Hopelessness and Related Factors Among Students of Dentistry: A Cross-Sectional Analytical Study

Full text

Hope is a belief or an expectation that there is
more than zero chance of a future aim to be real-
ized.1,2 In opposite, hopelessness or despair is defined
as a state of mind where an individual believes that
s/he cannot prevent her/his failures, and can never
solve her/his problems, even if great effort is given.3
Turkiye Klinikleri J Med Sci.2020;40(4):433-42
433
Hopelessness and Related Factors Among Students of
Dentistry: A Cross-Sectional Analytical Study
Diş Hekimliği Öğrencileri Arasında Umutsuzluk ve İlişkili Faktörler:
Kesitsel Analitik Bir Çalışma
Tülin ÇOBANa, Canan HEKİMOĞLUb, Dilek YILDIRIMa, Merve BÜKE ŞAHİNa,
Gulaiym BATYRBEKOVAb, M. Barış GÜNCÜb, Banu ÇAKIRa
aDepartment of Public Health, Hacettepe University Faculty of Medicine, Ankara, TURKEY
bDepartment of Prosthodontics, Hacettepe University Faculty of Dentistry, Ankara, TURKEY
The paper was accepted and presented as an oral presentation at the 25th TDA (Turkish Dental Association) International Dental Congress, held in Istanbul on 4-7 September 2019,
but was not included as full text in the proceedings. The English abstract of the report existing in the proceedings of this congress is given below.
ABS TRACT Objective: This cross-sectional analytical study investi-
gated hopelessness and related factors among dentistry students, with
the ultimate goal of providing evidence for effective interventions to
increase professional motivation and satisfaction. Material and Met-
hods: Of all students attending a selected school of dentistry, data were
gathered from 537 students (71.2%), using a standard questionnaire and
the Beck Hopelessness Scale (BHS). The authors used the SPSS ver. 23
for descriptive and analytical statistics; hopelessness status was further
modelled using logistic regression. Results: The authors examined
data and using BHS scores and classification, hopelessness status was
found as “minimal”, “mild”, “moderate”, and “severe” in 51.0%,
35.9%, 10.8% and 2.2% of the participants, respectively. Dichotomi-
zing hopelessness at BHS score of ≤3: in final logistic model, higher
paternal education (OR=1.58; 95% CI=1.08-2.33), and absence of
hobbies (OR=2.39; 95% CI=1.33-4.29); mismatch of education with
student’s professional expectations (OR=2.33; 95% CI=1.59-3.40)
and having thoughts on leaving school at any time ((OR=2.41; 95%
CI=1.64-3.54) were found positively associated with higher level of
hopelessness, controlling for gender and grade. Conclusion: Hope-
lessness is fairly common among dental students. Increasing awareness
of students on educational curricula and career options, together with
ensuring acquisition of/support for different hobbies can be useful as
preventive measures. Students with despair regarding their education or
a wish to leave school at one point should be prioritized in interventi-
ons.
Keywords: Hope; students, dental; education, dental;
hobbies
ÖZET Amaç: Bu kesitsel analitik çalışma, mesleki motivasyonu ve
memnuniyeti arttırmak için etkili müdahaleler oluşturulmasına kanıt
sağlamak amacıyla diş hekimliği öğrencileri arasındaki umutsuzluğu
ve ilgili faktörleri araştırmıştır. Gereç ve Yöntemler: Veriler seçilmiş
bir dişhekimliği okuluna devam eden tüm öğrencilerin 537’inden
(%71,2) standart bir anket ve Beck Umutsuzluk Ölçeği (BHS) kullanıla-
rak toplanmıştır. Yazarlar tanımlayıcı ve analitik istatistikler için SPSS
ver. 23’ü kullanmış olup umutsuzluk durumu için lojistik regresyon kul-
lanılarak ileri modellemeler yapılmıştır. Bulgular: Yazarlar verileri in-
celemiş ve BHS puanları ile sınıflandırmasını kullanarak, katılımcıların
sırasıyla %51,0; %35,9; %10,8 ve %2,2'sinde umutsuzluk durumunu
“minimal”, “hafif”, “orta” ve “şiddetli” bulmuştur. BHS skoru ≤3 olan-
lar “minimal düzeyde umutsuz” kabul edilecek şekilde veriler dikoto-
mize edilerek cinsiyet ve sınıfa göre düzeltildiğinde, son lojistik modelde,
baba eğitim düzeyinin daha yüksek olması (OR=1,58; %95 GA=1,08-
2,33), hobisi bulunmaması (OR=2,39; %95 GA=1,33-4,29), aldığı eğiti-
min mesleki beklentilerini karşılamaması (OR=2,33; %95
GA=1,59-3,40); ve herhangi bir zamanda okulu bırakmayı düşünmesi
(OR=2,41; %95 GA=1,64-3,54) yüksek umutsuzluk düzeyi ile pozitif
olarak ilişkili bulunmuştur. Sonuç: Diş hekimliği öğrencileri arasında
umutsuzluk oldukça yaygındır. Öğrencilerin eğitim müfredatı ve kariyer
seçenekleri konusunda farkındalığının arttırılması, farklı hobilerin edi-
nilmesi/desteklenmesi ile birlikte koruyucu tedbirler olarak yararlı ola-
bilir. Müdahalelerde eğitimleriyle ilgili umutsuzluğu veya herhangi bir
dönemde okulu bırakmayı istemiş olan öğrencilere öncelik verilmelidir.
Anah tar Ke li me ler: Öğrenciler, diş hekimliği; eğitim, diş hekimliği;
hobiler
ORİJİNAL ARAŞTIRMA ORIGINAL RESEARCH DOI: 10.5336/medsci.2020-74418
Correspondence: Tülin ÇOBAN
Department of Public Health, Hacettepe University Faculty of Medicine, Ankara, TURKEY/TÜRKİYE
E-mail: tulincoban87x@gmail.com
Peer review under responsibility of Turkiye Klinikleri Journal of Medical Sciences.
Re ce i ved: 20 Feb 2020 Received in revised form: 06 Sep 2020 Ac cep ted: 21 Sep 2020 Available online: 14 Dec 2020
2146-9040 / Copyright © 2020 by Türkiye Klinikleri. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Türkiye Klinikleri Tıp Bilimleri Dergisi
Turkiye Klinikleri Journal of Medical Sciences

434
Hopelessness is not considered as a health problem
by itself, but can also appear as a predisposing factor
or an indicator of other mental disorders. Despair is
thought to be a potential mediator of the depressive
effects of stress.4 Literature also reveals hopeless-
ness as a predictor of suicide attempts, including
those among university students; and, probability of
suicidal tendency was reported to be associated with
the level of hopelessness.1,5-7 Uncertainties about the
future and feelings of inadequacy can cause hope-
lessness.8 It is claimed that hopelessness is a natu-
ral consequence of this “learned helplessness”
process.9 In a study in the United States of America
(USA), uncontrolled stress factors were associated
with despair among adolescents.10 In chronic, repet-
itive or extreme situtations, such stress factors can
lead to psychological problems in students, includ-
ing depressive symptoms, anxiety, anger, behav-
ioral disorders, substance abuse, absenteeism,
reduced work efficiency, burnout and hopeless-
ness.11 Such situations may lead to decrease in stu-
dents’ interest and coping skills, increase
perceptions of incapability, and eventually result in
low academic performance and adversely affect stu-
dents’ daily social lives.12-14
Dentistry is one of the leading choices of pro-
fession in many societies due to its popularity and
high salaries.15-17 However, in line with other medical
occupations, dentistry education is a challenging pro-
cess, often associated with high stress levels, con-
straining mental and physical capacities of the
students.18 Symptoms of anxiety, depression, stress,
burnout, or even suicide risk, have been shown to be
more common among dentistry students compared to
that in general population.19-21 Factors that trigger and
affect mental problems either directly or indirectly
among dentistry students may either be associated
with a negative educational environment or more
likely to be related to financial problems, competi-
tion with peers, difficulty in coping with curriculum
and workload, fear of failing class, fear of con-
fronting parents after failure, difficulties in learning
manual and clinical procedures, insufficiency of rest-
ing hours, risk of blood-borne infectious diseases
(HBV, HCV, HIV) and lack of professional self-con-
fidence.18,22-25
Studies on the mental state of dental students and
related factors are limited and focused mainly on
stress, depression, anxiety and suicidal thoughts. The
number of published researches on hopelessness is
very limited. The aim of this study is to investigate
hopelessness and related factors among dentistry stu-
dents, with the ultimate goal of providing evidence
for effective primary interventions to minimize men-
tal problems, with a potential to increase professional
satisfaction and life quality of future providers of
dental care in communities.
MATERIAL AND METHODS
ParticiPants and Protocol
A cross-sectional analytical study was conducted to
include all (from first through fifth grades) students in
the dental faculty of a public university, in Ankara,
Turkey. No sample was selected and all students (N=
754) attending school in October 2018 were ap-
proached.
Data were obtained from 72% of 745 students
attending the school. Completion rates were slightly
different across grades; with percent values of 72.1%;
68.3%; 64.7%; 82.4%; and, 57.0% for the first thor-
ough the fifth (last) grades, respectively. The lowest
completion rate was for the last grade because many
students had exhaustive clinical workload and, thus,
did not want to participate in the study.
Ethical approval was obtained from Non-inter-
ventional Research Ethics Committee of the univer-
sity (date: 24-November-2018 and register no: GO
18/984). A pilot testing of the questionnaire and in-
terviewers were conducted on 20 students from an-
other dental school located in the same city. Data
were obtained though questionnaires completed by
the students in classroom settings, in October 2018,
following permission of instructers and informed
consent of students. No participant identifiers was re-
quested and all analyses were performed anony-
mously. Questionnaires included a line for voluntary
insertion of personal nick name/number for any stu-
dent who wanted to learn his/her personal score cal-
culated for hopelessness index, after the completion
of the study period.
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
434

435435435
Questionnaire and evaluation of HoPelessness
In the study, a standard questionnaire consists of 55
questions was used, with an additional Beck Hope-
lessness Scale (BHS) at the end. The questionnaire
included questions on personal, family-and educa-
tion-related characteristics that might confound the
total hopelessness score, and provide evidence for
future interventions to be tailored to high risk
groups.
Validation of the BHS in Turkish population was
conducted by Seber and Dilbaz in 1993, to be used
for measuring hopelessness in healthy Turkish adults
(Cronbach alfa=0.86).7 In 2006, the same scale was
reapplied by Durak and Palabıyıkoğlu on 201 hospi-
talized patients and 172 healthy hospital staff or pa-
tient relatives; and, was validated again as a valid test
for measuring hopelessness in Turkish adults (Cron-
bach alfa=0.86).26 The scale consists of 20 questions
and the arithmetic total obtained from the test consti-
tutes the “hopelessness score”. The total score is
grouped into four; so that a total score of 0-3, 4-7, 9-
14, and 15 or more are considered “minimal”, “mild”,
“moderate”, and “severe” hopeless.26
statistical MetHods
A total of 629 dentistry students completed the ques-
tionnaires, yet, 92 were excluded from analyses be-
cause at least one question was unanswered in BHS
(n=537). Descriptive statistics were presented with
the median value (minimum-maximum). Chi-square
tests were used for comparison of categorical
groups.Odds ratio (OR) and relavant 95% confidence
interval (CI) were used for revealing potential asso-
ciations, in binary analyses and logistic regression
modeling. According to the BHS scores, those with
“mildly, moderately or severely” hopeless were
coded as “hopeless” in models, and compared to
those with a total score of 3 or less (i.e., those with
minimal hopelessness).
In the study, for the evaluation of the presence
of confounding factors and effect modification, strat-
ified analyzes were conducted, and whether there was
a statistically significant difference between the
strata-specific odds ratios was examined by the MH
Odds Ratio values with Breslow Day statistics. If the
Breslow day statistic was not significant, it was de-
cided that there was no effect modification.Whether
there is a confounding factor according to MH Chi
square value was examined. If the confounding fac-
tor causes significant changes, CMH odds ratio val-
ues have been reported instead of crude OR values.
While designing the full model, all possible variables,
possible confounding factors and effect modificating
factors were added to the model. The most parsimo-
nious statistically significant model was reported
using the “Backward unconditional LR model” to
reach the final model.
Statistical Package for the Social Sciences
(SPSS) v. 23 was used for data entry and analysis.
RESULTS
Of the participants, 66.2% of were female and 98.7%
were single. The ages of the participants ranged be-
tween 18 and 30 years, with a median age of
21.Parental educational attainment was considerably
high; 46.2% of the mothers and 63.2% of the fathers
reportedly had university education or higher (Table
1). It was remarkable that 87.3% of all participants
had at least one hobby, while more than a hundred
different hobbies were noted in varying fields of art,
music and sports (Table 1).
Dental school was the first choice in the national
university enterance exam for 73.3% of the partici-
pants. Professional status of dentistry in the commu-
nity (47.8%) was the main reason for selecting dental
school and 64.6% of the participants stated that “they
would prefer dentistry, if they had a chance to enter
university exam again”. About 40% of the partici-
pants had thought of leaving the school at least once
over the course of their university education. When
participants were asked about their satisfaction with
the choice of profession, only 8.6% stated that they
were “dissatisfied”. Yet, 39% of participants consid-
ered their current curricula to be in line with their a
priori expectations (Table 2).
Based on BHS criteria, hopelessness about the
future was minimal in 51.0%, mild in 35.9%, moder-
ate in 10.8% and severe in 2.2% of the participants.
In other words, about half of the participants had
some level of hopelessness.
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
435

In binary analysis, level of hopelessness (at least
mild versus minimal) was not associated with grade
(p=0.131),gender (p=0.107), or educational attain-
ment of the mother (p=0.378). Hopelessness was
found to be significantly higher in dental students
whose fathers’ educational attainment was high (i.e.
university graduate or higher); odds of hopeless-
ness was 1.56 (95% CI=1.09-2.22) times among
those compared to students with lower paternal ed-
ucation (Table 1). Gender had a confounding role
in the study population in studying the potential as-
sociation between paternal education and hopeless-
ness (MH Chi-square p value=0.023):adjusting for
gender, ORadj=1.54 (95% CI=1.08-2.19), effect size
decreased slightly. In the stratified analysis of the
relationship between father’s education and hope-
lessness according to whether or not the family
choice was the reason for choosing the faculty, it
was found that if the reason for choosing the fac-
ulty was family desire, this situation caused the ef-
fect modification on father education-hopelessness
relationship (Breslow Day statistic p value= 0.035).
While the estimated risk for the relationship be-
tween father education and hopelessness was 4.79
(95% CI=1.48-15.48) in those who preferred den-
tistry because they wanted a family, this value was
1.33 (95% CI=0.91-1.94) in those who chose the
school independently. The relationship between
high father education and hopelessness was posi-
tive in both groups and this relationship persists
when other factors are controlled in advanced anal-
ysis.
In the stduy group, a negative association was
detected between having a hobby and hopelessness
score (OR=2.08; 95% CI=1.22-3.54) (p=0.006)
(Table 1). The presence of hobby showed a signifi-
cant difference compared to the current class. Sim-
ilarly, hopelessness is more pronounced and higher
in grades 2nd, 3rd, and 4th when compared to first
grades; the fifth grade shows a statistically insignif-
icant difference compared to the first grade. There-
fore, it was thought that class variable may be a
confounder in the relationship between hobby and
hopelessness. In the stratified analysis, it was found
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
436
Hopelessness Hopelessness
Mild/Moderate/Severe Minimal Total Odds ratio Chi- square test
n % n % n %* [95% CI**] p-value
Year of study (n=537)
First year 54 39.4 83 60.6 137 25.5 1.00 0.131
Second year 52 52.5 47 47.5 99 18.4 1.70 [1.01-2.87]
Third year 47 53.4 41 46.6 88 16.4 1.76 [1.03-3.03]
Fourth year 67 53.2 59 46.8 126 23.5 1.75 [1.07-2.85]
Fifth year 43 49.4 44 50.6 87 16.2 1.50 [0.87-2.58]
Sex (n=537)
Female 183 51.5 172 48.5 355 66.2 1.34 [0.94-1.93] 0.107
Male 80 44.2 101 55.8 181 33.8 1.00
Maternal education (n=533)
University graduate or higher 126 51.2 120 48.8 246 46.2 1.00 0.378
High school or lower 136 47.4 151 52.6 287 53.8 0.86 [0.61-1.21]
Paternal education (n=533)
University graduate or higher 178 47.2 159 52.8 337 63.2 1.00 0.014
High school or lower 82 41.8 114 58.2 196 36.8 0.64 [0.45-0.92]
Presence of any hobby (n=527)
No hobby 213 46.3 247 53.7 67 12.7 2.08 [1.22-3.54] 0.006
Has a hobby 43 64.2 24 35.8 460 87.3 1.00
TABLE 1: Distribution of level of hopelessness by personal characteristics.
*The percentage of the column is given. All other percentages are row values; **CI: Confidence Interval.

that the class did not cause any interaction (Bres-
low Day statistic p-value=0.386) but it played a role
as a confounding factor (MH Chi-square p
value=0.020).Therefore, in the evaluation of the
study findings, it was found appropriate to give the
power of the relationship between hobby and hope-
lessness by adjusting to the class (adjusted OR=1.96;
95% CI=1.14-3.33).
There was no statistically significant associa-
tion between hopelessness and the order of prefer-
ence for dentistry in university entrance exam
(p=1.000), nor with any desire to continue aca-
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
437
Hopelessness Hopelessness
Mild/Moderate/Severe Minimal Total Odds ratio Chi- square test
n % n % n %* [95% CI**] p-value
Order of dental school in university entrance exam (n=501)
First choice 178 48.5 189 51.5 367 73.3 1.00 1.000
Not first choice 65 48.5 69 51.5 134 26.7 1.00 [0.67-1.49]
Reason for choosing dental school (n=536)***
His/her ideal for future 81 37.2 137 62.8 218 40.7 0.45 [0.32-0.64] <0.001
Family desire 40 55.6 32 44.4 72 13.4 1.36 [0.83-2.25] 0.223
Dentistry is a respected profession 108 42.2 148 57.8 256 47.8 0.60 [0.42-0.84] 0.003
Taking a dentist as a role model 71 51.8 66 48.2 137 25.6 1.17 [0.79-1.73] 0.424
Having a dentist in family/neighbors 32 57.1 24 42.9 56 10.4 1.45 [0.83-2.53] 0.910
Chances of finding a job are high 145 48.8 152 51.2 297 55.4 0.99 [0.71-1.40] 0.976
High financial gain 161 48.9 168 51.1 329 61.4 1.01 [0.71-1.42] 0.974
Exam score was sufficient 47 49.5 48 50.5 95 17.7 1.03 [0.66-1.60] 0.899
No specific reason 14 66.7 7 33.3 21 3.9 2.15 [0.86-5.42] 0.096
Any wish to leave the school at one point (n=533)
Yes 145 63.3 84 36.7 229 43.0 2.80 [1.96-3.99] <0.001
No 116 38.2 188 61.8 304 57.0 1.00
Would you choose dental school again? (n=536)
Yes 129 37.3 217 62.7 346 64.6 1.00 <0.001
No 67 76.1 21 23.9 88 16.4 5.37 [3.14-9.18]
No idea 66 64.7 36 35.3 102 19.0 3.08 [1.95-4.89]
Level of satisfiction with school selection (n=535)
I am very pleased 37 29.8 87 70.2 124 23.2 1.00 0.001
I am glad 145 46.3 168 53.7 313 58.5 2.03 [1.30-3.16]
I am not pleased**** 79 80.6 19 19.4 98 18.3 9.78 [5.20-18.38]
How good school curriculum is to fulfill expectations (n=531)
Much better than expected 8 33.3 16 66.7 24 4.5 1.00 0.001
Better than expected 24 35.3 44 64.7 68 12.8 1.09 [0.41-2.92]
In line with expectations 81 39.1 126 60.9 207 39.0 1.29 [0.53-3.14]
Worse than expected level 91 64.5 50 35.5 141 26.6 3.64 [1.46-9.10]
Expectations not met 26 57.8 19 42.2 45 8.5 2.74 [0.97-7.70]
No idea 23 65.7 12 34.3 46 8.7 3.83 [1.28-11.5]
Any wish for staying in academia (n=533)
Yes 89 45.4 107 54.6 267 50.1 1.00 0.236
No/Unsure 171 50.7 166 49.3 266 49.9 1.24 [0.87-1.76]
TABLE 2: Distribution of level of hopelessness by academic choices, satisfaction and expectations.
*Column percentages are presented. All others are row percentages; **CI: Confidence Interval; ***Since more than one option can be selected, the percentages are based on the total
number of respondents; ****This option has been generated by combining “I am not satisfied”, “I regret” and “No idea” options.

demic career after graduation from dental school
(p=0.236) (Table 2).
Various reasons were stated to play a role in se-
lection of dental school in university entrance exam.
Of these reasons, only two were statistically signifi-
cantly associated with hopelessness in binary analy-
ses: These were, considering dentistry as “the ideal
profession for the self” (OR (95% CI) = 0.45 (0.32-
0.64)) (p<0.001) or “a respected profession” (OR
(95% GA)=0.60 (0.42-0.84)) (p=0.003) (Table 2).
Hopelessness was associated with any self-re-
ported wish to leave dental school (at least once over
the past year(s)): those who reported such a wish
were 2.80 times (95% CI=1.96-3.99) more likely to
have mild or more hopelessness at time of the inter-
view (p <0.001). Those who stated that would have
chosen dental school again, if they had a chance to
re-enter the university exam were 5.37 (95%
CI=3.14-9.18) times less likely to be hopeless. The
association between hopelessness and dissatisfaction
with professional (school) choice was even stronger,
with an odds ratio of 9.67 (95% CI=4.24-22.0)
among those who felt “regret” in choosing dental
school had 14.11 (95% CI=1.64-121.3) times odds of
those who stated that they were very satisfied with
their choice. Lastly, a significant assocaiton was de-
tected between hopelessness and students’ self-satis-
faction with the current formal training s/he obtains in
school: OR=3.64 (95% CI=1.46-9.10) times more
hopelessness than those who expected “much better
than expected”, and the difference was statistically
significant (p<0.001) (Table 2).
In stratified analyses, the reason for chosing den-
tal school family appeared as an effect modifier in
studying the association between paternal education
and hopelessness among student. Yet, this interaction
term appeared nonsignificant in multivariate model
and was excluded from the final model. In modeling
hopelessness among dental students, the final multi-
variate logistic regression model was reached as se-
lecting the smallest statistically significant model
(using Backward unconditional LR model, with an
alpha of 0.05); gender and grade variables were
added to the model intentionally, as these variables
are widely accepted confounding factors in published
articles. In this final logistic model, when gender and
class were controlled for, higher paternal education
(OR=1.58; 95% CI=1.08-2.33), absence of hobbies
(OR=2.39; 95% CI=1.33-4.29); mismatch of educa-
tion with student’s professional expectations
(OR=2.33; 95% CI=1.59-3.40) and having thoughts
on leaving school at any time (OR=2.41; 95%
CI=1.64-3.54) were found positively associated with
higher level of hopelessness (Table 3).
DISCUSSION
In the study about half of the students revealed at
least some sort of (mildly or higher) hopelessness.
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
438
Variable B p value Odds Ratio 95% CI*
Sex (ref.= male) 0.036 0.856 1.04 0.70-1.54
School grade
1. year (ref.) 1.00
2. year 0.220 0.455 1.25 0.70-2.22
3. year 0.120 0.698 1.13 0.62-2.04
4. year 0.090 0.749 1.10 0.63-1.91
5. year 0.203 0.507 1.23 0.67-2.23
Educational status of the father (ref.=high school or lower) 0.460 0.019 1.58 1.08-2.33
Presence of any hobby (ref.= at least one hobby) 0.871 0.004 2.39 1.33-4.29
Fulfillment of expectations (ref.= those who met their expectation) 0.844 <0.001 2.33 1.59-3.40
Any wish to leave dental school at one point (ref.= people who did not) 0.879 <0.001 2.41 1.64-3.54
TABLE 3: Logistic regression modeling of hopelessness based on the Beck Hopelessness Scale
(mild or higher hopelessness versus minimal).
*CI: Confidence Interval.

Although this study aimed to reach all students, miss-
ingness percent is not ignorable. Thus, the authors are
hesitant to give estimates of robust prevalance value
of hopelessness but rather investigated hopeless-
ness frequency in subgroups to investigate poten-
tial risk factors (if any), modifiable ones, in
particular. It is likely that some of such factors
could be universal for dental students in Europe
and, it is hoped to create a ground for discussion to
compare and contrast such factors across popula-
tions.
Use of the same scale in some other Turkish
study populations enabled to make some comments
on the overall level of hopeless in various groups. In
the study of Sahin, the despair among students of the
faculty of education was found as “mild and moder-
ate”;27 in the study conducted by Kodan among sci-
ence and classroom teacher students and in the study
conducted by Sanli Kula and Sarac among science
and literature students level of hopelessness were
“mild”.28,29 These findings suggested that, based on
the BHS scores, regardless of age and profession,
population values suggest some sort of hopelessness,
in general. However, several confounding factors be-
sides age and educational setting, could have caused
differences in overall scores.
Hopelessness scores in the second, third and
fourth grades were higher in the study group com-
pared to the first and final grades, and this was found
to be statistically significantly different from the first
grades. This situation can be explained by the fact
that the happiness of gaining the university in the first
year is replaced by stress, fear of failure and loss of
self-confidence starting from the second grade with
the course curriculum becoming increasingly diffi-
cult and the start of practical courses, and negatively
affects students’ expectations from the future. Peker
et al. showed that the stress level was significantly
higher in the fourth grade than the first grade. They
attributed this to concerns about future and profes-
sional opportunities.30 In a study conducted in Ger-
many, depression among the students was examined,
while the scores of the students were similar to the
normal population at the beginning of the first period,
it became more prominent, and the average levels de-
termined became a condition for clinical treatment
indication in the fifth period.31 In a study conducted
with third and fifth grade students in a faculty of den-
tistry in the USA, 34% of students had emotional
burnout, 17% had depersonalization, 9% had suici-
dal ideation, and 40% met the burnout criteria.24 De-
pression and hopelessness can be affected by
different sources, and their reflection in students may
vary. However, with the assumption that mental rest-
lessness, stress and anxiety will adversely affect both
conditions; hopelessness and depression can be ex-
pected to be similar in terms of the change according
to classes. As a matter of fact, in a study conducted in
India, perceived stress level of dental faculty students
increased in the later years of education due to factors
such as changes in the curriculum and onset of clini-
cal training. Possible factors were defined as the fear
of face-to-face with the family after the failure, work-
load, poor relations with staff, lack of confidence in
being a successful dentist, fear of unemployment, and
unwillingness to work with patients with poor oral
hygiene.18 In a study it was found that the amount of
experienced stress in clinical years in the faculty of
dentistry was higher than in the preclinical years and
that stress caused by academic factors and perfor-
mance pressure appeared more frequently as the
classes progressed. In the same study, the high level
of stress caused by neglecting personal life and fi-
nancial responsibilities of fifth grade students is not
fully correlated with the findings of our study.32 In the
fifth year of the study group, hopelessness improves
again, but the expectations for the future are not as
high as the first year. It can be thought that self-con-
fidence in professional knowledge and skills in-
creases, the students have better adaptation to the
school environment and positive expectations for the
future as they graduate. A significant part of the stu-
dent group states that they want to work in the pri-
vate sector or to continue post-graduate education.
For this reason, it is not a high concern to find a job
immediately after school; since the concerns about
the school decreased with graduation, the risk of last
year’s hopelessness could be perceived as low. The
change of hopelessness over the years cannot be ex-
plained only by the education period and different
personal, environmental and social characteristics can
affect this situation.
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
439

In this study, it was found that hopelessness was
not related to gender, but control was provided for
gender in modeling to ensure comparability with data
from other studies. In many studies, stress levels were
found to be higher in female students and this situa-
tion was attributed to girls being more affected by
emotional events, while in others were not related to
gender.22,33,34
A striking finding of the study is that the hope-
lessness scores of the students whose fathers have
university and higher education level are higher. The
level of father education can be indicators of the eco-
nomic and social structure of the family, the value
given to the child, the level of success expected from
the child and perfectionism.
In this study it was found that hopelessness sta-
tus was similar between those whose first choice was
dental faculty and not. In Turkey, the entrance to uni-
versities is made with a central exam and the students
are placed in schools based on test scores. The en-
trance base score of the faculty of dentistry chosen
for this study is quite high and it can be thought that
the majority of the applicants of this school are gen-
uinely willing to continue this particular school.
Thus, heterogeneity in terms of a “voluntary selec-
tion process” was quite low in our group, and the
finding of no difference in the population of this
study could have been explained by a type II error.
Similar studies to be conducted in future years may
be more informative if they are conducted in more
heterogeneous groups of larger sample sizes.
According to the results of this study, the most im-
portant factors in terms of hopelessness are the inabil-
ity to meet the expectations from the school, the low
level of satisfaction with vocational education is re-
markable and consistent with the results of previously
published studies. Ehtiyar and Unguren demonstrated
that students’ dissatisfaction with the educational insti-
tution increased their hopelessness levels.35
Another reason for differences across studies
could be the presence of other potential confounders.
In the studies conducted in Nigeria and Japan, it was
found that the level of perceived stress differed in those
who chose faculty of medicine as the first choice com-
pared to the faculty of dentistry; perceived stress levels
were found to be higher in those whose first choice was
medicine in Nigeria group and was dentistry in Japan
group.36,37 These findings suggest that the relationship
between hopelessness and the person who chooses the
school, whether it is the first choice may be influenced
by some external factors (if any). For example, Basu-
dan et al. found that the relationship between depres-
sion, stress and anxiety level and whether or not the first
choice of the faculty of dentistry was affected by factors
such as gender, satisfaction with faculty relations and
satisfaction with peer relations. It was stated that the
competitive environment, workload, clinical require-
ments, exams and grades could be effective in the high
level of stress.38
In this study, the most important factors in terms of
hopelessness are the inability to meet the expectations
from the school, the low level of satisfaction with vo-
cational education is remarkable and consistent with the
results of previously published studies. In a study, it was
found that hopelessness levels of the students who were
not satisfied with the department they studied were
higher than those who were satisfied.39 According to
the results of the study of Ehtiyar and Unguren, it was
found that students’ dissatisfaction with the educational
institution increased their hopelessness levels.35 In an-
other study of Unguren and Ehtiyar, it was found that
hopelessness levels of Turkish and German students
who were satisfied with the education they received
were lower than those who were not satisfied with the
education they received.40 In parallel, it can be predicted
that the level of hopelessness can be reduced as the sat-
isfaction levels of the students increase, with the efforts
to improve the quality of university education.
In many studies, students stated factors such as so-
cial media, watching television, reading books, sleep-
ing, shopping, getting emotional support, traveling,
eating, social relations as a method of coping with
stress.41,42 Harris et al. found that 94.8% of the students
of the faculty of medicine and dentistry participated in
the study directed to hobbies to combat stress.43 In our
study, hobbies were found to be protective factors
from hopelessness, similar to the literature. This find-
ing suggested that it will be beneficial to create sports
halls, art workshops, halls for music ensembles etc in
campus to provide a friendly and supportive envi-
ronment for students to engage with different hobies;
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
440

also avalaible clubs on photography/ cinema/hik-
ing/dancing etc. in the campus should be supported
administratively and financially.
The cross-sectional nature of the study limits a
thorough analysis of an exposure-outcome associa-
tion for hopelessness. Majority of reasons appearing
as cause of hopelessness can easily be outcomes of
hopeless situations or vice versa. Keeping such a lim-
itation in mind, the authors have studied some anal-
ysis for potential associations between hopelessness
and some personal and professional characteristics,
together with some modifiable environmental condi-
tions.
CONCLUSION
In conclusion,the authors could not locate any pre-
vious study published on hopelessness among den-
tistry students. In this respect, our study has a
pioneer feature. Inclusion of students from all
grades is valuable for examining the age/grade ef-
fect and repeating the same study in the following
years will be even more informative in this sense.
In the study group, the role of all possible con-
founding factors cannot be ruled out; other psycho-
logical problems like stress, anxiety and depression,
presence of any professional, drug use etc. need to
be investigated in future studies.
In light of the findings, it is recommended to the
administrative board of dental school that it will be
beneficial to introduce the educational content and
features at onset of each school year; to organize the
course programs in a way to support the success of
the students in the areas where they have difficulty,
and to clearly define the expected works in the in-
ternship. It is recommended to strengthen the current
pyschosocial counseling system. All students can be
given training on how to deal with the stress and to
increase personal resillience. Priority may be given
to the support programs that will be offered to high-
risk groups in terms of despair (those without hobby,
low level of satisfaction, etc.). Since the findings
show that there is a negative association between hav-
ing a hobby and hopelessness score; it is valuable to
encourage students to acquire hobbies and to create
an appropriate environment and time to perform their
hobbies on campus. Given the cross sectional design,
causality of the association cannot be claimed, fur-
ther studies on this issue are needed.In the coming
years, it would be beneficial to continue to conduct
similar quantitative studies repetitively, to support
these studies with qualitative and to tailor interven-
tion programs accordingly.
Source of Finance
During this study, no financial or spiritual support was received
neither from any pharmaceutical company that has a direct con-
nection with the research subject, nor from a company that pro-
vides or produces medical instruments and materials which may
negatively affect the evaluation process of this study.
Conflict of Interest
No conflicts of interest between the authors and / or family mem-
bers of the scientific and medical committee members or mem-
bers of the potential conflicts of interest, counseling, expertise,
working conditions, share holding and similar situations in any
firm.
Authorship Contributions
Idea/Concept: Tülin Çoban,Canan Hekimoğlu, Dilek Yıldırım,
Merve Büke Şahin, Gulaiym Batyrbekova, M. Barış Güncü, Banu
Çakır; Design: Tülin Çoban, Dilek Yıldırım, Merve Büke Şahin,
Banu Çakır; Control/Supervision: Canan Hekimoğlu, M. Barış
Güncü, Banu Çakır; Data Collection and/or Processing: Tülin
Çoban, Canan Hekimoğlu, Dilek Yıldırım, Merve Büke Şahin, Gu-
laiym Batyrbekova, M. Barış Güncü, Banu Çakır; Analysis and/or
Interpretation: Tülin Çoban, Canan Hekimoğlu, Dilek Yıldırım,
Merve Büke Şahin, Gulaiym Batyrbekova, M. Barış Güncü, Banu
Çakır; Literature Review: Tülin Çoban,Canan Hekimoğlu, Dilek
Yıldırım, Merve Büke Şahin; Writing the Article: Tülin Çoban,
Dilek Yıldırım, Merve Büke Şahin, Banu Çakır; Critical Review:
Banu Çakır; References and Fundings: Tülin Çoban,Canan
Hekimoğlu, Dilek Yıldırım, Merve Büke Şahin, Gulaiym Batyr-
bekova, M. Barış Güncü, Banu Çakır.
Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
441

Tülin ÇOBAN et al. Turkiye Klinikleri J Med Sci.2020;40(4):433-42
442
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