Self-reported psychological problems amongst undergraduate dental students: A pilot study in seven European countries

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. European Journal of Dental Education published by John Wiley & Sons Ltd 1Department of Clinical Dentistry, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway 2Faculty of Medicine, Institute of Odontology, University of Vilnius, Vilnius, Lithuania 3Department of Conservative Dentistry with Endodontics, Medical University of Lublin, Lublin, Poland 4Faculty of Dental Medicine, University of Medicine, Tirana, Albania 5Faculty of Dental Medicine, Medical University of Sofia, Sofia, Bulgaria 6Education Development Center, Vilnius, Lithuania 7Faculty of Dental Medicine, University Ss. Cyril and Methodius, Skopje, Macedonia 8Faculty of Dentistry, Victor Babes University of Medicine and Pharmacy of Timisoara, Timisoara, Romania


| INTRODUC TI ON
Dentistry is considered one of the most stressful professions. 1 Occupational stress has been a main factor in the higher risk for suicide amongst dentists; even before graduation, 6% of dental students in the United States tested above the cut-off for clinically significant suicidal ideation. [2][3][4][5][6] A systematic review concluded that psychological problems have the strongest association with suicide. 7 Moreover, numerous studies have reported a high prevalence of psychological problems amongst dental students all over the world. [8][9][10][11][12][13] A high level of stress at baseline and incremental increases throughout their education was found amongst dental students in several dental schools in Northern and Western Europe. 14,15 Multicountry studies showed that the perceived source of stress varied greatly amongst dental students in different countries 10,16,17 ; clinical training was one of the main stressors according to two systematic reviews. 18,19 A recent study in France identified high clinical task quotas and overly stressful examinations as stressors in clinical education. 20 Some work has been done to improve dental students' learning environment, like teaching stress management in the UK 21 and mindfulness in Germany. 22 Studies from India and Turkey suggested that spiritual health/religion may increase students' coping strategies. 23,24 However, although clinical work is one of the greatest stressors in dental education, it has not received much attention in the literature. The primary goal of each and every academic institution is to educate health professionals whilst supporting the health of these students; therefore, it is of the utmost importance to identify the stressful aspects of clinical work in dental education in order to improve the clinical learning environment. The aim of this pilot study was to map psychological problems amongst undergraduate dental students with a focus on clinical work in seven Eastern European and Scandinavian countries.

| MATERIAL S AND ME THODS
One dental school each in Albania, Bulgaria, Lithuania, Macedonia, Norway, Poland and Romania participated in this cross-sectional, questionnaire pilot study. All 3rd-4th and 5th-year undergraduate students enrolled in the dentistry programme of participating schools were invited to complete a questionnaire. In most of the participating schools, the length of education to obtain a dental degree lasts 5 years and it consists of theoretical, pre-clinical and clinical parts. There is a shift in the 3rd year from pre-clinical to clinical courses, and in the 4th and 5th years, courses are mainly clinical. The didactic courses extend throughout all 5 years of dental education.
The exception was the dental school in Macedonia, where the 3rdyear students only attend the pre-clinical courses.
We aimed to create a short questionnaire with a focus on students' perception of their psychological health, especially in relation to clinical work, as none of the existing validated instruments measured our construct of interest and were short. Our final, structured questionnaire collected information on age, gender, year of study, students' physical activity and self-perceived health (categorised as "good" if the respondent chose "very well/well," and "less than good" if the respondent chose "satisfactory/bad/very bad"). The questions related to psychological health included: "In your opinion, how does your work with patients affect your health?" (I feel nervous before working with patients; I experience a lot of stress whilst working with patients; I feel anxious/worried after working with patients; problems at work wake me up at night; dental practice is psychologically difficult); "Did you experience any of these psychological health complaints (nervousness, sleeplessness, anxiety, depression, mental exhaustion) before starting your dental education?"; and "How often have you experienced these psychological health complaints (nervousness, sleeplessness, anxiety, depression, mental exhaustion) over the past 6 months?" Participants responded using a 5-point Likert-type scale, where 1 meant "never" and 5 meant "always." The variables then were categorised as "never/rarely" and "sometimes/ often/always." The questionnaire was composed in English, face-val-

| RE SULTS
A total of 1063 students (females: 707, 67%; males: 356, 33%) agreed to participate (response rate: 70%; range: 100% in Lithuania to 27% in Norway). The majority of participants were female in all seven countries and all years of study (50% in 5th year in Romania and 100% in 3rd year in Norway; Table 1). Age amongst female students was between 19 and 37 years, whilst for male students, it was between 20 and 44 years; female students were statistically significantly younger (P < .0001) than male students (mean 22.8 years, standard deviation (SD) 2.2 and mean 24.0 years, SD 3.0, respectively).
When looking at self-reported psychological problems, 506 (48%) of the undergraduate dental students reported that they always/often/sometimes felt nervous before working with patients, with a statistically significantly higher proportion of female students giving this response than male students (367, 52% and 139, 39%, respectively;  (Table 4). Four hundred eighty-eight students (46%) experienced a lot of stress whilst working with patients, and this was reported by more female than male students (347, 49% and 141, 40%, respectively; Table 3). Female gender (OR 1.4, 95% CI 1.0-1.9), 3rd year vs 5th year of study (OR 2.2, 95% CI 1.3-3.6), having less than good self-perceived health (OR 2.5, 95% CI 1.7-3.5), and reporting sleeplessness before starting dental education (OR 3.5, 95% CI 2.3-5.3) resulted in higher odds for experiencing a lot of stress whilst working with patients (Table 4), whereas being a student in other countries vs Norway reduced these odds (Table 4).
Almost one-third (287, 27%) of students felt anxious/worried after working with patients (Table 3). Fewer years of study (3rd year vs 5th year, and 4th year vs 5th year) decreased the odds of feeling anxious/worried after working with patients (OR 0.5, 95% CI 0.3-0.8 and OR 0.6, 95% CI 0.4-0.9, respectively; Table 4). Less than good self-perceived health (OR 1.9, 95% CI 1.3-2.6), and reporting anxiety (OR 1.5, 95% CI 1.1-2.3) or mental exhaustion before starting dental education (OR 1.8, 95% CI 1.1-2.9) increased the odds of feeling anxious after working with patients (Table 4). Almost two out of 10 (162, 16%) students reported that problems at work woke them up at night (Table 3). Students who perceived their health as less than good had threefold higher odds (OR 3.0, 95% CI 2.0-4.5) of waking up at night due to problems at work.

| D ISCUSS I ON
The aim of this pilot study was to map psychological problems amongst undergraduate dental students with a focus on clinical work in seven Eastern European and Scandinavian countries. This was done to lay the foundation for further, more comprehensive qualitative studies on the stressful elements in clinical learning environments in each of these countries individually, so that these data can be used to design more supportive clinical learning environments.
TA B L E 1 Number of participants stratified by gender, year of study and countrywide response rate 3rd-y students 4th-y students 5th-y students Students in health professions, especially dentistry, have been shown to be exposed to stress and other psychological problems more often due to the clinical practice that is an integral part of dental education, compared to other professions that consist only of theoretical aspects and/or practice without involving patients. 25  The cross-sectional design of this pilot study did not allow us to investigate the sources of these self-perceived psychological problems; however, some associations with various factors could be identified. In the present study, worse self-perceived health was associated with increased nervousness before working with patients.

Both genders N (%)
It was also associated with stress whilst working with patients, being anxious after working with patients, and sleeping problems related to work. Self-perceived health has been associated with individual socioeconomic position 34 and could be considered a proxy of socioeconomic position in this study. Applying this proxy, our findings are in line with another study, performed more than 50 years ago, which showed that higher stress levels were related to socioeconomic position amongst dental students. 35 We assume that students in our study had similar social backgrounds, as the dental profession in all countries is perceived as prestigious and has good future prospects, and all participating dental schools were public. Thus, not only the academic environment but also socioeconomic position may have an impact on perceived stress. Future studies should include socioeconomic indicators when investigating stressful elements in the clinical learning environment.
In this study, female students were predominant amongst the respondents and also amongst the dental student populations in all seven countries. This is in line with the recent multicountry study demonstrating that female students are in the majority. 10 Female gender increased the odds of experiencing stress during clinical practice.
This finding is in line with a number of previous studies from other countries, which showed that female dental students were more stressed than their male counterparts. 10,[36][37][38] In addition, it has been shown that female students in Germany and Switzerland worried more about their competence in clinical work than male students, 39 and in the UK, stress amongst female students stemmed mostly from a perceived lack of confidence. 40 A systematic review found that male students have higher odds for burnout, which is a result of high-level, prolonged stress and other psychological problems. 41,42 In addition, a  study in India showed that male students were more prone to stress than female students. 43 It must be noted that, in the latter study, almost half of the respondents were male, whilst in our study, they represented only one-third of participants; thus, self-selection bias cannot be ruled out. In addition, our used questionnaire was self-constructed and not validated, which may have introduced bias, though face validity and test-retest reliability were acceptable. In general, questionnaires are prone to bias, especially regarding sensitive data, like psychological problems, where cultural values may prevent male students from expressing themselves; however, the use of self-administered questionnaires has been shown to decrease reporting bias. 44 Furthermore, the various instruments used across previous studies limit our ability to directly compare results. It is likely that female and male students are affected by different stressors at different stages of their clinical work. This gender aspect should be investigated further.
Self-reported experience of sleeplessness before starting dental education doubled the odds for nervousness before working with patients and stress during it. A systematic review has shown that job stress increased the odds of insomnia. 45 On the other hand, a recent study showed that sleeplessness is likely to mediate the association between school pressure and psychological symptoms. 46 It is likely that a stressful environment can lead to sleeplessness and thus to further psychological problems when working with patients.
Self-reported experience of anxiety and mental exhaustion before starting dental education was associated with being anxious after working with patients. This finding is in contrast to a study amongst pre-clinical dental students that found no association between history of psychiatric treatment and stress, 47 but it is in line with a study amongst clinical students that showed higher self-efficacy amongst those who had no history of psychiatric treatment. 24 It must be noted that the latter study requested information on more severe mental health conditions than those in our study. History of psychological and/or psychiatric health may be an important aspect to take into consideration when investigating psychological health in the clinical learning environment.
Being a 3rd-year compared to a 5th-year student doubled the odds for stress whilst working with patients. Most 3rd-year students were in transition from pre-clinical to clinical courses. It has been shown that this transition from theoretical or pre-clinical training to clinical activities can cause stress due to unfamiliar treatments and a discrepancy between knowledge and clinical situations. 48 One of our findings was also in line with a result from a qualitative study, which showed that 1st-year clinical students were stressed by the "lack of time for clinical tasks," which may refer to stress during the clinical activity. However, another finding from that same study contrasts with ours: they reported "worries about work quality" amongst their participants, which may refer to worries after clinical activity, 49

TA B L E 4 (Continued)
more stressful for students. 10,37,40,50,51  Being physically active has been shown to reduce psychological symptoms in general. 46 A Japanese study amongst dental students demonstrated that regular exercising was associated with lower stress levels. 52 This is in line with our finding: students who were physically active had almost twofold lower odds for reporting nervousness before clinical work.
The country in which dental students pursued their dental education seemed to have an impact on self-reported psychological problems in relation to clinical activity. This finding is in line with numerous previous studies that found country of dental education, 15 56 These differences may explain our results. In addition, being a dental student in Bulgaria, an Eastern European country, reduced the odds for nervousness before working with patients and being anxious after it. There might be several explanations for this finding. In Bulgaria, students are introduced to the clinical environment early in the curriculum, before they start clinical courses. Moreover, most of the students work as dental assistants during their education and/or they come from families of dentists. Furthermore, the patients that they treat are usually their family members and friends. How a student responds to stressful situations depends on the clinical learning environment, for example student/teacher ratio, which varies between and even within countries. But this response also depends on the political context, such as government support 51 and sociocultural environment, for example degree of competitiveness and communication in the academic hierarchy between students and teachers. 10,43,57,58 Perceived stress also depends on individual characteristics, such as beliefs and attitudes. 59 Personality is also an important factor for stress perception and coping abilities. 60 An Australian study amongst dental students found a personality profile similar to that of other students of health professions and concluded that observing changes in personality traits would help determine when to implement prevention strategies and support students. 61 Another study demonstrated a significantly lower student satisfaction with the dental profession in Lithuania compared to Poland, both of which are investigated in the present study. 62 Our results showed that statistically significantly more students in Lithuania reported being nervous before working with patients (both female and male students), stress whilst working with patients (female students only) and perceiving the dental profession as psychologically difficult (female students only) compared to students in Poland (data not shown). The latter finding might indicate differences in clinical learning environments in different countries, some being more supportive than others. On the other hand, a high number of students in Poland reported that they experienced psychological problems in relation to clinical work; thus, the environment there was also not optimal. A multicountry study showed that other circumstances, like being married, increased stress levels amongst dental students. 10 These factors should be taken into consideration in future investigations on stressors in connection with clinical work.

| CON CLUS ION
Within the limitations, the present pilot study showed a high number of undergraduate dental students reporting psychological problems in connection with clinical work. It is unlikely that "one size fits all"; therefore, further qualitative investigations on stressors in clinical learning environments should be done in order to design tailor-made supportive strategies.

Special thanks to Dr Ilona Wójcik-Chęcińska and Dr Marta
Nakonieczna-Rudnicka for the help in collecting questionnaires from dental students in Medical University of Lublin, Poland.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest related to this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.