COVID-19 has indeed affected dental students in various ways. Before the pandemic, commonly identified dental school stressors that placed dentistry as a stressful profession include extensive coursework, pressure to perform well, learning clinical procedures, and dealing with difficult patients [4, 8]. In addition to the usual stressors, dental students now face a global health crisis, institution closure, and challenges in practicing and honing their clinical skills. There is also an increased worry regarding dental protocols after the reopening of school, institutional responses to the pandemic, academic concerns, both physical and mental health concerns, and financial concerns which have added to the list of dental students stressors [4].
This study examined the impact of COVID-19 on dental students in Malaysia. Four main concerns were highlighted: physical health, mental health, financial health, and academic concerns. Based on our findings, year of study was the most important demographic criteria leading to outcomes. However, other demographic details such as gender, mode of study and living conditions have minor contributions to the result outcomes (Table 6).
Students were generally concerned about their mental health; feelings of stress and anger were predominant due to lack of control over the current situation. Previous studies have reported that stress in dentistry students varied according to their ethnic differences, gender, and year of study [9]. In this study, it was found that female students experienced more stress compared to their male counterparts, supporting previously reported findings [9, 10] (Result not shown). Females generally express their emotions to a greater extent than males do, which may be heightened by the pandemic. Studies indicate that females have a lower uncertainty tolerance compared to males and are subject to less coping strategies in times of uncertainty and stress, while males are more likely to avoid dealing with their emotions (avoidant coping) [2, 10].
Approximately 30% of the students were extremely concerned about getting infected by COVID-19 from their patients and transmitting the virus to their family members at home (Table 3). Since dental practice exposes practitioners to saliva, blood, and other bodily fluids, dentists face an increased risk of infection by the coronavirus from suspected/confirmed COVID-19 patients. Additionally, they carry an increased risk of transmitting this infection to their peers, families, and other patients [4, 11]. A study by Ahmed et al. [12] reports that dentists have a genuine fear of carrying infections from their dental practices to their families and this may also contribute to the worry of the students on their family members’ well-being.
Since the Movement Control Orders (MCO) and Standard Operating Procedures (SOP) were implemented by the Malaysian government, there has been a shift from physical classroom teaching to online teaching due to the closure of public and private education institutions at all levels nationwide. Almost half of the students (41.6%) stayed at home and did not return to their institutions after school break [3, 13]. Our findings show that students were apprehensive with respect to the quality of their online courses (Table 4). In contrast, Hung et al. [4] reported positive student feedback towards their online curriculum. Besides the online curriculum, Malaysian university students also faced challenges with the technological infrastructure required for online learning. Poor internet connection was cited to be a main hindrance to effective online learning [2]. Upgrade and improvement of internet services is required to help resolve this problem. Government and telecommunication companies should play a role in expanding high speed internet services across the country. The increasing usage of mobile phones to about 6–8 hours daily for attending online classes, high expectations from lectures, multiple assignments and non-flexible deadlines have contributed to insurmountable stress and health issues as stated by Sundarasen et al. [2].
The acquisition of adequate clinical skill time was the major concern among the dental students in this study, similar to findings by Hung et al. [4]. As a matter of fact, many expressed anxiety about simply being able to complete their degree or pass the dental board exams. Closing of institutions including the dental clinic, enforcement of strict standard procedures and limited number of patients during the pandemic translates into decreased learning time and less opportunities for clinical skill practice. Hands-on laboratory and clinical skills teaching have been disrupted during the COVID-19 pandemic and has been replaced with online learning. Unfortunately, this was proven to be ineffective at honing the students’ necessary psychomotor skills [14]. To improve online dental learning, some strategies were implemented, including simulation, demonstration, tele-dentistry, and videotaping cases with the faculty review. Sharing recorded videos of laboratory and clinical skills, in addition to online patient simulations or role plays is also beneficial [4, 14]. Fortunately, students were willing to cancel their travel plans, take shorter semester breaks and attend school 6 days per week in order to make up for the loss in education.
Moreover, many students reported lack of motivation and difficulty focusing on their studies following the pandemic (97.7% and 96% respectively) (Table 4). The sudden switch from in-person to online learning dental education forced students to adapt to a new way of learning and teaching [15]. A study by Ahmed et al. [12] on Malaysian postgraduate medical physics students, showed that students still favoured face-to-face compared to virtual learning modes. Compared to physical lecture sessions, the students found e-learning to be boring, less engaging and prevented them from effectively asking questions during lectures. In addition to loss of motivation and difficulty focusing on studies, the students also reported a drop in morale and internet connectivity problems as they need to adjust to new learning norms that require more independent and self-regulating learning approaches [12]. This can be improved by early introduction of online learning to the students, especially at the beginning of dental school enrolment and the expectations of virtual learning rather than face to face education should be made clear by explaining to the dental students in the course description along with reviewing current programmes and requirements related to the resources and infrastructure. Creativity of dental lecturers are required in order to make the students more eager and engage in online learning [16, 17].
Our findings also highlighted the financial concerns of dental students. Clinical students especially were anxious of being unable to cover their expenses in next few months (Table 5). Most students (96%) despite their year of study, were anxious that finding a job after graduating would be difficult, since unemployment is currently at its highest level since the depression era [4]. Based on a study in Malaysian university students, students were concerned with their ability to manage educational financial commitments due to family loss of income, loss of work opportunities and the possible need to self-finance their studies [2]. This finding is identical to reports by Hung et al. [4]. Hung et al. [4] further reports that students closest to finishing their studies and seeking jobs, i.e. senior dental students and residents (final year students in our study) expressed the most concern. Dentistry has the highest debt-to-income ratio, which may cause dental students who have invested many years into their education to face looming debt and unemployment. As the effects of the COVID-19 pandemic are felt by Malaysian dental students, further research is advised for the inclusion of successful coping strategies for students during this uncertain and testing time.
This study does present with its own limitation. Inability to reach all dental students from exactly 13 dental schools leads to disproportionate number of respondents presenting each dental school, thus may increase the risk of bigotry. In this study, data was collected in the months of March and April 2021 when most of the students had already being allowed to attend school after the closure of institutions during MCO. The concerns of the students could have been varied if the data had been collected at the peak of COVID-19, which was at the end of year 2020. Moreover, there is always uncertainty of whether the respondents answered the questions honestly when it comes to surveys with questionnaires.