Anxiety, sleep quality and associated variables of Brazilian postgraduate professors in Dentistry during COVID-19 pandemicAbstract
Aim To evaluate anxiety, sleep quality, and associated variables among Brazilian postgraduate (stricto sensu) Dentistry professors during the COVID-19 pandemic.
Methods A cross-sectional study was conducted through an online questionnaire distributed to 1,973 professors between January and March 2021. The instrument included sociodemographic variables, teaching activity, State-Trait Anxiety Inventory (State component – STAI-S) and Sleep Assessment Questionnaire (SAQ). Univariable and multivariable linear regression analyses were performed using SPSS® version 29.0.2. Statistical significance was set at p < 0.05.
Results 322 professors participated (189 females and 133 males), with a mean age of 49 (± 9.3) years. Female gender, difficulties in performing remote activities, total change in routine due to social distancing, and increased time spent on teaching activities were significantly associated (p < 0.05) with higher STAI-S and SAQ values in both univariable and multivariable analyses. In the multivariable analysis for STAI-S (cutoff > 40), women were more than twice as likely to report anxiety than men [OR = 2.23; 95% CI: 1.32–3.75; p = 0.003], as those who reported difficulties with remote activities [OR = 4.13 (95% CI: 2.25 – 6.96); p < 0.001], and those who perceived a “total” change in routine [OR = 1.60 (95% CI: 1.01 – 2.54); p = 0.047]. For the SAQ (cutoff > 40), the “reduced” category remained statistically significant [OR = 1.85; 95% CI: 1.01–3.41; p = 0.049].
Conclusion Anxiety and poor sleep quality were associated with gender, remote work challenges, and disrupted routines during the pandemic in this sample.
Keywords
Anxiety; COVID-19; Education, dental; Sleep
Introduction
During the COVID-19 pandemic, the reality of dental education underwent complex changes on the global and national panoramas, with face-to-face classes being replaced by remote classes, and many professors having to stop their activities until conditions in Higher Education Institutions (HEI) returned to normality or having to adapt to the so-called “new normal”1. There are reports in the literature of a series of symptoms and illnesses triggered by the adoption of restrictive measures during the COVID-19 pandemic, such as anxiety, depression, sleep disorders, acute stress and even manifestations of post-traumatic stress disorder among the general population2-4. Still with regard to the psychological impacts of social distancing, it was found that some people were more vulnerable and susceptible to suffering negative consequences for their mental health, especially health professionals5-7, in addition to women and younger people4.
In Dentistry, the challenges faced were due to high susceptibility to contamination by the virus during clinical care8, which made both patients and professionals feel afraid, even with all the biosafety standards being followed9,10. With regard to teaching Dentistry, including stricto sensu postgraduate program (PGP) professors, the difficulty of adapting to remote activities was notable, since the challenge lay in readjusting and transmitting knowledge, being able to interact while keeping students interested, and allowing them to perform well11. In addition, dental teaching is characterized by the practical application of knowledge in laboratories or clinics, so that students consolidate what has been learned, and with the COVID-19 pandemic, the restrictions imposed led to increased stress and anxiety in the academic environment12.
More recently, so-called technological stress stands out as being extremely relevant, that is, stress resulting from the inevitable need to adapt to technological innovations, a factor routinely identified as a causal agent of changes in emotional health13. For Dentistry PGP professors the pandemic also resulted in the impossibility of moving forward with research that was in progress, which caused several inconveniences for the scientific field14.
As far as we know, for the time being there is no study similar to the study presented here, and it is relevant to assess the impacts of the COVID-19 pandemic among stricto sensu Dentistry PGP professors, related to anxiety and sleep quality and the hypothesis of there being associated factors.
Material and Methods
This study was approved by the Institutional Ethics Committee (Certificate of Submission for Ethical Appraisal, Opinion No. 40558920.9.0000.5418).
We obtained a complete list of stricto sensu Dentistry PGPs from the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior - CAPES), containing a total of 1,973 professors. Initially, an Excel® database was created from that list. Searches were carried out on Dentistry PGP websites, with the aim of finding additional information about the professors, namely: name, e-mail, gender (female; male), age (in years, which was then dichotomized by mean age into < 49 or ≥ 49), legal status of the HEI (public; private), macro-region of the HEI (Southeast/South; Midwest/Northeast/North), PGP modality (academic; professional), teaching on more than one academic level - master’s degree, professional master’s degree or doctorate (yes; no), professors category (permanent; assistant/employee/visitor), employment relationship (civil servant; Consolidated of Labor Laws - CLL/employee/retired), employment contract (exclusive; full; partial) and working in more than one PGP (yes; no).
The invitation to participate in the survey was sent electronically (by email), between January and March 2021, to all professors. Upon agreeing to participate, professors had immediate access to the Free and Informed Consent Form. The deadline for replying was 15 days. After this deadline, a reminder was sent and the contacts of non-respondents were immediately eliminated from the database.
Only those who completed all answers within the stipulated period were included. After that period the electronic form was blocked so that no more answers could be input.
The questionnaire was developed using Google Forms® and contained 59 questions, including demographic and teaching activity variables: marital status (dichotomized into married/stable union; separated/divorced/single/widowed), having children (yes; no), how many children (0; 1 or 2; ≥ 3), age of the children (< 9; 9 – 15; > 15), who helps with taking care of the children (spouse/partner; family member/domestic worker; nobody), do you live alone (yes; no), who do you live with (partner/friend; partner, children and parents/relatives), do you have a domestic worker (yes; no), domestic servant (monthly worker, day laborer; other), whether the domestic worker was a day laborer, weekly frequency (≥ 3 times; 2 times; 1 time), and whether the domestic worker continued to work during the COVID-19 pandemic (normally; reduced; interrupted).
Other related questions were: teaching activity (remote; face-to-face; both), weekly workload at the HEI (8 hours; 8 – 12 hours; 20 – 40 hours), difficulties in carrying out remote activities (yes; no), if social distancing was done (yes, strict; yes, with exceptions; no), if social distancing changed their routine (minimum; moderate; total), and if they noticed any kind of change in the time spent to be able to carry out teaching activities during the COVID-19 pandemic (less time; same time; more time).
Verification of anxiety was measured using the State-Trait Anxiety Inventory (STAI) developed by Spielberger et al.15. STAI is a self-assessment questionnaire composed of two parts: trait-anxiety (STAI-T), which assesses personality; and state-anxiety (STAI-S), which assesses the individual’s current behavior. This is one of the instruments most used to analyze subjective symptoms related to anxiety16. In this research we used STAI-S, in which feelings of tension and intensity are expressed over a certain period of time. It is composed of 20 items, each one evaluated on a four-point scale where: 1 – not at all; 2 – a little; 3 – somewhat; 4 – very much so. Higher scores indicate a higher level of anxiety.
The Sleep Assessment Questionnaire (SAQ) is a questionnaire that assesses sleep quality, developed by Cesta et al.17. It is used to check for sleep disorders or triggers including: insomnia, non-restorative sleep, restlessness, daytime sleepiness, sleep apnea, and sleep schedule disorder. It consists of 17 items, whereby each item is rated on a five-point scale ranging from 0 to 4 (i.e. never/I don´t know, rarely, sometimes, often, always), so that the maximum score is 68. The higher the score, the poorer the quality of sleep.
Qualitative variables were expressed as absolute and relative frequencies, while quantitative variables were presented as means and standard deviations (mean ± SD).
Univariable and multivariable linear regression models were used to assess factors associated with STAI-S and SAQ. Model assumptions were verified through residual analysis, and multicollinearity was assessed using the variance inflation factor. Additionally, a cutoff score of 40 was applied to both STAI-S (indicative of clinically significant anxiety18) and SAQ (indicative of sleep disturbances, based on the sample’s median), logistic regression models were applied to identify associated factors. Odds ratio (OR) and corresponding 95% confidence intervals (95%CI) were reported.
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS®), version 29.0.2 (IBM SPSS Statistics, Armonk, NY, USA). A p-value < 0.05 was considered statistically significant.
Results
A total of 322 professors participated (16.3% response rate), including 189 women (58.7%) and 133 men (41.3%). Mean age was 49 (± 9.3) years, with a minimum of 32 and a maximum of 74 years. The mean values, respectively, for STAI-S and SAQ were 46.1 (± 11) and 40.6 (± 9.3).
Sociodemographic variables
The results for these variables are shown in Table 1. STAI-S and SAQ mean were higher for women, with respective values of 48.1 (± 10.9) and 40.3 (± 9.0). Statistically significant difference was only found for STAI-S (p < 0.001), which indicates more anxious characteristics for females.
With regard to age, in the case of individuals younger than 49 years (n = 178; 53.3%), the values of STAI-S and SAQ were 47.3 (± 10.9) and 41.1 (± 9.1), respectively; also with a significant difference for STAI-S (p = 0.028), that is, younger people reported more anxiety.
Separated, divorced, single or widowed professors (n = 68; 21.1%) had higher mean STAI-S and SAQ values, of 48.5 (± 11.8) and 42.8 (± 9.3). Both were found to be significant for members of these categories, with p-values of 0.046 and 0.027, respectively.
Regarding having children or not, no significant differences were found for the values found (p > 0.05). However, those without children (n = 70; 21.7%) showed mean of 48 (± 11.4) and 41.4 (± 9.0), with more reports of anxiety (p = 0.002) and sleep problems (p = 0.040), compared with those who had 1 or 2, or ≥ 3 children. The age of the children is another variable to be highlighted. We found that having younger children (< 9 years old) was associated with the poorer STAI-S (p = 0.005). Although association was not statistically significant (p > 0.05), there was an inverse behavior between the child’s age and SAQ, that is, the younger the child’s age, the poorer the quality of sleep. With regard to who takes care of the children, there were also no significant differences (p > 0.05). On the other hand, living alone (n = 34; 10.6%) increased STAI-S and SAQ scores, with p-values of 0.002 and < 0.001, respectively.
Among the participants, there was no significant difference in the scores of the variable regarding having or not having a domestic worker, employment relationship and frequency of work of this employee during the COVID-19 pandemic (p > 0.05). However, it should be noted that professors who have employees who provide services less frequently and who interrupted activities during the COVID-19 pandemic, had higher mean values of STAI-S and SAQ.
Teaching activity
The variables directly related to teaching activity are presented in Table 2. With regard to HEI legal status and macro-region variables, employment relationship, employment contract, weekly workload and teaching on more than one academic level, no results were found with significant differences in relation to outcomes (p > 0.05). The only difference (p = 0.004) was found for SAQ among those who did not work at more than one PGP, indicating poorer sleep quality for professors who only worked at one Program.
Most of the professors were working remotely when the survey was conducted (n = 178; 55.3%). The type of activity (distance, face-to-face or both) had no significant impact on the respondent’s anxiety (p = 0.369) or on sleep quality (p = 0.132) (Table 3).
As for difficulties in carrying out remote activities, 205 professors (63.7%) reported difficulties. The mean STAI-S and SAQ values for those who experienced difficulties were 49.3 (± 10.5) and 42.2 (± 9.4), respectively. These differences were significant (p < 0.001), which reveals a greater perception of problems by those who reported more difficulties (Table 3).
Categories related if the social distancing was done were not associated with outcomes (p > 0.05). However, the change in routine for those who classified this as “total” (n = 206; 64%) was significantly related to higher mean STAI-S (p < 0.001) and SAQ (p = 0.016) (Table 3).
Regarding the time spent on teaching activities during the pandemic, 244 (75.8%) reported wasting more time. They were also the ones who had significantly higher mean values for anxiety and poorer sleep quality, with p < 0.001 for both (Table 3).
Table 4 presents the results of the multivariate analysis. In the final model, the following variables remained statistically significant in relation to the STAI-S: being female (p = 0.007), having ≥ 3 children (p = 0.032), and reporting that social distancing changed the routine (moderate, p = 0.050; total, p = 0.012). Regarding the SAQ, a statistically significant difference remained for working in more than one PGP (p = 0.048). Living alone, having difficulties in carrying out remote activities, and having perceived “more time” required to perform teaching activities during the pandemic, showed significant differences (p < 0.05) with both, STAI-S and SAQ.
In the multivariable analysis for STAI-S with cutoff, female remained significantly associated (p = 0.003), with women being more than twice as likely to report anxiety compared to men (OR = 2.23; 95% CI: 1.32–3.75). Regarding difficulties in performing remote activities, those who responded affirmatively were the most anxious [OR = 4.13 (95% CI: 2.25 – 6.96); p < 0.001], as were those who reported a “total” change in routine due to the pandemic [OR = 1.60 (95% CI: 1.01 – 2.54); p = 0.047] (Table 5).
For the SAQ with cutoff, the reduction in the working of the domestic worker remained statistically significant [OR = 1.85; 95% CI: 1.01–3.41; p = 0.049]. For the same variable, the “interrupted” category lost statistical significance, as did the “yes” responses for the variable “having difficulties in carrying out remote activities” (Table 6).
Discussion
This study aimed to assess the impacts reported by Brazilian stricto sensu Dentistry PGP professors in relation to anxiety, sleep quality and associated factors, during the COVID-19 pandemic. Higher anxiety and poorer sleep quality were found among professors in association with some variables, which confirms the alternative hypothesis.
It is known that negative feelings and changes in behavior are consequences of the COVID-19 pandemic and can be explained by the degree of concern with various aspects of life, the uncertainty of how long this phase would last, in addition to the risk of losing family members or friends1.
Regarding gender, women had a higher degree of anxiety when compared to men19. This result was expected, as published studies reveal that women stood out in terms of psychosocial impacts during the period of the COVID-19 pandemic2,4,7,20,21. Like women in other professions, female professors face the challenge of balancing their careers with family and domestic responsibilities22-24. This accumulation of functions by women was fully evidenced and enhanced by the need to stay at home during social distancing, with a consequent increase in anxiety and stress25. Additionally, a survey of Latin American professors found that women spend more hours doing household chores than men26.
Younger professors (< 49 years) had higher STAI-S value, which identifies a higher level of anxiety. Solomou and Constantinidou4 found similar results, whereby younger individuals had more significant negative psychological symptoms. Such findings can be explained by the fact that the elderly have already experienced other moments of tension throughout their lives, having the opportunity to improve their adaptability and resilience to deal with stressful situations. Moreover, older professors, in general, have a more consolidated professional career, showing a lower degree of concern in the face of the uncertainty experienced by the moment of the COVID-19 pandemic. Unlike the result presented here, research conducted by Ferreira et al.21 reported a higher degree of anxiety in the elderly. This difference can be explained by the fact that among the participants in this research, on average the professors were 49 years old, that is, it does not include the elderly, who were the main risk group for COVID-1927.
Among the participants, separated, divorced, single or widowed professors had higher mean STAI-S and SAQ values, however, only sleep quality showed a significant difference in relation to being married or in a stable relationship. With social distancing and the need to stay indoors, the absence of company may have had a negative impact, this data also being corroborated by what was observed among professors who reported “living alone” and who showed more anxiety and poorer quality of life, with significantly poorer sleep. Individuals who lived alone, given the COVID-19 pandemic scenario and social distancing, remained in a situation of greater isolation, without social interaction. Xiao et al.28 concluded that these people felt more lonely and more anxious, these being findings that corroborate the results presented here. With regard to sleep quality, the literature does not offer a consensus on the influence of marital status. Some findings indicate that divorced people have more difficulty falling asleep29 and higher rates of sleep disturbances30, but other authors found no difference in sleep quality between married and single individuals31.
Regarding the existence of children, poorer STAI-S and SAQ values were found for professors without children. Furthermore, for those with younger children (less than 9 years old), state anxiety was more noticeable. During the COVID-19 pandemic, professors with children had to adapt and reorganize their routine at home, reconciling work and child care32. Although it appears to be a stressor, when it comes to children, parents have a natural and biological tendency to adapt, protect and manage a crisis in order to deal with the challenging situation without transmitting fear and anxiety33. Furthermore, having children also bridges the loneliness gap during the COVID-19 pandemic, helping to maintain mental health. On the other hand, those without children do not have this tendency, becoming more capable and prone to not dealing as well with the situation, which may explain their greater anxiety and the consequent worsening of sleep quality.
At this point, it is interesting to discuss the question of the age of the children. The findings indicated that the older the children were, the less the results were negative; it may be associated with the fact that younger children require more attention and care from parents, also due to schools being closed in the pandemic.
The influence of the presence of a domestic worker on the professors’ life during the COVID-19 pandemic period was also investigated. Despite the lack of significant differences, those who had sporadic employees (without a monthly or daily contract), those who had a day laborer only once a week, and those whose employee stopped working during the COVID-19 pandemic had greater anxiety and poorer sleep quality.
As for teaching performance, among all the variables investigated, only not working in more than one PGP determined the worsening of sleep quality significantly. This finding can be explained by the fact that those with more than one job were likely to experience less insecurity about unemployment, fewer concerns about maintaining financial stability and, therefore, fewer sleep disturbances.
Professors who reported having difficulties in performing remote activities and those who perceived spending more time than usual to perform tasks also reported greater levels of anxiety and poorer sleep quality. This can be attributed to the fact that, by not being able to perform their daily tasks remotely, professors increase the time spent on work activities, reducing the total time available for carrying out other daily tasks, with a consequent increase in anxiety and poorer sleep quality.
Respondents who stated having completely changed their routine due to the social distancing also had higher mean STAI-S and SAQ values, with a significant difference for those who reported moderate or minimal changes in their routine. Alencar et al.34 found similar results in their research with Brazilian dentists, also finding a higher anxiety rate in those who undertook social distancing during the pandemic and had their routine changed.
The results discussed here make it possible to understand some challenges faced during the COVID-19 pandemic and, through this knowledge, guide the necessary measures to be taken by HEIs and professors in order to minimize the negative psychological impacts. As seen and discussed throughout this manuscript, teaching is a profession with a high stress load, and these professionals should receive psychological support through their HEIs to control anxiety, in order to achieve positive impacts on better sleep quality and, consequently, better quality of life. It is suggested that HEIs implement psychological follow-up provided by trained psychologists, either through lectures or personalized services. It is recognized in the literature that doing regular physical activity is a way to maintain physical and mental health35, thus, HEIs can encourage sports through events aimed at physical health and sports activities.
As for the limitations of this study, the first refers to the period in which the data were collected, from January to March 2021, a phase in which the COVID-19 pandemic was already more advanced, which may have interfered with the results due to some professors having adapted to the situation, with less perception of the problems. The opposite may also have happened, as after a longer period of the pandemic, their psychological state may have worsened. Another limitation refers to the sample, which may not be representative of the Brazilian population of PGP professors. The low participation of PGP professors is noteworthy, as greater adherence was expected, based on the assumption that researchers are aware of the challenge of carrying out a survey such as the one presented here. Finally, the results of a cross-sectional study must be interpreted with caution, as it is not possible to establish causal relationships.
Regarding directions to be taken in the future, new studies can be carried out with similar groups to compare results after the critical period of the COVID-19 pandemic, allowing a longitudinal follow-up of these professors.
In conclusion, during the COVID-19 pandemic, there was greater anxiety and poorer sleep quality among Brazilian postgraduate (stricto sensu) Dentistry professors in association with gender, remote work challenges, and disrupted routines during the pandemic.
Acknowledgements
The authors deny any conflicts of interest related to this study.
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Data Availability:
Datasets related to this article will be available upon request to the corresponding author.
Edited by
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Editor:
Dr. Altair A. Del Bel Cury
Datasets related to this article will be available upon request to the corresponding author.
