SciELO - Scientific Electronic Library Online

vol.73 issue4Parents' perception of psychosocial factors, health-compromising behaviours and oral health among adolescents in South AfricaSynopsis of publications in Dentistry from the University of the Western Cape author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand



Related links

  • On index processCited by Google
  • On index processSimilars in Google


South African Dental Journal

On-line version ISSN 0375-1562
Print version ISSN 0011-8516

S. Afr. dent. j. vol.73 n.4 Johannesburg May. 2018




Does smartphone connectivity impact on undergraduate dental students' environmental stress?



Khan S.

BChD; PDD (Clin Dent); MSc (Dent); PhD(Comm Health). Senior Lecturer/ Principal Dentist, University of the Western Cape,Private Bag X01,Tygerberg. 7505





INTRODUCTION: Several studies have suggested that smartphone addiction has negative effects on mental health and academic performance and may contribute to the development of stress.
AIM: To determine the prevalence of smartphone addiction and its impact on stress levels of students registered for the degree BChD in 2017 at the University of the Western Cape.
OBJECTIVES: To establish the impact of smartphone addiction and associated stress levels on student performance.
METHODS: A cross-sectional descriptive study with a convenience sample of dental students, based on a self-administered closed-ended questionnaires:" Dental Environment Stress and Smartphone Addiction Scale". The responses were statistically analysed.
RESULTS: Ethical clearance was obtained for the study. The Mann-Whitney test output indicates no difference in attachment between smartphone and non-smartphone owners (p=0.615). Students agreed that mobile devices could be used for academic purposes but not that this usage be made compulsory.
CONCLUSION: More stress is experienced in certain domains and students displayed some degree of attachment, not addiction, to their smartphones. Serious impacts may be experienced by non-smartphone owners.




Mobile devices keep us connected to the world, even though some may question the quality of this connection.1 Cell phones, smartphones, tablets and computers must be appreciated as useful. They are a necessary addition to our tools of communication, having multiple functionalities which extend to application within the academic environment.2 In that scenario it is not just about the communication between students and staff, but notes may be downloaded and assessments conducted via these devices. Indeed, the acquisition of these very expensive IT units may become compulsory when they are required for assessments. Cell phones may then be seen as an asset in the lives of young people and their day-to-day activities, including academe.3 However, the insistent demands and the consistent presence of these devices may exacerbate the already stressed dental environment experienced by students.4-5 An added stress occurs when acquiring and then maintaining these expensive technological devices. Paradoxically, the use of cell phones was expected to have reduced the stress in the first place.

Stress is defined simply as a reaction to a stimulus that disturbs our physical or mental equilibrium and it is generally part of life.6 It is when the stressors become chronic, that there may be detrimental effects on the health and quality of life of individuals.1,7 Difficulties may be experienced in controlling these stressors when mobile devices are used.1 Consider the tensions involved, for example: keeping up with happenings via social media, wanting to create a social media persona, lack of privacy in social media, just being connected or separation anxiety when without a phone.1-2 Moreover, several destructive behavioural characteristics have also been observed in the lives of young individuals with constant exposure to these devices, namely; phone-addiction, sleep deprivation, poor academic performance and increased stress development.1,3,7

Stress-related research amongst dental students has been conducted globally.1-3,7-15 Several studies related to stress experienced by dental students have been conducted over the years at the University of the Western Cape (UWC).4,8,16 The researchers explored different aspects that ould cause stress and/ or increase the stress levels of students. The cohorts that were included had very different demographic features, for example:4,8,16

1. Hendricks, Joshi, Crombie and Moola (1994) determined the "perceived sources of stress among black dental students in South Africa (SA) prior to the democratic elections.16 This study, conducted more than 20 years ago, reported that non-academic (cultural and ethnic differences) rather than academic problems added more to students' stress levels.16

2. Naidoo et al. (2008) and Pau et al. (2009) determined the "emotional intelligence and its relation to perceived stress" by conducting a multinational survey across seven different countries (including RSA) which also included a qualitative study amongst English students.8-9 Differences in stress levels between countries and institutions were found as also reported in another study (Alzahem et al., 2011).8, 10 The differences highlighted were age, gender, educational background and satisfaction with career choices.8-9 A significant inverse relationship between emotional intelligence and perceived stress was detected, implying that students can indeed cope with the stressful demands of this career choice. More so, that emotional intelligence is important In professional competence, and thus has a key role in the selection of students to study Dentistry.8-9

3. Amongst the students of 2010, Wilson et al. (2015) determined their environmental stress levels and risk of burnout as these could contribute to a decrease in efficiency.4 This particular study found that dental stressors increase and reach a peak as students progress to their clinical years. The conclusions were that high levels of perceived stress in the particular academic environment subsequently resulted in psychological morbidity and emotional exhaustion among dental students,4 possibly predisposing them to professional burnout and decreased productivity.1,4

Students in different dental environments have experienced an Increase in stress levels with differing factors (both academic and non-academic) contributing to the problem.4,8,9,16

Within RSA, the protest actions that took place in the 2015 and 2016 academic years certainly added another dimension to the stress levels of students, impacting on their studies which could not proceed in an academically conducive environment. At such times of restricted contact, smartphones and computers may be expected to aid and assist communication and to improve accessibility. However, an already stressful setting may be further exacerbated if accessibility is affected, for whatever reason.

Smartphone use may serve as an aid or may impact as a non-academic stressor; its effects and impact on the lives of the UWC dental students have not yet been determined.



To determine the prevalence and addiction to smartphone use and to assess its impact on the stress levels of students registered for the degree BChD in 2017.



To determine

1. the prevalence of stress resulting from the current dental environment among dental students attending the UWC Faculty of Dentistry.

2. the prevalence of smartphone addiction among the dental students.

3. the correlations between stress levels, current protest actions and the use of smartphones and its impact on students' learning across the different study levels at UWC's Faculty of Dentistry.

Null Hypotheses

1. Stress levels do not differ amongst currently registered dental students from different ethnic or cultural backgrounds, genders and study levels.

2. Students are not addicted to smartphones and their use does not increase their stress levels

Materials and Methods

A cross-sectional descriptive study with a convenience sample Including undergraduate dental students registered for 2017 was conducted over a period of three months at the Faculty of Dentistry, UWC, SA. Data was obtained using two self-administered, closed-ended questionnaires:

1. A dental environmental stress (DES) questionnaire which was adapted from a previous study.5 It was also modified for RSA and translated to the medium of communication. The first questionnaire focussed on determining the stress levels of all dental students registered for 2017. The DES questions related to stress are categorized into seven main domains:6

Self-efficacy and Beliefs (SEB),

Faculty and Administration (FA),

Workload (W),

Patient Treatment (PT),

Clinical Training (CT),

Performance Pressure (PP) and

Social Stressors (SS).

Protest actions (PA)

2. A Smartphone Addiction Scale to determine the dependence of students on their smartphones and the impact on their stress levels and learning.17

The second questionnaire focused on the technological devices, such as smartphones (including cell phones), which are required by students and their addiction to that technology.17 The questionnaire was a validated and shortened version of the Smartphone Addiction Scale (SAS-SV) which has been tested for reliability.17

Additional questions were related to any protest actions (PA) which had been experienced by students previously. The answers were analysed to correlate the impact on the stress levels of participants. Specially designed questionnaire forms were distributed to the registered undergraduate dental students after information had been provided and their consent obtained to participate in the study. Responses from questionnaires were recorded using 4-point Likert scales: Not Applicable, No Stress, Moderate Stress, Severe Stress and Strongly Agree, Agree, Disagree or Strongly Disagree respectively.5,17 These responses were combined as described by Al-Sowygh and by Kwm et al. to produce indices of stress and of addiction.6,17

Basic student demographic data were also obtained from questionnaires. Statistical analysis included descriptive statistics (frequency distributions, mean and standard deviation calculations) and appropriate non-parametric tests for association between domains and other variables (e.g. Wilcoxon Rank Sum, Kruskal-Wallis and Mann-Whitney U tests). Regression analysis were executed according to the purpose(s) of the study.18



Ethical clearance was obtained from the UWC Ethics Committee (Registration Number: 13/7/16). All participants signed a consent form according to the Declaration of Helsinki before participating In the study.19

Demographic Data

The response rates for the different classes by year were relatively consistent at about 90%, except for Class 5 where the rate dropped to 53%. For this reason, a weighting was applied to each student to correct this deviation from the population class proportions which were used with all calculations. The weightings are calculated as population proportion/sample proportion as shown in Table 1.

Students' responses related to the DES questions indicated that stress was experienced in the SEB, W and PP domains as well as In those areas related to protest actions (PA) (Table 2).


Figure 1


Results from a Wilcoxon signed rank test clearly showed a significant bias towards females who experienced a greater prevalence of stress than their male counterparts (p=0.0000). A Mann-Whitney U test was also conducted, using the weighted average stress indices of males against females in all domains. The results showed extreme significance in all except the SS domain, which showed no gender difference (Table 3 and 4; Figure 2).



With regards to differences in stress levels between classes, it was no surprise (as in previous studies) that the fourth year class displayed positive levels of stress in the overall and average index (Table 4).4 The fifth year students experienced much stress in the PA domain (having been exposed to protests in both 2015 and 2016), whereas the third year class experienced greater stress in the W and PP domains than did the fifth years. The differences in stress levels across classes were found to be significant (p=0.000) from the results of the non-parametric Kruskal-Wallis tests for most domains except the SS and SEB domains.



Most students owned either a cell phone (35.8%) and/or a smartphone (92.2%); a Mann-Whitney U test output indicates no difference in attachment between smartphone and non-smartphone owners (p=0.615). Only five students had no smartphone, tablet or computer but this does not imply they had no access to these devices for academic purposes. Gender differences were again observed across questions (similar to the results of stress prevalence), but the Mann-Whitney U results indicated females displayed significant levels of agreement for questions related to 'missing work' (p=0.024), 'cannot not stand not having phone' (p=0.0001) and 'having phone on my mind' (p=0.009) (Table 5).

Students' responses related to addiction are significantly in agreement only with questions referring to 'cannot stand not having phones' and 'using phones longer than intended', yet they don't perceive themselves to be addicted.

Responses from students indicated agreement (66.5%) of 'being attached to phones' and of experiencing stress (95.7%) 'when losing phones. Students mostly agreed that mobile devices could be used for academic purposes (73.9%) but not that this should be made compulsory (40%); though this is not the major cause of their stress. Students' responses indicated they would be stressed (78.7%) when compulsory assessments are conducted using this medium. Generally, results thus Indicate students experience addiction symptoms such as ownership, attachment and usage for certain tasks. But, students disagree that they experience any additional signs of addiction such as fretfulness, constant checking and concentration problems.



Comparing the results from both questionnaires, students indicated an increase in stress mostly across the SEB, W, PP and PA domains and they also agreed to a level of attachment to smartphones, though not explicit addiction. Significant correlations were observed between DES domains of W, PP, SS, overall and average indices and smartphone addiction questions of 'cannot stand not having phones' and 'not give up using phone even if daily life affected' as well as being 'attached to phones.'

The regression analysis for each index significantly contributing to the prevalence of stress provided results as follows:

a. Self-Efficacy Beliefs (SEB) stress index

The overall stress average was negative, but for questions related to 'fear of unable to catch up' and 'fear of failure' the results indicated high average responses to stress. Correlations with these questions are significantly related to 'compulsory use of mobile devices.' That implies that students who experienced stress when the use of mobile devices become compulsory had a higher SEB stress index. The 'fear of failure' with a new medium or increased rate of failure due to increased difficulties might provide some related explanations.

b. Workload (W) stress index

Overall stress averages were positive for this domain, and the type of stress is related to gender, class, 'cannot stand not having phone' and if 'phones are used for academic work.'

c. Performance Pressure (PP) stress index

PP stress is significantly related to gender, class (females in the senior classes) and 'using phone too much.' The students who experience greater stress in the PP domain are those who admitted 'using their phone longer than intended.1

d. Protest Action (PA) stress index

Stress prevalence was the highest for this domain and it was significantly related to gender, class and smartphone ownership. As has previously been indicated, senior female students and those who do not own a smartphone displayed a higher stress index in the PA domain. The reasons for these responses could be varied; owners could view the situation regarding protests at any time or find distractions on their smartphones or they may be concerned at not being able to do assessments via this medium.



It is accepted that that smartphones are an indispensable and necessary tool used especially for connecting and communicating between people, in addition to the many other services provided.

Research has also shown that dental students experience stress throughout their career, and that an increase in stress levels is observed amongst senior females in their clinical years.1,4,8-10 The current study is in agreement with these findings. Exploring different conditions affecting student learning such as emotional Intelligence, cultural differences, burnout, disruptions within the academic setting such as protests and the impact of smartphone use (either social or compulsory academic) will allow researchers to understand their learning needs more comprehensively.1,4,8-10

The benefits of smartphones have been established, including their use in the academic setting as an alternate or additional aid In perusing reading material and in conducting assessments. The role of smartphones in creating anxiety, especially with regards to attachment to the device, lack of privacy, affecting their daily lives and academic performance has also been documented.13,7 The current study records the advantage of smartphone use for academic purposes and the disadvantage of attachment further exacerbating student stress levels. However, no significant addiction to smartphones was disclosed, and thus any destructive behaviour as referred to in other studies are not anticipated with this cohort of students.13,7

The interest in using smartphones for academic purposes must be explored further as these could be of major benefit especially during times of disruptions, for assessments may be conducted online. However, as the results indicated that more stress was experienced by non-smartphone owners, it would be prudent to engage students on this issue before any demand for the use of the devices became compulsory. Smartphones and maintaining them is a costly matter, thus these discussions must take place between students and the institution before finality is reached.

The other related issue of concern would be the role of educators who will need to explore varied assessment options when conducting these via smartphones or online. Senior students may be relieved somewhat if theoretical assessments are conducted via this medium, but being aware that clinical work quotas may not be completed may still be a source of major stress for them, especially during periods of disruptions as previously experienced.



More stress is experienced in certain domains related to work, performance and failure; both internal (ability to cope with work) or external (protests) factors may negatively influence these domains. There is some degree of attachment by students to their smartphones, though significant addiction has not been explicitly proven; however, nor can it be concluded that students are not addicted to smartphone use. Serious impact may be expected should compulsory use be implanted for both non-smartphone owners and educators, though this aspect was not researched.



DES: dental environmental stress

SEB: Self-efficacy and Beliefs

FA: Faculty and Administration

W: Workload

FT: Patient Treatment

CT: Clinical Training

PP: Performance Pressure

SS: Social Stressors



1. Murdoch KK. Texting while stressed: Implications for students' burnout, sleep and well-being. Psychology of Popular Media Culture 2013; 2(4): 207-21.         [ Links ]

2. Sapacz M, Rockman G, Clark J. Are we addicted to our cell phones? Computers in Human Behaviour 2016; 57:153-9.         [ Links ]

3. Samaha M, Hawi NS. Relationships among smartphone addiction, stress, academic performance and satisfaction with life. Computers in Human Behaviour 2016; 57: 321-5.         [ Links ]

4. Wilson VJ, Rayner CA, Gordon NA, Shaikh AB, Crombie Κ, Yasin-Harnekar S. Perceived stress amongst dental students at the University of the Western Cape. SADJ 2015; 70(6): 255-9.         [ Links ]

5. Al-Sowygh ZH. Academic distress, perceived stress and coping strategies among dental students in Saudi Arabia. The Saudi Dent J. 2013; 25: 97-105.         [ Links ]

6. Oxford Dictionary of English. 3rd Ed, Oxford University Press; 2015 doi:10.1093/acref/9780199571123.001.0001.         [ Links ]

7. Leena K, Tomi L, Arja R. Intensity of mobile phone use and health compromising behaviours-how is information and communication technology connected to health-related lifestyle in adolescence? J of Adolescence 2005; 28: 35-47.         [ Links ]

8. Naidoo S, Pau A. Emotional Intelligence and perceived stress. SADJ 2008;63(3): 148 -51.         [ Links ]

9. Pau A, Rowland MA, Naidoo S, Abdul Kadir, R, Makrynika, E, Moraru, R, Huang, B, Croucher R. Emotional Intelligence and perceived stress In dental undergraduates: a multinational survey. J Dent Educ. 2007; 71(2): 197-204.         [ Links ]

10. Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG.Zamakhshary MH. Stress amongst dental students: a systematic review. Eur J Dent Educ. 2011; 15: 8-18.         [ Links ]

11. Kumar S, Dagli RJ, Mathur A, Prabu D, Kulkarni S. Perceived sources of stress amongst Indian dental students. Eur J Dent Educ. 2009; 13: 39-45.         [ Links ]

12. Birks Y, Mckendree J, Watt I. Emotional Intelligence and perceived stress in health care students: a multi-institutional, multi-professional survey. BMC Medical Education 2009; 9:61-7.         [ Links ]

13. Al-Saleh SA, Ebtlssam MA, Nadia SA, Huda AA, Mohammed MS. Survey of perceived stress-inducing problems dental students in Saudi Arabia. Saudi Dent J. 2010; 22: 83-8.         [ Links ]

14. Silverstein ST, Kritz-Sllverstein DA. A longitudinal study of stress In first-year dental students. J Dent Educ. 2010; 74(8): 836-48.         [ Links ]

15. Dahan H, Bedos C. A typology of dental students according to their experience of stress: A qualitative study. J Dent Educ 2010; 74(2):95-103        [ Links ]

16. Hendricks SJH, Joshi A, Crombie K, Moola MH. Perceived sources of stress among black dental students in South Africa. J Dent Educ. 1994; 58(6): 406-10.         [ Links ]

17. Kwon M, Kim DJ, Cho H, Yang S. The Smartphone Addiction Scale: development and validation of a short version for adolescents. PLoS One J 2013; 8(12): e83558.         [ Links ]

18. Dawson B, Trapp RG. Basic and Clinical Biostatistlcs. 4th Ed, Lange Medical Books/ McGraw-Hill Publishing Division, New York, USA 2004.         [ Links ]

19. World Medical Organization. Declaration of Helsinki. Br Med J 1996; 313:1448-49.         [ Links ]



Tel: 021 9373006
Fax: 021 9312287

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License