Stress, Stressors and Coping Methods Among First Year Dental Undergraduate Students: A Qualitative Study

Introduction

Stress is defined as the response of an individual to the challenges presented.¹ The factors which bring about the stress response are called stressors. The methods adopted by the individuals to deal with the stressors are referred to as coping mechanisms. Stress response is protective as it enables the individual to confront the adversities. However, chronic stress response leads to problems with physical and mental health.²

The transition from pre-university to professional course is hard owing to number of factors.³ Change in living arrangements, making new friends and academic pressures of professional educations are some of the prominent stressors.⁴ A number of studies done in India point to the high levels of stress among dental students.^4-8 However, these studies are quantitative studies.

Quantitative studies generally use closed ended questionnaires to assess the stress, stressors and coping. As a result, students have to choose a response to better reflect their perspective. Hence, qualitative studies are needed as they allow students to express their perspectives better. Though a number of quantitative studies conducted focused on stress among dental students in India, the present study employed a qualitative methodology namely, focus group discussion to understand first year dental undergraduate students’ perspective on stress, stressors and coping.^4-8

Materials and Methods

Focus group discussions were conducted among students enrolled into first year dental undergraduate course during July 2022. Focus group discussion provides in depth understanding of the issue and helps in gaining insight to the participants’ opinions and attitudes.⁹ Students aged eighteen years or above were included in the study. Students who were on medication or undergoing counselling for anxiety, depression and other psychiatric issues were excluded. Ethical clearance was obtained from the Institutional Ethical Committee with protocol number GDCRI/IEC-ACM(2)/11/2021-22. The head of the institution of one dental teaching institution situated in urban cosmopolitan area was approached and permission was obtained to conduct focus group discussions.

The four focus group discussions were conducted with eight participants each. The first author facilitated the discussion as a moderator. Two trained recorders assisted by taking notes during the discussion. The reason for conducting the research was explained to the first year undergraduate students in a face to face meeting. The students were invited to participate and participation was voluntary. Purposive sampling was done to select participants using a sampling grid with representation of students from different gender and place of accommodation. Informed consent was obtained from the selected participants.

The various causes of stress, called as ‘Stressors’, result in a ‘Stress’ response. To deal with stress, students choose different coping methods. The focus group discussion followed this thematic framework as given in Figure 1. A discussion guide was developed for aiding in the focus group discussion. A questionnaire was used to collect demographic data of the participants. The discussion guide and questionnaire was pilot tested among a group of first year dental undergraduate students from a different dental teaching institution.

Measures were taken to protect the privacy of the participants and protection of data. The completed questionnaires were anonymized. Focus group discussions were moderated by one of the researchers. The discussions were held in the class room with the participants and moderator in a circular seating arrangement such that all the members of the group could communicate with the others. Participants were encouraged to give responses based on their experiences only. The discussion guide followed a funnelling pattern with general topic of stress at the beginning followed by specific topics of stressors, effects of stress and coping. The schedule of questions in the discussion guide is presented in Table 1.

The discussion was recorded using a digital audio recorder. The same discussion guide was used for all focus groups. Follow up prompts were used to encourage further discussion. The discussion was carried out till no further new themes emerged or to the point of redundancy. After the focus group, the participants were debriefed and requested not to discuss about the interview with their batchmates. The recordings of the discussions were transcribed verbatim. The transcripts were sent back to the students to obtain their feedback.

Content analysis was done to interpret the students’ perspective on stressors, stress and coping following Hutter-Hennink qualitative research cycle.¹⁰ Smallest meaningful units were identified within the transcript as codes. QDA Miner Lite Software was used for coding and analysis. Based on the discussion guide, codes were identified deductively. The transcript was read by the authors and new codes were further identified inductively. Codes were classified into various categories. The categories were further classified into three themes: stressors, effects of stress and coping. The authors arrived at a consensus regarding the codes, categories and themes by mutual discussion.

The frequency of codes for each category was analyzed and predominant codes were identified. Text retrieval was done for the codes and analyzed further to understand and interpret the responses of the participants. The manuscript has been developed in line with the ‘Consolidated Criteria for Reporting Qualitative Research’.¹¹

 Results

The demographic details of the participants are presented in Table 2. The major themes of stressors, stress and coping have been presented in Table 3.

Academic stressors

Exams were the most significant academic stressor. The overwhelming feeling of stress was experienced before exams and also during exams. One participant quipped, “Even before the exams, sometimes you enter the exam hall and you don’t remember anything at all, you feel that you are blank”.

Comparison with peers was another academic stressor that affected the participants. The following response demonstrates the importance of comparison: “Everything is changing. Earlier social media was not there. Everyone is more prone to know everyone’s life. They are always comparing themselves. I have seen many people comparing themselves after seeing social media posts. Earlier life was so simple; they used to just mind their own life.

Dental undergraduate students are often compared with medical students which is another stressor. One participant commented, “For dental students, everyone asks if dental course was your first choice. Did you choose it on your own? They are always comparing dental course with medical course”.

Syllabus load was seen as a prominent academic stressor as given in the response: “If you look at the study part, you have to constantly keep in touch with the subjects. If you miss studying even two to three days, you lose out on huge portions. So, you need to keep studying constantly. There is a lot to study. It is a volatile subject and you have to keep studying.”

Personal stressors

Concerns regarding future was the most striking ‘Personal Stressor’. The first year students have just made a choice of career and are really concerned if they will be successful in the chosen area as given in the response: “After twelveth, it is a broad field, which career you have to choose, where you have to step in. There is no coming back. Few people can, but once you go forward in some direction, then there is no coming back. That is stress. Whether you will prosper in that area or will you like that area. So it is stressful.”

Relatives are another important personal stressor as shown in the response “You go to some family parties, people have a lot of opinion on what you should be doing. They just raise assumptions and try to pull you down. This disturbs and causes a lot of stress.”

Financial concerns were another prominent personal stressor. The comment, “I don’t have money. I stay in hostel and my parents send me a certain amount of money and by end of month I get really stressed. I don’t know what to do about it,” exemplifies the stressor.

The students opined that some stressors were control-lable and certain stressors were beyond their control. The following quote reflects their view, “Stressors are both external and internal. Internal might be when we are not prepared for a situation. External is when we are in a situation and not able to cope with the situation.”

Stress

It was a general opinion that stress was a common occurrence. The students’ responses consisted of various challenges that they faced and is in line with the definition of stress. The following comment sums up this observation: “Reason might be different, but every person goes through at some point some level of stress.”

Effects of stress

The common physical effects of stress were felt as headache and loss of appetite. The response, “Stress in little amounts or normal stress is fine as we get motivation to study or complete the task, but prolonged stress may cause headaches or something” shows the physical effects of stress.

Mental effects of stress were reported as hampered thinking, demoralization and loss of focus. The following comment by the respondent shows the mental effects of stress: “I think that stress is okay in the short term but in the long term it will affect the personality of the person. The person is snatched away his confidence and he or she will start feeling inferior compared to others. So it is really harmful in the long term.”

The common emotional effects of stress were anger and irritability. The comment “When a person approaches me when I am stressed, then the way I respond will be different. I won’t be able to give a proper answer. I might get irritated”, demonstrates the altered emotions of participant when under stress.

Stress brings about notable behavioural changes like the person becoming quiet and communicating differently as seen in the response: “I feel that people who have stress do not speak much. Even if you go to them and speak, they are not ready to open up.”

Benefits of stress

It was revealed that stress had certain benefits too. Stress acted as motivation to the participants as revealed by the comment: “Certain amount of stress is good. It gives you that motivation to complete the work.” It was also believed to open perspective of a person and prepare them for future.

Coping

The common coping mechanism adopted by the participants was listening to music. The following response reasons out the choice of music as a coping method: “Because it is feasible. Listening to music can be done at anytime, it works out everywhere. I would also travel if it were possible. And also these methods should divert you.”

Speaking with parents and friends was followed frequently as a method of coping. The reason for the choice of coping method as reported by participants was their efficiency in reducing stress and their feasibility. The importance of speaking to parents and friends is shown by the response, “I also talk to my mother and some of my friends who are really good at finding solutions. Not just general solutions, but understand me and tell according to that.”

Suggestions

The participants suggested a few changes that might reduce stress in the academic environment. Incorporation of extra-curricular activities was the predominant change suggested as seen in the responses: “There are no extracurricular activities. The fun part is not there. It is just studies, finish assignments, record and diagrams” and “Everyone will have some talent. Something which encourages should be there.” The other notable changes suggested were, more consideration by teachers and maintaining of confidentiality of marks obtained by students.

It was a general perception that some stress training was needed to help the students as seen in the response, “Some methods to manage stress may be taught. Not the internal ways that we use, but some external methods. I think that there are some exercises which people have been taught to reduce stress.” There was also an opinion that counselling was needed and the stress management methods be reinforced.

Discussion

Qualitative studies have explored stress among Indian students, but not among dental students.^12-14 Four focus group discussions were conducted as it has been recommended to be appropriate for capturing sufficient data in qualitative studies.¹⁵ Content analyses was done and codes were grouped into categories across the three major themes, i.e., stressors, stress and coping.

Stressors were divided into two categories: academic stressors and personal stressors. Exams were the predominant academic stressor. This was a strong opinion expressed by students in various studies done across the world.^16-22 Preparation for the exam is considered to be a demanding task. The fear of the consequences of the exams is thought to be so severe that many students feel that they may go blank during exams.⁶

Comparison with peers puts students at loggerheads with their classmates. Similar opinion was given by participants of another qualitative study.²⁰ Social media has catalyzed the problem further. Students feel that grades, performance criteria and rankings spoil the positive environment of learning. Such feelings also occur in students of clinical years.²¹ Comparison with medical course is a unique observation in the current study. This is not reflected in studies done in other countries. Many students who join dentistry in India aspire for medical course and would have joined dentistry as a second option.⁶

Syllabus load was perceived as a major academic stressor in the current study. The students feel that they have to study constantly to keep up with the adding syllabus load. This opinion was shared by under-graduate students in other quantitative studies as well.^16,17,20 It has been commonly perceived that dentistry is a challenging course.¹²

Concerns regarding future was another significant personal stressor. Apprehension towards higher studies, job placements and earning after graduation were common stressors noted in other studies as well.^21,1 Interference and comments by relatives was also reported as an important stressor. Young adults are vulnerable to comments of people around them and feel the pressure to please family members.¹⁶ Students enrolling for undergraduate studies would have reached adulthood and being still dependent on parents for their financial needs poses stress among them. This is common among students in different countries.^14,18

The present study revealed that stress was common among dental students. This observation is supported by other studies as well.^22,23 The competencies expected out of students of professional course may have contributed to this. Physical effects of stress noted in this study were mainly headache and loss of appetite. Several other effects were also reported to be prevalent in other studies - gastric reflux, bruxism, sleeps disturbances, weight changes and tiredness.^17,21,24

Stress resulted in a number of mental effects, mainly, hampered thinking, demoralization and loss of focus as reported in the present study. Similar effects have been reported in various other studies.^17,20,21 Mental fatigue and negative thinking were reported as the chief mental effects of stress among dental students in another study.²⁴ Psychological symptoms were reported to be more than the physical symptoms.¹⁶

Anger and irritability were reported as the emotional effects of stress in the present study, as also in certain other previous studies.^20,21,24,28 Anger has been explained as displacement type of coping, wherein factors within the college are displaced into aggression and fights with others.¹³ Becoming quiet and communicating differently than the normal were reported by the participants in this study. Similarly, feelings of isolation and withdrawal were reported in a previous study.²⁴ However, negative behaviours like smoking, drinking alcohol and cheating were reported in another study.²⁰

Despite its harmful effects, stress was seen to be beneficial by the participants. Stress was perceived as a motivational factor for working hard in line with a similar study.²⁴ Previous literature indicates this to be a positive appraisal of the stressful event to result in growth and increased competence.¹⁹ However, the benefits of stress were reported to be limited and does not sustain at higher levels of stress.¹³

Listening to music and speaking with parents and friends emerged as prominent coping methods. Music focuses on the emotional effects of stress and distracts the students from stressors. Speaking with someone close can lend the required emotional support and also help sort the stressors. Such strategies are often resorted to by students.^19,22,24 However, research points out that such adaptive strategies are often used at low levels of stress.²⁵ Highly stressed students are susceptible to indulging in maladaptive strategies like smoking and alcohol dependence.¹⁷ No such practices were reported in the current study.

The participants strongly suggested incorporation of more extracurricular activities. Evidence shows that extra-curricular activities are best positive coping mechanisms.¹⁷ However, participation in extracurricular activities could get difficult with stress and lack of time for the students.²¹ Need for some stress management training was expressed by the participants. As dental students are known to be highly stressed, it was opined that incorporation of skills to recognize stress symptoms and strategies for positive stress management would be beneficial.^13,14,26 Such training might provide lifelong stress management tools to future dentists.^23,24

The limitation of this study was that it was conducted in an urban cosmopolitan area. Hence the results might be generalizable only to similar populations. However, it was the first qualitative study conducted in India to gain an insight into first year dental undergraduate students’ perspectives on stress.

Conclusion

Stress is perceived to be a common problem and exams were the main source of stress, followed by comparison with peers and syllabus load. Foremost effects of stress were reported as becoming quiet, experiencing anger and hampered thinking. Music, speaking with parents and friends were the coping methods considered as most effective. Participants suggested incorporation of extracurricular activities in college as a measure to reduce stress. Suitable measures need to be taken to tackle the issue of stress among first year dental undergraduate students.

Funding

The authors have not received any financial support for this study in the form of grants, equipment, drugs, etc.

Conflict of interest

Nil

Acknowledgements

The authors acknowledge the support of the dental education institution and the dental students for their participation in the study. The first author and the second author conceptualized the study, designed the study, analyzed the results and drafted the manuscript. In addition, the first author recruited the participants and conducted the focus group interviews with the participants.