*Statistical Analysis*

Data were exported to Excel from Google Docs initially and were then transferred to SPSS (version 22, IBM, Chicago, USA) for analysis. Sociodemographic characteristics of the participants were presented in the form of frequencies, percentages, mean, and standard deviation (where appropriate). A chi-square test was performed between demographics and perceived stress categories (low, moderate, and high) to compare them. Mean PSS score was compared for age categories, participants group, and level of education using One Way ANOVA. Logistic regression models were created to evaluate the crude association between PSS Score (dependent) and demographical characteristics (independent variables). Predictors with less than <0.10 were retained for the final regression model. All individual predictors were combined, and an unstandardized B coefficient, 95% CI, was presented. *p*-values ≤ 0.05 were considered significant.

#### **3. Results**

Our study had a response rate of 65%. In our study, more than half of the participants were female (65%), and majority of the participants (70%) were dental students with a mean age of 26.71 years. Among the dental students, 19% were junior students (second year), followed by fourth-year students and interns (18% each). Faculty participants were found to be the lowest among the respondents (15%) (Table 1).


**Table 1.** Showing demographics of the participants in our study.

The majority of participants showed moderate stress, and they were aged >40 years. Participants below 20 years were most stressed (21%), followed by 20–30 years old (18%), and the eldest participant group of the study showed no severe stress levels (0%). Age categories were significantly associated with the level of stress (*p*-value = 0.043). Female participants were more severely stressed than males (17% vs. 10%, respectively), and the association between gender and level of stress was also statistically significant (*p*-value = 0.040). Similarly, among the participants' group, the students were found more on the severe stress side (19%) (*p*-value = 0.002), and among them, the senior year level (6th year) showed significantly higher stress level compared to junior year students (*p*-value = 0.005) (Table 2).


**Table 2.** Showing stress levels of the participants involved in our study. Stress levels are presented as mean (SD).

\* significant at *p* < 0.05.

In the present study, the average PSS score for the participants was computed as 29.89 (range score: 0–52) which explains the moderate stress level seen in the participants. All the participants' groups when evaluated by age and academic year levels, showed a significant mean difference in PSS score (Table 3). The average PSS score significantly reduced with the increase in age (*p*-value = 0.001). Stress score was significantly higher among the students as compared to the faculty (31 vs. 28, *p*-value = 0.001). Among the students, the highest PSS score (34.41) was recorded among the most senior students (6th year) whereas, the lowest score (30) was recorded among the most junior students (2nd year), and the differences were statistically significant (*p*-value = 0.001).

**Table 3.** Showing the average PSS scores of the participants involved in our study.


\* significant at *p* < 0.05, a,b same alphabets show significant difference.

Hosmer and Lameshow test statistics support the model fitness (Ҳ<sup>2</sup> = 6.003, *p*-0.199), and small Negelkerke R-square values support the good of fit test (R<sup>2</sup> = 0.091). Logistic regression revealed that female students were more likely to have high stress compared to

the male participants (OR: 4.89, *p*-value = 0.027), whereas the increased-age participants were less likely to have stress compared to the younger age group participants (less than 20 years old) (Table 4).


**Table 4.** Logistic regression analysis associated with factors possibly related to high stress.

\* significant at *p* < 0.05.

#### **4. Discussion**

In the present study, the average 14-item PSS score for the participants was computed as 29.89 (range score: 0–52). Our results revealed a comparable stress level when they were compared to a study conducted on medical students in India, where the average PSS scale score was 27.60 [28]. This similarity in both countries indicated that the pandemic had left its effect on the minds of medical students [29]. Another study conducted in Saudi Arabia evaluated stress levels of the university students using the Arabic version of the PSS demonstrated that 86.7% of the participants had moderate- to high-stress levels [30]. Similarly, a Spanish study conducted by Odriozola-González et al. [31] reported moderate to extreme anxiety, depression, and stress scores (21.3%, 34.19%, and 28.14%, respectively) among the university students during the pandemic, which are in line with the stress score of our study. These psychological responses during the time of social distancing might be due to lack of interpersonal communication, the fear of getting infected, and transferring the disease to close family members. Son et al., previously reported increased levels of stress, depressive thoughts, and anxiety in medical students [32]. Our study also reports that most of the participants were moderate to severely stressed due to the pandemic situation. Almost similar stress scores in the above-mentioned studies from different countries in comparison to our study indicate that COVID-19 has affected students around the world similarly. In addition to social distancing, stress can be due to academic, financial, and social difficulties. Coping with the online mode of teaching might also be a challenge for students as they might have faced difficulty in dealing with technology, and faced other problems like absence of stable internet connection, and other online challenges [33]. Our results, when compared with the previously validated studies conducted on healthy populations [31,32,34], showed higher stress, which shows the adverse impact of the pandemic.

In the current study, the mean PSS scores were higher in female participants, with 65% of the female participants showing moderate to severe levels of stress. Another study reported that 73.5% of the females reported moderate to severe stress [35], supporting the current study findings. The female participants of our study were found to be more stressed than males (17% vs. 10%, respectively). A study conducted in South-Western China evaluated stress and anxiety, and the stress scores reported were higher in female quarantined communities during the COVID-19 outbreak when compared with their counterparts [35]. Similarly, another study conducted on undergraduate students in Turkey reported higher stress levels among female students [36]. Earlier studies conducted in Saudi Arabia have reported high-stress scores among different university students, and stress levels were higher among female students [6,17]. The high levels of stress seen in our female participants could possibly be attributed to the fact that males tend to hide their fears due to their conventional gender role [37], which could have led them to report less stress levels in our study. Another plausible reason could be owed to neuroticism (trait of being anxious and emotionally vulnerable), which is found to be more common in females [38], and this could have also resulted in the observation of higher stress levels reported by females in our study. It should also be considered that during the pandemic, mandatory lockdowns were implemented, and females are more at risk of suffering the effects of loneliness on their mental health compared with the males [39], and this could have triggered them to report higher stress levels in our study as well. In addition, in contrast to our study findings, a Chinese study conducted on university students during the COVID-19 outbreak reports no gender-related differences among male and female students regarding stress [40]. In general, medical studies are stressful [41], but a conclusive reason responsible for the different stress levels seen among female and male students could not be determined and requires further investigations.

The COVID-19 has inflicted psychological distress among all population groups [42]. Age-wise, the participants who were less than 20 years old were found to be more stressed, and the PSS score reported in our study decreased linearly with the increasing age of the participants. A previous study has reported that younger people were more vulnerable to depression, stress, and anxiety during the COVID-19 pandemic [43], and our study results are in agreement with that study. Another earlier study reported similar findings and revealed that younger-aged female participants reported more stress levels than all other groups [44]. A probable reason for this finding could be attributed to the fact that younger people worry about their health and academic performance, as shown by an earlier study [45]. On the other hand, older-aged people are better at developing coping strategies to tackle stress [46] and therefore, because of this, they reported lower stress levels in our study.

In the current study, dental assistants/nurses showed the average PSS scores of 27.0, which refers to a moderate stress scale. A Turkish study before the COVID-19 outbreak determined that nursing students face stress levels that could be classified as being above moderate levels [47]. Another study from India indicated moderate levels of PSS scores in nurses with a mean score of 21.88 [48]. Our study also identified moderate levels of stress experienced by the dental assistants/nurses during the pandemic. On the contrary, a study in Norway reported a substantial psychological impact of COVID-19 on dental assistants, causing more stress [49]. The reason for stress seen in this group could be attributed to the fact that dental assistants/nurses have to fulfill their duties even at the time of a pandemic. Lack of personal protective equipment (PPE), discomfort caused by the prolonged usage of PPE, increased workload, along with less experience to deal with the novel virus might have contributed to the stress levels seen in this group [50].

The average PSS score of the faculty in the study indicated the mean score of 28, which indicated that along with the students, the university faculty was equally affected by the pandemic. A study performed in India reported perceived stress to be moderate in dental faculties, which is not in line with our study [51]. However, a study from Norway reported that dental professionals could face increased psychological impacts related to the COVID-19 pandemic [49]. The high-stress score seen in the faculty in our study could be attributed to the fact that dental faculty not only have to be concerned about their own safety, but also for the well-being of their patients, students, and dental assistants as well. They are more vulnerable to infection because of having a close contact with their patients in clinics and while teaching their students during the clinical sessions. A previous study has also reported that dental professionals from all over the world perceive a higher risk of COVID-19 contamination [52]. The lack of knowledge about the controlling of infective virus might have also caused a widespread panic among the faculty in our study. A study conducted in China also reported higher levels of perceived stress in medical staff [53]. It should be noted that psychological stress weakens immunity and makes the person prone to infections [54]; hence, this problem should be tackled as early as possible.

Several countries, including Saudi Arabia, took measures to control the rapidly spreading virus. Citizens were asked to isolate themselves at home and take preventive measures since the advent of the pandemic. Outbreaks like Ebola [55], Severe Acute Respiratory

Syndrome (SARS) [56], and MERS [57] have shown some unique concerns related to the mental health of individuals. The situation of lockdown and missing out on major academic tasks (practical sessions and clinical rotations), might have made students more stressed about their future [58], as seen in our study. The effects of COVID-19 are global [59,60] and our study provides a platform for the institute's policymakers and administrators to provide social assistance to the vulnerable groups.
