyses are presented in standard tables and frequencies.
Results
Financial related factors to pandemic preparedness
The results indicated that most facilities received funds to run their operations from patient service charges (n = 178, 97.3%). Almost all the facilities that reported receiving support from donations and grants were mission- or faith-based facilities, apart from two government facilities. Conversely, most of the facilities that reported using loans for operational financial requirements were private. Of the facilities, 55.7% (n = 102) reported that funds available to them were not sufficient for COVID-19 emergency response, while 58.5% (n = 107) had no emergency response kitty, translating to an equal number of facilities (n = 107, 58.5%) that could not purchase emergency response appliances on need. Despite these challenges, over half of the facilities (n = 104, 56.8%) reported having an emergency response plan (Table 1).
Table 1. Use of finances in dental facilities.
| Frequency | Percent |
|---|
| Sufficiency of funds to address COVID-19 | No | 102 | 55.7 |
| Yes | 81 | 44.3 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Allocation of an emergency response kitty | No | 107 | 58.5 |
| Yes | 76 | 41.5 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Well stipulated budgetary protocol | No | 105 | 57.4 |
| Yes | 78 | 42.6 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Ability buy emergency response appliance on need | No | 106 | 57.9 |
| Yes | 77 | 42.1 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Shared budget with other departments | No | 81 | 44.3 |
| Yes | 102 | 55.7 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Whether shared budget affect COVID-19 preparedness | No | 113 | 61.7 |
| Yes | 70 | 38.3 |
| Total | 183 | 100.0 |
| | Frequency | Percent |
| Emergency response plan | No | 79 | 43.2 |
| Yes | 104 | 56.8 |
| Total | 183 | 100.0 |
Pandemic preparedness scores
Almost two-thirds of the facilities had “work to do” status (n = 133, 72.7%) to health emergencies based on the evaluation of financial, supply, and human resource factors. Only about one-fifth of the facilities in this study were determined to be fully prepared for health emergencies in the background of COVID-19 (n = 39, 21.3%), with a mean score of 64.5% and a median of 63.3% (Table 2).
Table 2. Pandemic preparedness percentage scores.
| Frequency | Percent |
|---|
ReadyScore
classification | Not ready | 11 | 6.0 |
| Work to do | 133 | 72.7 |
| Ready | 39 | 21.3 |
| Total | 183 | 100.0 |
| Preparedness percentage scores |
| Mean | 64.516 |
| Median | 63.300 |
| Variance | 299.311 |
| Range | 73.5 |
The preparedness scores proved a determinant in the continued operation of dental services among the facilities evaluated, although not to a similar magnitude. When asked if the incase of another lethal variant of COVID-19 would occur in Kenya, the facility wound close dental services only slightly above average cited that they would continue with dental services (n = 102, 55.7%).
Factors associated with pandemic preparedness scores
Bivariate analysis of the variables showed that the level of facility (p <0.001), presence of other departments (p <0.001), funds sufficiency for COVID-19 emergency response (p = 0.001), and clients attended per month (p = 0.017) were statistically significant with scores for pandemic preparedness (Table 3).
Table 3. Bivariate analysis of factors associated with pandemic preparedness.
| Preparedness
score |
|---|
| Preparedness score | Pearson Correlation | 1 |
| Sig. (2-tailed) | |
| N | 183 |
| Level of facility | Pearson Correlation | .361** |
| Sig. (2-tailed) | .000 |
| N | 183 |
| Type of facility | Pearson Correlation | -.003 |
| Sig. (2-tailed) | .962 |
| N | 183 |
| Staff numbers | Pearson Correlation | -.054 |
| Sig. (2-tailed) | .467 |
| N | 183 |
| Duration of operation | Pearson Correlation | .144 |
| Sig. (2-tailed) | .051 |
| N | 183 |
| Presence of other departments | Pearson Correlation | -.409** |
| Sig. (2-tailed) | .000 |
| N | 183 |
| Fund sufficiency for COVID emergency response | Pearson Correlation | -.253** |
| Sig. (2-tailed) | .001 |
| N | 183 |
| Clients per month | Pearson Correlation | .177* |
| Sig. (2-tailed) | .017 |
| N | 183 |
Analysis
The findings revealed that public facilities had a 75.5% reduced risk of poor pandemic preparedness (OR 0.245; 0.067 – 0.983, p = 0.038). Dental facilities that had been operational for up to 10 years as compared to those operational more than 10 years were 1.9 times likely to be ready for a pandemic (OR 1.945; 0.331 – 3.279, p = 0.004). In addition, primary (OR 3.837; 1.825–8.067, p value ≤ 0.001) and secondary level (OR 0.307; 0.145–0.648, p value = 0.003) dental facilities showed favorable odds for readiness. Finally, dental facilities that existed in the presence of other departments were more prepared than stand-alone facilities (OR 4.536; 2.573–22.533, p <0.001) (Table 4).
Table 4. Bivariate analysis.
| Variables | Category | OR | 95% CI | p-value |
|---|
| Type of facility | Public dental facilities vs Others | 0.245 | 0.067 - 0.893 | 0.038 |
| Private dental facilities vs Others | 1.974 | 0.812 - 4.795 | 0.138 |
Mission/ Faith based facilities vs
Others | 0.942 | 0.331 - 2.718 | 1.000 |
| Period of operation | Upto 10 years | 1.945 | 1.154 - 3.279 | 0.004 |
| Above 10 years | 0.629 | 0.482 - 0.821 | |
| Clients per month | 0 - 500 Clients | 1.060 | 0.947 - 1.186 | 0.251 |
| 500 - 1000 clients | 0.474 | 0.146 - 1.537 | |
| Number of staff | 0 - 10 staff members | 0.878 | 0.792 - 0.974 | |
| 11 - 20 staff members | 3.250 | 0.803 - 13.159 | 0.074 |
| Facility level | Primary level vs Others | 3.837 | 1.825 - 8.067 | <0.001 |
| Secondary level vs Others | 0.307 | 0.145 - 0.648 | 0.003 |
| Tertiary levels vs Others | 0.129 | 0.011 - 1.466 | 0.115 |
Presence of other
departments | Yes | 4.536 | 2.573 - 22.533 | <0.001 |
| No | 0.596 | 0.495 - 0.717 | |
After controlling all confounding factors, only the presence of other departments among the dental facilities proved significant in predicting readiness. Dental facilities with other departments were 4.5 times likely to be ready for a pandemic (aOR 4.591; 1.471 - 14.327, p value 0.009) (Table 5).
Table 5. Regression analysis.
| Variables | Category | OR | 95% CI | p-value | aOR | 95% CI | p value |
|---|
| Type of facility | Public dental facilities vs Others | 0.245 | 0.067 - 0.893 | 0.038 | 0.363 | 0.092 - 1.436 | 0.149 |
| Period of operation | Upto 10 years | 1.945 | 1.154 - 3.279 | 0.004 | 1.806 | 0.778 - 4.194 | 0.169 |
| Number of staff | 11 - 20 staff members | 3.250 | 0.803 - 13.159 | 0.074 | | | |
| Facility level | Primary level vs Others | 3.837 | 1.825 - 8.067 | <0.001 | 7.407 | 0.613 - 89.459 | 0.115 |
| Secondary level vs Others | 0.307 | 0.145 - 0.648 | 0.003 | 3.016 | 0.246 - 36.982 | 0.388 |
Presence of other
departments | Yes | 4.536 | 2.573 - 22.533 | <0.001 | 4.591 | 1.471 - 14.327 | 0.009 |
Discussion
This study aimed to determine the level of resource preparedness that contributes to the management of suspected COVID-19 cases in dental clinics in Nairobi County. Regarding financial preparedness, this study evaluated three variables: sufficiency of funds, budgetary guidelines, and challenges in the use of finances in dental facilities. Notably, 55.7% (n = 102) of the facilities reported that funds available to them were not sufficient for COVID-19 emergency response, while 58.5% (n = 107) had no emergency response, translating to an equal number of facilities (n = 107, 58.5%) that could not purchase emergency response appliances on need. Research has shown that emergency funds, flexible resource allocation, and fund diversification away from patient fees are crucial for cost-effective pandemic response (Fiest et al., 2020; Kain & Fowler, 2019).
Hospital budgetary funds for emergency services are essential because these resources are needed to ensure that institutions have adequate supplies, necessary infrastructural improvements, and well-trained personnel (Biancolella et al., 2022; Margini et al., 2020; Sanders et al., 2021). The study showed that 28.4% of all dentists had budgetary allocations, while 72% of these dental clinics were receiving their finances through the remuneration received from patient charges, which was nearly four times higher than those that were government-funded at 14.2%. This dependency on patient fees created financial challenges because there was a drop in patient appointments during the pandemic when patients were not able to have appointments and procedures due to government policies. The study concluded that dental facilities need to employ multiple funding sources as well as stable financing models, which will make dental facilities less dependent on patients' fees as the main income source.
The protection of healthcare providers was pivotal in the COVID-19 emergency response owing to their close contact with patients with COVID-19 (Mahendradhata et al., 2021). However, irrespective of the evidenced benefits, there were shortages of PPE, misuse, and general confusion regarding the type and method of using different available supplies (Battista et al., 2021). Additionally, Sanders et al. (2021) found disparities between private and public hospitals, indicating inequality in the availability of supplies in dental health facilities. The study further shows that supply preparedness in public dental facilities was affected by a lack of collaboration and communication with government agencies, including KEMSA, causing delays in supplies. On the other hand, supply related challenges in private facilities are caused by financial challenges that affect the cost of supplies, thus determining the availability of requisite supplies.
Human resources are an integral part of healthcare delivery and must be considered in any effective system. The study showed that 139 (76%) staff from a third of the facilities in this study had undergone training on IPC protocols related to COVID-19 emergency preparedness. The capacity of healthcare staff to handle the pandemic was crucial, and training was an important aspect of disease management by ensuring adherence to screening, diagnosis, management, and prevention guidelines provided by the WHO. Since COVID-19 is highly transmissible, adherence to infection prevention control measures is very important in reducing the disease burden (Aimrane et al., 2022; Hu et al., 2021).
Conclusion
This study aimed to explore financial, supply related, and human resource preparedness variables that had an impact on the dental facility response to the COVID-19 pandemic in Nairobi County, Kenya. The study revealed that financial, supply, and human resources aspects of the health care system had a strong relationship with preparedness levels and the ability to effectively manage a pandemic. Lack of work plans, budgeting policies, and allocation of funds to the dental department affected financial preparedness and the ability to effectively fund pandemic programs. Disruption of the supply chain impacts supply preparedness, affecting the purchase and quality of supplies in dental health facilities. Finally, gaps in the training of dental workers and IPC focal persons hindered the ability to control the spread of infections. The study concluded that dental health system readiness was significantly associated with financial, supply, and human resource preparedness. This study further highlights the knowledge gaps in human resources and poor budgetary allocation. This can be bridged by conducting training programs to build personnel capacities.
Limitations of the study
This study did not include the opinions of the heads of facilities who were unwilling to participate. Therefore, there could be a potential bias that limits the generalizability of the findings.
Ethical consideration
Approval was obtained from relevant approvals, including the Jomo Kenyatta University of Agriculture and Technology (JKUAT)Institutional Scientific and Ethics Review Committee (ISREC) JKU/ISREC/02316/0847 on the 20th of April 2023, National Commission for Science Technology, and Innovation (NACOSTI) NACOSTI/P/23/25744 on 11th May 2023, and the Nairobi County Director of Health. Each participant was asked to give his/her written consent before participating in the study and the participant's identity was not revealed in the study consent. The informants were at liberty to refuse to participate in the study without any repercussions. Anonymity, confidentiality was also assured. Data security measures, including password-protected computers and locked cabinets, were implemented to safeguard collected information and maintain data privacy and confidentiality.
Data availability
Underlying data
Dryad: Data from: Financial, supplies, and human resource preparedness in management of COVID-19 pandemic among dental facilities in Nairobi County, Kenya. https://doi.org/10.5061/dryad.brv15dvhj (Chematia et al., 2024a).
This project contains the following underlying data:
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
Extended data
Zenodo: Data from: Financial, supplies, and human resource preparedness in management of COVID-19 pandemic among dental facilities in Nairobi County, Kenya, https://doi.org/10.5281/zenodo.12720712 (Chematia et al., 2024b).
This project contains the following extended data:
Appendix_II_QUESTIONNAIRE.docx
Appendix_III_KII_GUIDES.docx
Appendix_I_CONSENTS.docx
This work is distributed under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) Both kobo collect is open-source android app that was used for collecting survey data
Author’s contribution
The author participated in the study's design and the paper's writing.
Faculty Opinions recommendedReferences
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