INTRODUCTION
The prevalence of mental disorders has in recent times increased at a surprising rate; approximately one in six individuals suffers from one or more psychiatric conditions that require medical intervention [1]. According to the 2019 Global Burden of Disease report, depression and anxiety disorders – two debilitating mental illnesses – rank among the top 25 causes of disease burden worldwide [2]. Stress occurs when environmental pressures and demands, whether real or perceived, exceed an individual’s capacity to cope [3]. For students, optimal stress levels can enhance learning capacity, whereas excessive stress can diminish it and lead to other negative outcomes [4]. Furthermore, stress is a contributing factor to depression, anxiety, misconduct, increased work absenteeism, reduced productivity, and job burnout [5].
According to the report of the World Dental Education Congress, “Dental education is regarded as a complex, demanding, and often stressful pedagogical exposure. It involves acquisition of required academic, clinical, and interpersonal skills during the course of learning” [6]. Research from various countries indicates that dental students commonly experience high levels of depression, anxiety, and stress. In India, the prevalence of depressive symptoms among dental students was found to be 38.50%, compared to 34.7% in medical students [7]. A study in Pakistan found that 31% of dental students suffered from depression, 9.41% experienced anxiety, and 5.12% were affected by excessive stress [8]. In Malaysia, nearly all dental students at the University of Malaya experienced stressful situations during their undergraduate education, and 89.7% of dentists reported that exposure to stress began during dental school [9, 10].
The study of dentistry is highly stressful, as it requires students to acquire a diverse set of skills, including theoretical knowledge per the curriculum, clinical proficiency, and effective communication [11]. This environment contributes to high levels of work-related stress among practicing dentists [12]. The sources of stress can be individual, interpersonal, or environmental [13]. The specific stressors for dental students, as identified in several studies, include excessive academic assignments, peer competition, fear of failure, difficulties in communicating with peers and professors, the complexity of treatments, the demands of comprehensive patient care, time pressures in clinical work, and managing anxious patients [14-18].
Improving communication skills is crucial for mitigating these psychological challenges. Communication skills refer to the ability to use appropriate verbal and non- verbal cues to interact effectively with others [19, 20]. This process of transmitting messages and information facilitates the clear expression of needs and the successful accomplishment of goals [21, 22]. In a healthcare setting, enhanced communication improves coordination among staff and enables better collection and use of patient information. This leads to fewer errors, greater overall satisfaction, increased productivity, and higher-quality care in overall [23]. The significance of these skills is underscored by studies linking insufficient communication skills to stress and depression in medical students [24].
Consequently, this study aimed to assess how anxiety, stress, and depression were associated with the communication skills of dental students at Jundishapur Ahvaz University of Medical Sciences in 2024.
Methods
Participants and procedure
This cross-sectional study was conducted in 2024 among dental students at Ahvaz Jundishapur University of Medical Sciences. A census sampling method was used, encompassing all students in their third to sixth years of study. The inclusion criteria required students to be enrolled in the third through to sixth years of the dental studies program. The participants who did not fully complete the questionnaires were excluded. The study protocol was approved by the Research Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (ethics code: IR.AJUMS.REC.1402.340). Informed consent was obtained from all participants prior to the study.
Measurement
Demographic questionnaire
The demographic section of the questionnaire ga-thered information on participants’ age, gender, marital status, place of residence, and year of dental education.
Communication skills of Queen Dam (CSTR)
The communication skills questionnaire used in this study was developed by Queen Dam in 2004. This 34-item instrument was designed to measure communication skills across five component areas: assertive communication, emotional control, listening skills, the ability to receive and send messages, and insight into the communication process. Participants rated each item on a five-point Likert scale, from 1 (never) to 5 (always), indicating the extent to which the statement described their current behavior. The total score ranges from 34 to 170, with scores of 34-68 indicating inadequate skills, 69-102 suggesting moderate skills, and scores above 102 reflecting high communication skills. The questionnaire demonstrated high reliability for this population, with a Cronbach’s α coefficient of 0.91 reported in previous research conducted in Iran [25].
Depression, Anxiety and Stress Scale (DASS-21)
The study used DASS-21, developed by F Lovibond and SH Lovibond in 1995. It includes 21 questions that are classified as stress (7 questions), anxiety (7 questions) and depression (7 questions). The participants are required to rate the frequency of experiencing the symptoms specified over the past week using a 4-point scale (ranging from 0 to 3). The scores for depression, anxiety, and stress are categorized based on the cut-off points of the DASS questionnaire, respectively for depression (normal = 0-4, mild = 5-6, moderate = 7-10, severe = 11-13, extremely severe = 14+); for anxiety (normal = 0-3, mild = 4-5, moderate = 6-7, severe = 8-9, extremely severe = 10+); and for stress (normal = 0-7, mild = 8-9, moderate = 10-12, severe = 13-16, extremely severe = 17+). This scale was validated in Iran by Sahebi et al. [26] in 2005. The internal consistency of the subscales was calculated through Cronbach’s α coefficient, and its values were 77% for depression, 79% for anxiety, and 78% for stress.
Statistical analyses
Data were analyzed using SPSS version 27 statistical software (IBM SPSS Statistics, Armonk, NY, USA). Qualitative variables were presented as frequency and percentage, and quantitative variables as mean and standard deviation. The normality of the data distribution was assessed using the Kolmogorov-Smirnov test. When the data were not normally distributed, non-parametric tests such as the Mann-Whitney U and Kruskal-Wallis tests were employed. Spearman’s correlation coefficient was used to examine the relationships between the variables. Structural equation modeling (SEM) via the partial least squares (PLS-SEM) approach was applied to investigate the relationships between communication skills and its components (the independent/exogenous variables) and the endogenous variables (depression, anxiety, and stress). A significance level of 0.05 was used for all statistical tests.
Results
Characteristics of the participants
In this study, out of 216 students who participated, 112 (51.9%) were male and 104 (48.1%) female. Most were single (89.4%) and half lived in dormitories (n = 112). The sample was split evenly between students in their third/fourth years (n = 110) and those in their fifth year or higher (Table 1).
Table 1
Demographic characters of participants (N = 216)
Correlation between depression, anxiety, stress and communication skills
The matrix of Spearman’s correlation coefficients for communication skills with depression, anxiety, and stress is presented in Table 2. The analysis revealed strong negative correlations between emotional control and both anxiety (ρ = –0.608) and depression (ρ = –0.613). A moderate negative correlation was also observed between insight into the communication process and stress (ρ = –0.477).
Table 2
Correlation between depression, anxiety, stress and communication skills (N = 216)
Structural equation model
Based on Table 3, the direct path analysis revealed that anxiety can predict emotional control (t = 4.437, p < 0.001), listening skills (t = 2.931, p < 0.05), and ability to send and receive messages (t = 3.263, p < 0.001). Also, assertive communication (t = 4.157, p < 0.001), emotional control (t = 4.552, p < 0.001), listening skills (t = 3.521, p < 0.05), and ability to receive and send messages (t = 2.17, p < 0.05) (β = −0.230, p = 0.05) was related directly to depression. Finally, there was a significantly different level of predictability for assertive communication based on stress level (t = 2.21, p < 0.05).
Table 3
The direct effects of stress, anxiety and depression scores on communication skills
The closer the coefficient is to one, the stronger the correlation, and the darker the arrow. Additionally, the R2 coefficient of determination measures the extent, to which changes in each dependent variable of the model are explained by the independent variables. A higher R2 value for the endogenous constructs indicates a better fit of the model. The blue circles display the R2 values, with 0.19, 0.33, and 0.67 representing weak, moderate, and strong values for the coefficient of determination, respectively.
The model quality of the structural model is as in Table 4 and including SRMR, d_UL, d_G and NFI. The Standard Root Mean Square Residual Index (SRMR), is the difference between the observed correlation and the correlation matrix of the structural equation model. If the index is less than 0.08, it indicates that the model fits properly so, the model does not fit well. NFI higher than 0.7 indicate an acceptable fit, which in this study NFI was 0.453. d_ULS squared Euclidean distance estimated 12.035 out of 10.727, which is higher value of the saturated equation model and indicates the good fit model.
Discussion
Based on the results of the current study, the mean communication skills score was high (104.20 ± 13.17), indicating appropriate communication skills among the dental students at Ahvaz Jundishapur University of Medical Sciences. This finding is consistent with Khalili et al. [27], who reported the score of 117.16 out of 155 for dental students’ communication skills and found that 43.3% of the students possessed skills at an acceptable level.
In contrast, another study reported a mean clinical communication skills score of 97.1 ± 38.0, suggesting a moderate skill level among its participants. A potential reason for this discrepancy is the use of different assessment tools and methods. For instance, the cited study employed an external evaluator, whereas the present study relied on self-reporting [28]. Consequently, the potential for social-desirability bias must be considered in the interpretation of our data.
The results indicated that anxiety was a significant predictor of emotional control, listening skills, and the ability to send and receive messages. This finding is supported by Ma and Lin [29], who demonstrated that social anxiety has a significant negative impact on students’ communication skills. It is plausible that anxious individuals exhibit weaker communication skills due to the lack of focus in selecting appropriate words and a reluctance to criticize or receive criticism [30, 31]. Furthermore, the results showed that depression was a predictor of emotional control, listening skills, insight into the communication process, and the ability to send and receive messages, while stress predicted only insight into the communication process. Consistent with this, Onan et al. [32], showed that stress in oncology nurses was related to their communication skills. In a contrasting finding, another study demonstrated that diabetic patients with severe depressive symptoms reported more extensive communication with physicians than those without depression, particularly in interactive and patient-centered domains [33].
This study has several strengths and limitations that should be acknowledged. To the best of our knowledge, it is the first study to examine the relationship between depression, anxiety, stress, and communication skills in dental students. However, its novelty also presents a challenge, as the lack of comparable prior research limits the discussion of our findings. Furthermore, the use of self-report methodology introduces the potential for social-desirability bias. Consequently, the findings should be interpreted with caution, and their generalizability may be limited.
Conclusions
Mental health, particularly in the case of depression and anxiety, is a significant determinant of communication skills in dental professionals. These conditions appear to diminish communication skills, primarily by impairing emotional control, listening skills, and the ability to send and receive messages. Conversely, a dentist with sound mental health is better positioned to establish effective relationships with patients, leading to improved health outcomes and a higher quality of care. It is therefore recommended that future research focuses on developing and evaluating targeted interventions for depression and anxiety to assess their efficacy in enhancing the communication skills of dental students.
