|Ahead of print publication
Assessment of perceived stress levels and its sources among indian students in Dental Colleges of Odisha - A cross-sectional study
Sonali Sarkar, Dhirendra Kumar Singh, Riddhi Awasthi
Department of Periodontology and Oral Implantology, Kalinga Institute of Dental Sciences - KIIT University, Bhubaneshwar, Odisha, India
|Date of Submission
|Date of Decision
|Date of Acceptance
|Date of Web Publication
Department of Periodontology and Oral Implantology, Kalinga Institute of Dental Sciences - KIIT University, Bhubaneshwar, Odisha
Source of Support: None, Conflict of Interest: None
Background: Dental school is a stressful experience for students as they face wide-ranging challenges related to patient care and pursuing academic excellence. Aim: The aim of the study is to estimate the psychological stress levels and its sources among undergraduate students at dental colleges in India. Materials and Methods: A cross-sectional survey was conducted among a sample of 308 undergraduate students in their 3rd year, 4th year, and internship from three private dental schools in Odisha. A self-administered questionnaire was designed and distributed where participants marked the stress levels caused by various academic and nonacademic stressors on a five-point Likert scale (strongly disagree to strongly agree). Demographic data of gender and year of study were also collected on the same questionnaire. Statistical Analysis Used: SPSS v27 was used to compute descriptive statistics, to perform tests for reliability and validity of the survey instrument and to perform two sample t-test for comparison of stressors with gender and one-way ANOVA for comparison of stressors year of study as factors. Results: Of the 300 completed questionnaires submitted, 49.7% of the participants were males (n = 151) and 50.3% were females (n = 149). Third-year students reported moderate stresses (mean stress >=3) due to factors related to curriculum structure, long classroom hours, reduced recreation time, homesickness, and hostel food. Fourth-year students reported severe stress (mean stress >=4) originating from stressors like completion of clinical quota and comparison with other professions. Interns reported severe stress (mean stress >=4) originating from stressors like family's expectations and fear of failure. There was a statistically significant difference in female participants who reported elevated stress compared to their male counterparts in dealing with stress related to workload and training (P = 0.008, two-tailed two-sample t-test). Conclusions: Students reported most stress originating from issues related to clinical workload burden, comparison with peers, family expectations, and personal relationship issues. We recommend that dentistry schools act with urgency to alleviate severe stressors with the formation of student advisory committees and appointment of counselors who can advocate for dental students' psychological well-being.
Keywords: Cross-sectional, dental students, India, perceived stress
According to a report of the Global Congress in Dental Education, “Dental Education is regarded as a complex, demanding and often stressful pedagogical exposure.” It involves acquisition of required scholastic, clinical and interpersonal skills during the course of learning. Anxiety is associated with autonomic arousal, skeletal muscle effects, and subjective experience of an anxious affect, and it is defined by the American Psychological Association as an emotion characterized by feelings of tension, worried thoughts, and physical changes such as increased blood pressure. Stress is defined as the body's reaction to a change that entails a physical, mental, or emotional response that may be positive, stimulating and motivating individuals to do the best, or be negative, depressing and reducing their performance. Perception of stress can vary among individuals depending on their beliefs, attitude, and occupation. Health professionals pursuing higher education can be hassled because of the clinical workshops elevating their stress levels. Cooper et al. further established some evidence that those in the dental profession exhibited higher levels of stress when compared to the normative population.
In India, the duration of the Bachelor of Dental Surgery program is four calendar years with successive examinations at the conclusion of each year, followed by a year of paid or unpaid rotatory internship. The perceived environmental stress for dental students can be greatly influenced during the undergraduate study period by stressors created due to increased clinical training intensity in various departments, interpersonal skills, academics as well as issues with classmates. Students' overall performance can be hindered due to the burden of manual exercises in particular, along with their exposure to varied patient-related stressors, which are similar to the ones faced by dental practitioners.
Unless requisite steps are taken, the environment-induced stress among dental students can negatively affect students' well-being. Prolonged periods of stress are often linked with deleterious effects on students, like difficulty in interacting with patients, loss of productivity, and other psychosocial conditions like depersonalization. Based on a person's system of beliefs and attitudes, high levels of stress can further result in mental and/or physical ill health, substance misuse, diminished productivity levels at work or at school. Consequently, identifying the various stressors at play could be very crucial in helping plan makers, academic staff, and administrators arm themselves with the requisite information so as to make positive changes to the teaching curriculum and to foster a healthier learning environment.
The aim of this study, therefore, was to estimate the perceived stress levels and its sources among undergraduate students at dental colleges in Odisha. Such empirical data might allow for various modifications to enhance student's psychosocial well-being and educational performance.
| Materials and Methods
This questionnaire-based, cross-sectional study was conducted in the first term of the 2018–2019 academic year. The primary objective of this study was to investigate the occurrence as well as levels of depression and stress in undergraduate dental students based on gender and academic year. For the purpose of this study, we targeted dental students at the College of Dentistry from KIIT University, SOA University, and Utkal University. A prior ethical approval (Ref: KIDS/RES/034/19) was obtained by the Institutional Ethics and Research Committee. For subject consent, the questionnaire was accompanied by a covering letter stating the objectives of the study, stressing the confidentiality of information, voluntary participation, anonymity of the data collected and concluding with an obligatory signature from the candidates for his/her inclusion. Sample size determination was done using the “pwr” package in R. To achieve a minimum power of 80%, a level of significance of 5%, effect size of 0.25 and 12 predictor variables (for a one-way ANOVA design), a sample size of 280 students was obtained for our analysis. Further assuming a factor of safety of 10% to account for incomplete questionnaires, our final sample size was determined to be 308 students. Students with incomplete questionnaires (n = 8) were removed from the final analysis.
Participants in their 1st or 2nd year of curriculum were excluded from the study as students in this cohort are confined only to preclinical and get little to no clinical exposure. Consequently, their workload may not be generally comparable to students in 3rd year, 4th year, or internship phase of curriculum. Subjects who refused to participate in the survey were excluded from the study. All willing participants from the 3rd or 4th academic and internship period who were present on the day the survey was conducted were included in the study.
The stress questionnaire was designed to be self-explanatory in nature and contained two survey instruments to measure stress levels associated with academic [Table 1] and non-academic stressors [Table 2], respectively, using a Likert scale to measure level of agreement with the statements in the questionnaire (1-strongly disagree to 5-strongly agree). The questionnaire items were adapted in part from stressors measured in Malathi et al. 2019, to better reflect the concerns of students pursuing a Bachelor's degree in Dental Surgery like stress caused by family expectations and comparison with peers. The stressors in these survey instruments were based on stressor categories like personal well-being-related stress (eight items), faculty and management-related stress (six items), workload and training related stress (five items), societal stress (five items). However, these categories were not displayed to the students in the distributed questionnaires. A data collection sheet was prepared for participants to input their responses. Class representatives were notified, and a 15-minute meeting was arranged for each student year. Furthermore, authors briefly elucidated the survey questions and how to answer the survey instrument to the students before distributing the hard copies of the questionnaire.
|Table 1: Nonacademic stressors questionnaire and associated stress categories
Click here to view
|Table 2: Academic stressors questionnaire and associated stress categories
Click here to view
Questionnaire reliability and validity
A Cronbach's analysis was conducted on the “Academic stressors” [Table 1] and the “Non-academic stressors” [Table 2] subscale for the stress study survey questionnaire. The “Academic stressors” subscale's alpha level were found to be 0.596 and the “Non-academic stressors” subscale's alpha level were found to be 0.63. Assuming an acceptable level of Cronbach's alpha to be 0.7 (based on Gliem et al. 2003), we further analyzed whether refining our questionnaire items improves the overall reliability of our survey questionnaire. Upon further analysis, we found that refining the questionnaire by removing the item ”I am often stressed because of relationship problems with friends and classmates” increases Cronbach's alpha for the “Non-academic stressors” to an acceptable level of 0.7. Similarly, for the “Academic stressors” subscale, we found that removing items “I am often stressed because of feelings of fear of failure,”, “I am often stressed because I find my faculty to be inaccessible,” “I am often stressed because of the high frequency of tests,” and “I am often stressed because of inadequate facilities in the clinical setup” increases Cronbach's alpha to an acceptable level of 0.72. It was further found that the “Academic stressors” subscale was positively correlated with the “Non-academic stressors” subscale (r = 0.28, P < 0.001 (2 tailed)).
The completed questionnaires with coded data were entered into and analyzed using SPSS v. 27 (IBM Corp., Armonk, NY, USA). The study data were presented as frequencies with proportions or means with standard deviations (SDs), where appropriate.
A total of 300 dental students participated in the study, out of which 49.7% were female and 50.3% were female [Table 3].
Mean stress levels by stressors in dental students
When comparing academic stressors with participant's year of degree [Figure 1], we found that students in their 4th year of degree completion reported “Completion of clinical quota,” “High workload,” “High frequency of tests,” “Comparison with other professions” and “Long teaching/curriculum hours” as severe stressors (>4 on mean stress scores). We further found that interns reported “Inadequate facilities” and “Fear of failure” as severe academic stressors (>4 on mean stress scores) and “Comparison with others” and “High workload” as moderate academic stressors (>3 on mean stress scores). Finally, we found that “Long teaching hours,” “Curriculum structure,” and “High workload” were reported as moderate stressors (>3 on mean stress scores) for participants in their 3rd year of degree completion. Finally, we found no statistically significant difference in reported stress levels among the student cohorts based on teaching methods or pedagogy employed at school (P =0.131).
|Figure 1: Mean stress scores for academic stressors. Data label values are mean stress scores and error bars are ± 1 standard deviation of stress scores
Click here to view
When comparing nonacademic stressors with participant's year of degree [Figure 2], we found that students in their 3rd year of degree completion reported “Expenses and financial constraints” as a severe stressor while reporting “Personal relationship issues,” “Lack of interest in their chosen profession,” “Feelings of homesickness,” and “Hostel food” as moderate stressors. We also found that interns reported “Family expectations” as a severe stressor while reporting “Personal relationship issues” and “Lack of interest in profession” as moderate stressors.
|Figure 2: Mean stress scores for non-academic stressors. Data label values are mean stress scores and error bars are ± 1 standard deviation of stress scores
Click here to view
Comparison of stress levels by stress category
A test for homogeneity of variances was run for mean stress scores for each stress category by year and we found a statistically significant Levene's test (P < 0.01) indicating a lack of homogeneity of variance among groups. Consequently, a Welch's ANOVA test (homogeneity of variance not assumed) was run to compare mean stress scores from stress category between years. It was found that mean stress scores were significantly different, P < 0.001 (2 tailed), between years of curriculum across stress categories [Table 4].
To further understand where this difference in stress levels among the three groups was coming from, we conducted a post hoc Games-Howell test which gave us a pairwise comparison of mean stress levels for each group [Table 5]. It was found that students in their 4th year of curriculum were significantly less stressed about “Faculty and management” and “Personal wellbeing” related stress factors and significantly more stressed about “Workload and training” related stress factors as compared to their 3rd year and intern counterparts. It was further found that interns were significantly less stressed about “Workload and training” related stress factors as compared to their counterparts in 3rd and 4th years.
|Table 5: Post hoc comparison of mean stress scores by stress category and year
Click here to view
Comparison of stress levels by stress factor and gender
Finally, a test for homogeneity of variances was conducted for mean stress scores for each stress category by gender and we found Levene's test to be not significant (P > 0.05) indicating a homogeneity of variance among gender cohorts. Consequently, two-sample t-test was conducted to compare mean stress scores from stress categories between the genders [Table 6]. It was found that mean stress scores were significantly different, P = 0.008 (2 tailed), between genders for the “Workload and training” stress factor with female participants experiencing slightly elevated levels of stress compared to their male counterparts.
Undergraduate dental education is a 5-year program in India as per the Dental Council of India where the initial 2 years consist primarily of courses in fundamental, medical, and dental sciences followed by 3 years of intense clinical training and theoretical workload. Students enroll to a dental institution directly from intermediate school; the level of competition is soaring, and only the bright students with the highest grades with performance indicators at school, as well as those who qualify entrance examination and interviews are accepted. In addition, Kumar et al. 2009 found that, in Indian dental students, stress stemming from competitiveness continues throughout the dentistry program, with good grades and above-average performance anticipated to be the norm. Dental school is a consequential source of stress for students as they are required to face challenges associated with their profession, like practicing in a manual workshop for clinical work, establishing direct patient contact, managing patient stress, and administering treatments for patients that could be detrimental if performed without dexterity. As primary emphasis in clinical sciences often requires students to concentrate heavily on manual skills, an additional source of academic pressure for dental students is the difficulty in mastering the technical skills required of them as part of their curriculum and in keeping abreast with new developments in their field of study. Garbee et al. 1980 further established that if stress is not effectively tackled, it can lead to physical and psychological symptoms which can endanger the health of individuals. Schmitter et al. noted that dental education is more stressful than even medical education. Albajjar and Bakarman 2019 also confirmed that depression in dental students and interns appears more frequently than in the general population, with evidence of mental health deterioration over the course of their medical training.
In our study, we found that dental students in their 3rd year of curriculum reported significantly higher amounts of stress (all moderate; mean stress >3) due to stress factors related to curriculum structure, long teaching/classroom hours, reduction in recreation time, homesickness, and hostel food compared to their counterparts in 4th year and internship (P < 0.05). We further observed a statistically significant decrease in mean stress scores associated with nonacademic factors like hostel food and homesickness as students' progress through the curriculum and ostensibly acclimatize to the hostel setting. This outcome is in concurrence with findings from Srivastava et al. 2020 and Jain et al. 2016 where the authors established that type of accommodation was a predictor of stress among dental students. We observed a similar trend with financial stressors as well with interns reporting significantly lower stress, followed by 4th year students and 3rd year students.
Students in 4th year reported significantly higher stress originating from academic factors like stress associated with completing clinical quota (severe; mean stress >4) and comparison with other professions (severe; mean stress >4) compared to their peers in 3rd year and internship cohort. Stress associated with “Completion of clinical quotas” usually arises from 4th year students typically having to complete a clinical quota per subject as part of their curriculum. The underlying reason could be studying nine vast subjects at a stretch, followed by other elements such as balancing between clinical quota as well as theoretical examination, difference of opinion between the staff and searching an ideal case for the university practical examination. This was in accordance with the investigation carried out by Sravani et al. 2018 as well as Shaik et al. 2019 and Jowkar et al. 2020 where primary sources of stress were academic factors and clinical education. The prevalence of stress commenced on a milder note in the 3rd year, dropping marginally among few students, followed by a continuous incline till the final year and a decrease again in the internship period.
Students in the internship cohort reported significantly higher stress, compared to their peers in 3rd and 4th year, originating from non-academic factors such as issues associated with family's expectations, drug use/substance abuse, and academic concern associated with fear of failure. Further analysis revealed that societal stress factors such as family expectations and the fear of failure are highly correlated. Moreover, fear of failure is also significantly correlated with stress originating from issues of drug use or substance abuse.
We also observed a statistically significant difference in mean stress levels between the male and female participants related to workload and training-related stressors, where female participants reported more stress than their male counterparts. This observation could potentially be explained by the previously observed intrinsic psychological differences between genders as females are more likely to articulate their worries and emotions as reported by Basudan et al. 2017. The uncertainty of settlement after dentistry adds to the student's stress, keeping their future prospectus in mind. This was in concurrence with the study reported by Al-Sowygh 2013 and a recent investigation by Ahad et al. 2021 in which female participants reported more stress compared to their male counterparts. In contrast to these findings, Sheetal et al. in 2018 and Lee et al. 2021 stated that they found no correlation or statistical significant difference among both the genders, while in another survey by Kumar et al. in 2009, male participants reported higher levels of distress and anxiety.
Our study presents a comprehensive evaluation of stress factors among dental students and how they interact with demographic factors of gender and year of study. The focus of this study was on undergraduate students as those pursuing postgraduate courses as well as dental auxiliary or hygienists typically have distinct syllabus, course structure, ambitions, and challenges. It is worth noting that survey responses analyzed here are self-reported attitudinal data from a sample of colleges in Bhubaneswar and therefore we must be circumspect in generalizing these findings to the general population of dental students across India, particularly those belonging to different sociocultural contexts.
COVID-19 added a lot of uncertainty, and thereby stress, for dental students. Bagde et al. recently conducted a study to assess the stress intensity among dentistry students during COVID-19 and found that stress levels and dental self-efficacy have a detrimental relationship. In another cross-sectional study conducted during the COVID-19 pandemic, Menon et al. found that the primary source of anxiety stemmed from a sense of a dubious future which was exacerbated predominantly due to online teaching. They further concluded that the students' education outlook suffered as a result of lack of hands-on experience in a clinical setting. Finally, there was an increased sense of anxiety and fear among dental students in India caused by stressors such as the increased risk of infection among dentists, the lockdown, and the declining economy.
Stress is psychologically debilitating and can not only have a deleterious effect on the academic performance of dental students but also on the quality of care they provide to their patients. Based on the evidence presented in this study, we recommend that dental school administrations invest in availing resources for students and their guardians, especially during their early phase of the curriculum, so as to set realistic expectations of employment opportunities and career growth trajectories. In addition, we feel that there is a pressing need, in dental schools, for incorporating student advisory committees and counselors who can engender, track and advocate for the psychological welfare of dental students. Revisions in existing curriculum such as smaller group assignments, formative assessment, and incentivizing collaboration with peers in laboratory environment can go a long way in both stimulating learning and alleviating stress arising from lack of interpersonal rapport among students. Future research using qualitative ethnography methods with dental students to understand underlying causal factors to the stressors outlined in this study is warranted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Kazdin AE. Encyclopedia of Psychology. Washington, DC: American Psychological Association; 2000.
Folkman S. Stress: Appraisal and coping. In: Gellman MD, Turner JR, editors. Encyclopedia of Behavioral Medicine. New York: Springer; 2013. p. 1913-5.
Cooper CL, Watts J, Kelly M. Job satisfaction, mental health, and job stressors among general dental practitioners in the UK. Br Dent J 1987;162:77-81.
Jowkar Z, Masoumi M, Mahmoodian H. Psychological stress and stressors among clinical dental students at Shiraz school of dentistry, Iran. Adv Med Educ Pract 2020;11:113-20.
Champely S, Ekstrom C, Dalgaard P, Gill J, Weibelzahl S, Anandkumar A, et al
. Basic functions for power analysis. R package ver 2017;1:665.
Malathi Suresh SM, Kannan S, Anuradha B, Regunathan H. Stress among dental students in a private dental college. Int J Pharm Res 2019;11:421-24. [Doi: 10.31838/ijpr/2019.11.03.071].
Gliem J, Gliem R. Calculating, Interpreting, and Reporting Cronbach's Alpha Reliability Coefficient for Likert-Type Scales. 2003 Midwest Research to Practice Conference in Adult, Continuing, and Community Education; 2003.
Kumar S, Dagli RJ, Mathur A, Jain M, Prabu D, Kulkarni S. Perceived sources of stress amongst Indian dental students. Eur J Dent Educ 2009;13:39-45.
Garbee WH Jr., Zucker SB, Selby GR. Perceived sources of stress among dental students. J Am Dent Assoc 1980;100:853-7.
Schmitter M, Liedl M, Beck J, Rammelsberg P. Chronic stress in medical and dental education. Med Teach 2008;30:97-9.
Albajjar MA, Bakarman MA. Prevalence and correlates of depression among male medical students and interns in Albaha University, Saudi Arabia. J Family Med Prim Care 2019;8:1889-94.
] [Full text]
Srivastava R, Jyoti B, Pradhan D, Kumar M, Priyadarshi P. Evaluating the stress and its association with stressors among the dental undergraduate students of Kanpur city, India: A cross-sectional study. J Educ Health Promot 2020;9:56.
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. [Full text]
Sravani A, Doshi D, Kulkarni S, Reddy P, Reddy S. Depression, anxiety, and stress among undergraduate dental students in Hyderabad City, Telangana, India: A cross-sectional study. J Indian Assoc Public Health Dent 2018;16:26-9. [Full text]
Shaik PS, Pachava S, Palli CB. Factors affecting stress among students in dental colleges of neo-capital state in India. J Indian Assoc Public Health Dent 2019;17:41-7. [Full text]
Basudan S, Binanzan N, Alhassan A. Depression, anxiety and stress in dental students. Int J Med Educ 2017;8:179-86.
Al-Sowygh ZH. Academic distress, perceived stress and coping strategies among dental students in Saudi Arabia. Saudi Dent J 2013;25:97-105.
Ahad A, Chahar P, Haque E, Bey A, Jain M, Raja W. Factors affecting the prevalence of stress, anxiety, and depression in undergraduate Indian dental students. J Educ Health Promot 2021;10:266.
Sheetal S, Narayan SJ, Yadalam U, Apoorva M, Hareem F. Assessment of stress perceived in dental students: A questionnaire survey. Int J Sci Res 2018;7:47-9.
Lee LS, Abu Bakar N, Ahmad Basri N, Mohamed Ludin S. Levels of depression, anxiety, and stress and their association with the clinical training phase amongst undergraduate dental students. Int J Allied Health Sci 2021;5:2150.
Bagde R, Dandekeri S. Fear, stress and stigma of covid-19 among Indian dental practitioners. J Evol Med Dent Sci 2021;10:2433-8.
Menon B, Sannapareddy S, Menon M. Assessment of severity of stress among medical and dental students during the COVID-19 pandemic. Ann Indian Acad Neurol 2021;24:703-7. [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]