Perceived Stress among Undergraduate Dental Students in Relation to Gender, Clinical Training and Academic Performance.

AIM: This study aimed at evaluating the perceived stress and its sources among undergraduate dental students at Jazan University, Saudi Arabia.
MATERIALS AND METHODS: In this cross-sectional study, the data were collected using the DES questionnaire. The overall score of stress and scores by individual domains were described and analyzed by different grouping factors: gender, study level, marital status and GPA.
RESULTS: A total of 366 dental students agreed to take a part in this study. Up to 57% of the participants were females. The overall DES score was 1.67 ± 0.45. Female students and married students scored higher stress levels than their counterparts. Stress increased significantly among students as their educational level increased. Inversely, the stress levels were lower in participants with high GPA. Multiple linear regression analyses revealed that "Study level" and "Gender" were significant independent determinants of overall DES and, also, most of the stress domains. Forty one percent of the variability in DES score can be explained by these determinants.
CONCLUSION: DES among dental students in Jazan University is moderate and slightly higher. It is higher among females and increases significantly with study progression. However, students who had higher GPA showed lower levels of stress. CLINICAL SIGNIFICANCE: Reduction and/or relief of stress among dental students will reflect positively on persistence and academic achievement, which will lead to better management and care of patients.

Introduction

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 (, ). The perception of stress differs greatly among people and can be affected by, among others, the individual’s beliefs, attitudes and occupation. Higher education poses stress over the enrolled students, more specifically the education related to health sciences. Unfortunately, dental schools are considered highly stressful learning environments and stress levels among dental students have been revealed to be higher than stress levels in general population (-). Moreover, the perceived dental environmental stress can be greatly influenced during the undergraduate study program. Clinical training, in particular, can affect dental students’ performance due to their exposure to different patient-related stressors which are similar to the ones faced by dental practitioners (, ).

Unless necessary steps are taken, the dental environment-induced stress can negatively affect the students’ well-being. If stress persists, students may be unable to continue working, may find difficulty to interact with their patients, and may suffer from depersonalization, which means that they will be psychologically distancing from others. Ultimately, elevated levels of stress can deteriorate academic achievement and reduce career options and life style choices (, ).

In this regard, determining the provoking-stress factors is very important. It will arm the policy makers, academic staff and administrators with the required weapons to modify the teaching curriculum or/and environment in a way that is more beneficial to the students. The aim of this study, therefore, was to evaluate the perceived stress and its sources among undergraduate dental students at dental college affiliated to Jazan University in Saudia Arabia.

Materials and methods

This descriptive questionnaire-based, cross-sectional study was conducted in the first semester of 2106/2017 academic year. It targeted all dental students at College of Dentistry, Jazan University, Saudi Arabia. A prior ethical approval was obtained by the Ethics and Research Committee of the College. For subject consent, the questionnaire was accompanied by a covering letter describing the objectives of the study, stressing the confidentiality of data, and voluntary participation and finally concluding with mandatory signature from the participant’s for his/her inclusion.

For better understanding, a bi-language (Arabic and English) modified version of Dental Environment Stress (DES) questionnaire was used. Apart from the demographic data, it comprised 41 items grouped under seven stress-provoking domains as follows: self-efficacy beliefs (nine items), faculty and administration (ten items), workload (six items), patient treatment (four items), clinical training (four items), performance pressure (three items), and social stressors (five items), (). However, these domains were not displayed to the students in the distributed questionnaires. The responses to each item in the questionnaire were modified into a three-point Likert scale with 1 = no stress, 2 = moderate stress, and 3 = severe stress A fourth possible response (0 = not applicable) was added where the stress situation under question was not applicable to the participant.

Completed questionnaires with coded data were entered into SPSS version 21 (IBM Corp., Armonk, NY, USA). The study data were presented as frequencies with proportions or means with standard deviations (SDs), as appropriate. The summary scores of individual domains and of overall DES, presented as means and SDs, were considered dependent variables. Normal distribution of these variables was tested using Kolmogorov-Smirnov test. Gender, marital status, Grade Point Average (GPA) and the level of study were considered independent variables. Depending on the normality of the data, differences by gender were analyzed by Mann-Whitney U test or independent t-test, while differences by study levels and by GPA categories were analyzed by Kruskal Wallis or one-way ANOVA. Pairwise comparisons were followed whenever Kruskal Wallis or one-way ANOVA revealed significant differences. The multiple linear regression analyses were performed to determine the independent determinants of the overall stress, and stress by individual domains. A P-value of less than 0.05 was considered significant.

Results

A total of 366 dental students, with a mean age of 21.8 + 1.6 years, agreed to take part in this study. Up to 57% of the participants were females and 14% were married. The sample was equally distributed (approximately 20%) among different levels of study. Most of students (84%) obtained a GPA higher than 3.5 (Table 1).

Table 1

Socio-demographic characteristics of the participants

Variables	N (%)
Gender (N=366)
Male		157 (42.9%)
Female		209 (57.1%)
Age (N=351)
Mean (+ S.D)		21.78 (+1.59)
Median		22.00
Range		7 (19-26)
Marital status (N=361)
Married		52 (14.4%)
Unmarried		309 (85.6%)
Study year (N=366)
Second year		74 (20.2%)
Third year		73 (19.9%)
Fourth year		76 (20.8%)
Fifth year		76 (20.8%)
Sixth year		67 (18.3%)
GPA (N=351)
<2.5		5 (1.4%)
2.5-3.5		39 (10.7%)
> 3.5-4.5		167 (45.6%)
>4.5		140 (38.3%)

Out of 3, the overall DES score was 1.67 ± 0.45. The highest fraction of this stress was attributed to “Workload” (2.21 ± 0.46) and “Performance pressure” (2.07 ± 0.59). With the exception of “Social Stressors” domain, females scored higher stress than males (Table 2). Similarly, married participants scored higher stress levels than singles except for “Self-efficacy beliefs” and “Social stressors” domains (Table 3).

Table 2

Level of significance of DES domains with gender

Domains	Gender		Total	P- Value*
	Male	Female
Self-efficacy beliefs	1.79 (0.49)	1.85 (0.60)	1.79 (0.55)	0.029
Faculty and administration	1.46 (0.51)	1.61 (0.57)	1.53 (0.54)	0.01
Workload	2.13 (0.48)	2.27 (0.45)	2.21 (0.47)	0.004
Patient treatment	1.48 (0.90)	1.73 (0.94)	1.62 (0.93)	0.003
Clinical training	1.49 (0.74)	1.74 (0.82)	1.62 (0.79)	0.001
Performance pressure	1.98 (0.60)	2.14 (0.58)	2.07 (0.59)	0.012
Social stressors	0.80 (0.41)	0.87 (0.71)	0.82 (0.58)	0.33
Total DES	1.58 (0.41)	1.75 (0.47)	1.66 (0.44)	0.001†

*: Mann Whitney U unless otherwise indicated.

†: Independent t-test test.

Table 3

Level of significance of DES domains with marital status

Domains	Marital Status		P- Value*
	Married	Unmarried
Self-efficacy beliefs	1.76 (0.63)	1.80 (0.54)	0.616
Faculty and administration	1.70 (0.48)	1.50 (0.55)	0.011
Workload	2.33 (0.44)	2.19 (0.47)	0.021
Patient treatment	2.08 (0.70)	1.54 (0.94)	< 0.001
Clinical training	1.90 (0.68)	1.57 (0.80)	0.006
Performance pressure	2.19 (0.62)	2.05 (0.59)	0.061
Social stressors	1.15 (0.75)	0.77 (0.53)	< 0.001
Total DES	1.83 (0.45)	1.63 (0.43)	0.011†

*: Mann Whitney U unless otherwise indicated.

†: Independent t-test test.

The overall stress, or stress by individual domains increased significantly in higher academic levels (Table 4). Inversely, the scored stresses were lower for participants with high GPA, with except for “Social stressor” domain (Table 5).

Table 4

DES domains across different study levels

Domain	Study level					P-Value*
	2nd	3rd	4th	5th	6th
Self-Efficacy	1.70a(0.61)	1.70a(0.55)	1.78a,b (0.54)	1.87a,b (0.48)	1.98b(0.56)	0.021
Faculty	0.98a(0.42)	1.25b(0.43)	1.67c (0.43)	1.81d (0.35)	1.96e(0.47)	< 0.001
Workload	1.99a(0.44)	2.02a(0.53)	2.37b (0.32)	2.33b (0.42)	2.36b(0.45)	< 0.001
Patient treatment	0.68a(0.78)	0.83a(0.86)	2.13b (0.44)	2.25b (0.38)	2.18b(0.48)	< 0.001
Clinical training	0.71a(0.72)	1.31b(0.69)	2.05c (0.43)	2.03c (0.50)	2.06c(0.54)	< 0.001
Performance	1.63a(0.48)	1.73a(0.58)	2.37b (0.46)	2.32b (0.45)	2.31b(0.50)	< 0.001
Social stressors	0.64a(0.45)	0.72a,b(0.50)	0.70a,b (0.47)	0.82b (0.50)	1.34c(0.78)	< 0.001
Total DES	1.24a(0.36)	1.37a(0.35)	1.80b (0.29)	1.87b,c (0.28)	2.00c(0.43)	< 0.001†

*: Kruskal Wallis test unless otherwise indicated.

†: ANOVA test.

Means with (a) different superscript lowercase letter(s) are statistically different.

Table 5

DES Domains across the categorized grade point average

Domains		GPA			P-value*
	<2.5	2.5 - 3.5	3.6 - 4.5	> 4.5
Self-efficacy beliefs	2.08a,b (0.48)	1.90a (0.51)	1.88a (0.52)	1.67b (0.59)	0.005
Faculty and administration	1.68a,b (0.29)	1.72a (0.52)	1.60a (0.52)	1.41b (0.58)	0.004
Workload	2.20a,b(0.39)	2.36a (0.47)	2.22a (0.47)	2.15b (0.45)	0.028
Patient treatment	2.05a,b (0.51)	1.85a (0.98)	1.81a (0.81)	1.30b (0.98)	< 0.001
Clinical training	1.80a,b (0.41)	1.75a (0.69)	1.79a (0.68)	1.38b (0.90)	0.001
Performance pressure	2.40a,b (0.68)	2.23a (0.54)	2.15a (0.57)	1.93b (0.59)	0.001
Social stressors	0.36a (0.35)	0.85b (0.49)	0.90 (0.63)	0.79 (0.60)	0.064
Total DES	1.78a (0.30)	1.80a (0.39)	1.74 (0.42)	1.53 (0.47)	< 0.001†

*: Kruskal Wallis test unless otherwise indicated.

†: ANOVA test.

Means with (a) different superscript lowercase letter(s) are statistically different

Multiple linear regression analyses revealed “Study level” and “Gender” as significant independent determinants of overall DES and most of the stress domains. Both determinants explained 41% of the variability in the overall DES scores. More specifically, they explained 41%, 13%, 46%, 40% and 26% of the variabilities in “Faculty and administration”, “Workload”, “Patients treatment”, “Clinical training” and “Performance pressure” domains, respectively. Although GPA played a minor role, it was a significant independent determinant of stress related to “Self-efficacy” and “Social stressors” domains. Marital status was also seen to be a significant independent determinant of stress related to “Social stressors” domain (Table 6).

Table 6

Regression analysis between domains of DES and independent variables

Independent Variables	B	Confidence Interval		Adjusted R-Square	P-Value*
Self – Efficacy
GPA	- 0.12		- 0.21; - 0.03	0.052	0.009
Study level	0.05		0.004 ; 0.095		0.032
Gender	0.12		0.003; 0.24		0.045
Faculty and Administration
Study level	0.25	0.21; 0.28		0.408	< 0.001
Gender	0.17	0.08; 0.27			< 0.001
Workload
Study level	0.11	0.07; 0.14		0.125	< 0.001
Gender	0.15	0.06; 0.25			0.002
Patient treatment
Study level	0.46	0.4; 0.51		0.463	< 0.001
Gender	0.29	0.145; 0.44			< 0.001
Clinical training
Study level	0.36	0.31; 0.40		0.399	< 0.001
Gender	0.26	0.128; 0.393			< 0.001
Performance pressure
Study level	0.21	0.17; 0.25		0.256	< 0.001
Gender	0.18	0.07; 0.29			0.001
Social stressors
Study level	0.14	0.099; 0.19		0.143	< 0.001
Marital status	0.30	0.136; 0.466			< 0.001
GPA	0.09	0.003; 0.18			0.043
Overall DES
Study level	0.20	0.17; 0.23		0.405	< 0.001
Gender	0.17	0.095; 0.253			< 0.001

*: Stepwise multi-linear regression analyses. The included independent variables were: Gender, Marital status, Study level and GPA.

Discussion

Various scales have been used to investigate the stress among dental students such as: Dental Environment Stress scale (DES), (), Maslach Burnout Inventory (MBI), (), and Psychosocial Stress Inventory (PSSI), (). However, DES is the most frequently used scale (). An understanding of stress levels is of paramount importance to provide professional bodies with relevant information on students’ well-being. Typically, it will enable the policy makers, and administrative and academic staff to reduce stressors, to adopt stress-coping strategies among students, and to modify teaching curriculum and teaching environment in order to alleviate perceived stresses. Regarding students, being aware of the stress-inducing circumstances and behaviors will motivate them to adopt more positive coping strategies. In the current study, we assessed the stressors and their levels as perceived by dental students at Jazan University with regard to many important factors such as gender, marital status, study level, and a GPA based on the grades they earned during the previous semester. The measurement tool, DES, was slightly modified to be suitable for the local culture, dental environment and curriculum. Dental program in Saudi Arabia takes longer journey than elsewhere; in addition to ordinary five years, there is a preparatory year and an internship year. Without doubt, such a unique program adds extra stress compared to dental education elsewhere. Another unique feature of higher education in Saudi Arabia is a general policy of gender segregation. Nevertheless, it is difficult to judge whether the above mentioned facts might add to the current stress.

The overall DES level reported in this study was moderate to slightly elevated. (1.66±0.44). From the literature review, we have learned that few studies have been found calculating the overall DES level. Abu-Ghazaleh et al. () and Murphy et al. () have reported the overall DES among Jordanian (2.4±0.50 point) and American (2.39±0.40 point) dental students, respectively. The maximum rating scale used in these studies was 4, ranging from 1 to 4 in the Jordanian study and from 0 to 4 in the American study. Our maximum rating scale was 3, ranging from 0 to 3. Taking these differences into consideration, it can be noted that our overall DES level is approximately the same, or slightly lower than that reported in other two studies. Noteworthy, however, is that the overall DES in the current study is lower than that reported in a previous study conducted in Saudi Arabia in 2010 (), where the overall stress was 2.23±0.31. These differences in results might be attributed to the difference in teaching curricula and/or duration of dental program. In general, stress perceived by dental students is variable in different countries and even within a country.

Regarding individual domains, the most stressful ones were “workload” and “performance pressure.” Both are related mostly to the availability of time, difficulty of assigned class work and to grades obtained and examinations. These two domains were also reported the most stress-provoking in many other studies (-). Regarding the “workload” domain, the most individual stressor item was “lack of time for relaxation”. With the “performance pressure” domain, the most individual stressor item was “Examination and quizzes”. More specifically, these two domains were significantly higher in female than in male students. The difference reported for the “workload” domain was also significantly higher among married students. This can be attributed to additional responsibilities (non-academic) that married students have. Similarly, DES reported by domain was significantly different between study levels. This might be due to the fact that the higher year of study more learning and clinical responsibilities the students encounter.

Generally, students in clinical years (4th, 5th and 6th) scored higher levels of stress compared to students in preclinical years (2nd and 3rd). This result is in concordance with other cross sectional studies conducted among dental students (, , , ). This difference is mostly attributed to logical differences in the following main domains: “Patients treatment” and “Clinical training”. Pre-clinical students had not yet been exposed to clinical training or patient treatment. Other domains revealed higher stress levels among final year dental students, but those differences were not significant. In general, responsibility toward their patients, proximity to graduation and thinking about their future plans and goals are the factors affecting work-life balance amongst male and female dental students in Saudi Arabia.

Apart from “Social stressor” domain which was not significantly different regarding genders, female students scored higher stress levels compared to their male counterparts. This implies different styles of coping with stressful circumstances and indicates the extent to which positive coping and endurance are exerted by male students. The most stressor items for females were as follows: “Examinations and quizzes” followed by “Lack of time for relaxation”. For male subjects, however, the most stressor items were: “Examinations and quizzes” followed by “Late ending day”. These items were found to be scored higher in female students compared to male students. Similar gender variations were also reported earlier by few studies (, -). In line with our results, a previous study conducted in Saudi Arabia didn’t reveal a significant gender difference regarding the “Social stressor” domain (). To the contrary, Telang et al. in their study on Malaysian dental students found no significant differences between male and female students in most of DES domains ().

Similarly, married dental students in the current study perceived higher levels of stress when compared to their single colleagues regarding the total DES score and, also, regarding individual domains except for the “self-efficacy beliefs” domain. These findings are not similar to previous studies from Saudi Arabia, where they reported significant differences between married and single students for only few domains (, ). In fact, only 2.5% of male students reported to be married in contrast to 23.5% of females (Data not shown). Therefore, the role of marital status can be strongly attributed to gender difference instead, as highlighted above. However, we cannot overlook the fact that married persons have more responsibilities than single ones. Being married cannot be overlooked as a source of stress as reflected obviously by the significant difference in “Social stressors” domain in favor of married students. This result was supported by the multiple linear regression where the role of marital status was only significant with regard to “Social stressors” domain. Simply, marriage is known to add social responsibilities to one’s own toward her/his family.

Another interesting finding was that dental students, who scored high GPA in their most recent assessment, scored lower levels of stress than their peers. This indicates that academically brilliant dental students are more confident and more efficient in handling, coping with and overcoming different domains of stress. This finding is consistent with findings of other studies which showed that students with low grades are more susceptible to exhibit more stress (, , ).

An important limitation of the current study is its cross sectional design. Consequently, the findings may not portray the cause and effect relationship between the assessed independent variables and the stress domains of DES. Another limitation is that it was carried out in one dental school. In this way, the results might have been different if more dental schools had been included. Hence, the authors suggest that a comprehensive study with a longitudinal design should be performed in future to report more remarkable findings.

Conclusion

In conclusion, DES among dental students at Jazan University is moderate or slightly elevated. It is higher among females and increases significantly with study progression. It is worth mentioning that students who earn higher GPAs have lower levels of stress, and vice versa.