918 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu A Cross-Sectional Study of Environment Stress Among Undergraduate Dental Students Huda A. Yaseen, Dhaffar Alwan Majbil, Wathba Mohammed Jabber, Reyadh R. Al-Rashidi, Umelbaneen J. Alalawy, Sarab M. Zeki Radhi College of Den*stry, University of Kut, Wasit, Iraq Abstract ObjecEve: Stress is a prevalent issue in the field of dental educaEon, with numerous studies highlighEng its impact on students. CreaEng a supporEve and stress-free environment is vital in dental educaEon, not only for the well-being of students but also to minimize haz- ards which are frequently linked to stress. The main objecEve of the study was to invesE- gate the top stressors among the clinical years’ dental students. Material and Methods: A modified "Dental Environment Stress" quesEonnaire-based con- venient sample from fourth- and fiSh-year dental students in the University of Wasit and Kut University College was collected from November 2023 to December 2023. Prior to data collecEon, an ethical approval was taken from the Kut University College Research Ethics CommiZee (KREC) and each parEcipant provided a wriZen informed consent. The data were analysed using the StaEsEcal Package for the Social Sciences staEsEcal soSware (SPSS version 25.0). Results: 392 students parEcipated with a female to male raEo (2.4: 1). The "Self-efficacy Belief" domain emerged as the most impaccul stressor. FiSh-year students experience higher stress related to Eme management and clinical requirements compared to fourth- year students. Stress levels are similar between students from private and public universi- Ees. Conclusion: The study highlights that dental educaEon induces significant stress among students. Efforts to improve paEent organizaEon and engagement are recommended to alleviate stress among students. Open Access Cita%on: Yaseen HA, et al. (2025) A Cross-Sec%onal Study of Environment Stress Among Undergraduate Dental Students. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.918 Received: April 26, 2025 Accepted: May 22, 2025 Published: June 26, 2025 Copyright: ©2025 Hadi AM, et al. This is an open access ar%cle licensed under a Crea%ve Commons ATribu%on Work 4.0 United States License. Email: Huda.Yaseen@alkutcollege.edu.iq Introduc)on The term "stress" according to WHO, refers a state of worry or mental tension caused by a dif;icult situation. Stress is a natural human response that prompts us [1]. The brain plays a crucial role in perceiving and re- sponding to stress with exceptional plastic- ity. " Eustress" is a positive form of stress that can motivate and energize individuals, helping them to perform better and achieve their goals. On the other hand, when stress- ors overwhelm an individual's ability to cope, stress can transform into a negative form " distress" that can lead to anxiety, de- pression, and other health issues [2,3]. The crisis behind being stressed is the endless physical and mental consequences and ;i- nally, burnout [4]. Physical consequences can be fatigue/tiredness, mood alteration, ef- fect on performance, headaches and sleep disturbance. Psychological distress mani- fests in terms of showing higher levels of de- pression, obsessive-compulsive disorders, and interpersonal sensitivity than age- matched norms [5,6]. Stress is not exclusive to medical and dental students but is more pronounced among them. What worsens the A Cross-Sec+onal Study of Environment Stress Among Undergraduate Dental Students Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu 2 condition is the high expectation that they are capable of handling stress and not be greatly affected by it [5]. The current dental school curricula strongly emphasize devel- oping a wide range of skills among students, such as theoretical knowledge, clinical ex- pertise, and the ability to effectively interact with anxious patients and supervisors. [7]. In Iraq, the cost of studying dentistry is the highest among all undergraduate programs, even at governmental universities, which adds another burden on dental students. Many studies reported that dental students, compared with their counterparts in the medical ;ield, experience more stress partic- ularly during their clinical study years [8- 10]. Stress among dental students has been assessed using various stress scales, includ- ing "Dental Environment Stress Scale" (DES), the "Maslach Burnout Inventory" (MBI), and the "Psychosocial Stress Inventory" (PSSI). Among these, DES is commonly used [11]. Fourth-year dental students are anxious about their career prospects, while newly ar- rived students are greatly concerned about having little time for rest [12]. When investi- gating the main stressors in a multi-country study, Divaris and Polychronopoulou con- cluded that performance pressure, work- load, and self-ef;icacy beliefs constituted the students' main concerns [13]. Another study reported that the major stressors for ;ifth- year students were: examinations, patients being late to appointments and the amount of assigned work [14]. Creating a healthy and relaxed environment without hazards is a priority in the dental setting. Stress has been shown to be a common cause (50%) of nee- dle-stick injuries [9], which can lead to dis- ease transmission and harm to practitioners. The prevalence, frequency and the main con- tributors of stress among dental students in Wasit governorate have not been previously investigated. Wasit currently has two Uni- versities. Therefore, an attempt was made to study the mental health issues among this population particularly the clinical years stu- dents. Materials and Methods A cross-sectional study conducted in the 1st semester of the academic year 2023/2024 during the period from November 2023 to December 2023. A convenience sampling of participants was recruited from fourth- and ;ifth year dental students in the University of Wasit and Kut University College, Wasit Province, Iraq. The questionnaire used in the study was the modi;ied "Dental Environment Stress" (DES) questionnaire by Al-Sowygh [2], which was selected due to the religious and cultural similarities between the two so- cieties. Prior to data collection, the question- naire underwent translation into Arabic by a professional language translator. The Arabic version was then tested on a small sample of students (10%) to ensure that the questions were clear, understandable, and culturally relevant. The translated questionnaire in Ar- abic showed a satisfactory Cronbach’s alpha of 0.84. The questionnaire consisted of de- mographic data (the student’s gender, stage, and university) and 32 stress-provoking items. Each item had ;ive potential re- sponses: not stressful, slightly stressful, moderately stressful, severely stressful, and very severely stressful. These items were grouped into 6 major domains: academic challenge, workload, performance pressure, Self–ef;icacy beliefs, clinical training and pa- tient treatment. However, the distributed questionnaire among the participants did not include the grouped domains. The re- searchers received approval to conduct the study from the Kut University College Re- search Ethics Committee (KREC). Also, each participant provided a written informed consent. The questionnaires were distrib- uted anonymously, and participants were as- sured that all information would be kept strictly con;idential and used solely for re- search purposes. The data were analysed us- ing the Statistical Package for the Social Sci- ences statistical software (SPSS version 25.0). Descriptive statistics (Proportion, mean and standard deviation) were used to describe the study and outcome variables. Independent sample t-test for difference of means between two groups for the catego- rial variables. All tests were conducted with a con;idence level of 95% and a signi;icant level of 0.05. Results The research examined the stress levels among 392 dental students, with most par- ticipants being female (70.20%) compared to male (29.80%), as shown in Table 1. Re- garding academic stage, more students were from the 5th grade (56.4%) compared to the 4th grade (43.6%). Age of participants ranged from 21 to 24 years old, the mean age was 22.30 years, with a standard deviation of 0.763 years. Most of participants (57.4%) pursued education in private institution. As demonstrated in Table 2, the "Self-ef;i- cacy Belief" domain emerges as the most sig- ni;icant stressor among the domains, record- ing a mean of 3.25±0.893. Following closely is the domain of " Academic Challenge" with a mean score of 2.50±0.615. Conversely, the domain of "Patient Management" registered the lowest stress levels with a mean score of 1.59±0.509, indicating relatively lesser con- cerns among participants in this aspect of their education. In Table 3, signi;icant stress level differences were observed across domains based on gender, grade, and type of education. Specif- ically, males exhibited lower stress in the "Academic Challenge" domain (mean: 2.39, p = 0.015) compared to females (mean: 2.55). While no signi;icant gender differences were found in "Time Management" (p = 0.393), males reported lower stress in "Self-ef;icacy Belief" (mean: 3.29, p = 0.58) than females (mean: 3.24). Signi;icant grade disparities were noted in "Time Management" (p = 0.003), with 4th-grade participants report- ing lower stress (mean: 2.03) compared to 5th-grade participants (mean: 2.21). No sig- ni;icant grade differences were found in "Self-ef;icacy Belief" or "Academic Perfor- mance." Regarding the comparison between stressors among the type of education, it is obvious that the "Performance Pressure " is higher in the pubic than the private colleges (mean: 2.50 vs. 2.34, p=0.003). Stressor responses varied between genders. Notably, males reported lower stress in "Lack of con;idence in being a successful dental student" (mean: 3.64, p = 0.626) com- pared to females (mean: 3.71), as found in Table 4, while no signi;icant gender differ- ences were found in "Thinking about the possibility of not succeeding in the profes- sion in the future" (p = 0.212) or "Lack of co- operation among colleagues" (p = 0.436), males exhibited lower stress levels in "Fac- ing criticism in how you do your work" (mean: 2.21, p = 0.006) compared to females (mean: 2.56). No signi;icant differences were noted in other stressors between genders. Stressor responses also differed between grades. Notably, signi;icant grade disparities A Cross-Sec+onal Study of Environment Stress Among Undergraduate Dental Students Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu 3 were observed in "Lack of cooperation among colleagues" (p = 0.000), with 4th- grade participants reporting lower stress (mean: 3.16) compared to 5th-grade partici- pants (mean: 2.55), as shown in Table 5. Sim- ilarly, signi;icant grade differences were noted in "Some teachers treated students in- appropriately" (p = 0.002), with 4th-grade participants exhibiting lower stress levels (mean: 2.56) compared to 5th-grade partici- pants (mean: 2.90). No signi;icant grade dif- ferences were found in other stressors. Table 6 demonstrates varying stress levels between types of education. Participants from private universities reported higher stress in domains such as "Lack of con;i- dence in being a successful dental student" (mean: 3.84 vs. 3.48, p = 0.003), "Thinking about the possibility of not succeeding in the profession in the future" (mean: 3.48 vs. 3.20, p = 0.019), and "Language barrier and dif;iculty learning medical terminology" (mean: 2.92 vs. 3.24, p = 0.011) compared to those from public universities. Conversely, public university students experienced higher stress levels in "Fear of failure in the semester or academic year" (mean: 2.87 vs. 2.60, p = 0.022). However, no signi;icant dif- ferences were observed in domains such as "Facing criticism in how you do your work," "Some teachers treated students inappropri- ately," and "Responsibility for obtaining suit- able patients." Discussion Previous studies have found that dental edu- cation induces stress among students, re- gardless of the country or educational sys- tem. This highlights the challenging nature of dental education, which requires students to acquire extensive knowledge and profes- sional hand skills while maintaining a posi- tive attitude towards patient care within a limited timeframe. The primary goal of this study was to determine the perceived factors causing stress among dental students in their clinical study years, Wasit governorate, Iraq. Out of the total 392 dental students, 70% were females. Low participation rate of males was also observed in several studies [8,9,15]. Female students scored higher level of stress than males in the overall mean score with signi;icance observed in both "ac- ademic challenge" and "clinical training" domains. This is consistent with most of the studies regardless of the main stressor and coinciding with the fact that stress level is higher in females in the general population due to the hormonal, physiological, and stressor variations between the genders. [2,8,16]. In contrast, ;indings reported by Tangade et al. indicated that males had stress more than females and attributed that to the socioeconomic burden on men in In- dian society [7]. The mean scores of 4th and 5th-year students did not show a signi;icant difference. However, 5th-year students re- ported higher stress levels in "time manage- ment" and "clinical training" compared to 4th-year students. This could be due to the increased number and complexity of case re- quirements for 5th-year students. A study conducted in Jordan yielded similar results. [9]. When considering the top ten stressors, "Being treated inappropriately by teachers" was a signi;icant source of stress for 5th-year students. These ;indings agree with an In- dian study by Tangade et al. but contradict the ;indings of Al-Sowygh et al. study con- ducted in Saudi Arabia, where the mentioned stressor was more signi;icant among 4th- year students [2,7]. Regarding the type of ed- ucation, the average scores were almost the same for students in private and public uni- versities, which was concordant with a study from Pakistan in 2024 [17]. This proximity may be due to the comparable social and ;i- nancial support, as well as similar challenges experienced by both groups. However, it was observed that in terms of domains, "perfor- mance pressure" and particularly "Lack of cooperation among colleagues. ", "Language barriers" and "Fear of being unable to catch up with colleagues" were signi;icantly higher among public university students. Further- more, "Lack of technical laboratories", one of the perceived top 10 stressors, was surpris- ingly signi;icantly more prominent among private university students. This could be be- cause the private university has a larger stu- dent population than the public university. "Fear of failure in the course’’ ranked among the top 10 stressors and was found to be sig- ni;icantly higher among public university students. A study conducted in Russia showed that it was among the top stressors but had no signi;icant difference regarding to the type of education [15]. The "Self-ef;icacy Belief" domain has emerged as the most impactful stressor among all the domains, which was inconsistent with most of the per- ceived local and outside studies where "workload " domain was the most signi;icant stressor [2,8,11,15]. This may be attributed to the social and academic stigma associated with private universities in Iraq, as the ma- jority of the present study participants were from a private university. In fact, the top two stressors "Lack of con;idence in being a suc- cessful dental student" and "Thinking about the possibility of not succeeding in the pro- fession in the future" that fall under the um- brella of "Self-ef;icacy Belief" domain were signi;icantly higher among private compared to public university students. Continuing in the list of the top stressors in the current study, females experienced higher levels of stress from being criticized by teachers and treated inappropriately compared to males, and ;ifth-year students reported feeling even more stressed by this criticism. However, a study by AL-Sowygh et al. found that males and fourth-year students experienced this fear more [2]. The difference could be due to variations in staff, rules, and other factors among the universities. Patient-related fac- tors and dif;iculty ;inding a suitable patient were listed the last of the top stressors among both 4th and slightly less in 5th-year students, regardless of gender, coinciding with the ;indings of a Jordanian study in 2024 [9]. Despite being insigni;icant, private university students were more stressed about this issue. This discrepancy might be due to being away from the city centre. Therefore, Kut University could improve ef- forts to organize the process of obtaining pa- tients and consider offering incentives to promote patients’ engagement. Finally, each university may have unique stressors depending on various factors re- lated to students, the university and society environment. Identifying these factors might help alleviate students' anxiety and, hence, improve their performance. Conclusion The study highlights that dental education induces signi;icant stress among students, particularly female students, due to aca- demic challenges and clinical training. Fifth- year students experience higher stress re- lated to time management and clinical re- quirements compared to fourth-year stu- dents. Stress levels are similar between A Cross-Sec+onal Study of Environment Stress Among Undergraduate Dental Students Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu 4 students from private and public universi- ties, though speci;ic stressors like perfor- mance pressure and lack of technical labora- tories vary. The "Self-ef;icacy Belief" domain emerged as the most impactful stressor. Ef- forts to improve patient organization and en- gagement are recommended to alleviate stress among students. Acknowledgement The authors would like to express their sin- cerest gratitude to all dental students, as this study would not have been possible without their cooperation and participation. Moreo- ver, the authors thank Dr. Hawra’s excep- tional support in writing and reviewing this manuscript. 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[11] Saleem T, Yasmin R, Aziz A, Mahboob U, Sethi A. Perception of academic stressors among dental undergraduate students. JPDA. 2021;30(4): Oct-Dec. [12] Polychronopoulou A, Divaris K. Perceived sources of stress among Greek dental stu- dents. J Dent Edu. 2005;69(6):687–692. [13] Polychronopoulou A, Divaris K. Dental stu- dents' perceived sources of stress: a multi- country study. J Dent Educ. 2009 May;73(5):631-9. PMID: 19433538. [14] Suha B. Abu-Ghazaleh, Hawazen N. Sonbol, Lamis D. Rajab. A longitudinal study of psy- chological stress among undergraduate dental students at the University of Jordan. BMC Medical Education. 2016. [15] Myrvold B. Stress among dental students: A survey from Arkhangelsk, Russia [Master’s thesis]. Tromsø, Norway: UiT The Arctic Uni- versity of Norway; 2017. Available from: https://munin.uit.no/bitstream/han- dle/10037/12910/thesis.pdf?sequence=1 [16] Al Okaili AG, Khalaf AH, Hassan TS. A cross- sectional study of stress and anxiety among dental students at Ajman University. Tikrit J Dent Sci. 2017;5(2):87-97. [17] Ayub A, Ali S, Issrani R, Sethi A, Khattak O, Iq- bal A. Burnout among Dental Students of Pri- vate and Public Dental Colleges in Pakistan - A Cross-Sectional Study. Pesqui Bras Odon- topediatria Clıń Integr. 2024; 24:220176. doi:10.1590/pboci.2024.016. Table 1. Characteristics of all participants. Frequency Percent Gender Male 117 29.80% Female 275 70.20% Grade 4th 171 43.60% 5th 221 56.40% Type of education Public 167 42.6% Private 225 57.4% Age Mean ± SD. (Years) 22.30 ± 0.763 Table 2. Dental environment stress domains scores (n=392). Domains Mean ± SD Academic Challenge 2.50 ± 0.615 Time Management 2.12 ± 0.608 Self-ef;icacy Belief 3.25 ± 0.893 Clinical Training 2.09 ± 0.627 Patient Management 1.59 ± 0.509 Performance Pressure 2.41± 0.530 A Cross-Sec+onal Study of Environment Stress Among Undergraduate Dental Students Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu 5 Table 3. Comparison between responses by domain according to gender, grade, and education. Domain Male (Mean ± SD) Female (Mean ± SD) Gender (p-value) 4th Grade (Mean ± SD) 5th Grade (Mean ± SD) Grade (p- value) Public (Mean ± SD) Private (Mean ± SD) Educa- tion (p- value) Academic Challenge 2.39 ± 0.63 2.55 ± 0.60 0.015 2.46 ± 0.60 2.54 ± 0.62 0.18 2.51 ± 0.63 2.49 ± 0.64 0.794 Time Man- agement 2.17 ± 0.62 2.11 ± 0.60 0.393 2.03 ± 0.59 2.21 ± 0.60 0.003 2.14 ± 0.64 2.11 ± 0.56 0.556 Self-Ef;i- cacy Belief 3.29 ± 0.84 3.24 ± 0.92 0.58 3.27 ± 0.94 3.24 ± 0.86 0.758 3.18 ± 0.97 3.30 ± 0.82 0.185 Clinical Training 1.96 ± 0.56 2.15 ± 0.65 0.008 1.99 ± 0.62 2.17 ± 0.62 0.007 2.02 ± 0.63 2.14 ± 0.61 0.075 Patient Manage- ment 1.59 ± 0.51 1.59 ± 0.51 0.926 1.62 ± 0.46 1.57 ± 0.54 0.344 1.62 ± 0.50 1.56 ± 0.51 0.307 Perfor- mance Pressure 2.38 ± 0.51 2.44 ± 0.54 0.312 2.47 ± 0.53 2.38 ± 0.53 0.088 2.50 ± 0.53 2.34 ± 0.51 0.003 Table 4. Comparison between responses by top ten stressors according to gender. Top Ten Stressors Mean ± SD (Male) Mean ± SD (Female) p-value Lack of con;idence in being a successful dental stu- dent 3.64 ± 1.200 3.71 ± 1.198 0.626 Thinking about the possibility of failing in the pro- fession in the future 3.48 ± 1.103 3.32 ± 1.204 0.212 Lack of cooperation among colleagues 2.74 ± 1.212 2.85 ± 1.263 0.436 Language barrier and dif;iculty learning medical ter- minology 2.97 ± 1.249 3.09 ± 1.192 0.369 Fear of not being able to catch up with colleagues if you fall behind them 2.75 ± 1.299 2.91 ± 1.237 0.269 Facing criticism in how you do your work 2.21 ± 1.097 2.56 ± 1.146 0.006 Fear of failure in the semester or academic year 2.76 ± 1.215 2.69 ± 1.187 0.617 Some teachers treated students inappropriately 2.64 ± 1.178 2.80 ± 1.052 0.178 Lack of quali;ied technical laboratories 2.26 ± 1.054 2.62 ± 1.125 0.004 Responsibility for obtaining suitable patients 1.71 ± .881 1.72 ± .939 0.915 A Cross-Sec+onal Study of Environment Stress Among Undergraduate Dental Students Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.918 http://dentistry3000.pitt.edu 6 Table 5. Comparison between responses by top ten stressors according to grade. Top Ten Stressors Mean ± SD (4th Grade) Mean ± SD (5th Grade) P-value Lack of con;idence in being a successful dental student 3.71 ± 1.192 3.67 ± 1.204 0.756 Thinking about the possibility of failing in the profession in the future 3.44 ± 1.218 3.31 ± 1.142 0.275 Lack of cooperation among colleagues 3.16 ± 1.287 2.55 ± 1.149 0.000 Language barrier and dif;iculty learning medical terminology 3.08 ± 1.248 3.04 ± 1.181 0.739 Fear of not being able to catch up with col- leagues if you fall behind them 2.96 ± 1.285 2.78 ± 1.231 0.169 Facing criticism in how you do your work 2.43 ± 1.203 2.47 ± 1.093 0.745 Fear of failure in the semester or academic year 2.67 ± 1.178 2.75 ± 1.209 0.488 Some teachers treated students inappropriately 2.56 ± 1.117 2.90 ± 1.051 0.002 Lack of quali;ied technical laboratories 2.54 ± 1.189 2.50 ± 1.056 0.723 Responsibility for obtaining suitable patients 1.75 ± .957 1.69 ± .893 0.478 Table 6. Comparison between responses by top ten stressors according to education. Top Ten Stressors Mean ± SD (Public Univer- sity) Mean ± SD (Private University) p-value Lack of con;idence in being a successful dental student 3.48 ± 1.246 3.84 ± 1.138 0.003 Thinking about the possibility of failing in the profession in the future 3.20 ± 1.205 3.48 ± 1.142 0.019 Lack of cooperation among colleagues 2.99 ± 1.289 2.69 ± 1.202 0.021 Language barrier and dif;iculty learning medical terminology 3.24 ± 1.142 2.92 ± 1.242 0.011 Fear of not being able to catch up with colleagues if you fall behind them 3.01 ± 1.331 2.75 ± 1.189 0.039 Facing criticism in how you do your work 2.43 ± 1.159 2.47 ± 1.130 0.732 Fear of failure in the semester or academic year 2.87 ± 1.257 2.60 ± 1.134 0.022 Some teachers treated students inappropriately 2.69 ± 1.081 2.80 ± 1.101 0.300 Lack of quali;ied technical laboratories 2.28 ± 1.124 2.69 ± 1.078 0.000 Responsibility for obtaining suitable patients 1.69 ± .883 1.73 ± .950 0.681