Psychological Distress among Bangladeshi Dental Students during the COVID-19 Pandemic

Background: Psychological sufferings are observed among dental students during their academic years, which had been intensified during the COVID-19 pandemic. Objectives: This study assessed the levels and identified factors associated with psychological distress, fear and coping experienced by dental undergraduate students in Bangladesh. Methods: A cross sectional online survey was conducted during October-November, 2021. The Kessler Psychological Distress Scale (K-10), Fear of COVID-19 Scale (FCV-19S) and Brief Resilient Coping Scale (BRCS) were used in order to assess psychological distress, fear and coping strategies, respectively. Results: A total of 327 students participated; the majority (72%) were 19–23 years old and females (75%). One in five participants were infected with COVID-19 and 15% reported contact with COVID-19 cases. Negative financial impact (AOR 3.72, 95% CIs 1.28–10.8), recent or past COVID-19 infection, and contact with COVID-19 cases were associated with higher levels of psychological distress; but being a third year student (0.14, 0.04–0.55) and being satisfied about current social life (0.11, 0.03–0.33) were associated with lower levels of psychological distress. Being a third year (0.17, 0.08–0.39) and a fourth year student (0.29, 0.12–0.71) were associated with lower levels of fear. Health care service use and feeling positive about life were associated with medium to high resilience coping. Conclusions: This study identified dental students in Bangladesh who were at higher risk of psychological distress, fear and coping during the ongoing pandemic. Development of a mental health support system within dental institutions should be considered in addition to the academic and clinical teaching.


Introduction
The ongoing coronavirus disease (COVID- 19) pandemic has been linked to more than 140 million cases worldwide, with approximately 3 million deaths [1]. The pandemic has caused the most cases and deaths in the United States of America, followed by India, Brazil, France, the Russian Federation, the United Kingdom, Turkey, Italy, and Spain. The first three cases of COVID-19 were identified in Bangladesh on 8 March 2020. As of 29 November 2021, Bangladesh has reported 1,575,579 confirmed COVID-19 cases and 27,975 deaths [2]. In response to the pandemic crisis, the Government of the People's Republic of Bangladesh has designed a Multisectoral Action Plan. Lockdown in major cities, social distancing, closure of schools and universities, working from home arrangements where possible, widespread public awareness campaigns for handwashing practices, use of masks in public places, imposed regulations on international travel from hotspots, management of quarantine centers and nationwide testing facilities were a few of the initiatives taken by the Government to mitigate the impact of the pandemic. In addition, guidelines for COVID-19 clinical management were developed, public and private hospitals were designated for treating positive cases, isolation units were established in various hospitals, and regular public reporting was initiated based on the surveillance of COVID-19 cases and deaths [3,4].
The pandemic has impacted global communities in different ways. Besides the impact on physical health, it also triggered a slew of psychological issues, including panic disorder, anxiety, and sadness, in both COVID-19 patients and healthy people [5]. Due to the contagious nature of COVID-19, concerns such as spatial segregation, lockdown, travel limitations, and isolation, as well as social and economic ramifications, resulting in despair, anxiety, fear, panic, stress, suicidal thoughts, post-traumatic stress disorder and other mental health issues [6]. A recent study examining factors associated with psychological distress, fear of COVID-19, and coping across diverse community members in 17 countries showed that doctors had greater levels of psychological distress but lower levels of fear of COVID-19, whereas nurses had higher levels of resilient coping. Females and individuals with pre-existing mental health issues were identified as the most vulnerable groups of people having COVID-related psychological impact [7]. Bangladeshi individuals also experienced a great deal of psychological discomfort and terror, according to a recent study [8]. People with pre-existing mental health problems, females, frontline workers or essential service workers, current and one-time smokers, providing care to a known or suspected case of COVID-19, having an overseas travel history, being in quarantine, having positive test results for COVID-19, and having higher levels of fear of COVID-19 were associated with higher psychological distress [8]. The study also demonstrated that having an income source was associated with medium-to-high resilient coping [8]. The relationship between stress and coping had been explained by Lazarus and Folkman; stress could be explained by primary and secondary appraisals of the situation, whereas coping could be emotion-focused or problem-focused. Depending on the way people respond to a stressful situation, they could demonstrate adaptive or maladaptive coping behaviours [9].
The pandemic has posed a challenge to healthcare workers including dental clinicians around the world, prompting a variety of responses. Medical and Dental schooling are widely seen as demanding environments, with students experiencing higher levels of stress, anxiety, and depression than classmates studying other subjects [10]. Obtaining a Bachelor's degree in Dentistry is a time-consuming process that demands extensive study and expertise of the discipline. In Bangladesh, the program is of five years duration, with the last two years dedicated to clinical training and a yearlong internship following graduation. An undergraduate Dentistry student needs to demonstrate theoretical knowledge, practical experience, and interpersonal skills, all of which are assessed at the end of each academic year via oral, written, and practical assessments. These ongoing academic responsibilities, as well as non-academic stress such as coordinating with faculty and administrative formalities, are often overwhelming for students [11,12]. Most dental treatments, particularly those involving the use of a dental hand piece, produce aerosols. During the pandemic, that practice potentially increased the risk of spreading infection at the dentist practice. It has been demonstrated that the virus in the aerosol may survive for more than 3 h, with surface stability over 72 h [13]. Development of that scientific evidence generated anxiety and stress amongst the students doing their clinical placement. Many countries have postponed elective dental procedures, and a few countries have even closed dental schools, clinics and teaching hospitals [14,15]. For months, dental clinics, dental schools, dental teaching hospitals and universities were closed in many countries such as USA, Canada, Japan, China, India etc. [16][17][18]. In addition, all academic dental institutions and dental clinics in Bangladesh were temporarily closed during the pandemic. Only emergency dental treatments were provided.
Following the necessity for social distancing due to the COVID-19 pandemic, physical presence at schools, colleges, and universities around the world was restricted and transitioned to a virtual learning environment. There were similar arrangements for Dental schools all over the world including Bangladesh. Such a new way of learning allowed the academics and students to gain more personalized educational experience. In addition, for preclinical simulation exercises, certain teaching institutes adopted the social distancing methods in their dental laboratories following the strict COVID-19 guidelines (for example: students were divided into small subgroups in their clinical class, wearing masks and face shields, using hand sanitizers) [19][20][21]. However, evidence showed that Dental and Medical students suffered from psychological anguish due to the change in learning environment during their academic and professional years [22]. Prior evidence showed that dental students reported a number of mental health issues including depression, anxiety, obsessive-compulsive disorders and interpersonal sensitivity in their academic years during the pre-pandemic environment [23][24][25][26]. However, very limited evidence was generated from South Asian settings. Due to variation of available resources, diversity in dental education curriculum and requirements for accreditations, variable nature of COVID-19 impact on countries, relevant restrictions and compliance to public health messages amongst population, it was necessary to assess the impact on dental students in South Asian settings during the current COVID-19 pandemic.
Studies focusing on the impact of COVID-19 on Bangladeshi students, specifically, who were pursuing studies on health sciences including dentistry were very limited. However, it was important to assess their psychological impact not only due to the pandemic, but also due to the changed learning environment and clinical training. Therefore, we aimed to assess psychological distress, fear of COVID-19 and coping amongst Bangladeshi dental students and identify factors associated with those issues. Specifically, we intended to examine the extent of psychological distress, fear of COVID-19 and coping amongst them, and intended to identify the high-risk groups of individuals based on the identified factors utilizing validated study tools, so that future interventions can be targeted for such a cohort of dental students in Bangladesh.

Study Design
A cross-sectional study was conducted from October to November 2021 where students of two different private Dental colleges participated via online platform.

Study Sites
Two large private Dental Colleges in the capital city of Bangladesh were selected as the study sites. Both sites had both teaching and clinical training facilities besides outdoor services. The first site had 444 students with 130 patients used to attending the hospital daily; the second site had 318 students with daily visit of 60 patients.

Study Population
Current students of those two study sites from first to fourth academic years were eligible for this study. Because of the inaccuracy of the responses, any study participant who took less than 1 min to complete the questionnaire was omitted from the analyses.

Sampling
The Snowball sampling technique was used for collecting data. Once a participant filled up the online questionnaire, he/she was requested to forward the survey link to his/her personal/professional networks. Sample size was calculated using Open Epi. Considering total students of 759 from two study sites, expected frequency of psychological distress as 70% based on the previous study in Bangladesh [8], 95% confidence intervals and 80% power, the estimated minimum sample size was 227.

Data Collection
The online link of the survey was emailed to all the students at both sites inviting them to participate. The volunteer nature of the study was highlighted. Data were collected during October to November, 2021. On the first screen, the plain language information statement (PLIS) and consent form were displayed. Only those who provided consent could proceed to the following screens. The following screens displayed the entire study questionnaire.

Data Analyses
Data were analyzed using IBM SPSS v. 25 (Armonk, NY: IBM Corp.). At first, descriptive analyses were conducted. Categorical variables were reported as proportions and continuous variables were reported as mean (±SD). In that way, levels of psychological distress, fear of COVID-19 and coping were reported. Then, inferential analyses were conducted to identify the factors associated with those outcomes. At first, chi-squared tests were conducted to determine existence of association and p < 0.05 was considered significant. Then, univariate logistic regression was conducted to determine the strength of association; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Finally, multivariate logistic regression was conducted to control potential confounders; adjusted ORs (AORs) and 95% CIs were reported. In addition, to examine the relationship amongst the study tools, Pearson correlation tests and multiple linear regression were used with p < 0.05.

Ethics
The study protocol was reviewed and approved by the Human Research Ethics Committee at one of the study sites (ref no: SDC/C7/2021/829). The survey was completely voluntary in nature and it was clarified in the PLIS, so that participants got the opportunity to have an informed choice to participate in the study. No identifying information includ-ing any personal sensitive information were collected. Responses were anonymous and non-identifiable data were handled only by the study investigators.

Results
A total of 327 Bangladeshi dental undergraduate students participated in the study. The majority (71.6%) of the students belonged to the age group of 19-23 years and were females (74.9%). The mean age (± SD) was 22.5(±1.7) years with the majority (62.4%) from clinical years (third and fourth year). Almost all of the participants (95.1%) reported financial dependence on their families and more than half (58.1%) reported that the pandemic negatively impacted on their financial situation; yet most of them (81.9%) were satisfied with their current social life.

Psychological Distress
Univariate analyses showed that perceived safety in living places, being third year clinical dental students, negative impact of COVID-19 over financial situation, perceived satisfaction with current social life, irritating experience related to use of social media and feeling positive about life were significantly associated with moderate to very high levels of psychological distress compared to their counterparts. After adjustment of potential confounders, those who were at the third year of their academic year (AOR 0.14, 95% CIs 0.04-0.55, p = 0.005) and who reported satisfaction with current social life (AOR 0.11, 95% CIs 0.03-0.33, p < 0.001) were less likely to report moderate to very high levels of psychological distress. On the other hand, those who reported negative impact of COVID-19 over financial situation (AOR 3.72, 95% CIs 1.28-10.8, p = 0.015), who were infected with COVID-19 both recently and in the past, who were unsure of the contact with COVID-19 cases were more likely to report moderate to very high levels of psychological distress. (Table 5).

Levels of Fear
Univariate analyses showed that being female and those who were living in joint families were more likely to report high levels of fear of COVID-19. On the contrary, being a student of second, third and fourth year, being a smoker and those who were medium to high resilient copers were more likely to report low levels of fear of COVID-19. After adjustment of the potential confounders, it was found that those who were at the third year (AOR 0.17, 95% CIs 0.08-0.39, p < 0.001) and fourth year (AOR 0.29, 95% CIs 0.12-0.71, p = 0.006) clinical students had low levels of fear of COVID-19 (Table 6).

Coping Strategies
Univariate analyses demonstrated that those who were living in a hostel and those who had high level of COVID-19-related fear were more likely to be low resilient copers. On the other hand, those who were quite often positive about life and those who used health care services to overcome COVID-19-related stress were more likely to be medium to high resilient copers. However, after adjustment of the potential confounders, it was revealed that those who were females (AOR 0.47, 95% CIs 0.24-0.93, p = 0.030), living in hostel (AOR 0.51, 95% CIs 0.29-0.89, p= 0.018) and who were quite often positive about life (AOR 3.67, 95% CIs 1.17-11.5, p = 0.026) were more likely to be low resilient copers; those who were quite often positive about life (AOR 3.67, 95% CIs 1.17-11.5, p = 0.026) and those who used health care service to overcome COVID-19-related stress (AOR 2.19, 95% CIs 1.15-4.17, p = 0.017) were more likely to be medium to high resilient copers (Table 7).

Correlation within the Study Tools
When the total scoring of the K-10 tool was compared with the total scoring of the FCV-19S and BRCS tools, it was found that the psychological distress significantly predicted the fear of COVID-19 (r = 0.159, p < 0.01), but not the coping (r = −0.100, p > 0.05). Similarly, multiple linear regression also showed that the scoring of K-10 significantly predicted the scoring of FCV-19S (r = 0.258, p < 0.01), but not the scoring of BRCS (r = −0.305, p > 0.05) [F(2, 324) = 5.544, p < 0.01, R 2 = 0.033].

Discussion
This is one of the very few studies conducted in Bangladesh amongst dental students about their mental health impacts during the current COVID-19 pandemic. Levels of psychological distress, fear and attempt to overcome the impact of ongoing pandemic was assessed; factors associated with those issues were also identified. Medical and dental education are considered highly stressful globally, because students experience higher levels of anxiety, stress and depression in comparison to students studying other subjects [32][33][34]. After the emergence of the COVID-19 pandemic, dental education was affected significantly owing to the need for reducing in-person contacts and enforcing social distancing in communities. Although several studies were conducted regarding psychological impact and fear of COVID-19 among the general population and medical students, this cross-sectional study was the first ever carried out in Bangladesh among dental students to assess the severity and to identify factors associated with psychological distress, levels of fear and coping strategies during the COVID-19 pandemic.
In this study, most of the dental students had moderate to high level of psychological distress (84.1%). That level was significantly higher than the medical students (65.9%) [35], general students (18.1%) [36] and general population (30.1%) [37] in Bangladesh during the COVID-19 pandemic. This might be due to increased risk of exposure of COVID-19 among dental students. Moreover, prior evidence indicated that dental education generated more stress and burnout than medical educations [38], due to more interactive involvement with patients during theoretical and clinical courses [39]. In this study, third year clinical students were more prone to having psychological distress due to COVID-19. A similar finding was reported in other studies, where clinical years had moderate to high levels of stress [40]. Another study by AL-Sowygh et al. showed that third year students had more stress due to performance pressure during clinical examination [22,41]. In this study, those who were infected with COVID-19 and who were unsure about the direct or indirect contact of COVID-19 cases were more prone to developing psychological distress. A similar finding was reported in the study conducted among the Australian population [27]. Those respondents in this study who reported a negative impact on their financial situations tended to have moderate to very high levels of psychological distress. As most of the dental students who took part in this study were fully dependent on their families, the negative financial impact could have hampered their academic progress.
Low levels of fear were reported amongst dental students in this study. That finding was in contrast to the finding from another study conducted in Bangladesh, which reported higher levels of fear amongst frontline or essential service workers [8]. Nevertheless, study findings from this study were consistent with the findings of another study where COVID-19-related fear was low among frontline health care workers. Similarly, low levels of fear among the doctors was observed in another study [42]. This might be due to increased engagement with the patients with a higher risk of exposure to COVID-19 and the availability of the protective gear during the time of data collection in Bangladesh. In this study, female dental students had higher levels of fear. Similar trends were observed among female dental and medical students and general population conducted elsewhere in Bangladesh [35,[42][43][44][45]. This might be due to their inherent caregivers' roles both in profession and families, hormonal changes, and expression of emotions, which could have contributed to the increased intensity of fear of COVID-19. In this study, third and fourth year clinical dental students had low levels of fear which was similar to a global study where doctors demonstrated lower levels of fear [7]. Medium to high resilient copers were more likely to have low level of fears in this study, which could be explained by the inherent capacity of high resilient copers to manage their fear, emotion, and stress more positively than the low resilient copers. Study participants who used healthcare services to combat COVID-19-related stress were more likely to be medium to high resilient copers. Similar findings were also reported in an earlier study, where visiting healthcare providers in persons was associated with high level of coping during the COVID-19 pandemic [7].
On the other hand, female students and students living in hostels tended to be low resilient copers. Students who had been living in hostels could have been dealing with a variety of concerns such as financial difficulties, home sickness, concerns on the safety of parents and relatives, change in sleeping and eating habits, and issues adjusting to their new surroundings, all of which probably made them more susceptible to psychological distress, hence low coping. Overall, this study identified that study participants were more low resilient copers, which could be due to high female respondents in this study. Although literature suggests that masculinity can explain part of the gender differences for stress and coping [46], in order to properly analyze these concerns, further research and study need to be conducted. In addition, further research could examine the link between coping and resources available for stress management in Bangladesh.
This study had few limitations. It was conducted among the students of two private dental colleges situated in Dhaka, Bangladesh, hence findings could not be generalized for all the dental students of Bangladesh. This was an online-based study, therefore the students who were only active online and had better internet connection were more likely to respond to this study. The inherent limitations of a cross-sectional study design could also not be ignored, which limited the ability for causal inference regarding the identified factors associated with psychological distress, fear and coping in this study. In addition, distressed students were more likely to respond in this study, which might have resulted in selection bias. On the other hand, dental students had different sorts of assessments and examination all the year round, so it could happen that the students who felt overwhelmed with their studies or clinical loads did not have time to respond to the survey. However, considering the ongoing pandemic crisis, it was inevitable to collect data online because of restriction of movement and social distancing. Nevertheless, this study was the first of its kind in Bangladesh to reveal the psychological distress, fear, and coping strategies of dental undergraduate students in Bangladesh.
Based on the findings from this study, few initiatives could be considered to support psychological wellbeing of dental students in Bangladesh. Counselling services should be incorporated into the dental institutes, where both staff and students would get access to resources and professionals during the crisis periods including such pandemic situations. Those services could be supported by the local institutes or Government. Trainings on pandemic and disaster preparedness should be incorporated as part of dental curriculum. Training on the use of personal protective equipment should be made mandatory for the third year dental students, where they commence their clinical placements, which would reduce distress and fear during such pandemic situations. Hybrid training models including both face-to-face and online components could be introduced incorporating theoretical, practical and clinical components, so that disruptions on learning could be minimized during any crisis period if the delivery options switched to online only. Finally, a financial support scheme should be considered for the students affected financially during the pandemic period. Easy student loan schemes could be considered from the institutes or Government.

Conclusions
This study identified that most of the dental students experienced moderate to very high levels of psychological distress while half of them had low levels of fear of COVID-19 with most of them being low resilient copers. The factors identified in this study should be considered in addressing mental health impacts of dental students in Bangladesh. Developing policies and support strategies for addressing health and wellbeing of dental students is imperative besides the core support for academic and clinical skills development. Future studies could focus on stakeholders and students of both public and private dental institutions in Bangladesh about the specific support strategies for psychological wellbeing during and post-pandemic. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Any information which could identify any individual were not collected.
Data Availability Statement: The data are available upon reasonable request from the corresponding author.