key: cord-1005336-fix7ta31
authors: Silva, Paulo Goberlânio de Barros; de Oliveira, Carlos Alysson Lima; Borges, Marcela Maria Fontes; Moreira, Danna Mota; Alencar, Phillipe Nogueira Barbosa; Avelar, Rafael Linard; Bitu Sousa, Renata Mota Rodrigues; Sousa, Fabrício Bitu
title: Distance learning during social seclusion by COVID‐19: improving the quality of life of undergraduate dentistry students
date: 2020-08-11
journal: Eur J Dent Educ
DOI: 10.1111/eje.12583
sha: 6fc46e0ca7d3a3cd7f7918f9d41f9e9fdb49b7c9
doc_id: 1005336
cord_uid: fix7ta31

BACKGROUND: Social isolation is ongoing worldwide with the aim to stem the spread of the novel coronavirus SARS‐CoV‐2 responsible for the COVID‐19 pandemic. However, social isolation leads to significant psycho‐emotional changes. This study aimed to assess the effect of distance education (DE) activities implemented due to social isolation, on the quality of life of undergraduate dentistry students. METHOD: An e‐questionnaire (Google Forms®) was administered to identify specific DE activities after social isolation and included the World Health Organization Quality of Life (WHOQOL)‐bref questionnaire. The e‐questionnaire was sent 14 days after the initiation of social isolation, remaining available for 48h. Cronbach’s alpha and the means of the quality of life domains were calculated and analyzed using the Friedman/Dunn and Spearman’s correlation tests. After ranking, Chi‐squared and Fisher’s exact tests plus multinomial‐logistic‐regression were performed (SPSS, p<0.05). RESULT: There was an excellent internal consistency of WHOQOL‐bref (α=0.916), and the mean quality of life (0‐100) was 70.66±12.61. The psychological domain was the most affected (p<0.001). The social domain exhibited the weakest correlation with overall quality of life (p<0.001, r=0.688). The use of the Internet, cell phones, and streaming media increased, although all students had DE activities. In the multivariate analysis, attending virtual meetings (p=0.028) and performing DE activities in an office/study room (p=0.034) were significantly associated with good quality of life. CONCLUSION: Facing social isolation never previously experienced by this generation, undergraduate dentistry students are at risk of reduced quality of life. Therefore, performing DE activities through devices with teacher‐student interaction is a key coping tool.

Since December 2019, cases of coronavirus disease 2019 (COVID- 19) , which emerged in Wuhan of the Hubei Province in China, have spread throughout the world, causing great concern 1 . The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in widespread infections with severe outcomes. The effects, in terms of mortality rate and global economic impact, have not been seen since the 1918-1919 Spanish flu, which killed 675,000 people in the United States and 50 million worldwide. The damages resulting from COVID-19, not only in terms of health but also the economy and social context, are incalculable. The spread of the virus has caused school closures, company shutdowns, and bans on all public meetings with the aim to minimize the deleterious effects 2 .

On January 30, 2020, the Emergency Committee of the World Health Organization (WHO) declared a global health emergency based on rising case notification rates in Chinese and international locations. Currently, the case detection rate is changing daily at an alarming rate 3 . According to the Ministry of Health (Ministério da Saúde -MS), at 12:02PM of April 04, 2020, Ceará was the third most affected Brazilian state, only behind the states of Rio de Janeiro and São Paulo, respectively. 4 To control COVID-19 transmission, various governments implemented strict domestic quarantine and social isolation policies. This measure has proved effective in decreasing the spread of new cases of infection in countries affected by COVID-19. However, recent research has demonstrated that these measures may have adverse psychological effects on the quarantined population 5 .

After traumatic events, people may experience acute stress with long-term mental and physical health impairment, including psychiatric disorders, in addition to family conflicts 6, 7 .

Quarantine is an unpleasant and traumatic experience, and separation from loved ones, loss of freedom, uncertainty towards the future, and boredom may lead to major sequelae. 8 An important consequence of social isolation is its psychological impact on students. Stress factors, such as prolonged isolation, fear of infection, frustration and boredom, inadequate Accepted Article information, lack of personal contact with colleagues, friends and professors, lack of personal space at home, and financial loss for the family, may have even more problematic and lasting effects, especially on children and adolescents. 9 The Ceará state government, on March 16, 2020 , declared the suspension of activities involving crowds to promote social isolation and consequently reduce the spread of COVID-19, and such measures included the suspension of classroom instruction. 10 By March 18, public and private colleges and universities of Ceará were no longer conducting classroom activities. However, Christus Faculty (Centro Universitário Christus -Unichristus), on the same day, began preparing online lessons and training/ instructing faculty members via distance learning to avoid disruption of the activities of its numerous undergraduate degrees.

Although dentistry is a highly practical profession, the high load of theoretical classes renders it possible to temporarily convert theoretical activities into distance education modalities with the aim to keep adolescent students active and reduce anxiety and discomfort levels during confinement. 9 Thus, since social isolation significantly reduces quality of life, and access to technology can minimize this discomfort, 11 this study aimed to assess the effect of maintaining distance education activities on undergraduate dentistry students in social isolation due to the COVID-19 pandemic.

This observational cross-sectional study, which involved the anonymous opinion of undergraduate dentistry students from a higher education center of reference in a specific region (Unichristus, Fortaleza, Ceará, Brazil), followed the rules of Resolution 510/16 12 As an inclusion criterion, students were only included if they answered yes to the first two items of the questionnaire: "Do you wish to participate in this study?" and "Are you an Accepted Article undergraduate dentistry student at Unichristus (Fortaleza, Ceará, Brazil)?" These were the only non-mandatory items of the questionnaire. Questionnaires filled in after the deadline set in the item "sample calculation and questionnaire administration period" and questionnaires in which these two non-mandatory items were not filled were excluded from the study.

The questionnaire was designed with four blocks of questions: block 1 contained questions regarding age, sex, semester, shift, and extracurricular activities prior to social isolation and block 2 contained questions regarding study practices prior to and during social isolation, as well as the use of concentration killers (TV, cell phone, streaming media, etc.) during this period;

The block 3 (data from student profile) was developed in a 4-step approach to select items. 13 Firstly, a thematic review of questionnaires evaluating study profile in e-learning was accessed to understand the important items to investigate this profile. 14-16 Secondly, a teaching expertise designed a structured questionnaire based on the information previously described. Thirdly, the items were evaluated by three specialists, a doctor in health education, a doctor in teaching and a doctor in biostatistics. Fourthly, minor item disposition corrections (objectification of responses) was made based in suggestion of the three specialists and the questionnaires were launched. This process was made in four days (one process per day) to minimize fatigue bias and the meetings were by videoconference due to the context of the COVID-19 pandemic. So, block 3 contained questions regarding distance education activities performed during social isolation. The questionnaire as showed in annex 1.

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Based on the study by Hawton 19 , which observed significant variation in the quality of life of socially isolated elderly people aged 65 to 74 years in relation to individuals with low social isolation (EQ-5D DSI scores 0.67±0.29 vs. 0.74±0.23), 230 students should be evaluated to obtain a sample that represents the alternative hypothesis of this study with a power of 90% and a confidence level of 95% (Student-t test).

As determined by the Ministry of Health (Ministério da Saúde -MS), practical classroom instruction was suspended, and the recommendation to teach theoretical lessons using digital platforms in the format of distance learning was promptly followed by the institution on the first day of isolation. The instrument was launched 14 days (on March 18, 2020) after the state government suspended classroom activities and was available for 24 hours on the 14 th day of social isolation (April 01, 2020; 0:01AM).

During this period, the questionnaire was completed by 135 students. Each dentistry class at Unichristus has a leader, so we contacted by WhatsApp the class leaders who sent the questionnaires to their WhatsApp groups. So, to reach the number set in the sample calculation, the questionnaire remained available for another 24 hours (15 th day of social isolation), totaling 236 completed questionnaires. Our dental school has 654 enrolled students, so, we response rate in these two days was 36.1%.

Among them, four forms were filled after the 48h deadline (April 03, 2020; 0:01AM), and two students failed to answer the items mentioned in the exclusion criteria, thus the sample size reached 230. Since all items of the blocks of questions were mandatory, the students could not move to the next block without answering all items from the previous block. Thus, all mandatory items of the 230 questionnaires included in this study were properly completed. The number of days in social isolation (14 or 15) was calculated by subtracting the date when the questionnaire was filled out on Google Forms® by the date when classroom activities were suspended at the start of social isolation.

Data from the completed surveys were exported to a Microsoft Excel spreadsheet using the command "View responses in Sheets" of Google Forms®, and subsequently encoded and analyzed using the software Statistical Package for the Social Sciences (SPSS) version 20.0 in Windows (p<0.05).

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The scores of the WHOQOL-bref and of each domain were converted to a linear scale from 0 to 100, according to the syntax proposed by the WHOQOL group. The means and standard deviations were calculated, along with the overall Cronbach's alpha and the Cronbach's alpha values excluding each domain, and the correlation of each domain was analyzed with the WHOQOL-bref (Spearman's rank correlation tests). The Friedman/test was used to analyze the domains, and subsequently the WHOQOL-bref scores of each student were classified as dissatisfied/uncertain for scores from 0 to 70 and satisfied for scores from 70 to 100. 20 The two categories (low/moderate quality of life (0-70) and high quality of life (70-100)) were associated with all items of the first three blocks of the questionnaire using the Pearson's chi-squared test or Fisher's exact test. The variables with p <0.200 were analyzed using a multinomial logistic regression model (multivariate analysis).

The mean quality of life of dentistry students after two weeks of social isolation was 70.66±12.61 with a median of 71.90 points, and scores ranging from 36.20 to 96.20.

Cronbach's alpha showed adequate internal validity of the construct (α=0.916) and no exclusion of any domain significantly reduced these values. All domains showed a strong correlation with the overall quality of life score ( 

The sample consisted of students who were mostly older than 20 years (n=142, 61.7%), with a mean age of 22.4±4.8 years that ranged from 17 to 46 years. Most students were females (n=179, 77.8%) and completed their pre-clinical and clinical semesters (n=109,

This article is protected by copyright. All rights reserved 53.4%) in evening classes (n=119, 51.7%) ( Table 2 ). Most students participated in extracurricular activities, primarily study groups (n=136, 59.1%), followed by teaching assistant jobs (n=121, 52.6%), continuing education (n=54, 23.5%), and scientific initiation (n=31, 13.5%) projects. Of the 230 questionnaires completed, most were completed on the 14 th day of social isolation (n=135, 58.7%), while 95 (41.3%) were completed after the 15 th day of social isolation ( Table 2) . None of these variables were significantly associated with the scores for overall quality of life (p>0.05) ( Table 2 ).

The study routine of most students prior to social isolation involved either 4-6 hours (n=63, 27.4%) or 2-4 hours (n=62, 27.0%) of study per day. During social isolation for COVID-19, the numbers were similar, with the highest prevalence of study routines at 2-4 hours (n=63, 27.4%) and 4-6 hours (n=54, 23.5%) of study per day, respectively. Thus, no significant difference was found between the two periods (p=0.146), since although 91 (39.6%) students stated that they spent more time studying daily after social isolation for COVID-19 than previously, 89 (38.7%) stated that they reduced their time studying, while 50 (21.7%) maintained their daily study time (Table 3 ).

Most students stated that they increased their use of the Internet (n=204, 88.7%) and cell phone (n=188, 81.7%), as well as the time they spent watching TV (n=102, 44.5%) and engaging with streaming media (n=124, 53.9%), during isolation. The increase in Internet and cell phone use was significantly higher than the increase in time spent watching TV or engaging with streaming media (p<0.001) ( Table 3 ). The only variable of study routine and use of concentration killers that was significantly associated with quality of life during social isolation was watching TV. The students who reduced their time spent watching TV in isolation reported worse quality of life than the students who maintained their time spent watching TV (p=0.016) ( Table 3) .

All students evaluated in this study attended some type of distance learning or used some type of educational technology during the 14 days of interruption in classroom

This article is protected by copyright. All rights reserved instruction and social isolation. Nearly all students (n=222, 96.5%) had virtual meetings with professors using online platforms, such as Zoom or Skype, and received assignments through the educational platform Moodle (n=207, 90.0%). The system developed by the university was the third most used platform for lessons and distance education activities (n=175, 76.1%) and video lessons on YouTube was an approach cited by 169 (73.5%) students ( Table 4 ). The high quality of life was prevalent significantly higher among students with virtual meetings through online platforms, such as Zoom or Skype, compared to among students without virtual meetings (p=0.013) ( Table 4 ).

The most used device to access distance education content was the computer (n=201, 87.4%), followed by the cell phone (n=198, 87.4%). The study environment most frequently used to access distance education content was the bedroom (n=184, 80.0%), followed by the living room (n=70, 30.4%), dining room (n=40, 17.0%), and office or study room (n=32, 13.9%). The students who performed distance education activities in an office or study room had a higher prevalence of high quality of life compared to the students who did not perform those activities in this room (p=0.005) ( Table 4 ).

Most students stated that they lived in a household with more than three people (n=131, 57.0%) and that their homes had more than five rooms (n=155, 67.4%) and more than one room was deemed suitable for studying (n=165, 71.7%). Students whose homes had more than five rooms (p=0.017) and more than one room was deemed suitable for studying (p=0.004) exhibited better quality of life (Table 4 ). In the multivariate analysis, students who completed distance education activities through virtual meetings using online platforms, such as Zoom or Skype (p=0.028), in the environment of an office or study room (p=0.034) exhibited a 9.01 and 2.85 higher prevalence of good quality of life, regardless of other variables (Table 5 ).

According to Johns Hopkins University, which updates numbers in real time, at 12:00PM on April 04, 2020, 1,140,327 people were infected worldwide, with 60,887 confirmed deaths. The United States of America had the highest number of diagnosed cases (278,568), while Italy had the highest number of deaths (14, 681) . According to the same website, on the same day, Brazil had 9,216 confirmed cases, with 365 deaths, 3 

This article is protected by copyright. All rights reserved Social isolation and quarantine measures have been adopted worldwide to control the spread of COVID-10, 2 and on March 16, 2020, activities involving crowds of people, such as classroom activities, were suspended in our state (Ceará, Brazil) . 10 On March 18, the Brazilian government regulated an ordinance published seven days earlier, authorizing higher education institutions to engage in distance education activities through communication technologies to maintain the classroom activities of undergraduate degrees. 21 On the same day, distance lessons and activities were made available to students on the systems and platforms of Unichristus, thus avoiding the interruption of teaching activities; nevertheless, social isolation was inevitable. We performed a web-based questionnaire invitation, because this was the only method to conduct the study in COVID-19 pandemic. But, although this method being descripted as having lower response rates (36.3%) than paper-based questionnaire invitations (46.0%), our response rate (36.1%) was strongly similar to previously descripted. 22 So, a good adhesion to research was obtained.

Long periods of social isolation are associated with mental health problems, posttraumatic stress symptoms, avoidance and anger behaviors, and family conflicts. 6, 7, 23 

This article is protected by copyright. All rights reserved Social isolation has a strong impact on children and adolescents, 9 which prompted the initiative of maintaining distance education activities to mitigate this process. However, most students increased the use of the Internet, cell phone, and streaming media due to the idleness and boredom that comes with being secluded at home. 9 The use of technologies in individuals in social isolation improves interaction with society and mitigates dissatisfaction with life. 19 However, technologies are important concentration killers, and reduce knowledge retention and the benefits that distance education activities can provide. 28 Various factors, including shift, sex, age, and length of social isolation (14 or 15 days), exhibited no significant effect on quality of life. Interestingly, no significant effect was observed on the quality of life of students who had performed extracurricular activities prior to socially isolating due to COVID-19. Extracurricular activities are associated with improved social interaction and life satisfaction. Accordingly, the group of students who had adhered to extracurricular activities are expected to show a greater decrease in quality of life after such activities are temporarily prevented. 29 Therefore, maintaining distance education activities may help to retain these indices.

All dentistry students of our university attended some type of distance instruction, but virtual meetings using online platforms, such as Zoom/Skype, were the most used distance education modality, significantly affecting quality of life. These technologies with advanced interaction structures between people, even over long distances, virtually increase social contact, reduce distance, and promote interaction between students and professors. 30 Distance education has been used worldwide as a rich tool to access education. Despite the resistance of students and teachers to this technological innovation, 31 distance education adds value to those who lack access to information through conventional means. 32 Thus, distance education, particularly with online interaction devices, plays a key role in this period of social isolation due to the COVID-19 pandemic, even becoming a way to manage stress. 8 Despite the benefits of online learning, content must be accessed in a suitable environment to both maintain a level of adequate concentration and favor its assimilation. 33 The results of this study indicate that performing distance education activities in an office or study room was an important factor to maintaining a high quality of life. A suitable study and work environment is crucial for improved academic and professional performance. 34, 35 The home environment's role as educator is interdependent with many other, continuing, changing, and frequently competing roles that it fulfill and the home atmosphere strongly support the academic achievement. 36 The size of the study site, the amount of light and even the color of the environment influence the quality of learning. 37 When associated to a good e-

This article is protected by copyright. All rights reserved learning environment, a pleasant environment for study can improve the quality of life of students by dedicating themselves to their main activity, the study. 38 Therefore, the use of more appropriate environments to conduct distance learning activities is recommended.

Thus, undergraduate dentistry students, who are globally encountering social isolation on a scale that has never been experienced previously by this generation, are at a risk for reduced quality of life. Performing distance education activities using devices that promote thorough interaction with professors is a key coping tool. However, these activities must be improved and conducted in an appropriate environment for quality education and student satisfaction. Although our short-time results, we recommend to carry out future studies with a longer isolation time to assess the real impact of a major confinement as is happening today.

Undergraduate students in dentistry are young and the and youth predisposes to anxiety.

Facing social isolation never previously experienced by this generation, this sample are at risk of reduced quality of life. Therefore, performing DE activities through devices with teacher-student interaction is a key coping tool. 

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Accepted Article This article is protected by copyright. All rights reserved

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Accepted Article