|Year : 2016 | Volume
| Issue : 4 | Page : 434-439
The stress of clinical dental training: A cross-sectional survey among dental students and dentists of a dental college in India
Meena Jain1, Ankur Sharma1, Shilpi Singh2, Vishal Jain3, Sahiba Miglani1
1 Department of Public Health Dentistry, Manav Rachna Dental College, Faridabad, Haryana, India
2 Department of Public Health Dentistry, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India
3 Private Practitioner, Faridabad, Haryana, India
|Date of Web Publication||15-Dec-2016|
Department of Public Health Dentistry, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Psychological disturbances in clinical dental students and teachers remain largely unknown. Aim: To describe the psychological health of clinical dental students and their trainers in an institution in India. Materials and Methods: A cross-sectional, questionnaire-based study was conducted among clinical dental students and faculty of an Indian dental college in November 2014. The questionnaire consisted of depression anxiety stress scales-21 (DASS 21), a short version of the original 42-item DASS. Data were compiled on SPSS version 21. Group comparisons were done and P values were obtained. All tests were two-tailed with significance set at P< 0.05. Results: Stress scores were found to be higher in students as compared to trainers (P = 0.040), with the highest scores for undergraduate students. Statistically, significant difference was seen in stress scores between graduate and postgraduate trainers (P = 0.015), undergraduates and postgraduate trainers (P = 0.005), and postgraduate trainers and students (P = 0.029). A significant difference was also observed between depression scores in graduate and postgraduate trainers (P = 0.006) as well as postgraduate trainers and students (P = 0.041). Females had significantly higher level of stress (P = 0.007) and anxiety (P = 0.003) scores as compared to males. Conclusion: Stress, anxiety, and depression scores in dental students are higher than trainers. Undergraduate students among all showed the highest scores for all three parameters. Different approaches to reduce them should be further investigated and utilized at the earliest.
Keywords: Dental, education, educational, mental health, occupational health, professional, psychology, students
|How to cite this article:|
Jain M, Sharma A, Singh S, Jain V, Miglani S. The stress of clinical dental training: A cross-sectional survey among dental students and dentists of a dental college in India. J Indian Assoc Public Health Dent 2016;14:434-9
|How to cite this URL:|
Jain M, Sharma A, Singh S, Jain V, Miglani S. The stress of clinical dental training: A cross-sectional survey among dental students and dentists of a dental college in India. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Oct 21];14:434-9. Available from: http://www.jiaphd.org/text.asp?2016/14/4/434/195827
| Introduction|| |
Mental health has a profound effect on individual, interpersonal, and institutional aspects of a student's life. It also affects their academic performance, use of effective learning strategies, and completion of education. Behavioral problems in students have a huge impact on peers, faculty, and staff in an institution. These problems also affect the institutional management system in terms of legal challenge that they pose.
Mental health problems are known to be highly prevalent among college students. Stress, anxiety, and depression were the three important factors affecting academic performance of the students. An increasing trend is observed in the prevalence of severe psychological problems in postsecondary students over the past years.
Dental education is a challenging pursuit. Dental students have a high degree of psychological stress ,,, and fare poorly as compared to their medical and engineering counterparts. Clinical dental and medical teaching is in a unique position as the student is expected to learn both academic and clinical skills. Studies have shown that both clinical and academic factors contribute to stress among the dental students. Hence, psychological status and its determinants in clinical dental students are expected to be different from preclinical students.
Student–teacher relationship contributes immensely to both intrinsic and extrinsic motivation of a learner. Teachers hold an important position in identifying psychological weakness in the students. Tutor-related behavior also has an important role to play in learning. Social congruence of tutor is important in a problem-based learning scenario. Psychological health of the tutor in clinical dental education system, therefore, becomes important part of an effective learning system. This has been a neglected part of the dental education system and much remains unknown about tutor's mental health.
A lot of literature is available on psychological stress among dental students and its causes. Studies have been done to assess the other determinants of mental health such as anxiety and depression in dental students. However, prevalence of psychological disturbances in clinical dental students and teachers remains largely unknown. The present paper aims at describing the psychological health of clinical dental trainees and their trainers in an institution in India.
| Materials and Methods|| |
A cross-sectional, questionnaire-based study was conducted among clinical dental students and faculty of a dental college in Faridabad, India, in November 2014. Ethical approval for the study was obtained by the Institutional Ethics Committee. A study was conducted among 4th-year undergraduate students, undergraduate interns, postgraduate students, graduate, and postgraduate faculty attending various clinics in a teaching hospital in Faridabad, India.
The questionnaire consisted demographic data such as age of the respondent, education level, and gender. Education level was classified into undergraduate student, graduate, postgraduate student, and postgraduate. The respondents' identity was not revealed anywhere in the questionnaire as no identity-based information was collected to ensure anonymity.
The second part of the questionnaire consisted of depression anxiety stress scales-21 (DASS 21) which is a short version of the original 42-item DASS described by Lovibond and Lovibond in 1995. The DASS 21 scores assess how a person ranges as compared to the population mean and not according to severity of the disease; therefore, the rating levels of mild, moderate, severe, and extremely severe should be interpreted on this basis rather than the severity of the disease. The scale consists of three components having seven questions each. The depression scale, through questions 3, 5, 10, 13, 16, 17, and 21, assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia. The anxiety scale consisting of questions 2, 4, 7, 9, 15, 19, and 20 measures skeletal musculature effects, autonomic arousal, situational anxiety, and subjective experience of anxious affect. Questions 1, 6, 8, 11, 12, 14, and 18 form the stress scale and measure difficulty in relaxing, nervous arousal, impatience, susceptibility to agitation, and irritability. The respondent answers each question according to the extent to which he/she has felt the particular symptom outlined in the question on a four-point scale ranging from 0 to 3.
The questionnaire was administered to those who gave consent to participate in the study. The respondents were briefed about the questionnaire and given specific instructions. The Hindi version of DASS 21 was also made available to the respondents because English was a second language for many of them. Out of the total 214 students and faculty present on the days of the survey, 200 students consented to participate. Response rate was 93.5%. Out of the 200 forms received, nine were excluded from the study as they were found to be incomplete. Hence, data from a total of 191 subjects were included for data analysis.
Data were compiled on Microsoft Excel and cross-checked for consistency. Analysis was done using SPSS version 21 (IBM Chicago). Rating scores for questions pertaining to each of the three scales are added separately to obtain sum of scores. The sum of scores for each scale is further multiplied by 2 to obtain depression, anxiety, and stress scores. Group comparisons were done and P values were obtained. All tests were two-tailed with significance set at P < 0.05.
| Results|| |
The results of the study are based on responses from 191 participants. Of these, 70.68% were females in confirmation with the recent trends in dental college demographics in India. Trainees comprised 79.58% of the study participants, and rest of the participants were trainers. According to education level, 59.16% of the participants were undergraduates, 7.85% were graduates, 20.42% were postgraduate students, and 12.57% were postgraduates [Table 1].
In the overall sample, 19.38% of the participants had stress at a higher level than the population norms. Anxiety level was higher than the population norms in 44.5% of the participants and depression levels were higher in 28.27% of the participants. Anxiety scores of about 10% (9.42%) participants could be classified under “extremely severe” category [Table 2].
Stress scores were found to be higher in trainees as compared to trainers. This difference was statistically significant with P = 0.04; however, a statistically significant difference in anxiety and depression scores between trainees and trainers could not be established. Undergraduates had highest mean stress, anxiety, and depression scores [Table 3]. Statistically, significant difference was seen in stress scores between graduate and postgraduate trainers (P = 0.015) as well as between undergraduates and postgraduate trainers (P = 0.005). There was a statistically significant difference in stress scores of postgraduate trainers and students (P = 0.029). A significant difference was also observed between depression scores in graduate and postgraduate trainers (P = 0.006) as well as postgraduate trainers and students (P = 0.041).
In dental students, about 22% of the participants showed higher level of stress as compared to the population, 46.71% showed a higher level of anxiety, and 29.61% showed a higher level of depression as compared to the normal population levels. For clinical trainers, stress level was higher than population norms in 10.26% of the participants, anxiety level was higher than the population norms in 35.9% of the participants and depression level was higher than population norms in 23.08% of the participants [Table 4].
Females had significantly higher level of stress (P = 0.007) and anxiety (P = 0.003) scores as compared to males. Percentage of females having higher scores for stress anxiety as well as depression as compared to population norms was also higher as compared to males [Table 5].
| Discussion|| |
The present study was conducted to understand the psychological status of clinical dental students and trainers. It analyzed stress, anxiety, and depression, the three most important determinants of psychological status of an individual. In our study, 19.38% of the participants showed a stress level higher than the population average.
Stress level was found to be high in 21.24% of the undergraduate participants which was only a little lower than that reported in Indian undergraduate dental students (28.7%) by Waghachavare et al. However, the percentage of high stress level among undergraduates in this study was considerably lower than that reported by the studies conducted outside India, especially in the Middle East where percentage of students showing high stress level was alarmingly higher at 70% in Jordan  and 63.8% in Saudi Arabia. The mean stress score (DASS 21) for the undergraduates was found to be similar to that observed for 4th- and 5th- year dental students in India by Madhan et al. and was mildly higher than the population level. The comparison shows that the mean stress score of undergraduate clinical dental students in the present study sample was similar to the study conducted in India, but high stress levels were shown in a lower percentage of participants as compared to earlier Indian study.
For postgraduate students, the mean stress score was found to be in normal level and differed from the level of stress reported in postgraduate orthodontics students in India in a past study. The difference could be contributed to geographical and sociocultural factors. Another cause of difference could be that the study by Madhan et al. was conducted among students belonging to one dental specialty unlike the present study which has considered postgraduate students of all the specialties.
The mean anxiety score for undergraduate students in the present study was higher as compared to Indian undergraduates in a previous study. However, mean anxiety score for postgraduate students was lower in the present study as compared to study in Indian postgraduate students in orthodontics in 2011. Prevalence of anxiety at a higher level as compared to population was 50.44% of undergraduates and 35.9% of postgraduate students in the present study. This was considerably lower than prevalence of anxiety among dental undergraduates (98.7%) in a study conducted in Nigeria  and postgraduate students (62.4%) in a study conducted in India.
The mean depression scores in the study sample were 13.80 and 5.94 for undergraduate and postgraduate students, respectively. These were higher than the mean scores for Indian undergraduates (10.80) while they were lower than mean anxiety score for Indian orthodontic postgraduate students (11) in the past studies. Percentage of undergraduate students showing higher level of depression (31.86%) was considerably higher than those screened positive for depression (3.8%–14.5%) in a Spanish study. However, the difference may be attributed to different measurement tools used in the studies. In contrast, 23.08% of the postgraduate students showed higher level of depression as compared to 63% in a study conducted on Indian orthodontic postgraduate students.
Undergraduate clinical students showed higher levels as well as numbers as compared to postgraduate clinical students in all the three parameters. In addition, even though the percentage of undergraduate students having higher level of stress, anxiety, and depression was less than earlier studies; the mean scores were higher. This may mean that those with higher scores as compared to population norms showed more severe levels of problem even though the number of such people is lesser than earlier studies.
As compared to the students, the trainers had lower mean stress anxiety and depression scores. However, graduate trainers had a higher level of mean stress, anxiety, and depression scores as compared to both postgraduate students and trainers. The percentage of graduate trainers having higher levels of anxiety and depression according to the population norms was also higher than both postgraduate students and trainers. The postgraduate trainers had the lowest level of stress, anxiety, and depression; both according to the percentage of participants above population mean levels as well as according to DASS 21 mean scores. It can thus be established that education level is associated with stress, anxiety, and depression levels in clinical dental trainers and students. Further, females were observed to have higher score than males; thus, gender could be another factor associated with psychological status.
Lower percentages of individuals at a higher level of stress, anxiety, and depression in the present study may be attributable to introduction of mentorship, campus social network, and integrated learning for both undergraduates and postgraduates at the institution where the present study was conducted. Mentorship and campus social network may help in reduction of both anxiety and depression according to the past research. Lower level of stress in trainers may lead to more involvement with students and better learning environment ,, that may be responsible for lesser percentage of students having anxiety, depression, and stress. However, higher mean scores, particularly in undergraduates, indicate a need for introduction of psychological counseling in dental education and various practices for reduction of stress in clinical dental settings in teaching hospitals.
The results of the present study may be limited due to the fact that it is an institutional study and the results may differ with varying sociocultural contexts. However, the results invariably show difference in trends in psychological status of clinical dental students and trainers and a need of considering academic clinical dental population as a whole rather than as independent entities. It also therefore paves the way for future research in this field.
| Conclusion|| |
Percentage of students and trainers with stress, anxiety, and depression was less in the institution when compared to results from other studies conducted in different parts of the world. However, the scores for all parameters were high compared to general population. Stress, anxiety, and depression scores in dental students at the institution are high than trainers. Undergraduate students showed the highest scores for all three parameters and different approaches to reduce them should be further investigated and utilized. One approach can be more interactive and integrated curriculum and psychological counseling for all the students.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I: Educational attainment. Am J Psychiatry 1995;152:1026-32.
Kitzrow MA. The mental health needs of today's college students: Challenges and recommendations. NASPA J 2003;41:167-81.
American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Fall 2013. Hanover, MD: American College Health Association; 2014.
Gallagher RP. National Survey of College Counseling Centers 2013. The International Association Services, Inc., USA; 2013.
Lee JS, Jeong B. Having mentors and campus social networks moderates the impact of worries and video gaming on depressive symptoms: A moderated mediation analysis. BMC Public Health 2014;14:426.
Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and psychological disturbance among dental students in the West Indies. J Dent Educ 2002;66:1021-30.
Stewart DW, de Vries J, Singer DL, Degen GG, Wener P. Canadian dental students' perceptions of their learning environment and psychological functioning over time. J Dent Educ 2006;70:972-81.
Humphris G, Blinkhorn A, Freeman R, Gorter R, Hoad-Reddick G, Murtomaa H, et al.
Psychological stress in undergraduate dental students: Baseline results from seven European dental schools. Eur J Dent Educ 2002;6:22-9.
Waghachavare VB, Dhumale GB, Kadam YR, Gore AD. A study of stress among students of professional colleges from an Urban area in India. Sultan Qaboos Univ Med J 2013;13:429-36.
Alzahem AM, Van der Molen HT, Alaujan AH, De Boer BJ. Stress management in dental students: A systematic review. Adv Med Educ Pract 2014;5:167-76.
Nukpe P. Motivation: Theory and use in Higher Education. Investig Univ Teach Learn 2012;8:11-7.
Chng E, Yew EH, Schmidt HG. Effects of tutor-related behaviours on the process of problem-based learning. Adv Health Sci Educ Theory Pract 2011;16:491-503.
Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-43.
Singh B, Prabhuappa KP, Eqbal S, Singh AR. Depression, anxiety and stress scale: Reliability and validity of Hindi adaptation. Int J Educ Manage Stud 2013;3:446.
Abu-Ghazaleh SB, Rajab LD, Sonbol HN. Psychological stress among dental students at the University of Jordan. J Dent Educ 2011;75:1107-14.
Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: A cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr 2011;29:516-22.
Madhan B, Barik AK, Patil R, Gayathri H, Reddy MS. Sense of humor and its association with psychological disturbances among dental students in India. J Dent Educ 2013;77:1338-44.
Madhan B, Rajpurohit AS, Gayathri H. Mental health of postgraduate orthodontic students in India: A multi-institution survey. J Dent Educ 2012;76:200-9.
Obarisiagbon A, Azodo C, Omoaregba J, James B. Do stages of dentistry training affect anxiety provoking situations? Ann Med Health Sci Res 2014;4:869-74.
Galán F, Ríos-Santos JV, Polo J, Rios-Carrasco B, Bullón P. Burnout, depression and suicidal ideation in dental students. Med Oral Patol Oral Cir Bucal 2014;19:e206-11.
Montgomery C, Rupp AA. A meta analysis for exploring the diverse causes and effects of stress in teachers. Can J Educ 2005;28:458-86.
Haidet P, Stein HF. The role of the student-teacher relationship in the formation of physicians. The hidden curriculum as process. J Gen Intern Med 2006;21 Suppl 1:S16-20.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]