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Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 294-298

Association of extracurricular activities and burnout among students in a dental teaching institution in India

Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission04-Jun-2021
Date of Decision12-Jul-2021
Date of Acceptance08-Nov-2021
Date of Web Publication15-Dec-2021

Correspondence Address:
Venkitachalam Ramanarayanan
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi - 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_95_21

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Background: Burnout syndrome (BS) is related to work and is generally seen among health-care professionals including students. Students use various coping mechanisms to deal with stress and burnout and extracurricular activities are one among them. Aim: The aim of the study is to assess the burnout levels of dental students and its association with the indulgence in extracurricular activities (ECA). Materials and Methods: A cross-sectional questionnaire study was conducted among students of a deemed university dental school in south India. All the students from 1st year to 5th year (internship), both regular and supplementary batches were included. Maslach Burnout Inventory-Student Survey was used to assess burnout which consists of 15 items on three domains emotional exhaustion (EE), cynicism (CY), and professional efficacy (PE). All the responses were scored on a five point Likert scale. Mann–Whitney U-test and Poisson log-linear model were used. A P ≤ 0.05 was considered as statistically significant. Results: A total of 208 participants were included in the final analyses. Majority of the participants were females (84.1%) and 1st-year students (26.4%). The mean age of the participants was 20.6 ± 1.8 years. The prevalence of BS was 19.7%. A significant difference was seen for the participation in ECA and all the three domains (EE, CY, PE) of BS (P values 0.029, 0.004 and 0.006, respectively). Conclusion: The prevalence of burnout can be considered as high among the participants. Early screening for burnout in dental students and effective interventions at earlier stages is required.

Keywords: Burnout, dental, leisure activities, students, syndrome

How to cite this article:
Kumar YS, Ramanarayanan V, Rajesh R, Francis ST, Ganesan S, Kumar S V. Association of extracurricular activities and burnout among students in a dental teaching institution in India. J Indian Assoc Public Health Dent 2021;19:294-8

How to cite this URL:
Kumar YS, Ramanarayanan V, Rajesh R, Francis ST, Ganesan S, Kumar S V. Association of extracurricular activities and burnout among students in a dental teaching institution in India. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Aug 19];19:294-8. Available from: https://www.jiaphd.org/text.asp?2021/19/4/294/332541

  Introduction Top

Burnout is the end result of prolonged exposure to stressful environments. Burnout syndrome (BS) can be defined as “a progressive process of emotional exhaustion (EE) and loss of professional interest, due to a prolonged period of exposure to high levels of stress arising from work situations, emerging especially among professionals who exercise care for others.”[1] The 11th Revision of the International Classification of Diseases-11 defined burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”[2] BS is a multidimensional syndrome, usually associated with dehumanization, reduced work efficiency, emotional fatigue, insomnia, and depression.[3] BS can be considered as a public health issue due to its physical, mental, and social health implications for individuals.[4]

Stress may be experienced by all in different aspects of their lives but BS is related to work and is generally seen among health-care professionals, teachers, social workers and in other occupations where caring for others is required.[5] However, recently, BS concept is extended to all occupations including students. Medical, dental, and paramedical studies are arduous tasks requiring long hours of study, resulting in mental fatigue. Students are exposed to an immense amount of knowledge which they are expected to master in a short span of time. The stress thus created gradually multiplies through preclinical and clinical years leading to burnout and depression in many students.[6] Preclinical years are stressful because of the need to accumulate vast amounts of theoretical data while patient care, clinical knowledge, and skill acquisition stress the students in the clinical years.[7] A study reported BS as an independent risk factor among US medical students for suicidal ideation and can lead to dropping out of the course.[8]

Students use various coping mechanisms to deal with stress and burnout.[9],[10] Many indulge in extracurricular activities (ECA) such as sports, arts, music, reading, and social activities such as volunteering, community services. The perks of participation in ECA are well reported in literature. Leadership abilities, social self-confidence, conflict resolution, competitiveness, companionship, teamwork were reported higher among students who volunteer.[11] These activities reduce stress levels and also greatly improve both physical and mental health. Such activities involve analysis of problem, positive interpretation, radical thinking, and problem solving. The social support and expression of emotion reduce stress and burnout.[12] They create a sense of emotional support, clarity of mind, and companionship that helps to cope with academic situations.[7] A longitudinal study reported that the total number of ECA's was positively associated with psychological resilience, school belonging, and academic peers.[13]

Most of the research in literature focused on working physicians and medical students, especially during the clinical years and studies among dental students are scarce in the literature.[14],[15],[16],[17] Hence, the aim of this study was to assess the burnout levels of students in a dental school in India and its association with the indulgence in ECA.

  Materials and Methods Top

A cross-sectional questionnaire study was conducted during the period of January 2019 to April 2019 among students of a dental school (recognized by Dental Council of India) in South India. All the students from 1st year to 5th year (internship), both regular and supplementary batches who were willing to participate and present on the day of survey were included. Prior approval from the Institutional Ethical Committee was obtained (IRB-AIMS-2018-256). Students were instructed to respond in 10 min to the items in a pretested self-administered questionnaire which consisted of three sections. The first section consisted of demographic information like age, sex, year of study. The second section included seven questions regarding the participation, frequency, opinion of participation in ECA, and type of ECA like sports, arts, volunteer and community work, music, and clubs. Finally, the third section consisted of 15 questions from the “Maslach Burnout Inventory-Student Survey (MBI-SS).”[14] Pretesting was done in a sample of 10 students (who were not included for the main study) for face validity and to evaluate the time taken for completion of questionnaire.

BS has three domains, namely “(EE-due to educational demands),” “Cynicism (CY) (CC-indifference/apathetic attitude toward academic activities),” and “low professional efficacy (PE-perception of incompetence as a student).” MBI-SS consists of 15 items to evaluate BS with five items evaluating EE, four items evaluating CC, and six items evaluating PE. All the responses were scored on a five-point Likert scale, namely “never,” sometimes,” “often,” “regularly,” and “always.” The scoring for the items in PE domain was reversed. Higher scores in EE, CC and lower scores in PE indicate BS.

The BS is grouped into three categories based on the total scores as low level (“EE” [0–9], “CY” [0–1], “PE” [>27]), moderate level (“EE” [10–14], “CY” [2–6], “PE” [23–27]), and high level (“EE” [>14], “CY” [>6], “PE” [<23]). This study also classified students having tri-dimensional burnout (“EE” [>14] and “CY” [>6] and low for “PE” [<23]) and bi-dimensional burnout (“EE” [>14] and “CY” [>6]).

The Statistical Package for the Social Sciences (SPSS) Version 20 was used for analysis. A P ≤ 0.05 was considered as statistically significant. Normality of the data was tested using Kolmogorov–Smirnov test. Mann–Whitney U test was used to compare the mean score of subscales with demographic variables. Poisson log-linear model was used to evaluate the effect of participation in ECA after adjusting age and gender with dependent variable as subscales of the MBI-SS.

  Results Top

A total of 208 participants were included in the final analyses. Majority of the participants were females (84.1%) and 1st-year students (26.4%). The mean age of the participants was 20.6 ± 1.8 years. Nearly 88% of the participants felt that active participation in the ECA helped in enhancement of skills and provide value addition to academic achievements. Forty percent of the students opined that the activities does not clash with academics and 66% perceive them as enjoyment and felt that they add extra weightage to resume. Almost all the students (96.6%) participated in some kind of extracurricular activity and 90.4% participated in more than one activity. For more than half of the participants, the course was second choice and 25% considered dropping out. Twenty-one percent of the students reported of taking some type of medications due to stress-related to studies. The prevalence of bi-dimensional burnout was 19.7% and tri-dimensional was 1.9% [Table 1].
Table 1: Characteristics of the study participants

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The mean scores of EE (6.38 ± 4.07), CY (2.71 ± 2.86), and PE (8.07 ± 4.60) were significantly better among the students who participated in ECA (P = 0.029, 0.004, and 0.006, respectively). The mean CY scores were significantly less (P = 0.013) in the students who felt that active participation in ECA (2.66 ± 2.89) helped in enhancement of skills compared to those who did not participate (4.04 ± 2.88). The students who had a good opinion about ECA had significantly lower score for EE (P = 0.038) and CY (P = 0.001) domains [Table 2].
Table 2: Mean domain scores according to items on extracurricular activities and domains of Maslach Burnout Inventory-Student Survey

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Poisson regression analysis was performed to evaluate the relationship between predictors and outcome variables. Participation in ECA showed a significant association with EE (relative risk [RR] = 1.48; 95% confidence interval [CI] = 1.15–1.89), CY (RR = 2.22; 95% CI = 1.62–3.03) and PE (RR = 1.63; 95% CI = 1.32–2.01). Furthermore, the association remained significant with a slight decrease in the RR values even after adjusting age and sex. For the item “Active participation in ECA helps in enhancement of skills?” there was a significant association with CY (RR = 1.4; 95% = 1.22–1.89). The association remained significant but a slight decrease in RR was seen after adjusting for age and sex [Table 3].
Table 3: Poisson regression model to evaluate the participation in extracurricular activities and domains of Maslach Burnout Inventory-Student Survey

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  Discussion Top

This was the first study to evaluate any association between BS and ECA among dental students. The MBI-SS was validated across Europe[14],[18] and Asia[19] in different languages. Although many other instruments are available in literature such as “Oldenburg inventory-SS,”[10] “Copenhagen inventory-SS,”[20] “ Utrecht work engagement scale for students,”[21] and “professional quality of life 9,”[22] the MBI-SS is most commonly used, and hence, we used the same instrument in our study to assess the burnout levels.

The BS is seen commonly in dentist professions both during training[15],[23],[24],[25] and during practice[26],[27],[28],[29],[30] involving both physical and mental efforts. However, the causes and risk factors for burnout are different during a student stage and practitioner stage. The prevalence of burnout in this study was 19.7% which was similar to prevalence reported by Campos et al.[14] and Yeturu et al.[15] However, studies in literature reported varying prevalence of burnout among dental students due to use of different instruments and also improvement in the education and technology in general over time. A systematic review by Singh et al.[31] summarized that younger age, male gender, high working hours, clinical departments, and certain personality types were the most prevalent and significant factors related to BS.

The type of personality and its relation to BS was investigated by some authors in the literature. Baran[29] reported that some personality types are over-represented in the dental field and these personality types are more inclined to study dentistry. Hence, they may be more able to deal with the pressures of their working environment and making them less prone to burnout.

The effects of ECA generally reported a positive and protective in literature.[13] However, the evidence among medical students and interns reported little to no association between ECA and BS.[7],[32],[33] However, the different types of ECA were associated with the individual domains of BS. The interns who were participating in some kind of community activities had lower levels depersonalization,[32] music-related activities significantly correlated with low burnout, physical exercise was significantly associated with low stress, and social activities were significantly correlated to low CY.[7] Similar results were seen in this study with significant differences for all the three domains of BS between the students who participate in ECA and who do not. The association stayed significant even after adjusting for age and gender. A study by Almalki reported that students who were organizer for various ECA were less likely to have low PE. More emphasis should be on the quality of involvement in ECA rather than the quantity (frequency).[33] All the studies reported in the literature were conducted either in medical students or medical interns. As this study was conducted among dental students, a direct comparison with literature was not possible. The ECA could be viewed as an expression of student's autonomy and increasing motivation.

The study suggests a difference between the domains of BS and the ECA participation, highlighting the importance of ECAs that may influence the development of occupational diseases in dentistry students. It is important to mention the possibility of a selection bias and social desirability bias in this study. Being a cross-sectional study, the direct of relation between BS and ECA cannot be explored. A gender-based comparison could not be done due to a skewed gender ratio in the study population.

  Conclusion Top

The prevalence of burnout was 19.7%. A significant difference was seen for the participation in ECA and all the three domains of MBI-SS. Most of the students were low in EE and moderate in CY and PE. Early screening for burnout in dental students and effective interventions at earlier stages is required.

Financial support and sponsorship

This was a self-funded study.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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