Psychological well-being and perceptions of stress

amongst Japanese dental students

G. Sugiura, K. Shinada and Y. KawaguchiDepartment of Oral Health Promotion, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan

The purpose of this study was to investigate the relationshipbetween Psychological General Well Being (PGWB) and per-

ceived sources of stress amongst dental students in Japan.Second to sixth year dental students of Tokyo Medical and

Dental University were invited to participate in the questionnairesurvey. The questionnaire collected information on demographic

and social background, lifestyle behaviours, the PGWB indexand the Dental Environment Stress (DES) questionnaire. A total

of 320 students (56% male) participated, with a response rate of91%. Male students had significantly higher PGWB scores and

lower DES scores than female students (P < 0.05). There wereno significant differences in the year of study for DES mean score

and PGWB total score. Students whose first choice of admission

was dentistry experienced less stress than those whose firstchoice was another discipline (P < 0.05). Students who regularly

exercised showed significantly lower stress levels and higher

well-being status than those students who did not exercise(P < 0.01). Correlational analysis showed an inverse relationship

between PGWB and DES scores (r ¼ )0.544, P < 0.001).Multiple regression analysis revealed that DES mean score

was significantly related to gender, first choice of admission andPGWB total score. It is suggested that perception of stress

amongst Japanese dental students is influenced by gender,dentistry as first choice for admission and students’ general well-

being.

Key words: dental student; stress; questionnaire; well-being;

dental education.

ª Blackwell Munksgaard, 2005Accepted for publication, 4 May 2004

T he dental profession has been considered a

stressful occupation (1–6). Stressors associated

with dental practice include time and scheduling

pressures, managing uncooperative patients, and the

highly technical and intensive nature of the work.

Cooper et al. reported in 1987 that the dental profession

was the most stressful of all the health professions (7).

Studies on dental student stress have also been

conducted in several different countries, for e.g. UK,

USA, Jordan, Singapore, Israel and Australia. These

studies have some degree of consensus concerning

what dental students find stressful. ‘Examinations’,

‘fear of failing’, ‘work load’ and ‘completing course

requirements’ ranked highest amongst stressors rela-

ted to dental student training and the academic

environment (8–13). Newbury-Birch et al. recently

reported that about 70% of final-year students in a

UK dental school had suffered from stress and

pathological anxiety (14). In a survey of first-year

dental students from seven European dental schools,

Humphris et al. (15) described prevalence estimates of

36% for psychological distress and 22% for emotional

fatigue. It was also reported that almost half of the

students in a Caribbean dental school were in the

clinical range indicating significant psychological dis-

turbance (16). Generally, the presence of psychological

stressors, when prolonged or untreated, could lead to

stress symptoms including anxiety, depression, pho-

bia, hostility, fear and tension (17, 18), as well as

physical complaints such as sleeplessness, fatigue,

dizziness, tachycardia and gastrointestinal system

distress (19). As the perception of stress is frequently

influenced by one’s personal system of beliefs and

attitudes (9), the socio-cultural background of the

student will undoubtedly have a strong influence on

the tolerance to and motivation by stress (12, 20). It has

also been suggested that diet, exercise, sleeping and

other health habits are related to the ability to cope

with and handle stress (21). These reports suggest the

need for dental educators to appreciate factors related

to stress and to assist in the development of appro-

priate stress-reduction programmes for dental stu-

dents.

Perceived stress can also affect students’ well-being

and academic performance (22). Previous studies of

dental students’ stress have mainly focused on sources

of stress related to the dental training environment.

More recently, to obtain a comprehensive understand-

17

Eur J Dent Educ 2005; 9: 17–25All rights reserved

CopyrightªBlackwell Munksgaard 2005

european journal of

Dental Education

ing of Dental Environment Stress (DES), investigators

have begun to further explore the relationship

between dental students’ stress and subjective well-

being status using the Emotional Intelligence scale, the

Brief Symptom Inventory and General Health Ques-

tionnaire (15, 16, 23). Subjective well-being comprises

contentment, satisfaction, happiness, hope, and good

feelings about one’s past life, present life and one’s

presumed future life (24). One of the approaches to

subjective well-being is the presence of positive affect,

i.e. a person’s good feelings. Conversely, another

influence is the absence of negative affect or not

feeling bad. These two characteristics are independent

of each other (25).

Tokyo Medical and Dental University (TMDU) is

the largest national dental school in Japan and located

in Tokyo. In Japan, the dental education program for

dentists is 6 years. For the first one and a half years,

students study liberal arts and basic sciences. During

their second to fifth years, students learn dental pre-

clinical studies, and the clinical training programmes

starts from the end of the fifth year. After graduation

from dental school, students have to pass the National

Board Examination in order to get a dental license to

practice in Japan. Reviews of international studies and

experience in Japan strongly suggest that dental

educators must understand students’ subjective well-

being and perception of stress in order to enhance

students’ ability to perform academically and cope

better with their future practice as dental profes-

sionals.

The aims of this study, therefore, were to under-

stand better, in a Japanese population:

1. How perception of stress may be affected by social

background, choice and health-related habits, and

2. To examine the relationship between perception of

stress and subjective well-being in Japanese dental

students.

In addition, the objectives of this study were to:

1. Identify general well-being status and perception of

stress amongst Japanese dental students.

2. Investigate social background, health practices and

other factors affecting well-being status and per-

ception of stress.

3. Investigate the relationship between general well-

being of the students and perception of stress.

Methods

The subjects of this study were second to sixth year

dental students of TMDU. First year students were

excluded from the study, because they were not yet

involved in the dental course programme. The total

number of subjects in this study was 352. The

questionnaire survey was conducted from December

2002 to January 2003. The survey schedule was

planned to be independent of the students’ assessment

period and the questionnaire was administered to the

students when they were attending a lecture together.

After the lecture, a researcher explained to the

students the purpose of this survey and assured them

of confidentiality. Participation in this study was also

voluntary, and all participants remained anonymous.

The questionnaire included demographic details

(age, gender, year of study) and social background

(parents’ occupation, first choice for admission, type of

dwelling living arrangements, scholarships, part-time

employment). For lifestyle behaviours, seven ques-

tions on sleeping habits, eating breakfast daily, snack-

ing between meals, physical activity (regularity of

exercise), alcohol consumption, cigarette smoking and

obesity were asked of the students. These were the

seven common health-related activities described by

Breslow (26). In addition, the Psychological General

Well Being (PGWB) index and the DES questionnaire

were administered to the students.

The PGWB index is a self-administered question-

naire which measures subjective well-being and dis-

tress (25). Developed by Dupuy, the PGWB was

incorporated into the United States National Health

and Nutrition Examination Survey 1 (NHANES1). The

literature has shown the high validity, mainly by

concurrent validation, and reliability of this instru-

ment and recommended its wide use wherever an

indicator of subjective well-being of individuals is

required. The original English version has been largely

applied to both people living at home and clinical

patients in English-speaking populations (27–29). In

some analyses it has been used as a predictor of health

outcomes as well as an estimator of psychological

well-being.

The PGWB index includes 22 items that can be

summated to provide a total score. Further the index

can be divided into six dimensions: (i) general health,

(ii) positive well-being, (iii) vitality, (iv) depressed

mood, (v) anxiety and (vi) self-control. For each

question, there are six response options scaled from

0 to 5; the most negative option for general well-being

are scored 0, and the most positive option is scored 5.

Thus the total score of the PGWB gives a maximum

value of 110 and minimum of 0. The total score

represents one’s comprehensive subjective well-being.

Each of the six dimensions also represent the subject-

ive well-being of the particular dimensions, e.g. the

higher score for depressed mood and anxiety mean

Sugiura et al.

18

the more cheerful minded and more relaxed the

individual, respectively.

The DES questionnaire (19) assesses sources of

stress associated with undergraduate course work

and training in dental students. It is a 38-item

questionnaire based on a 4-point Likert scale, with

1 ¼ not stressful, 2 ¼ slightly stressful, 3 ¼ moder-

ately stressful and 4 ¼ very stressful. Example items

include ‘difficulty of classwork’, ‘lack of confidence to

be a successful dental student’ and ‘fear of failing the

course’. In this study, we applied a modified DES

questionnaire (10) to our dental students. Twelve

items that referred to stressors involving some refer-

ence to patients were omitted for second to fifth year

students because they are not applicable to those

4 years, which are essentially pre-clinical. At TMDU

clinical training programmes start from the end of the

fifth year. DES score was calculated as the mean value

of the 38 items for clinical students and the 26 items

for pre-clinical students.

All the questionnaires were prepared in English at

first, and then translated into Japanese. To confirm the

questionnaires had the same contents, other research-

ers translated the Japanese questionnaire back into

English. Pre-test evaluation was conducted to check

the average time of answering the questionnaire

before the application to the TMDU dental students.

Statistical analysis was undertaken using SPSS for

Windows 11.0. Proportional changes within social

background groups and lifestyle behaviours were

determined by chi-square analysis. Cronbach’s alpha

coefficient was used to test the reliability of the

outcome measures on DES questionnaire and PGWB

index. ANOVA was used to assess any differences on

outcome measures of DES and PGWB between the

years of study. Post hoc analysis was performed with

Scheffe’s test. Students’ t-test was used for two group

comparisons, e.g. gender differences. Pearson’s corre-

lation coefficients were used to assess the association

between DES mean score and PGWB total score and

dimension scores. Subsequently, stepwise multiple

regression analysis was carried out with DES mean

score as the dependent variable. Statistical significance

was set at P < 0.05.

Results

Demographic profileTable 1 shows the number of dental students who

participated in the survey. A total of 179 males (55.9%)

and 141 females (44.1%) answered the questionnaires,

and the total response rate was 91% (320/352). The

mean age and 95% CI of the sample was

23.7(23.4—24.1) years.

Social backgroundIn response to the question on parents’ occupation,

25% of the students reported their parents occupation

as ‘dentist’. Sixty-six per cent of the students reported

that dentistry was their first choice of admission and

30% reported medicine as their first choice. The rate of

students who had dentistry as first choice was signi-

ficantly different whether the parents’ occupation was

dentist (84.6%) or not (60.2%) (v2 ¼ 15.73; P < 0.01).

The rate of students who were living with their

parents was 54.4% in total. Female students (63.8%)

showed significantly higher rates than male students

(46.9%) who lived with their parents (v2 ¼ 9.08;

P ¼ 0.03). Twenty-four per cent of the students

received some kind of scholarship and 66% of the

students were engaged in a part-time work.

Lifestyle behavioursStudents’ lifestyle behaviours were investigated by

responses to each item of Breslow’s seven common

health-related activities. Proportional difference be-

tween gender is shown in Table 2. Statistically signi-

ficantly greater proportions of males, compared with

female students, reported smoking cigarettes

(v2 ¼ 31.21; P < 0.01). There were no differences for

each of the seven health practices amongst the year of

study.

Psychological General Well Being indexReliability analysis was conducted based on the

average of the inter-item correlation of the PGWB

index. Cronbach’s alpha was 0.92 which showed good

reliability of the index. Table 3 shows the mean and

95% CI of the total scores and the six dimension scores

of the PGWB index by gender. Table 4 shows the

PGWB index and component dimensions by year of

study. Significant differences in mean scores by year of

study were compared by using Scheffe’s test.

Male students had statistically significant overall

higher mean scores for PGWB compared with female

students. Analysis of each of the six dimension scores

TABLE 1. Demographic details, response rate and mean age

Year Male Female Total % Mean age 95% CI

2 38 30 68 99 22.2 21.5—23.03 31 19 50 91 22.6 22.0—23.34 30 28 58 73 23.8 23.1—24.65 49 31 80 98 24.4 23.8—25.06 31 33 64 97 25.2 24.5—26.0

Total 179 141 320 91 23.7 23.4—24.1

Psychological well-being and perceptions of stress

19

showed significantly higher scores for male students

in the dimensions of depressed mood and anxiety

(P < 0.05).

Fifth year dental students’ anxiety dimension score

for the PGWB was significantly lower than that of

third year students’. However, there were no signifi-

cant differences for PGWB total score and the other

five dimension scores by year of study.

Dental Environmental Stress questionnaireAccording to the reliability analysis, the internal

consistency (Cronbach’s alpha) was 0.93 for the DES

questionnaire. Table 3 shows the mean scores and 95%

CI for the DES questionnaire by gender, and Table 4

shows them by year of study. Female students had

significantly higher mean scores for DES compared

with male students. There were no significant differ-

ences of DES mean score by year of study using

Scheffe’s test.

Association between PGWB/DES score and socialbackground/lifestyle behavioursTable 5 shows the association between students’

PGWB/DES score and social background/lifestyle

behaviours. PGWB total scores were not associated

with any of the social background factors. However,

the students who had a habit of regular exercise

reported a significantly higher well-being mean score

(72.42) than those without such a habit (64.86;

P < 0.05).

The DES mean score was significantly associated

with the first choice for admission. The students

whose first choice for admission was not dentistry

(2.07) reported a significantly higher DES mean score

than those whose first choice for admission was

dentistry (1.92). Other social factors such as parents’

occupation, type of dwelling, holding a scholarship, or

part-time job were not related to DES mean scores.

Amongst the health behaviours, physical activity

again was associated with DES mean score. Those

students who had a habit of regular exercise showed a

statistically significantly lower DES mean score (1.88)

than those who did not exercise regularly (2.07). Other

health behaviours were not related to DES mean score.

Relationship between PGWB and DESThe total score of the PGWB index was significantly

associated with DES mean score (r ¼ )0.54, P < 0.001).

The scores of each dimension of the PGWB index –

general health, positive well-being, vitality, depressed

mood, anxiety and self-control – also showed sig-

nificant associations with mean DES score (P < 0.05).

These relationships were all inverse correlations, i.e. as

PGWB increased, DES decreased.

Stepwise multiple regression analyses were conduc-

ted for further investigation. Hierarchical multiple

regression analysis was conducted with the dependent

variable being DES mean score. The independent

variables were introduced in two blocks. The first

block consisted of the demographic variables (clinical

TABLE 3. Mean scores and 95% CI of PGWB index and DES questionnaire by gender

Total* (n = 320) Male* (n = 179) Female* (n = 141) t F P

PGWBTotal 68.63 (66.88—70.37) 70.33 (68.05—72.61) 66.45 (63.76—69.14) 2.18 0.98 <0.05General health 10.40 (10.12—10.72) 10.66 (10.27—11.08) 10.07 (9.64—10.54) 1.96 0.13 NSPos. well-being 9.93 (9.58—10.29) 9.96 (9.47—10.45) 9.88 (9.38—10.42) 0.21 0.70 NSVitality 10.60 (10.26—10.94) 10.77 (10.31—11.24) 10.38 (9.89—10.88) 1.11 0.68 NSDepressed mood 11.24 (10.92—11.58) 11.65 (11.26—12.08) 10.71 (10.17—11.25) 2.79 4.95 <0.01Anxiety 16.43 (15.89—16.96) 17.01 (16.34—17.68) 15.68 (14.80—16.54) 2.40 4.71 <0.05Self-control 9.98 (9.64—10.35) 10.23 (9.78—10.69) 9.67 (9.12—10.25) 1.57 1.41 NS

DES 1.98 (1.91—2.02) 1.91 (1.83—1.97) 2.06 (1.97—2.14) )2.70 0.30 <0.05

NS, not significant.*Mean (95% CI).

TABLE 2. Health behaviours of dental students and differences between gender

Total[n = 320 (%)]

Male[n = 179 (%)]

Female[n = 141 (%)] v2 P

Sleeping 7—8 h on average 31 29 33 0.68 0.41Eating breakfast every day 60 55 65 3.24 0.07No snacking between meals 41 51 28 18.38 <0.01Regular exercise more than once a week 50 61 36 19.28 <0.01Drinking alchohol less than once a week 56 50 63 5.74 0.02Having no smoking habit 78 67 93 31.21 <0.01Body mass index <25 94 92 97 21.97 <0.01

Sugiura et al.

20

or pre-clinical year of study and gender) defined by

two dummy variables with the pre-clinical sample and

female subjects acting as baseline. The second block

consisted of the social background factors, health

behaviours and the PGWB total score. As the varia-

bles, except for gender, the PGWB total score, and first

choice for admission, were excluded in the course of

analysis, Table 6 only shows the data from the final

step model. At first, a dummy variable (gender) was

chosen from the first block. Then two variables (the

PGWB total score and first choice for admission) were

chosen from the second block. After entering the other

two variables, the PGWB total score and first choice

for admission, the R2 increased markedly (0.03—0.31).

As a single variable, the PGWB total score was related

most strongly to DES mean score (r ¼ )0.52,

P < 0.001).

Discussion

Stress has been described as a two-edged sword that

can either stimulate and motivate the students to peak

performance or reduce the students to ineffectiveness

(19). Previous studies have reported that dental

education induces considerable stress on students.

These findings are almost universal phenomena in

different countries with different education systems

and curricula. It is difficult to eliminate all the stressful

problems in a dental education programme. To

become a responsible dental professional, students

have to reach high levels of knowledge and profes-

sional skill, as well as developing good attitudes

towards patient care; all within a short period of time.

Our study was conducted to understand better

the factors influencing student perception. To assess

the psychological well-being of dental students, the

PGWB index was used, and the DES questionnaire

was applied for the evaluation of students’ perception

of stress at dental school. Social background and

lifestyle behaviours that impact on dental students’

perception were also analysed; and the relationship

between psychological well-being and perception of

stress amongst Japanese dental students was also

investigated.

In this study, a response rate of more than 90% was

obtained from all the students enrolled in TMDU.

Moreover, Cronbach’s alpha coefficients for both

PGWB index and DES questionnaire showed very

high reliability. Therefore, we consider that the results

of this study reflect the students’ concurrent status in

TMDU. However, this study was cross-sectional in

design and the results may be influenced by class/TA

BL

E4.

Mea

nsc

ores

and

95%

CI

ofP

GW

Bin

dex

and

DE

Squ

esti

onn

aire

byye

arof

stu

dy

Second(n

=68)

Third(n

=50)

Fourth(n

=58)

Fifth

(n=80)

Sixth

(n=64)

P

PGWB

Total

69.06(65.17—

72.95)

71.72(67.70—

75.74)

70.89(66.35—

75.43)

66.84(63.97—

69.37)

66.13(61.46—

70.79)

NS

Generalhealth

10.43(9.79—

11.06)

10.66(9.91—

11.41)

10.29(9.72—

11.07)

10.34(9.75—

10.92)

10.36(9.56—

11.16)

NS

Pos.well-being

10.10(9.26—

10.95)

10.24(9.33—

11.15)

10.57(9.66—

11.59)

9.60(9.00—

10.20)

9.36(8.58—

10.14)

NS

Vitality

10.57(9.79—

11.36)

10.98(10.18—

11.78)

11.13(10.37—

11.93)

10.10(9.48—

10.72)

10.52(9.65—

11.39)

NS

Depressedmood

11.38(10.72—

12.04)

11.58(10.86—

12.30)

11.32(10.52—

12.31)

11.36(10.77—

11.96)

10.58(9.67—

11.49)

NS

Anxiety

16.81(15.68—

17.94)

18.10(16.97—

19.23)

17.20(15.78—

18.68)

15.18(14.22—

16.13)

15.61(14.25—

16.97)

3>5*

Self-control

9.76(8.94—

10.59)

10.16(9.37—

10.95)

10.00(9.14—

11.01)

10.26(9.59—

10.93)

9.70(8.85—

10.55)

NS

DES

1.91(1.77—

2.04)

1.95(1.81—

2.10)

1.84(1.67—

1.92)

2.09(1.98—

2.20)

2.04(1.92—

2.15)

NS

Valuesare

mean(95%

CI).NS,notsignificant.

*P<0.05.

Psychological well-being and perceptions of stress

21

generation norms and characteristics of the students.

Therefore, the results obtained from this study should

be treated with caution, as they may not be directly

applicable to other dental schools. The social back-

ground will differ between national dental schools

and private schools in Japan, and may also differ from

other international dental schools.

Social background of the studentsTwo-thirds of TMDU students entered the university

in hope of becoming a dentist. However, the rest of

the students had failed the entrance examination for

study in other courses and entered dental school as

second choice. In Japan, university admission is

highly competitive and medicine is usually reserved

for the students having the highest score, followed

by dentistry. In TMDU 30% of the dental students in

this study reported that they wanted to become a

medical doctor. More than half of the students were

living with their parents. In Japanese culture, chil-

dren usually do not live independent lives from

their parents until after marriage. It is also a norm

that parents are responsible for the educational

expenses of their children even during their

university study.

Lifestyle behaviours of the studentsGender difference was found in some items of com-

parison with healthy lifestyle behaviours, for example,

cigarette smoking. Cigarette smoking rate for male

students was 33% and it was very high compared with

a previous study on dental students smoking rate

which reported a rate of 16% for males (21). As

lifestyle-related diseases are the national concerns in

Japan, it is imperative to advise dental students on

changing their lifestyle behaviours, especially the

high-risk habit of smoking.

In TMDU, 61% of male and 36% of female

students reported that they enjoyed regular physical

exercise more than once a week. Most of these

students probably were participating in some kind of

sport club activities of the university. Club members

consist of students from different faculties and

different years of study. Club membership also

promotes good human relationships and values. In

TMDU, more than 18 different sports clubs are in

existence, such as baseball, tennis, rugby, swimming,

judo, archery and boat clubs. Promotion of active

club memberships for dental students may well

assist in reducing stress and promoting a sense of

well-being.

Psychological well-being of the students measuredby PGWB indexThe scores of PGWB index show subjective well-being

and distress status in students’ general situation.

Correlation of PGWB index with other health-related

scales was previously well documented in the USA

and Sweden (27–29). These studies indicate that

TABLE 6. Stepwise multiple regression analysis for associationbetween DES mean score and candidates

Variable B Beta SE P

DES mean score: R 2 = 0.31Gender (female) 0.10 0.09 0.05 0.049PGWB total score )0.02 )0.52 0.00 <0.001First choice of admission )0.11 )0.11 0.05 0.026

TABLE 5. Mean scores and 95% CI of PGWB index and DES questionnaire according to social background and a habit of physical activity

n (%)

PGWB DES

Mean (95% CI) t F P Mean (95% CI) t F P

First choice of admissionDentistry 212 (66) 69.51 (67.33—71.69) 1.39 0.18 NS 1.92 (1.85—1.98) )2.53 <0.01 <0.05Other 108 (34) 66.92 (64.00—69.84) 2.07 (1.97—2.17)

Parents’ occupationDentist 78 (25) 67.68 (64.31—71.04) )0.62 0.21 NS 1.89 (1.78—2.00) )1.72 0.94 NSOther 241 (76) 68.87 (66.81—70.92) 2.00 (1.93—2.06)

Living with familyYes 188 (54) 68.12 (65.83—70.41) )0.47 0.78 NS 2.00 (1.92—2.07) 0.89 0.04 NSNo 168 (46) 69.12 (66.40—71.84) 1.94 (1.85—2.03)

ScholarshipYes 76 (24) 68.45 (64.36—72.54) )0.14 4.00 NS 1.99 (1.87—2.11) 0.37 0.04 NSNo 243 (76) 68.61 (66.68—70.54) 1.97 (1.90—2.03)

Part-time workYes 87 (66) 68.57 (66.49—70.65) 0.01 1.72 NS 1.95 (1.88—2.02) )0.97 0.64 NSNo 268 (34) 68.58 (65.36—71.81) 2.01 (1.91—2.11)

Regular exerciseYes 160 (50) 72.31 (69.92—74.69) 4.39 0.20 <0.01 1.87 (1.80—1.94) )3.53 3.42 <0.01No 160 (50) 64.87 (62.42—67.31) 2.07 (1.99—2.15)

NS, not significant.

Sugiura et al.

22

normal values can be considered to be in the range of

78—83 (25).

In this study, the total score on the PGWB index for

TMDU students was 68.6. This value is relatively

lower than the population norm of the PGWB total

score (80.9—82.2) (25, 27). However, subjective well-

being varies across cultures. People from collectivist

cultures, such as Asian cultures, report less well-being

than do people from more individualistic cultures,

e.g. mainstream United States and Western European

cultures (24). This difference may arise from the fact

that subjective well-being is typically defined and

measured with an emphasis on an individual’s sub-

jective feelings and beliefs. We should be extremely

cautious when using cut-off points for the classifica-

tion and only nation-specific cut-off points should be

employed (30). Unfortunately, normal values for a

Japanese population are not available. In TMDU, the

psychological well-being of the students was higher if

they had a habit of regular exercise. This suggests that

students participating in the university club systems

had also good human relationship through sports

activities. Statistically significant gender differences

were observed in total score and depressed mood and

anxiety dimension scores of PGWB. This suggests that

male students’ overall well-being status was better

than females.

Perception of stress on the students by DESquestionnairePrevious studies have shown that students who had

medicine as first choice for admission tended to have

higher stress levels than those whose first choice was

dentistry (10, 20). As a student may have wanted to

join a course that is neither medicine nor dentistry, a

third opinion of ‘others’ was included. Differences in

responses may reflect a feeling of dissatisfaction with

the future profession as dentistry was not chosen

willingly by these students. Dental educators need to

be sensitive to these groups and perhaps consider

either counselling or special group seminars to discuss

issues related to their choice and dentistry as a career

with significant opportunity for these students.

In agreement with previous reports (9–12, 16, 23),

female students were more stressed than their male

counterparts. This study tends to support the view

that there are some gender-derived differences in

dentists in Japan. The distribution of Japanese dentists

by gender shows the ratio of female dentists is less

than 20% (31). Usually dentistry in Japan is perceived

to be a profession for males by virtue of the physical

work demand. Dentistry in Japan is a male-dominated

profession and the percentage of female dental

students for each class seldom exceeds 50%. Female

students may feel inadequate due to their minority

status and lack of role models. However, in recent

years, as the number of female students is increasing

in Japanese dental schools, this perception may be

changing. These differences may diminish in future as

women assume a more assertive role in dentistry in

Japan.

No significant differences were found in mean DES

score for year of study. This finding is different from

previous reports (13, 15, 23). Students’ stress level

showed highest in the transition year from pre-clinical

to clinical training, because of additional pressures on

unfamiliar patients’ care. In TMDU, fifth year students

had the highest stress scores but significant differences

were not found with another years of students. Sixth

year students are the only students involved in

delivery of direct patient care. Fifth year students are

in the transition year from pre-clinical to clinical

training. This elevated finding of stress is consistent

with international trends and also suggests that the

longer pre-clinical training of Japanese students may

increase their confidence thus reducing, in part at

least, their levels of perceived stress.

Consistent with a previous study, the habit of

physical activity was only related to the students’

perceived stress (21). Stress level of dental students

was not associated with any of the other six health

behaviours. Students with a habit of regular exercise

of more than once a week showed significantly lower

stress levels. Practising some kind of sports should be

recommended as a stress-reduction programme for

dental students.

Association of general well-being and perceptionof stressSignificant inverse associations were detected

between general well-being scores (both the total

and each of the six dimension scores) and the

perception of stress amongst dental students. The

results indicate that students with high well-being

scores experience less stress. To investigate the

extent to which perception of stress was affected

by social background, health behaviour and psycho-

logical well-being, stepwise multiple regression ana-

lysis was conducted. The model had a high

coefficient of explaining variability in DES. Theoret-

ically, the model accounted for 31% of the variability

in students’ perception of stress at dental school.

According to the stepwise multiple regression ana-

lyses, the most strongly related variable for percep-

tion of stress was psychological well-being followed

by first choice for admission and gender.

Psychological well-being and perceptions of stress

23

Promoting a new curriculumAt present in TMDU, the faculty plans to launch a

new curriculum including problem-based learning

and early exposure systems, along with providing

greater flexibility for students to develop their pro-

fessional attitudes. In order to design a new curricu-

lum to enhance students’ well-being and academic

performance as well as clinical skills, the faculty

conducted workshops for both teaching staff and

students. The findings of this study could be useful to

develop a student-oriented new curriculum. Accord-

ing to the present study, the faculty should promote

physical exercise and counselling within their student

programmes, especially for female students, students

who choose another discipline as their first choice,

and for smokers. And it would be fruitful to conduct

a follow-up study after the new curriculum has been

launched.

Conclusions

The results of the present study may not represent

student perception of stress in other dental schools.

This study revealed that the perception of stress

would be influenced by gender, first choice for

admission and PGWB. Physical activity was signifi-

cantly related to the low perceived stress levels and

high PGWB status. There were no differences in

perception of stress and psychological well-being

between the years of study. It would be of interest to

compare the present dental students in TMDU with

students who attend the same school several years

later as considerable changes in curriculum will be

introduced in a few years.

Acknowledgements

We acknowledge the valuable academic advice of

Professor F. A. C. Wright, Chief Advisor (Oral Health)

New Zealand Ministry of Health, former visiting

professor of Tokyo Medical and Dental University.

Part of this research was presented at the 22nd

Congress of Japanese Dental Education Association

in Nagasaki, 2003.

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Address:

Dr Go Sugiura

Department of Oral Health Promotion

Graduate School

Tokyo Medical and Dental University

1-5-45 Yushima, Bunkyo-ku

Tokyo 113-8549

Japan

Tel: +81 3 5803 5476

Fax: +81 3 5803 0194

e-mail: gosan15jp@yahoo.co.jp

Psychological well-being and perceptions of stress

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