Introduction
Stress is a term that denotes a condition of the being or person in which we perceive an existing threat to our own integrity (1, 2). Stimuli that cause stress are called stressors. If people are constantly exposed to stressors so that there is no time to recover between them, it leads to chronic stress, which can have a major effect on the body (2, 3). An individual reaction to stress is the result of: individual sensitivity, the way difficulties are overcome, the person’s overall health condition, external factors and the stressors themselves (2, 4). Reactions to stress can be psychological, behavioural, and physiological (5).
The World Health Organization has declared stress in the workplace as the worldwide health epidemic of the 21th century (6, 7). Every workplace may be at risk for the occurrence of certain diseases, but some occupations are considered to be more stressful, including the occupation of dentistry (2, 8). Many factors at work can lead to stress. Some of these are: clinical work, adverse working conditions, work with nervous and anxious patients, work that often causes pain in the patient, time pressures and other limitations, an obligation to continuously work on additional training in order to allow the dentist to perform his / her own tasks more effectively. These are general factors that represent the main challenges every dentist must face in order to be able to provide their patients with the highest quality healthcare and to show a humane attitude to them, and they are also combined with full and strict compliance with the medical code of ethics (6, 9, 10). In addition to these stressors, dentists are also exposed to a number of other occupational risks (stressors) in their workplace that are specific to this particular profession. These also include biological risks (the possibility of biological infection), chemical risks (contact with different chemicals), and physical risks (radiation) (8, 11). The consequences of dissatisfaction in the workplace are reflected in frequent sick leave, errors at work, professional burnout, job abandonment, reduced satisfaction of the healthcare service recipient, and the reduced quality of mental health in doctors (12-14). There is an ever increasing necessity to undertake a comprehensive analysis of the stress levels suffered by dentists during their work, and to determine the stress factors, including an analysis of the effectiveness of different anti-stress or stress management methods, in order to improve their general health and enable them to practice their medical profession more efficiently, while achieving a higher degree of service quality (6).
It is worth noting that at no point is due attention paid to how to deal with stress, not even at first and second year level, during undergraduate, postgraduate and professional education studies, or during courses for continuous training.
This research has been conducted with the aim of screening and examining the levels of stress experienced by doctors of dental medicine in the age group between 25 and 45 years, but also with the aim of making gender-aggregated comparisons with regard to whether a higher level of stress is recorded in female or male doctors of dental medicine. This is the first study of stress levels among dentists in Bosnia and Herzegovina . There are currently no relevant data on total stress in the population.
Materials and methods
The research included a number of dental doctors throughout Bosnia and Herzegovina. Given the uncertain number of dentists employed in Bosnia and Herzegovina, a sample of 100 respondents was taken to be representative, relying on other studies using the PSS 10 scale as a measuring instrument (15). The study was approved by the Ethics Committee of the School of Dental Medicine in Sarajevo, (No. 02-3-4-203-2/19). All participants signed the informed consent and voluntarily filled out the survey form. The survey involved 105 respondents (66 female dentists or 62.9% and 39 male dentists or 37.1%). The age of the subjects ranged from 25 to 45 years. The research was carried out during the months of January and February 2019. This cross sectional study was conducted using an electronic questionnaire. Together with the survey questionnaires, all respondents signed informed consent for participation in the survey. A total of 235 copies of the survey questionnaires were sent to the respondents. The total number of 117 respondents voluntarily agreed to the survey and completed the questionnaire. The inclusion criteria were that the subjects were doctors of dental medicine, and that they were 25-45 years of age and did not use drugs with effects on the nervous system. All other respondents were excluded by age. Out of that number, 7 respondents were excluded from the research on account of taking medication that affects the nervous system, 3 respondents were disqualified on account of completing the survey questionnaires inadequately, and 2 were disqualified on account of their current age (both respondents were over 45 years of age). Accordingly, the total number of respondents who were ultimately included in the research was 105.
The tool used was the Perceived Stress Scale PSS 10, which focuses on simplicity, easy access, higher speed and flexibility. The PSS was designed for use in community samples with at least a junior high school education. The items are easy to understand, and the response alternatives are simple to grasp. The questions in the PSS ask about feelings and thoughts. The survey participants were asked to evaluate their experiences by using a linear 5-point Likert Scale with the following range of evaluation scores used to express their feelings and thoughts with regard to the perceived levels of stress experienced in the workplace: 0-Never, 1-Almost Never, 2-Sometimes, 3-Fairly Often, 4-Very Often. PSS scores are obtained by reversing responses (e.g., 0=4, 1=3, 2=2, 3=1 and 4=0) to the four positively stated items (items 4, 5, 7, & 8) and then totalling scores across all scale items. A short 4 item scale could be made from questions 2, 4, 5 and 10 of the PSS 10 item scale (reliability, α = 0,85) (16).
The Perceived Stress Scale (PSS 10) has been confirmed by representatives of sub populations to measure stress by age group, race, gender and socio-economic status, and it reflects any changes in stress levels that occur over time. Various studies have shown the good discriminatory validity of the research (17, 18).
The Statistics IBM SPSS v.21. and Microsoft Excel 2010 packages were used for the purpose of statistical analysis of the research results, whereas descriptive statistics, X2 test and T-test were used for statistics data processing.
Results
The response rate to the disseminated on-line survey questionnaires was 49.8% - 117 dental doctors responded to the total number of 235 questionnaires disseminated. Bearing in mind the fact that 12 respondents were excluded, 105 or 44.7% of the total number of the disseminated survey questionnaires were included in the survey.
Table 1 shows the gender structure of the respondents. Tables 2 and 3{ label needed for table-wrap[@id='t3'] } show the total stress level scores for female and male respondents. Table 4 shows the PSS-10 gender-aggregated comparison of stress levels, where the scores for female and male respondents are presented for each particular question separately.
| Variables | Categories | Frequency n (%) | Valid Percentage (%) | Cumulative Percentage(%) |
|---|---|---|---|---|
| Age Gender Total | 25-45 years Male Female | 105 (100) 39 (37,1) 66 (62,9) 105 | 100% 37,1% 62,9% 100% | 100% 37,1% 62,9% 100% |
| Group Statistics | |||||
|---|---|---|---|---|---|
| Q Gender | N | Mean | Std. Deviation | Std. Error Mean | |
| Q1-Q10 Male Q1-Q10 Female | 41 71 | 22,366 23,493 | 4,5263 5,4481 | ,7069 ,6466 |
{ label needed for table-wrap[@id='t3'] }
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Out of the total number of respondents of 105, an analysis of the gender structure of the respondents involved in the assessment of the stress levels in doctors of dental medicine shows a statistically significant difference in relation to the respondents’ gender. The Chi-square test was used to examine the gender structure of the dentists. According to the results of X2 = 6.94 (df = 1), we concluded that the difference is statistically significant with respect to the gender of the respondents. The respondents provided answers to each and every question in the Perceived Stress Scale without any significant statistical difference between the male and female doctors of dental medicine detected in the 25 to 45 year age group. According to T-test results, where T = 1.1 (p = 0.26) (df = 8), we may conclude that the difference were not shown to be statistically significant when the level of stress in male and female dental medicine doctors is concerned. On the basis of these results, we can accept the H0 hypothesis indicating that: “There is no statistically significant difference in the stress scores detected in the female doctors of dental medicine compared with the male doctors of dental medicine in the 25 to 45 year age group”.
Discussion
The results of our research show that the average stress score for our respondents - doctors of dental medicine in the average age group of 25-45 years, was about 23 (Table 3), which is higher than the average value of the PSS-10 scale score, where the normal values for the indicated subpopulation are between 13 and 14 (Table 5). These results suggest that dental medicine is a stressful occupation. There was also an additional objective set in this research, to examine whether there was a difference in the level of stress between the female and male doctors of dental medicine. No statistically significant difference was found in stress levels between the female and male respondents. The stress score in the female respondents was 23.5, while the stress score in the male respondents was 22.4 (Table 2.). A number of other studies have also dealt with this issue.
The Study of Self- Perceived Stress in Relation to Anxiety, Depression and Health-related Quality of Life among Health Professions Students reported high degree of stress in students (18). "High" stress levels were reported in other studies (19, 20).
An extensive study conducted by Myers & Myers in 2004, involving 2441 respondents, reported that dentists were under considerable stress, but no significant difference was identified in stress levels between the genders (21). We need to mention that the stress assessment study mentioned above used the identical PSS-10 questionnaire that we also used in our research. Some stress studies that have examined stress levels among students of dental medicine have obtained some results in gender terms as well, therefore, we can correlate our findings with those obtained by these studies. The most extensive of these studies was the one conducted by Alhajj M.N. et al. in the 2016/2017 academic year, where a group of 18 researchers examined stress levels in 3568 students of dental medicine in 14 countries. Their results show that the stress level perceived in female students was higher than that perceived in male students, except in the domain of social stressors, that showed quite the opposite trend (22). These results are in line with the results of a number of other studies that also examined stress levels among students of dental medicine (23-25). Sing et al. (2015) wrote a scientific review paper dealing with the topic of various factors resulting in professional burnout, and by basing their findings on another 115 studies from the relevant databases, they came to the conclusion that professional burnout is a multifactorial phenomenon that may occur even at an early point of time in a dentist’s career. They also highlighted the need to devise a screening program and undertake preventive measures (26). Similar results were also revealed by other groups of authors: Ab-Maurat et al. among Malaysian dentists, and Te Brake et al in their a longitudinal study, among dentists (27, 28). According to a series of research conducted by some authors, no significant differences in stress levels were reported between female and male doctors of dental medicine (29-33), while some other studies have reported that female doctors of dental medicine were found to suffer from higher stress levels than males in the same profession (34, 35).
The American Psychological Association (APA) published a survey dealing with the impacts of stress. The survey included 2020 respondents over the age of 18. It examined the prevailing views among its respondents about the levels and causes of stress, the rate of respondents’ participation in various stress management workshops, and the ways in which respondents cope with stress. The highest impact of stress was reported by the respondents in the 18 to 47 year age group. Accordingly, this is the age group of younger and middle-aged respondents who have a great number of important life events ahead of them and a number of important decisions to make in the future, such as the decision to continue with their education, to seek employment, to enter into a marriage relationship, establish a family, etc. All groups of respondents stated that their stress level is way above the level considered to be an ideal level from the point of view of human health. Nevertheless, respondents over the age of 67 are apparently closer to this ideal level, that is otherwise not harmful for human health. However, the younger population group is not differentiated only by the multitude of decisions and stressful events they are exposed to in comparison with the population in the over 67 age group. The younger respondents stated that they are more inclined towards exhibiting some unhealthy forms of behaviour, and expressing anger and nervousness in response to the stress they feel. Also, they do not sleep long enough and do not have sufficient knowledge about stress management compared with the older population groups. A healthy lifestyle is often not within easy reach for those younger than 47, because they often “struggle” with stress by compulsive overeating, excessive alcohol consumption and immoderate cigarette smoking. One of the most common methods of coping with stress, which is more pronounced in the younger age group of respondents, is to go on obsessive-compulsive shopping sprees, while older respondents increasingly resort to practising religion (36).
Female respondents reported a higher level of stress than male respondents. However, both groups exceeded the limits of the stress level that is considered not harmful to health. Exposure to an extremely high level of stress was reported more often by female respondents, which was an unexpected development, considering that on average women have longer life-expectancy than men. Physical exercise and listening to music are the most common stress-coping activities for both genders. Unlike men, women cope with stress by using a number of social methods, such as socializing with family and friends, shopping, reading books, but also overeating, most commonly by eating unhealthy foods. Neither gender tends to seek any professional help for coping with stress and its causes (36). A. Sliskovic, I. Buric, I. Knezevic conducted research which included 1892 teachers in primary schools, 1658 of which were women and 231 men. All the participants were aged between 23 and 65. Their satisfaction in the workplace was measured using the Job Satisfaction Scale (37, 38). The results attained after statistical analysis showed that all the participants displayed a greater level of stress in relation to the scale used. Women significantly differed from men, in the sense that they were under more stress, but that result was taken into account with reservations considering the fact that there was a statistically significant difference between the number of male and female participants (38). In their paper ‘A comparison of stress and mental strength in nurses and police officers’ Sindik et.al. examined and compared stress and mental strength in police officers and medical staff. The goal of the research was to determine the differences in experienced stress and in the aspects of mental strength in the positively selected police officers and medical nurses / medical technicians. The research was conducted on purposeful samples of 75 nurses in Dubrovnik and 63 criminalists in Zagreb. The questionnaires that were applied were the Stress Test and Short Scale of Strength. The analysis of the main components showed the existence of two stress components: exhaustion/lack of control, and difficulties with eating/sleep. Nurses experience more stress in both components, but they have more mental strength in the dedication aspect. The gender differences in both stress components point to greater stress in women, who also show more prominent dedication. The greater level of stress in nurses and in women can be interpreted by the on-average greater stress in medical professions, as well as the stressful dual role of modern women, regardless of their profession (39).
One of the limiting factors that could have influenced the study results is the fact that we had inadequate distribution of the sample, where the total number of female respondents was higher compared with the total number of male respondents. Sixty-six of them were female respondents, and 39 of them male respondents. Furthermore, the respondents’ gender and age were the only factors taken into account as the inclusion criteria. We did not take into account information such as, for example, the respondents’ years of service, whether the respondents work in private or public practice, whether the doctors of dental medicine are general practitioners or specialists, whether they are just private practice employees or owners of such a practice, or whether they are married or not, which can be a strong recommendation for any further research on this particular subject matter. One of the criteria that could also have been taken into account was whether the respondents have any kinds of hobbies, whether they practice any regular physical activity or exercise, or some other form of relaxation and thus cope with stressful situations. Taking this factor into account would otherwise enable a more detailed discussion about how effective some therapeutic and preventive stress management measures could be.
As a research tool, this kind of survey itself can be a moderator of research results in some of the respondents, since in his research conducted in 2000, Myers found that some respondents, who possess a repressive coping style, failed to report negative effects, and answer many self-reporting measures in such types of surveys in an overly positive fashion. The new studies should be appointed to the groups of individuals who appear to introduce themselves in a positive light. Nevertheless, it is necessary to use more than one technique for information assortment in order to overcome the better understand link between repressive coping and adverse physical health (40).
Conclusions
Various kinds of research indicate that the occupation of doctor of dental medicine falls within the category of very stressful professions. Doctors of dental medicine aged 25 to 45 are exposed to various stressors that accompany this profession. Statistical analysis has shown that there is no difference in the level of stress between female and male doctors of dental medicine in the age group of 25 to 45 years.
