key: cord-0686500-tb5jyof7 authors: Poma, Malosi; Al Amri, Firas; Tawse‐Smith, Andrew; Ma, Sunyoung title: How are you coping with the COVID‐19 pandemic? Survey of undergraduate dental students’ well‐being during an unexpected global event date: 2021-09-23 journal: Eur J Dent Educ DOI: 10.1111/eje.12721 sha: c14c2433ab21b7b061f051d94709b3bbeb5d745d doc_id: 686500 cord_uid: tb5jyof7 BACKGROUND: COVID‐19 pandemic has led to major life changes including suspension of dental education programmes worldwide. The impact of this unexpected disruption in clinical teaching needs to be assessed. AIM: The aim of this study was to evaluate the impact of the COVID‐19 restriction measures on the undergraduate dental students’ perception regarding their physical, mental and social well‐being as well as financial stress and anxiety for their future careers. MATERIALS AND METHODS: An electronic questionnaire (Qualtrics, Provo, Utah, USA) with main themes (general well‐being, academic stressors, financial implications and dental career concerns) related to the COVID‐19 lockdown was sent to the undergraduate dental students at the University Of Otago, New Zealand. Participants were asked to rank their answers according to a 5‐level Likert scale (strongly disagreed‐strongly agreed). Other questions included demographic, fee‐paying status and living situation. RESULTS: There were 301 out of 376 students who responded to the survey. Generally, the students perceived that the COVID‐19 restrictions affected their behavioural and social well‐being (3.20 ± 0.75) and less impact on their physical (2.75 ± 0.82) and psychological (2.79 ± 0.62) well‐being. Students were significantly worried about their academic work and future careers (3.41 ± 1.20), but less concerned with their financial situation (2.74 ± 1.14). CONCLUSIONS: The study provides valuable information on the impact of COVID‐19 pandemic on undergraduate dental students, and areas that the University should consider when providing support to the affected students. It is important that the University is proactive and prepared to deal with future pandemics effectively and efficiently. they were no longer able to provide care for their patients and gain confidence and competency in their clinical skills. As the country entered the alert level 4, the responsibility fell on academic staff to actively repurpose and redeploy resources, upskill their digital competencies and develop new material to transition traditional face-to-face and blended programmes to a remote learning and/or online education delivery mode. 11 As the method of didactic teaching delivery shifted completely to online, it was not yet known how effective this was going to be compared to the face-toface classroom lectures. Pandemic crises inadvertently ignite social disruption and mental disturbance such as increased fear and anxiety among the public. Therefore, it may be hypothesised that some dental students who were already stressed due to the demands of the training course may feel even more emotionally unsettled by the disruptions caused by COVID-19 restrictions, affecting them psychologically, physically and emotionally. The fear of being infected and the unknown could also lead to negative public behaviour. Consequently, pandemics such as COVID-19 could result in a broad range of public health concerns including distress reactions such as anger, insomnia and fear of illness. It may also have impact on the health risk behaviours such as increased use of alcohol, tobacco and social isolation as well as mental disorders such as depression and lowered perceived health. [12] [13] [14] The aim of this study was to evaluate the impact of the COVID-19 restriction measures on the undergraduate dental students' perception of their physical, mental and social well-being, as well as their financial stress. This study also investigated the students' perceived level of anxiety in relation to their future dental careers. An electronic questionnaire was structured using an online platform (Qualtrics, Provo, Utah, USA) with four main themes related to the ongoing COVID-19 situation as well as the four-week COVID-19 lockdown period. The questionnaire was modelled according to the Depression, Anxiety and Stress Scale (DASS-42) 15 and the Perceived Wellness Survey (PWS). 16 Participants were asked to rank their answers according to a 5-level Likert scale (1-strongly disagree, 2-somewhat disagree, 3-neither agree nor disagree, 4-somewhat agree and 5-strongly agree). To allow easier management of results within each theme of the online questionnaire via Qualtrics, any positively worded questions from the PWS were modified with a negative wording approach and followed the general trend of negatively worded questions based on the DASS-42. This meant that lower Likert scale would indicate a positive outcome, whereas the higher Likert scale would indicate a negative outcome. Other questions included demographic information, tuition fee-paying status and living situation during the lockdown period. Free-text comment boxes, which were optional to complete, were also available at the end of each theme for the participants to elaborate further on the answers that they have given. The ethical approval for this study was obtained from the Human Ethics Committee (Category B), University of Otago, New Zealand. The online link to the survey was distributed to all undergraduate participants were under the common knowledge that there will be a government decision on 20 April 2020 whether the nationwide lockdown will be lifted from 23 April 2020. A reminder email was sent to the students during the first week of data collection and the online survey was closed prior to the government announcement on the changes in the Alert Level. Student participation was on a voluntary and anonymous basis and no incentives were used to improve the rate of responses. The means for the respondents for each item were calculated and used to compare between genders, year of study, accommodation status, tuition fee-paying status and part-time job status using the Mann-Whitney U test. A Kruskal-Wallis test for non-parametric data was used to compare the differences in the physical, psychological, behavioural, financial and academic concerns between different year groups. Pairwise comparisons were performed using Dunn's procedure with a Bonferroni correction for multiple comparisons. Adjusted p-values of <0.05 were used to determine any statistical significance. Mean values below 3 were used as a cut-off value to indicate that the COVID-19 restrictions have no adverse effect on the students. The free-texts associated with each theme were also collated and reviewed according to the theme that the participants were commenting on. Inductive codes were then derived by two authors (SM, ATS) independently to confirm for their appropriateness under each theme before being included to support the quantitative data and the statistically significant results. There were 301 out of 376 undergraduate dental students (80.1% Respondents mainly gained information about COVID-19 through social media such as Facebook or Twitter (32.58%) as well as online government or news websites (36.81%). Less than 1% of the respondents chose not to listen to any information related to COVID-19. Overall, students perceived their physical well-being as relatively on the positive side (mean Likert score 2.75 ± 0.82). There "I would like to go to the gym." -Year 4, male (Likert score = 3.6). -Year 3, female (Likert score = 4.5). On average, students reported a similar level of impact on their psychological well-being (2.79 ± 0.62) compared to their physical well-being. There was no statistically significant difference in the psychological and emotional well-being in relation to the year of study. However, female students (2.85 ± 0.60) reported to be more psychologically and emotionally affected compared to their male counterparts (2.67 ± 0.65) (p = 0.011). There was also a difference in the psychological well-being between those who stayed in Dunedin (2.89 ± 0.63) in comparison to those who relocated to be with their families (2.63 ± 0.58) (p = 0.001). "Emptiness…" -Year 5, male, did not live with his family during the lockdown period (Likert score = 3.7). A statistically significant difference was also seen when comparing the students with (3.08 ± 0.75) and without dependents (2.72 ± 0.57) (p = 0.000). International students (3.09 ± 0.57) were also more negatively affected when compared to their domestic-fee paying classmates (2.66 ± 0.60) (p = 0.000). Some students commented on racially related reasons that affected their psychological and emotional well-being. On average, students appeared to be more affected (3.20 ± 0.745) in terms of their behavioural changes due to the COVID-19 situation. There was no difference in the behavioural and social well-being of students in relation to the year of study or gender. Students commented on some of their feelings related to the changes in their behavioural and social well-being. There was no difference in terms of gender when academic concerns were discussed. However, there was a statistically significant differ- Table 1) . Some of the students explained further on their academic concerns as the online teaching was carried out during the lockdown period. "Genuinely concerned about the load of assessments/ end-of-year exams… it really has been a stressful period and not the same at all without access to conducive environment for everyone… so hard to study like this, no matter how hard I try to make it conducive for myself" -Year 2, international-fee paying (Likert score = 4.67). "I accept that changes will be made to our academic programmes. This will affect everyone equally and no one should be disadvantaged by these changes." -Year 3, domestic-fee paying (Likert score = 2.6). On average, students were not too significantly affected in terms of financial concerns (2.74 ± 1.14). There was also no difference when On average, students were negatively affected by the COVID-19 situation in terms of their future career prospects International tuition fee-paying students were more affected (p = 0.034). However, there was no difference in terms of dependent status (p = 0.108) ( Table 2 ). COVID-19 pandemic has affected people in various ways and recognition of the impacts of such unexpected events is essential to understand the challenges and limitations experienced by different groups of people. Therefore, the aim of this study was to evaluate the impact of COVID-19 situation and experience of being in an extensive period of lockdown for undergraduate dental students. The questionnaire focused on analysing students' perception in four areas: general well-being, academic stressors, financial implications and future dental career concerns. Wellness or well-being can be broadly defined as the quality of being healthy in body and mind. 17 It is composed of physical, emotional, spiritual, intellectual, occupational and social health. 18 Investigating the perceived wellness of individuals is valuable because studies have validated that perceived wellness is a good indicator of future health outcomes. 16, 19 Therefore, it was essential to know the students' perception about their well-being during the COVID-19 lockdown so that appropriate assistance could be prescribed and to minimise the number of students progressing towards disease phase. Generally, the current study found that the restrictions caused by the COVID-19 pandemic did not negatively affect the students' physical, psychological and emotional well-being. However, the students' behavioural and social well-being were strongly impacted including concerns for their academic work and their future career. Physical wellness is the positive perception and expectation of physical health. 16 responsibilities such as caring and providing for their children and families at home physically, emotionally and financially. Therefore, it was no surprise to see that parents in New Zealand with schoolaged children were reported to be increasingly stressed as the Government announced plans for prolonged online schooling as they tried to juggle childcare and home-schooling. 27 The location of students during the lockdown period showed a significant difference in their response to psychological well-being questions. Those students who moved back to their hometown tended to respond more positively to their psychological well-being compared to those students who stayed back in Dunedin, physically isolated from their families. This also included all of our international students who could not return home overseas as the international border was closed during the lockdown period. The students who spent the lockdown period at their hometown may have been in a more positive and comforting environment with the support of their parents, siblings and relatives. On the other hand, those students who chose not to or did not have a choice to return home may have felt isolated and anxious during the prolonged lockdown period. Therefore, it is suggested that in preparation for any other future disasters, universities should work on providing emergency psychological services to those in need, as it is easy for students to be affected by disease-associated fear and pressure. 26 International students reported that they were negatively affected psychologically (3.09 ± 0.57) which was significantly different from their domestic counterparts (2.69 ± 0.6). One international student revealed that it was hard to focus and keep motivated, while another student mentioned a feeling of "emptiness." There was a frequent statement regarding overwhelming stress about families overseas. International students, undoubtedly, have additional stress and burden in terms of living in another country away from families, adapting to a new culture, and financial commitment of higher tuition fees and related living expenses. One participant felt that the tuition costs have gone to waste as the clinical teaching has discontinued. It was no surprise to see that the uncertainties of the COVID-19 pandemic, especially in relation to border closures and disrupted access to clinics caused significant psychological impact on our international students. Globally, teaching and learning has shifted to online and media formats since the COVID-19 pandemic. While this has helped many institutions to continue with their teaching, it has also identified many issues such as access to technology, student acceptance of learning online and adaptability of teaching staff within a short timeframe. 30 Socioeconomic disparity between students did not become apparent until they could no longer access the universityowned resources and this meant that not all students had access to computing resources or high-speed internet. This caused concerns for some students, as they could not keep up with their didactic learning and felt disadvantaged, while others were being more productive during lockdown. During the lockdown period, the University of Otago worked with each Faculty to gain contact details of students that could not access computing resources and these students were provided with the university-loan equipment. Some students reported that their home environments were not conducive to study and therefore it is important for tertiary institutions to recognise and understand this problem when assisting students. Some students reported increased pressure of financial burden as they were impacted by their parents' job status and difficul- Students who had previously experienced or preferred faceto-face learning required support in the transition to learning remotely. 31 Lack of physically present peers or teaching staff can also lead to negative learning experiences. With the unexpected and unpredictable changes during the COVID-19 pandemic, as well as an increase in cognitive load placed on the students through the change of learning environments, may further affect their mental capacity to construct knowledge. 32, 33 Teaching staff at the University of Otago were forced to embrace and quickly learn different modes of teaching while they were given less than one week to accommodate the transition to online delivery. In a recent study, it showed that universally, there were shared concerns about the extraordinary workloads that the online teaching transition required, 34 The COVID-19 pandemic has affected the undergraduate dental students in different ways, especially for those coming to the end of their 5-year dental programme facing a particular challenge of thinking about their future job prospects. Those who were part-way through their programme appeared to be anxious in terms of their course delivery, assessment and how the lost time would be compensated for. At the time of conducting the questionnaire, assessments remained the most complicated and yet-to-be-determined component of the New Zealand dental programme, as it was uncommon to have online assessments in Dentistry. A recent study which interviewed academics in Anatomy also expressed awareness of students' concerns that centred around future degree and career progression 36 as well as the perception of "missing out" or "getting what they paid for." 36 These concerns were also reported in the current study and emphasised especially by the international students as they paid five times higher tuition fees. Concerns for cancelled outplacement rotations for the graduating class were also expressed, as it was acknowledged that no virtual sessions could duplicate the real clinical experience with patients. Final-year dental students also reported anxiety and stress in ending up being less employable than previous graduates due to disruption in their clinical experience during the COVID-19 pandemic. It is therefore extremely important that the dental school continues to work with the government and professional dental bodies and maintain a transparent communication path to ensure the quality of the graduates while safeguarding the health of students, staff and patients. 36 It is acknowledged that there are some challenges in establishing e-learning or online assessments in dentistry. However, universities should not wait for another emergency or unexpected events to include online courses or e-learning in dental curriculum. Proactive interventions such as training academic and administrative staff as well as students are essential to develop skills which could help in promoting resilience when faced with a different way of teaching and learning. 23 The effectiveness of online teaching and assessments should be trialled and measured from a pedagogical, organisational, teaching and learning perspective. This will then allow for some flexibility already built in the way courses are planned, designed and delivered across the programmes at all levels so that any urgent and necessary changes can be implemented in a timely manner. 38 There are some limitations with this study in terms of the data being collected via questionnaires rather than face-to-face interviews. However, considering the number of participants that we aimed to include, an online survey was the most appropriate form of data collection. The current study presented self-reported mea- sures and therefore the results should be interpreted with some caution, as they could be over-or under-reported. 39 The current study also represented a cross-sectional view of undergraduate dental students' well-being in one tertiary institution and therefore there were no data from the pre-or post-COVID-19 lockdown period for comparison. The study provides valuable information on the extent and severity of the impact brought on by the COVID-19 pandemic on undergraduate dental students. Given the prevalence of natural disasters and the inevitability of their occurrence, the results of this study showed various areas that the University should consider when providing support and assistance to students during unprecedented times. The importance of open communication and being familiar with the needs of students cannot be underestimated. University staff should be receptive to learning new technology to minimise disruptions in their teaching and be adaptive to changes. It is extremely important that the University is proactive and be prepared to deal with future pandemics effectively and efficiently by learning from the experiences of COVID-19 pandemic. The authors would like to thank all participants for their valuable time. The authors confirm that there is no conflict of interest in preparing this manuscript. Research data are not shared. 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