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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 5  |  Page : 443-449

The correlation between well-being and stress in a cohort of dental students: A cross-sectional survey


1 Assistant Professor and Consultant of Oral Biology, Department of Diagnostic Sciences and Oral Maxillofacial Surgery, Riyadh Elm University (Formerly Riyadh Colleges of Dentistry and Pharmacy), Riyadh, Kingdom of Saudi Arabia
2 Demonstrator Department of Diagnostic Sciences and Oral Maxillofacial Surgery, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
3 Dental Intern, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia

Date of Submission07-Dec-2019
Date of Decision12-Mar-2020
Date of Acceptance12-Mar-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Dr. May Wathiq Al-Khudhairy
Assistant Professor of Oral Biology and Temporomandibular Joint Disorders at Department of Diagnostic Sciences and Oral Maxillofacial Surgery in College of Dentistry, Riyadh, Kingdom of Saudi Arabia, King Fahd Highway, Namuthajiya Campus, South Building, 3rd Floor, Room 304.
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_333_19

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  Abstract 

Aim: Mindfulness is the act of “focused at the moment” process encompassing a paradox of terms including and not limited to well-being. The aim of this study was to find a correlation, be it positive or negative, between well-being and stress. Materials and Methods: The cross-sectional study included a questionnaire-type format recruiting a convenient multicenter study sample of 744 participants across the different dental schools in Riyadh, Saudi Arabia. The study design included an operator-designed questionnaire and well-being tool kit having six domains of which some are inherent to the cultural aspects of the region. The domains were religious and meditation wellness, academics wellness, social and cultural wellness, mental wellness, environmental wellness, and physical wellness. Spearman’s correlation, Cronbach’s alpha coefficient, and multivariate analysis were conducted by Statistical Package for Social Sciences. Results: There was a positive inverse relationship between each of the domains relative to the perceived stress scale (P < 0.005). Conclusion: This study is the first of its kind in Saudi Arabia, and the six-domain tool kit with a favorable alpha coefficient can be used in future studies of well-being in such a vulnerable population, university students. “Burn out syndrome” is a reality that must be addressed, better yet to provide prophylaxis against via a custom designed well-being tool kit that can identify those vulnerable to the effects of a world laced with artificial intelligence, technology, and work-related stress.

Keywords: Dental Students, Mindfulness, Perceived Stress Scale, Toolkit, Well-being


How to cite this article:
Al-Khudhairy MW, Rubayan AB, Al Khayari D, Al Shahri A, Al Subhi N. The correlation between well-being and stress in a cohort of dental students: A cross-sectional survey. J Int Oral Health 2020;12:443-9

How to cite this URL:
Al-Khudhairy MW, Rubayan AB, Al Khayari D, Al Shahri A, Al Subhi N. The correlation between well-being and stress in a cohort of dental students: A cross-sectional survey. J Int Oral Health [serial online] 2020 [cited 2020 Nov 29];12:443-9. Available from: https://www.jioh.org/text.asp?2020/12/5/443/298794




  Introduction Top


In today’s world, there exists a materialization of actions all contributing to the emerging field of contemplative practices, which are in reality a testimony to advances in a human’s perception of a good life. Among these there are subdisciplines within the field, including and not limited to psychology, preventive medicine, education, religious studies, sociology, and philosophy to name a few. Well-being is under the umbrella of mindfulness, which in itself is a confusing term.[1]

Williams and Kabat-Zinn[2] noted that mindfulness encompasses a multitude of habits, actions, and subjective beliefs that encourage one to live mindfully.

Mindfulness can best be described as concentrating needlessly for long periods of time.[3] Mindfulness and psychological flexibility coincide at times. The latter refers to the power of resilience, transformation, or even perseverance in an attribute that has an incentive of gain.[4] There is a growing literature that supports the idea that psychological flexibility is instrumental for the success of mindfulness-based interventions.[5]

According to Hayes and Plumb,[6] the gift of cognitive perception of one’s environment, one’s response to it, and its acceptance give rise to a person’s awareness of his/her reaction to situations, and how to be in better control should they arise another time. This is the process of mindfulness in a nutshell and this can be taught in many ways.[6]

Anxiety and depression are common in undergraduate students; if left untreated, they would cause serious deleterious effects on its victims. Hence, it is recommended and imperative to appreciate and integrate mental well-being into the equation thereby reducing anxiety and depression. Therefore, when you exercise the process of mindfulness through well-being, you in turn decrease depression.[7]

Stress verses anxiety? Stress is a consequence of an insistence, be it physical and/or mental, leaving its victim nervous or frustrated. Anxiety on the contrary incites an element of despair, apprehension, or unrest and may be a reflex to stress.[8]

A study conducted by Oriellana et al.[9] on the staff working at a palliative care center found that mindfulness helped alleviate their perceived stress and anxiety levels after an intervention of well-being that lasted 10 weeks.

Hankin et al.[10] have raised our attention to the astounding increased risk to depression, which shows twice as much susceptibility in females as compared to males, starting at ages 12 (females) and 14 (males) and rising sharply to young adulthood.

In a systematic review (by Ibrahim et al.,[11]) on depression across university students, around 24 studies elaborated a mean prevalence of 31% (10%–85%). One of the concerns is the erratic sleep pattern and self-directed learning that are inherent hazards of the new university life.

Undermined mental health will jeopardize a student’s academic career that is reflected and at a higher risk of dropping out.[11]

College students have just completed the age of adolescence upon matriculating in their program of choice. Foster et al.[8] state that adolescence is a period of enlightenment that is sandwiched between childhood and adulthood, a time where an identity is built. A time of one’s life that is crucial for one’s progression, at the same time vulnerable to deleterious environmental stressors. In principle, these nuisances including stress, anxiety, and depression have a ripple effect that portrays negatively on their personality, grades, procurement of skills, and social interactions.[8] The latter two are gravely fundamental in a dentist’s profession and success. It is this reason that this study was conducted to correlate stress and well-being. Is well-being affected by stress?


  Materials and Methods Top


Study design

A survey tailored to assess well-being and stress was conducted, a questionnaire on stress (perceived stress scale), a valid and reliable tool to evaluate stress, as well as demographics and variables from six domains were incorporated to measure well-being.[12] The survey was sent on the March 12, 2018, and collected over a period of 2 months. The target population included senior dental students from around the city of Riyadh. Study was ethically approved by Riyadh Elm University’s (REU) institutional review board members (approval number RC/IRB/2018/1413).

Sampling criteria

All participants were Dental University undergraduates living in Riyadh, Saudi Arabia. Of university dental schools, four were conveniently chosen after their respective institutions granted permission. A total of 250 questionnaires were allocated to each of the universities by electronic Survey Monkey. The response rate was 74%; 26% of the participants did not complete the survey of the total 1000 that were sent. Inclusion criteria to participate in the study included a willingness to complete survey and being an enrolled undergraduate dental student in Riyadh in one of the four allocated dental schools. There was no bias; it was simply voluntary enrollment of a conveniently ready sample.

Questionnaires

The questions in the operator-designed questionnaire included demographics (age, gender, year at dental school, name of dental school, living situation, and marital status). The six domains in the well-being questionnaire were related to religion and meditation, academics, social/cultural wellness, mental wellness, environmental wellness, and physical wellness. Each domain had five questions, which were reached upon via popular consensus based on homogeneity and area of the world we live in, applicable for students in the health field.

Translation and formulation of questionnaire

As the targeted group was native Arabic speakers, the questionnaire was first translated from English to Arabic by an expert and then the translated version was converted back to English to check any ambiguity. This was followed by the distribution of the questionnaire among a pilot of 15–20 undergraduates and postgraduates to conduct the pretest, and after minor corrections of ambiguities, the questionnaire was distributed to the targeted group.

Validity and reliability

The data were inserted in Statistical Package for Social Sciences software (SPSS, version 22, SPSS Inc., Chicago, IL, USA) (IBM, Chicago, IL) to determine the reliability using Cronbach’s reliability coefficient alpha. The validity of the questionnaires’ contents was affirmed by sending it to experienced researchers and faculty in REU where slight modifications were made according to their feedback and comments. The questionnaires were included in one survey as three parts and completed by the participants in one go.

Data collection

Data were collected both as hard and soft copies by three senior dental students.

  • (a) The following include the variables that accounted for the well-being questionn aire: Never, Almost Never, Sometimes, Fairly Often, and Very Often. The choices were used qualitatively for evaluation of the mentioned well-being questionnaire, then analyzed quantitatively as Never = 0, Almost Never = 1, Sometimes = 2, Fairly Often = 3, and Very Often = 4; high degree of well-being: scores of >60–120, moderate degree of well-being: scores of >30–60, and low degree of well-being: scores of 0–30.


  • (b) The following 10-item perceived stress scale[12] was noted: Never, Almost Never, Sometimes, Fairly Often, and Very Often. Similarly the choices were used qualitatively to assess their level of stress and were further scored as Never = 0, Almost Never = 1, Sometimes = 2, Fairly Often = 3, and Very Often = 4.


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Reverse scores of questions 4, 5, 7, and 8 were scored as 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0. This was carried out by the investigator.

  • Scores ranging between 0 and 13 = low stress perception


  • Scores ranging between 14 and 26 = moderate stress perception


  • Scores ranging between 27 and 40 = high stress perception


  • Data analysis

    SPSS, version 22.0, was utilized in analyzing differences. Value of significance was kept under 0.05. We compared continuous scores of different categories of well-being and perceived stress scale, and found correlations between them. The reliability of well-being questionnaire was also calculated.


      Results Top


    The study’s recruited participant number boasted a power of 0.80 (mean of 1.267, standard deviation of 0.4722, alpha power of 0.05, and beta error of 0.20). This study was a multicenter convenient sample of dental students whose mean age was 25.76 years (±3 years). Among the recruited 744 students from different dental schools, majority of these participants were females at 90% (n = 677) and a mere 10% (n = 77) were males.

    [Table 1] shows that an inverse correlation exists between self-care and perceived stress scale (PSS), indicating that as each of the domains of self-care habits increases, the PSS score similarly decreases. Cronbach’s alpha test was conducted on all the questions in all the categories for the reliability and consistency of the questions in the questionnaire and it was found excellent (0.923).
    Table 1: Correlation between the mean perceived stress scale and the six mean well-being domains

    Click here to view


    It can be observed from [Table 2] that living style has a strong relation with education and mental wellness, a moderate relation with religious and mediation habits and physical wellness, and a weak relation with social and cultural wellness and environmental wellness. On the other hand, sleeping well during the week has strong relationship with religious and meditation habits, social and cultural wellness, environmental wellness, and physical wellness, and has moderate relation with education and mental wellness. We can also observe that perceived stress scale has a weak relation with living style but has a strong relation with sleeping well during the week.
    Table 2: Regression analysis

    Click here to view



      Discussion Top


    Our study elaborated the inverse relationship between well-being and perceived stress. Furthermore, well-being in each of the domains incorporated is the silver lining that helps shackle stress. In other words, well-being is aligned with a decrease in perceived stress scale, which ultimately results in better academic performances.

    One study by Greco et al.[13] showed that self-reporting of well-being across pediatric populations has been shown to be related to an increased sense of content and joy in one’s life.

    Foster et al.[8] on emotional intelligence, mindfulness, depression, and anxiety elaborated in their study that being aware and attentive to one’s well-being was more likely to enable and encourage the growth of areas in the human brain pertaining to attentiveness and analysis of emotions, which ultimately diminishes anxiety and depression.[8] A person with a heightened sense of being mindful and aware is less likely to be associated with depression as well as anxiety. In 2010, Carver et al.[14] emphasized the growth of research in the field of well-being and how fundamental it is for general health promotion as a prophylactic against the pandemic health concerns of the twenty-first century.

    Rumination is closely associated to well-being; however, it is antagonistic as it heightens one’s attention and focus on factors related to one’s distress and not necessarily ways to dissipate them. Nolen-Hoeksema[15] proposed this initially in 1991 as part of the Response Styles Theory. Ruminative thinking is a process entertained by humans when sad or depressed and it is a cycle that does not lead to planned problem-solving. This might prolong or even exacerbate one’s symptoms of the blues. There are at least four ways where rumination opposes well-being: first, enhancing a person’s depressed mood, thereby being cognizant of one’s current situation by fueling it with negative thoughts; second, meddling with adequate problem-solving; third, opposing conductive behavior; and finally, rumination severs social relations and contacts, which ultimately aggravates the depression.

    Mindfulness-based interventions through well-being have been proposed decades ago with the most popular methods related to controlling stress, which in turn abate symptoms of depression and decrease incidence of relapse. Virgili[16] stated that the interventions opposition to catastrophic effects of depressive symptoms justifies the incentive toward investment of time and money into such programs.

    A systematic review on mindfulness-based interventions showed that teachers with enhanced mental well-being positively affected perseverance in the work environment and diminished exhaustive symptoms of psychological stress and depression.[17]

    In a cohort of female patients with breast cancer, sleep was shown to improve by practicing informal program of mindfulness.[18]

    Falling asleep is a positive side effect of mindfulness exercise, which is seen in our study that shed light into sleeping well during the week had a strong relationship with well-being in aspects of religious and meditation habits, social and cultural wellness, environmental wellness, and physical wellness, and a moderate relation with education and mental wellness. The absence of sleep has a deleterious effect on centers in the brain that harness stress such as the medial prefrontal cortex. That is, diminished sleep increases your risk of anxiety by 30%.[19]

    Similarly, family support such as the case in our research (living with family vs. in dormitories) was more productive in ameliorating the stresses of dental school students by improving well-being. This is supported in mindfulness literature by Birtwell et al.,[20] which showed the synergistic effect of familial support and mindfulness was in compliance with both formal and informal programs. Furthermore, a 2018 study incorporated a mindfulness approach to improve health care staffs’ stress.[21],[22]

    The effect of stress on anxiety and depression can be looked at sequentially. If there is a stressful event, the sympathetic adrenomedullary system will be activated, meaning that anything that affects a person’s homeostasis and norm will ultimately aggravate it. This in turn is carried to the fight and flight center in the hypothalamus, which stimulates the secretion of epinephrine and norepinephrine, by the medulla. These catecholamines will cause a domino effect of hypertension, palpitation, and sweating among others. Parallel to this, the hypothalamic pituitary adrenocortical axis is also activated whereby corticotrophin-releasing hormone is secreted to activate the pituitary to release adrenocorticotropic hormone, which causes the flow of glucocorticoids, by the adrenal cortex, namely cortisol the most infamous of all.[22] Chronic stress causes an upregulation of cortisol, which ultimately leads to a state of anxiety and personality disorder, namely depression.[23]

    A study by Pippi et al.[24] in 2014 touched base on the personality traits of those subjects with oral lichen planus compared to their age-matched healthy controls and showed a discrepancy in coping ability. That is, those afflicted had lower levels of cortisol the following day, which is depleted amounts from chronic stress, but also had a diminished ability in handling stressful situations.[24]

    It is therefore imperative for us as health care professionals to implement behavior interventions of well-being that can empower us and counteract against the deceitful treads of stress, anxiety, and depression.

    Several limitations must be brought to light regarding this study. The majority of the participants were females (around 90%) of the total. However, this is common in research with psychosomatic conditions and studies addressing well-being, sleep, and pain among others.[25] This is elaborated in Pippi et al.[24] where majority of participants were females. Promotion of well-being therapy through formal and informal classes is most sought by females.[24]

    Another concern is the wide phenotype of dental students of different socioeconomic status (some on fully paid scholarships, others self-pay at private dental schools). There might be some bias in the response of the participants to the well-being tool kit that was not taken into consideration. The sample included participants that were conveniently recruited and not randomly selected, which is not representative of the dental student population of the region. In addition, time was the greatest obstacle as this was conducted in such a short period of time due to funding purposes; if had more time been invested, then a greater number and representative sample of participants could have been procured. A presented study proposed that attending to one’s well-being is not a superficial luxury; on the contrary, it is an essential allotted time for one’s survival in this case as a dental student.

    Conclusion

    The domains of well-being in our research all had a direct statistically significant inverse relationship with the perceived stress scale, meaning that as one’s well-being improved in each of the six domains (religious and meditation, academics, social and cultural wellness, mental wellness, environmental wellness, and physical wellness), ultimately the perceived stress scale decreased. Furthermore, the mean well-being score was statistically significant in reducing the mean perceived stress scale.

    Historically, there has been a chameleon effect in the description of disease. The end of the twentieth century saw a paradigm shift in disease definition based on the need for its classification. While, First World Countries had to shackle the spread of infectious diseases toward the end of the twentieth century, they are now battling the ever-challenging psychosomatic conditions that have taken the twenty-first century by storm. “Burn out syndrome” was unheard off but is now becoming well versed by the most junior of society. How can humans retain well-being while competing in a world laced with artificial intelligence, technology, and mentally challenging environments? This can at its best be tolerated for but a period of time without causing detrimental psychosomatic effects on its prey.

    Acknowledgement

    We sincerely thank the dental school participants that generously offered their time to the research, as well as the Institution’s and staff that assisted with recruitment.

    Financial support and sponsorship

    Nil.

    Conflict of Interest

    The authors declare no conflict of interest.

    Authors Contribution

    We all contributed substantially to this study. M.W. conceived and presented the idea, conceived and planned the data collection, devised the project, designed and directed the project, contributed to the design and implementation of the study, suggested the analytical component post processing of the data. M.W provided significant constructive feedback to each other, A.B, D.K., A.S., N.S., carried out the fieldwork whereby collected the data, tabulated it, designed the model and computational framework for interpretation.

    Ethical Policy and Institutional Review Board Statement

    This study was ethically approved by Riyadh Elm University’s (REU) institutional review board members (approval number RC/IRB/2018/1413).

    Patient Declaration of Consent

    Written consent was obtained electronically upon initiation of survey questionnaire; all anonymity measures were undertaken to ensure participant identity privacy.

    Data availability Statement

    Data can be obtained upon written correspondence to corresponding author on valid request.



     
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        Tables

      [Table 1], [Table 2], [Table 3], [Table 4]



     

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