Psychological Impact of Online Learning During the Pandemic COVID-19 on Preclinical and Clinical Dental StudentsABSTRACT
Objective: To assess stress, anxiety, and depression among preclinical and clinical dental students during online learning, as well as the factors that contributed to these conditions.
Material and Methods: A cross-sectional study was conducted in late 2021 involving 580 dental students from Indonesian dental faculties. Data were collected via an online questionnaire distributed via social media, using a snowball sampling approach. The questionnaire included informed consent, sociodemographic data, behavioral factors, lecture activities, and the Depression Anxiety Stress Scale (DASS-21). Data analysis was performed using Chi-square and logistic regression.
Results: The prevalence of anxiety, stress, and depression among the total 607 students enrolled was 70.8%, 63.1%, and 51.6%, respectively, with preclinical students showing higher levels. Regular exercise was associated with a 37% reduction in stress, while attending online shortly lowered the likelihood of anxiety by 56%. Conversely, having family or friends diagnosed with COVID-19 increased the risk of depression by 1.53 and 1.88 times, respectively.
Conclusion: Stress was related to lack of exercise and insufficient sleep, anxiety to higher online learning frequency, and depression was reduced by extracurricular activities but worsened by COVID-19 cases among family or friends.
Keywords:
Mental Health; Anxiety; COVID-19; Students; Dental; Education; Distance.
Introduction
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogenic virus that causes COVID-19, a contagious disease that results in acute respiratory syndrome. After its debut in Wuhan, China, this disease quickly spread worldwide [1]. The rapid spread of viruses across countries has heightened local government concerns, prompting the implementation of social restrictions and the prohibition of various gatherings. One of the affected areas is the education sector. Elementary education to the university level transforms offline learning into online learning. Many universities worldwide have either postponed or cancelled large-scale gatherings, including conferences, workshops, sporting events, and other activities, due to the growing fear of the COVID-19 pandemic [2]. Several countries (Jordan, the Philippines, Saudi Arabia) reported that faculty rearranged the curriculum or learning methods to be delivered online while still meeting competencies [3-5].
Online learning is a learning model that can facilitate students' learning more broadly and in a more varied manner. The facilities provided allow students to interact without being limited by location and time. The learning materials studied are a mix of verbal, visual, audio, and motion [3]. However, there were perceived disadvantages associated with implementing online learning. Evidence suggests that online learning may lead to low performance and concerns about capabilities due to limited interaction between students and teachers, as well as online platforms that are not readily adaptable for students with special needs.
Additionally, online learning can cause exhaustion due to excessive activity, repetitive tasks, and a lack of movement, as well as inadequate Internet access [3-5]. The unprecedented 'home quarantine' has a mixed effect on students' psychology. University students' mental health problems, including stress, anxiety, sadness, and acute stress reactions, were exacerbated by activities like in-person interactions, the conversion of in-person learning models to virtual learning, and restrictions on social connections [6,7].
Many countries report the effect of online learning on student psychology. In a 2020 study across 62 countries, mainly students expressed anxiety about their future competencies and skills burnout, anxiety, and frustration [8]. Saudi Arabia confirmed that a virtual learning method was significantly associated with depression (74.4%), stress (75%), and fear (79%) of the students [5]. According to a study conducted in Bangladesh, 18.1% of students experienced severe anxiety, and 15% had moderately serious depression [7]. Even after the lockdown period was lifted, 9.2%, 13.2%, and 6.6% of Malaysian students reported having severe to extremely severe sadness, anxiety, and tension, respectively [9]. A meta-analysis reveals that 35% of dental students were thought to experience anxiety overall [10].
The COVID-19 pandemic has caused pathological mental circumstances in people, which are linked to higher morbidity and mortality from a variety of illnesses, including heart disease, an elevated risk of stroke, hypertension, and even suicide [11]. So, it is essential to do early detection and mitigation of mental disorders among students to prevent complications. This is useful for reducing or even avoiding the destructive effects of mental disorders, ranging from mild ones, such as sleep disorders, to severe ones, namely heart disease and even suicide. A study on the psychological condition of graduate students in Indonesia during the COVID-19 pandemic has been carried out [12], specifically among dental students, which is scarce. Based on this, research is needed to determine the level of depression, anxiety, and stress in preclinical and clinical dental students in Indonesia as a result of online learning.
Material and Methods
Study Design and Ethical Clearance
This cross-sectional survey was carried out among dental students at the Faculty of Dentistry in Indonesia between December 2021 and February 2022. The State Polytechnic of Health in Malang, Indonesia's Health Research Ethics Committee granted ethical permission for this study (Reg. No.: 962/KEPK-POLKESMA/2020).
Data Collection
This study used the snowball sampling technique. Key staff from student organizations at the faculty disseminated Google Forms questionnaires to responders via social media, which collected the data. Through the WhatsApp group, the main person will send out surveys to preclinical and clinical students. Informed consent was provided on the Google form's initial page. Those who consented to participate might keep answering the survey, while those who didn't want to could stop. Respondents must be active dental faculty students in Indonesia (i.e., not on academic leave) enrolled in either a preclinical or a clinical program to be eligible. During their first through fourth years, preclinical students concentrate on developing their clinical and theoretical knowledge. Clinical students are fifthto sixth-year students who enter the stage of comprehensive theoretical deepening and clinical skills development by handling patient cases under close supervision from a clinical supervisor. Students who enter the preclinical and clinical stages will be assigned a new student registration number corresponding to the year of entry. With a sample size determined using G*Power 3.1.9.4, assuming an effect size of 0.3, α = 0.05, and a power size of 0.95, respondents who fit these criteria will be included in the study. 580 was the predicted sample size.
Instruments
The distributed questionnaire consisted of two sets. The first questionnaire consists of self-identity, daily activities and lectures (online lecture schedules, extracurricular activities, physical exercise routinely in the last month, and sleep duration), social environment (including living with family, friends, or family diagnosed with COVID-19, seeking information about COVID-19 through any media and complying with the COVID-19 such as wearing a mask, cleaning hands regularly, keeping a distance from others, and limitation of activity).
The second questionnaire is the DASS-21 instrument used to measure anxiety, stress, and depression, which has been adapted in the Indonesian version. In previous studies involving student respondents, the Indonesian version of the DASS-21 was reported to have good internal consistency. The Cronbach alpha values obtained for the depression, anxiety, and stress domain questions were 0.85, 0.84, and 0.84, respectively [13]. The DASS-21 consists of 21 questions, divided into three domains: depression, anxiety, and stress, with seven questions in each domain. In the instructions for completing the DAS-21 instrument, respondents were asked to provide answers about their experiences with online lectures. On a scale of 0 to 3, each participating student should rate the degree to which the statements apply to them. A score of 0 means that the statement did not apply to them at all, a score of 1 means that the statement applied to them to some extent or occasionally, a score of 2 means that the statement applied to them to a significant extent or frequently, and a score of 3 means that the statement applied to them often or most of the time. Each item's score is multiplied by two to yield a score between 0 and 42, with higher scores indicating worse results [14]. The total score obtained is categorized into five, as described in Table 1.
Data Analysis
The collected data were analyzed both descriptively and analytically using the Chi-square test and the multivariate logistic regression ENTER method, performed in SPSS, version 28 (IBM Corp., Armonk, NY, USA). The bivariate analysis aimed to determine the differences in conditions of anxiety, stress, and depression in preclinical and clinical students. Multivariate logistics was used to analyze the variables that affect anxiety, stress, and depression. Categorization of anxiety, stress, and depression for logistic regression was divided into: (0-7) for no anxiety and > 7 for anxiety, (0-14) for no stress and >14 for stressed, (0-9) for not depressed and > 9 for depressed.
Results
A total of 635 respondents from ten of the 32 dentistry faculties in Indonesia filled out the e-survey, and 607 met the criteria. The ten faculty of dentistry were from Universitas Brawijaya, Universitas Gadjah Mada, Universitas Prof. Dr. Moestopo, Universitas Airlangga, Universitas Jember, Universitas Syiah Kuala, Universitas Udayana, Universitas Mahasaraswati Denpasar, Universitas Padjadjaran, and Universitas Sumatra Utara. Participants were excluded due to duplicate entries and incomplete answers. Table 2 shows that the respondents were predominantly women (82.2%) and that most students were at the 3rdor 4th-year level (57.7%). Behavioral and clinical conditions, mostly non-smokers (93.7%), do sports (75.1%), have no systemic disease (94.1%), have extracurricular activities (73.8%), sleep duration < 7 hours (62.9%), and learning online 4-5 days per week (64.7%). Most personal characteristics were related to seeking information about COVID-19 (72.7%). Furthermore, 92.8% of respondents reported following the protocol to prevent COVID-19 transmission, 54% had friends who had COVID-19, and 76% had a family member who had COVID-19. The number of students who experienced anxiety, stress, and depression was 70.8%, 63.1%, and 51.6%, respectively.
Distribution of participants according to socio-demographic, behavioral, and personal characteristics.
Figure 1 illustrates that respondents who experience anxiety, stress, and depression more than those who do not, both preclinical and clinical students. The highest percentage was anxiety, followed by stress and depression, respectively. Compared to clinical students, preclinical students had higher levels of stress, anxiety, and depression. As many as 74% of preclinic and 67% of clinic students experienced anxiety. As many as 66% of preclinical and 60% of clinical students experience stress. 52% of preclinical and 51% of clinical students experienced depression. There were differences in anxiety conditions between preclinical and clinical students (p=0.046).
Percentage frequency and differences between pre-clinical and clinical students with respect to anxiety, stress, and depression.
Standard, mild, moderate, severe, and extremely severe classifications of anxiety, stress, and depression in preclinical and clinical students do not differ, according to Table 3.
The final multivariable logistic regression for the stress-influencing factors is displayed in Table 4. Stress was caused by physical activity, sleep length, and friends who had been diagnosed with COVID-19. Those who regularly exercised reported feeling 37% less stressed than those who didn't. Compared to respondents who slept more than seven hours, those who slept fewer than seven hours were 1.78 times more likely to experience stress. The likelihood of stress is 1.65 times higher for respondents who have friends with a COVID-19 diagnosis than for those who do not.
The final multivariable logistic regression model for the variables influencing anxiety is shown in Table 5. An online schedule, day/week, and a friend with a COVID-19 diagnosis were the causes of the anxiety. Respondents who participated in online learning one to three days a week had a 56% lower risk of anxiety than those who participated in online learning four to five days a week. The likelihood of anxiety is 1.64 times higher for respondents who have acquaintances with a COVID-19 diagnosis than for those who do not.
The final multivariable logistic regression for the factors impacting depression is displayed in Table 6. Involvement in extracurricular activities, family members with a COVID-19 diagnosis, and friends with a COVID-19 diagnosis are factors that lead to depression. Compared to respondents who did not participate in extracurricular activities, those who did had a 66% lower chance of experiencing depression. Compared to respondents who did not have family or friends with a COVID-19 diagnosis, those who did had a 1.53 and 1.88 times higher chance of feeling depressed.
Discussion
The COVID-19 pandemic has caused local authorities to impose restrictions on social interaction. This policy has led to changes in learning methods at the Faculty of Dentistry, moving from offline to online, both globally and in Indonesia. Research in several countries has reported psychological impacts on students who do online learning in the form of stress, depression, or anxiety, including in Bangladesh [7], the United Kingdom [16], and China [17]. This study was conducted to investigate the impact of online learning on preclinical and clinical dental students in Indonesia, measuring stress, depression, and anxiety levels associated with academic activities, behavioral factors, and their social environment.
Universities changed their teaching strategies during the COVID-19 pandemic, switching from offline to online instruction. Among these modifications were case-based learning, online whiteboard instruction, recorded lectures, online classrooms, and video tutorials. Additionally, this approach is applied in dentistry education; however, its use is limited because some courses require hands-on practice and are skill-based [18]. Dental students, during their educational period, face a very demanding and stressful environment, as it requires both theoretical depth and clinical skills, including interaction with actual patients at the clinical stage [19].
In Indonesia, nationally, dental education is completed in two stages: preclinic and clinical. In the first through fourth years, the preclinical stage focuses on mastering theory and basic medical and dental skills using a phantom. At the clinical stage, namely in the fifth to sixth years, students conduct dental chairside teaching, treating some patients with the approval and supervision of a certified clinical instructor [20].
The results of the current study indicate that overall, students who experience anxiety were 70.8%. A study using the DASS-21 instrument on dentistry students in Turkey showed an anxiety rate of 30.2% [21]. In Palestine, it was 76% [22], but in Saudi Arabia [23], Germany [24], and Malaysia [25], it was lower, namely 37.02%, 26.5%, and 26.9% respectively. Statistically, in the current study, the condition of students who experienced anxiety between preclinical and clinical students differed. The results indicate that a more significant percentage of preclinical students experience anxiety than clinical students. This finding is similar to research in Saudi Arabia, where first-year to third-year students reported higher levels of anxiety than senior students during the COVID-19 pandemic. This may be because younger students do not yet have the experience to meet the graduation requirements, unlike senior students, who have greater knowledge and maturity [23]. Students at the initial level may have concerns about not being able to perform laboratory skills properly when they are done online.
Overall, 63.1% of students experienced stress. Stress studies using DASS-21 were conducted during the COVID-19 pandemic on dental students in many countries, such as Turkey [21], Palestine [22], Saudi Arabia [23], Germany [24], and Malaysia [25], reporting percentages 27.2%, 28.9%, 34.9%, 25.6%, and 8.6%, respectively. Compared to these five countries, Indonesia is higher. Previous research on the relationship between the dental environment and perceived stress among dentistry students during the COVID-19 pandemic at a university in Indonesia found that the highest stressors were fear of failure, poor grades, lack of relaxation time, and difficulty in studying clinical procedures [26]. The current study found that a higher proportion of preclinical students experienced stress than clinical students. This finding differs from that of Naidu et al. [27] in Trinidad and the West Indies and Kwaik et al. [22] in Palestine, who found that severe stress was more common among clinical students or in higher years. According to a comprehensive review of research on stress among dental students, the majority of studies found that preclinical students' primary sources of stress were academic variables such as workload, grades, and tests. Clinical students found that the primary source of stress was academics, followed by clinical variables, such as learning specific clinical procedures and concerns about handling uncooperative patients [28]. The findings in the current study may be due to preclinical students experiencing an adaptation phase during the transition from conventional to online methods. At the same time, they are students only for 1-2 years, which impacts their mental condition.
The overall depression experienced by students was 51.6%, with almost the same proportion between preclinical and clinical students. The results of a survey conducted in a similar situation to the current study in several countries, such as Turkey [21], Palestine [22], Saudi Arabia [23], German [24] regarding depression using the DASS-21 instrument, the researchers found that the percentage of respondents who experienced depression was 11.4%, 39.4%, 60.6%, 36.5%, and 24% respectively. A previous study on the incidence of depression in dentistry students was conducted in Thailand. The results show that depression is more common in final-year and second-year students than in firstand third-year students. The difference in the incidence of depression in this study is due to the different curriculum burdens at each level [29]. A study on depression in dentistry students was also conducted in Korea. This study found that the incidence of depression and burnout is related to academic workflow and satisfaction with educational programs [30].
Respondents who undergo online learning not fully per week have a lower risk of anxiety than those who experience it fully per week. Research shows that the intensity of using video conference platforms can result in “Zoom fatigue", where users experience mental exhaustion after interacting excessively with Zoom or other video conference technologies [31]. This can harm psychological and mental health, including a consequent increase in depression and anxiety [32,33].
Respondents who regularly exercise tend to be less stressed than those who do not. A potential mechanism underlying this is the influence on several core biological processes that can increase neuroregeneration, as well as the balance between inflammatory/anti-inflammatory and oxidative/antioxidative markers [34]. Respondents with shorter sleep duration had a greater risk of experiencing stress than those with sufficient sleep. This was also reported in a study conducted by Gaş et al. [21], which found a correlation between sleep quality and DASS-21. A survey report from Australia stated that the average sleep time for adults is 7-9 hours [35]. In the current study, respondents with sleep times of more than 7 hours had a lower risk of experiencing stress.
Respondents who participate in extracurricular activities have a lower risk. Taking more extracurricular activities means having the opportunity to make more friends. A study in India before the COVID-19 pandemic found that having friends can be social support, including emotional support, to reduce the pressure associated with depression [29]. However, this condition, on the other hand, also found that respondents who have family and friends diagnosed with COVID-19 have a high risk of experiencing stress, depression, and anxiety compared to those who do not have family or friends who have been diagnosed with COVID-19.
The limitation of this study is that the participating dental students represent only a portion of the dental faculty in Indonesia. However, the results of this study can provide information on the mental health condition of the respondents. The factors that influence the occurrence of stress, anxiety, and depression are numerous; further research needs to add other variables such as economic factors, nutritional intake, academic workflow, faculty/university policy, number of clinical requirements, and systemic diseases suffered to provide complete information. Future research must also investigate the correlation between mental health conditions and learning outcomes and achievements during the COVID-19 pandemic. This study used a cross-sectional method, which cannot yet explain cause and effect. However, it can provide information on the relationships between variables that can be further investigated with a longitudinal design.
Conclusion
Respondents, primarily preclinical students, had high levels of stress, anxiety, and sadness. The presence of a friend with a COVID-19 diagnosis, exercise, and sleep patterns are the elements that lead to stress. The density of online learning activities and friends who have been diagnosed with COVID-19 are factors that contribute to anxiety. Extracurricular activities and the presence of friends and family with COVID-19 diagnoses are influencing factors for depression. Given how many dental students suffer from stress, anxiety, and depression, the faculty and institution must address these issues to keep them from having a detrimental effect on the students' academic performance and quality of life.
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Financial Support
The study received financial support from the Faculty of Dentistry, Universitas Brawijaya 1360 /UN10.F10/PN/2021.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
References
-
[1] Gasparoni A, Kanellis M. Covid-19 and dental emergencies: Reflections on teledentistry. Braz Dent Sci 2020; 23(2):1-4. https://doi.org/10.14295/bds.2020.v23i2.2270
» https://doi.org/10.14295/bds.2020.v23i2.2270 -
[2] Sahu P. Closure of universities due to coronavirus disease 2019 (COVID-19): Impact on education and mental health of students and academic staff. Cureus 2020; 12(4):e7541. https://doi.org/10.7759/cureus.7541
» https://doi.org/10.7759/cureus.7541 -
[3] Almahasees Z, Mohsen K, Amin MO. Faculty’s and students’ perceptions of online learning during COVID-19. Front Educ 2021; 6:638470. https://doi.org/10.3389/feduc.2021.638470
» https://doi.org/10.3389/feduc.2021.638470 -
[4] Almonte J, Badillo E, Candelaria K, Tadle I. Academic performance, fatigue, and stress in online learning among college students: A multivariate analysis. In 6th North American International Conference on Industrial Engineering and Operations Management 2021; 2430-2441. https://doi.org/10.46254/NA06.20210429
» https://doi.org/10.46254/NA06.20210429 -
[5] Azmi FM, Khan HN, Azmi AM. The impact of virtual learning on students’ educational behavior and pervasiveness of depression among university students due to the COVID-19 pandemic. Global Health 2022; 18(1):1-9. https://doi.org/10.1186/s12992-022-00863-z
» https://doi.org/10.1186/s12992-022-00863-z -
[6] Sankhi S, Marasine NR. Impact of COVID-19 pandemic on mental health of the general population, students, and health care workers. Europasian J Med Sci 2020; 2(4):64-62. https://doi.org/10.46405/ejms.v2i2.131
» https://doi.org/10.46405/ejms.v2i2.131 -
[7] Islam MA, Barna SD, Raihan H, Khan MNA, Hossain MT. Depression and anxiety among university students during the COVID-19 pandemic in Bangladesh: A web-based cross-sectional survey. PLoS One 2020; 15 15(8):e0238162. https://doi.org/10.1371/journal.pone.0238162
» https://doi.org/10.1371/journal.pone.0238162 -
[8] Aristovnik A, Keržič D, Ravšelj D, Tomaževič N, Umek L. Impacts of the COVID-19 pandemic on life of higher education students: A global perspective. Sustain 2020; 12(20):1-34. https://doi.org/10.3390/su12208438
» https://doi.org/10.3390/su12208438 -
[9] Woon LSC, Leong Bin Abdullah MFI, Sidi H, Mansor NS, Nik Jaafar NR. Depression, anxiety, and the COVID-19 pandemic: Severity of symptoms and associated factors among university students after the end of the movement lockdown. PLoS One 2021; 16(5):e0252481. https://doi.org/10.1371/journal.pone.0252481
» https://doi.org/10.1371/journal.pone.0252481 -
[10] Santabarbara J, Idoiaga N, Ozamiz-Etxebarria N, Bueno-Notivol J. Prevalence of anxiety in dental students during the covid-19 outbreak: A meta-analysis. Int J Environ Res Public Health 2021; 18(20):10978. https://doi.org/10.3390/ijerph182010978
» https://doi.org/10.3390/ijerph182010978 -
[11] Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J Affect Disord 2020; 277:55-64. https://doi.org/10.1016/j.jad.2020.08.001
» https://doi.org/10.1016/j.jad.2020.08.001 -
[12] Abubakar A, Ma’ruf MF, Mizfaruddin M, Yusuf F, Maghfirah D, Muhsin M. Anxiety to COVID-19 pandemic amongst university students is related with gastrointestinal symptoms. Bali Med J 2021; 10(2):847-580. https://doi.org/10.15562/BMJ.V10I2.2412
» https://doi.org/10.15562/BMJ.V10I2.2412 -
[13] Arjanto P. Uji reliabilitas dan validitas Depression Anxiety Stress Scales 21 (DASS-21) pada Mahasiswa. J Psikol Perseptual 2022; 7(1):60-80. https://doi.org/10.24176/perseptual.v7i1.6196
» https://doi.org/10.24176/perseptual.v7i1.6196 -
[14] Ali AM, Ahmed A, Sharaf A, Kawakami N, Abdeldayem SM, Green J. The Arabic Version of The Depression Anxiety Stress Scale-21: Cumulative scaling and discriminant-validation testing. Asian J Psychiatr 2017; 30:56-58. https://doi.org/10.1016/j.ajp.2017.07.018
» https://doi.org/10.1016/j.ajp.2017.07.018 -
[15] Lovibond P, Lovibond S. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995; 33(3):335-343. https://doi.org/10.1016/0005-7967(94)00075-u
» https://doi.org/10.1016/0005-7967(94)00075-u -
[16] Chen T, Lucock M. The mental health of university students during the COVID-19 pandemic: An online survey in the UK. PLoS One 2022; 17(1):e0262562. https://doi.org/10.1371/journal.pone.0262562
» https://doi.org/10.1371/journal.pone.0262562 -
[17] Yang C, Chen A, Chen Y. College students’ stress and health in the COVID-19 pandemic: The role of academic workload, separation from school, and fears of contagion. PLoS One 2021; 16(2):e0246676. https://doi.org/10.1371/journal.pone.0246676
» https://doi.org/10.1371/journal.pone.0246676 -
[18] Farrokhi F, Mohebbi SZ, Farrokhi F, Khami MR. Impact of COVID-19 on dental education - A scoping review. BMC Med Educ 2021; 21(1):1-12. https://doi.org/10.1186/s12909-021-03017-8
» https://doi.org/10.1186/s12909-021-03017-8 -
[19] Alzahem AM, Van Der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH. Stress amongst dental students: A systematic review. Eur J Dent Educ 2011; 15(1):8-18. https://doi.org/10.1111/j.1600-0579.2010.00640.x
» https://doi.org/10.1111/j.1600-0579.2010.00640.x - [20] The Republic of Indonesia. Minister of Research, Technology and Higher Education. Regulation of the Minister of Research Technology and Higher Education of Indonesia. Standar Nasional Pendidikan Kedokteran; 2018.
-
[21] Gaş S, Ekşi Özsoy H, Cesur Aydın K. Association between sleep quality, depression, anxiety, and stress levels, and temporomandibular joint disorders among Turkish dental students during the COVID-19 pandemic. Cranio 2023; 41(6):550-555. https://doi.org/10.1080/08869634.2021.1883364
» https://doi.org/10.1080/08869634.2021.1883364 -
[22] Kwaik AA, Saleh R, Danadneh M, Kateeb E. Stress, anxiety and depression among dental students in times of covid-19 lockdown. Int J Dent Oral Sci 2021; 8(2):1397-1401. https://doi.org/10.19070/2377-8075-21000310
» https://doi.org/10.19070/2377-8075-21000310 -
[23] Hakami Z, Khanagar SB, Vishwanathaiah S, Hakami A, Bokhari AM, Jabali AH, et al. Psychological impact of the coronavirus disease 2019 (COVID-19) pandemic on dental students: A nationwide study. J Dent Educ 2021; 85(4):494-503. https://doi.org/10.1002/jdd.12470
» https://doi.org/10.1002/jdd.12470 -
[24] Mekhemar M, Attia S, Dörfer C, Conrad J. Dental students in germany throughout the COVID-19 pandemic: A psychological assessment and cross-sectional survey. Biology 2021; 10(7):611. https://doi.org/10.3390/biology10070611
» https://doi.org/10.3390/biology10070611 -
[25] Samsudin AD, Jaafar A, Idaham NI, Yunos MHMJ. The effect of COVID-19 pandemic on psychological wellness among dental students of a Malaysian public university. Ulum Islam 2021; 33(3):87-97. https://doi.org/10.33102/uij.vol33no3.323
» https://doi.org/10.33102/uij.vol33no3.323 -
[26] Astoeti TE, Josephine H, Widyarman AS, Sudhana W. Correlation between dental environment and perceived stress scale among dental students during the COVID-19 pandemic in Indonesia. Kesmas 2021; 16(3):165-170. https://doi.org/10.21109/kesmas.v16i3.4653
» https://doi.org/10.21109/kesmas.v16i3.4653 - [27] Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and psychological disturbance among dental students in the West Indies. J Dent Educ 2002; 66(9):1021-1030.
-
[28] Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, Bedos C. A systematic review of stress in dental students. J Dent Educ 2014; 78(2):226-242. https://doi.org/10.1002/j.0022-0337.2014.78.2.tb05673.x
» https://doi.org/10.1002/j.0022-0337.2014.78.2.tb05673.x -
[29] Raghunathan D, Ramakrishnan D, Iris Valsan KV, Ambika S. Prevalence of depression among students of a dental tertiary care center in Kerala. Indian J Community Med 2017; 42(1):147-150. https://doi.org/10.4103/ijcm.IJCM
» https://doi.org/10.4103/ijcm.IJCM -
[30] Kwak EJ, Ji YA, Baek SH, Baek YS. High levels of burnout and depression in a population of senior dental students in a school of dentistry in Korea. J Dent Sci 2021; 16(1):65-70. https://doi.org/10.1016/j.jds.2020.07.009
» https://doi.org/10.1016/j.jds.2020.07.009 -
[31] de Oliveira Kubrusly Sobral JB, Lima DLF, Lima Rocha HA, de Brito ES, Duarte LHG, Bento LBBB, et al. Active methodologies association with online learning fatigue among medical students. BMC Med Educ 2022; 22(1):74. https://doi.org/10.1186/s12909-022-03143-x
» https://doi.org/10.1186/s12909-022-03143-x -
[32] Fauville G, Luo M, Queiroz ACM, Bailenson JN, Hancock J. Zoom exhaustion & fatigue scale. Comput Hum Behav Reports 2021; 4:100119. https://doi.org/10.1016/j.chbr.2021.100119
» https://doi.org/10.1016/j.chbr.2021.100119 -
[33] Dhir A, Yossatorn Y, Kaur P, Chen S. Online social media fatigue and psychological wellbeing. A study of compulsive use, fear of missing out, fatigue, anxiety and depression. Int J Inf Manage 2018; 40:141-152. https://doi.org/10.1016/j.ijinfomgt.2018.01.012
» https://doi.org/10.1016/j.ijinfomgt.2018.01.012 -
[34] Schuch FB, Stubbs B, Meyer J, Heissel A, Zech P, Vancampfort D, et al. Physical activity protects from incident anxiety: A meta-analysis of prospective cohort studies. Depress Anxiety 2019; 36(9):846-858. https://doi.org/10.1002/da.22915
» https://doi.org/10.1002/da.22915 -
[35] Adams R, Appleton S, Taylor A, McEvoy D, Antic N. Report to the Sleep Health Foundation 2016 sleep health survey of Australian adults. Sleep Heal 2017; 3(1):35-42. https://doi.org/10.1016/j.sleh.2016.11.005
» https://doi.org/10.1016/j.sleh.2016.11.005
Edited by
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Academic Editor:
Wilton Wilney Nascimnto Padilha
*Continuity correction; Statistically significant (p < 0.05).