Journal of Indian Association of Public Health Dentistry

: 2014  |  Volume : 12  |  Issue : 4  |  Page : 283--292

Relationship between psychological well-being and perceptions of stress among undergraduate dental students in Bengaluru city: A cross-sectional study

M Anushri, R Yashoda, Manjunath P Puranik 
 Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, India

Correspondence Address:
M Anushri
Department of Public Health Dentistry, Government Dental College and Research Institute, Room No. 9, Fort, Victoria Hospital Campus, Bengaluru 560 002


Introduction: The dental profession has been considered a stressful occupation. The origins of this stress may also lie in the process of dental education. The perception of stress is frequently influenced by one«SQ»s personal system of beliefs and attitudes. Aim: The aim was to assess the relationship between psychological well-being and perception of stress among undergraduate dental students in Bangalore city. Materials and Methods: A cross-sectional questionnaire survey was conducted among 800 1-4 th year dental students. Information on demographics, social background, and health behaviors were collected. The psychological general well-being (PGWB) index and the dental environment stress (DES) questionnaire were used to measure PGWB and perceptions of stress, respectively. Multiple intergroup comparisons were carried out using ANOVA. Correlation analysis was done to find out relationship between PGWB and DES. Regression analysis to find out the strongest predictor of PGWB. P <0.05 was considered as statistically significant. Results: There was no significant difference in PGWB among different year of study. Female students had significantly lower PGWB scores and higher DES scores than male students. The stress differed among different year of study with highest stress in final year students in all domains except for clinical/preclinical training, which was highest among 1 st year students. Correlational analysis showed a negative relationship between PGWB and DES score. Stepwise multiple regression analysis revealed that «DQ»workload,«DQ» «DQ»patient treatment,«DQ» «DQ»performance pressure«DQ» and «DQ»others«DQ» domains of stress were significant predictors of PGWB. Conclusion: This study revealed that the perception of stress is influenced by gender and health behaviors which in turn affect PGWB.

How to cite this article:
Anushri M, Yashoda R, Puranik MP. Relationship between psychological well-being and perceptions of stress among undergraduate dental students in Bengaluru city: A cross-sectional study .J Indian Assoc Public Health Dent 2014;12:283-292

How to cite this URL:
Anushri M, Yashoda R, Puranik MP. Relationship between psychological well-being and perceptions of stress among undergraduate dental students in Bengaluru city: A cross-sectional study . J Indian Assoc Public Health Dent [serial online] 2014 [cited 2019 Jun 26 ];12:283-292
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Stress has been described as a two-edged sword that can either stimulate and motivate the students to peak performance or reduce the students to ineffectiveness. [1],[2] Research on stress in dental students has developed from investigating the perceptions of stress to experiences of burnout and general psychological well-being. [3] Published reports on the prevalence of stress in dental students exist for the United States, [3] United Kingdom, [4],[5] Germany, [6] Greece, [7] Jordan, [8] Nigeria, [9] Canada, [10] India, [11],[12],[13],[14] Singapore, [6] Japan, [1] Australia, [15] West Indies, [16] Malaysia, [17] Fiji, [18] and Turkey. [19],[20]

The stressors in dental school are multifactorial. [11],[21] Stressors associated with dental practice include time and scheduling pressures, managing uncooperative patients, commercial issues and the highly technical and intensive nature of the work. [1],[11] These findings are almost universal phenomena in different countries with different education systems and curricula. [1],[2],[8],[11] It is difficult to eliminate all the stressful problems in a dental education program. [1],[2] It has been proposed that the ability to perceive emotions in self and others, manage them, and handle relationships are important attributes for health care providers because these attributes contribute to health maintenance, including mental health, and career development. [4]

Furthermore, stress has been linked to serious side effects such as emotional exhaustion, anxiety, or depression. These side-effects can lead to alcohol abuse, drug consumption, and even thoughts of suicide. Consequently, providing a positive learning atmosphere for students and limiting the amount of stress they feel are increasingly aims for dental educators. [21] Further, dental students' anxiety predicts poorer academic performance, and their anxiety might interfere with their performance during dental procedures. [7]

Perceived stress can also affect students' well-being and academic performance. [1] To obtain a comprehensive understanding of dental environment stress (DES), investigators have begun to further explore the relationship between dental students' stress and subjective wellbeing status using the Emotional Intelligence scale, the Brief Symptom Inventory and General Health Questionnaire. [5],[15] Subjective well-being comprises contentment, satisfaction, happiness, hope, and good feelings about one's past life, present life and one's presumed future life. [1]

Hence, the present study aims to find out the relationship between psychological well-being and perceptions of stress among undergraduate dental students in Bangalore city.


To assess the psychological well-being and perceptions of stress among undergraduate dental studentsTo assess social background, health behaviors affecting stress and psychological well-being of undergraduate dental studentsTo find out relationship between psychological well-being and perception of stress among them.


A cross-sectional questionnaire survey was conducted from May 2013 to July 2013 among 1 st year to 4 th year undergraduate dental students of Bangalore city. A pilot study was conducted among 50 students to test the applicability and feasibility of questionnaire. Based on the results of the pilot study, some minor modifications were made in the proforma and used for the main study. Informed consent was obtained from all study participants. Ethical approval was taken from Institutional Review Board, and also necessary permissions were taken from head of the institutions.

From the list of colleges obtained from websites of health university present in Bangalore city, [22] five Dental colleges were randomly selected by simple random sampling.

Sample size estimation

Sample Size = {Z 2 *(p)*(q)}/Δ2

Where Z = Z value for the confidence level chosen = 1.96 (for 95% confidence level-from standard normal distribution)

P = 85% = 0.85 (percentage of samples who have stress, based on pilot study)

q = 1 − P = 15% = 0.15

Δ = Margin of error which is acceptable = 0.05 (or 5%)

Therefore, SS = ([1.96] 2 *[0.85]*[0.15])/(0.05) 2

SS = 195 which was rounded off to 200

A total of 200 from each year of study (1 st , 2 nd , 3 rd , 4 th ) were taken. Hence, number of subjects included in this study was 800 from various dental colleges in Bangalore city.

The questionnaire was administered after explaining the purpose of the survey and assured them of confidentiality and only those who volunteered were included in the study. Time taken by the participants to fill the questionnaire was on an average 15-20 min and the questionnaires were collected back on the same day and checked for any nonresponse.

Study tools

The questionnaire included demographic details (age, gender, year of study) and social background (first choice for admission, scholarships). For health behaviors, six questions on sleeping habits, eating breakfast daily, snacking between meals, physical activity (regularity of exercise), alcohol consumption, smoking were asked to the students. [23] In addition, prevalidated psychological general well-being (PGWB) index [24] and the DES questionnaire [25] were administered to the students (see Annexure).

The PGWB index is a self-administered questionnaire, which measures subjective well-being and distress. It includes 22 items that can be summated to provide a total score. For each question, there are six response options ranging from 0 to 5; the most negative option for general well-being are scored 0, and the most positive option is scored 5. Thus, the total score of the PGWB gives a maximum value of 110 and minimum of 0. The total score represents one's comprehensive subjective well-being.

The DES questionnaire assesses sources of stress associated with undergraduate course work and training in dental students. It is a 37-item questionnaire based on a 4-point Likert scale, with 1 = not stressful, 2 = slightly stressful, 3 = moderately stressful and 4 = very stressful. In this study, items that referred to stressors involving some reference to patients were omitted for 1 st and 2 nd year, because at RGUHS clinical training program starts from 3 rd year.

Descriptive statistics was computed. Individual item means were calculated for the questionnaires. This was followed by grouping the means according to the sub domains of the questionnaires and average group values were calculated. Multiple intergroup comparisons were done using ANOVA and independent t-test for group wise comparisons. Pearson's correlation was used to test relationship between DES and PGWB, followed by stepwise multiple logistic regression to find out significant predictor for PGWB. P < 0.05 was considered as statistically significant. All the statistical analyses were done with the Statistical Package for Social Sciences, Version 16.0 (IBM Corporation, SPSS Inc., Chicago,IL, USA) software package.


Eight hundred dental students participated in this study. The mean age of participants was 20.43 ± 1.67 years; 28.6% were males and 71.4% were females. There was no significant difference in mean scores of stress and psychological well-being levels among participants whose first choice of admission was dentistry or not (P > 0.05). Similarly, no difference was observed among people who were getting scholarship or not [Table 1].{Table 1}

There was significant difference between DES mean scores among the responses for the variables related to food habits (breakfast), exercise and habits (smoking and alcohol) whereas there was significant difference between mean response scores of PGWB only for the variable regular exercise (P < 0.05) [Table 2].{Table 2}

Significant difference in mean stress scores was observed between males and females (questions (1-3, 10, 14-19, 21-23, 25, 26, 28-, 31, 34, 36) [P < 0.05]) and domain wise there was significantly higher stress among females compared with males, whereas psychological well-being was significantly higher among males compared to females (P < 0.05) [Table 3].{Table 3}

There was a significant difference for all the questions of DES among different year of study except for the following questions (12, 33, 36). Among different year of study mean scores of all domains of stress was significantly higher for 4 th year except for clinical training domain where 1 st year reported highest stress whereas psychological well-being was lower among 4 th year students compared with others, but it was not statistically significant (P < 0.05) [Table 4].{Table 4}

Pearson's correlation showed a negative correlation between various domains of stress and psychological well-being (P < 0.001), [Table 5]. Step-wise multiple regression analysis showed that "workload," "patient treatment," "performance pressure" and "others" domains of stress were significant predictors of psychological well-being. 6% change in psychological well-being was attributed to workload (P = 0.001), 7% to patient treatment, 8% to performance pressure and 9% to others (P = 0.05), and overall 30% change in psychological well-being was attributed to stress [Table 6].{Table 5}{Table 6}


Previous studies have reported that dental education induces considerable stress on students. [11],[15] To become a responsible dental professional, students have to reach high levels of knowledge and professional skill, as well as developing good attitudes towards patient care; all within a short period of time. [1] This study was conducted to understand better the factors influencing student perception.

Social background of the students

Mean DES scores and mean PGWB scores were similar among participants whose first choice of admission was dentistry or not. This is in contrast with findings of other studies, [1],[11] in which dental students whose first choice was medicine scored significantly higher on the DES items than students whose first choice was dentistry. These students either had a low opinion of dentistry and its future scope or were not confident of completing the course, which in turn could have made them have a pessimistic outlook. [1],[11],[14] The mean scores of DES and PGWB among those getting scholarship or not was not statistically significant and this is in agreement with the Japanese study. [1]

Health behaviors of the students

Mean DES scores and mean PGWB scores did not vary significantly regarding sleep, habit of having in between snacks. In the present study mean stress was less among participants who consumed their breakfast daily and who had the habit of regular exercise. It was also found that because of higher stress, students had the habit of smoking and consuming alcohol. Mean DES and PGWB scores became significant for the variable regular exercise, that is, participants who had habit of regular exercise had higher PGWB and experienced less stress, this is in agreement with the Japanese study. [1]

Psychological well-being of the students measured by psychological general well-being index

The scores of PGWB index showed subjective well-being and distress status in students' general situation. Correlation of PGWB index with other health-related scales was previously documented in the USA and Sweden. [26] These studies indicate that normal values can be considered to be in the range of 78-83.

In this study, the average score of PGWB index for students on an average was 61.7 which is less compared to Sugiura et al. study. This value is relatively lower than the population norm of the PGWB total score (80.9-82.2). [1] However normal values for an Indian population are not available. Subjective wellbeing varies across cultures. People from collectivist cultures, such as Asian cultures, report less well-being than do people from more individualistic cultures, e.g. mainstream United States and Western European cultures. This difference may arise from the fact that subjective well-being is typically defined and measured with an emphasis on an individual's subjective feelings and beliefs. [1] The psychological well-being of the students was higher if they had a habit of regular exercise, similar to study done by Sugiura et al. [1] Statistically significant difference were not observed in average score of PGWB among different year of study and the mean scores of psychological wellbeing was higher among males (63.1) when compared to females (60.3) which is consistent with Japanese study. [1]

Perception of stress on the students by dental environment stress questionnaire

In this study for all the domains of stress, 4 th year students got highest score, except for clinical training domain where 1 st year reported highest stress. This is in contrast with other studies. [11],[14],[15] and also in this study the mean scores of DES was highest among 4 th year students and this is supported by two Indian studies [11],[14] and also a West Indies study. [16]

For self-efficacy, faculty and administration, workload, patient treatment, performance pressure and other questions of stress mean scores of 4 th year was highest and mean scores of first, second and 3 rd year was significantly different from 4 th year. Undergraduate dental students in the final year are subjected to increased workload, because they have to take up exams in eight subjects at the end of the year, [13] and this is the year where most of the advanced clinical disciplines are learnt and practiced. Criticism from clinical supervisors in front of patients appears to be an issue for dental students worldwide. [18] Although, the students in the first 3 years of the undergraduate program have to appear for few exams only. However, the first major stressor for all the students was examinations and grades, which is in accordance with previous findings. However, a mean score of 3.2 (standard deviation 1.00) is similar when compared with studies from the USA, Singapore, Australia, and Jordan where the mean scores were 3.22, 3.14, 3.34 and 3.49, respectively. [27]

There was a trend of increasing overall mean stress scores over the years with a peak in the 3 rd year, which is the transition to a greater clinical contact and may represent a problem for many students, which is a finding in other studies, [11],[16] whereas in our study there was increase in stress from 1 st to 4 th year. This increase in student stress levels during the 4 years of their education may reflect a cumulative effect or, alternatively, suggest that each progressive year of training becomes more difficult and stressful with year-specific stressors. This finding is similar to findings in Australia, where the cumulative effect of performance pressure and workload was thought to be the cause of higher stress levels in the clinical years, but differs with findings in the United States, where overall mean DES score for years 1-4 of the program were 2.19, 2.16, 2.16, and 2.27, respectively, indicating no trend of increasing stress. [16]

This is opposed to the findings which expressed that final year students, who should be more experienced, mature and have greater coping skills, express less stress. [1],[25] Others have found however that final year students show greater anxiety about the future. [2],[10],[14],[15] Uncertainty about the dental career increases as the students progressed reaching a peak in the 4 th year. This is unfortunate as career doubts have been identified as a potent source of stress. This uncertainty may be because of the fear of unemployment after graduation. [9]

Stressors related to the financial situation of the students were more significant in western countries than in eastern countries, and stressors related to resources and dental material supply were more significant in poor countries in Africa. [28]

Many studies reported that female dental students showed more stress than male, and sometimes the literature shows that there is a difference between preclinical and clinical years. Preclinical years stress affect female more than male, but clinical years affect male more than female students. Some sources of stress were found more often in female than male, such as lack of confidence in clinical decision making, and doubt to be a successful dentist. [12] The explanation for higher reported stress in female students may be that female students find it easier to express their experiences of stress than do male students. [3]

In this study, higher stress was observed among females in relation to all domains of stress compared to males and also mean total stress scores of females (89.9) was higher than males (82.9) which is similar to Japanese study. [1] In another study among West Indies, females were more stressed only in relation to academic work and clinical factors. [15]

On contrary few studies have shown that overall males perceived more stress than female students, which was in agreement with Acharya and Kumar et al. [11],[12] In India, man's income is considered the primary source of earning in the family, and he has to take care of his parents, wife and children. Because of such responsibilities and long tenure of dental profession, men could be under considerable stress. [2]

Association of general well-being and perception of stress

Significant negative relations were detected between perception of stress (both the total and each of the six domain scores) and the general well-being scores among dental students. The results indicate that students with high well-being scores experience less stress. Step-wise multiple regression analysis showed that "workload," "patient treatment," "performance pressure" and "others" domains of stress were significant predictors of PGWB.

However, there were some limitations to this study. Notably, the self-reported nature of the data (social desirability) could have resulted in information bias, and also since this study was conducted just before the exams, students were already stressed, so interpretation of stress due to various factors should be made cautiously.


A congenial environment needs to be created by the dental faculty so that students can pursue their studies with less anxiety or fear. This can be achieved by periodic interaction of the dental faculty with trained educational psychologists who can train the faculty in the latest educational methodologies to maximize student performance and minimize stressThe college can appoint the counselor so that students can cope up with stressful environmentChanges in the curriculum and method of teaching, an emphasis on modular teaching, student support mechanisms at departmental/institutional level with appropriate policy changes, mentorship programs, etc., need to be considered, to assist the students in coping with identified stressors and to make learning a joyful rather than a laborious processFurthermore, more studies are needed for programs or courses for prevention and intervention of stress.

If these improvements are introduced, hopefully stress on dental students will be reduced helping them to be more successful as students and eventually, as dentists.


This study revealed that the perception of stress would be influenced by gender, and health behaviors, which in turn affects PGWB. Physical activity was significantly related to the low perceived stress levels and high PGWB status. There were differences in perception of stress between different years of study also perceptions of stress had a negative impact on PGWB of students. The findings of this study could be useful to develop a student-oriented new curriculum.



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