Introduction

Student debt is a contentious issue in Great Britain. Stress among dental students can come from a variety of sources, such as: examinations, accommodation-related issues, family responsibilities and financial worries to name a few.

Debt can significantly increase stress levels, which may affect academic performance and quality of life. Amongst others, studies by C. Fitch and the Associated Press-America Online have shown that individuals dealing with significant debt are more likely to report health problems such as headaches, increased blood pressure, gastro-intestinal ulcers, depression and anxiety.1,2 It cannot be concluded that all these symptoms are the direct result of financial stress, however, they are representative of chronic stress.1

In England, prior to 2012, university tuition fees were £3,290 a year, in 2012 they rose to £9,000 a year for dental students.3 However, there is conflicting evidence regarding whether the size of the debt matters; in a systematic review the majority of studies found a link between a higher level of debt and a higher level of stress, anxiety and depression. Students' estimates of future debt were also found to produce higher amounts of stress, impacting on anxiety and depression.2

A British Dental Association (BDA) survey carried out in 2013 of final year UK dental undergraduates, discovered their average total debt to be £24,734. With the authors predicting that by 2018/19 the total debt of a graduate from an English dental school is likely to surpass £60,000.3 The BDA also found that 94% of the undergraduate dental students completed their degrees with some debt. Many students reported struggling to meet living and study costs, with almost all students who had experienced financial difficulties suggesting it had caused them stress and worry.3

Even with student loans, grants and bursaries some students still report being short of money, sometimes subsequently having to take out bank loans, seek part-time employment and borrow from relatives.3 This can lead to more stress resulting from time pressures from part-time jobs and asking family members for money. Dental students may also be found to be disproportionately affected by debt than other university students as they have more timetabled hours than the majority of courses, shorter holidays (less opportunity for part-time and summer jobs), as well as lasting five years in duration compared to a typical three year course.4

Student debt can also be a determining factor in dentists' career decisions after they graduate. Dentists with higher initial debt are less likely to specialise and more likely to enter private practice with higher remuneration than a public health or faculty position and work longer hours.5 The effect of debt on future career decisions, however, was found to be small compared with the effects of sex and race.5 Debt payback times were found to be increasing, however, dentists' earnings appear to be stagnating;5 this has the potential to increase stress levels on future generations of dentists as they will spend longer paying off the debt.

The issue of student debt can impact on both university students and prospective university students. In a paper by the Institute for the Study of Labour – Germany (IZA) in collaboration with Kings College London (KCL) it broadly found that applications decrease in response to higher fees, especially for courses with lower salaries and lower employment rates. It states that the increase in tuition fees in England in 2012 reduced applications to university by 25 log points; this equates to a 1.6% reduction for every £1,000 increase in fees.6

Objectives

  • Determine whether student debt has any noticeable effect on student stress levels

  • Investigate whether student debt has any effect on dentists' career choices

  • Investigate whether the increase in tuition fees has influenced the number of applicants to study dentistry at the University of Birmingham.

Methodology

An anonymous questionnaire was completed by 4th and 5th year BDS and DCT 1, 2, 3. (DCTs or Dental Core Trainees are salaried junior hospital dentists, most having graduated within the last four years). The questionnaire consisted of circling the response which best fitted the participant's answer and a 'Likert scale' to assess the participant's response to a series of questions regarding their level of stress and future career path.

Applications to study dentistry at the University of Birmingham were obtained from the head of admissions. The data collected were analysed in Excel and a statistician calculated the statistical significance of the results.

Results

After gathering the data, the results were split into three main categories: gender, year group and student debt (Tables 1, 2, and 3 respectively).

Table 1 This table shows the percentage of male and female responses to each statement
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Table 2 This table shows the percentage of BDS4, BDS5 and DCT responses to each question
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Table 3 This table shows the percentage of responses of students with a total debt of less than £40,000 (66 participants) and those with a total debt greater than £40,000 (64 participants)
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Table 1 shows a large proportion of the participants experience some stress as a result of their student debt; with 40% of male and 44% of female respondents agreeing/strongly agreeing that their total student loan causes them stress. However, one significant difference between gender is that 37% of male compared with 61% of female respondents agreed/strongly agreed that student debt would deter them from undertaking further study; this was found to be highly significant (P <0.001).

Males were more likely to underestimate the cost of university with 73% agreeing/strongly agreeing that costs have been much higher than they expected, compared to 58% of females. Both genders decisively agreed that having no student debt would reduce their stress levels, with 80% of males and 83% of females agreeing/strongly agreeing that; having no student debt would reduce their stress levels.

The introduction of £9,000 a year to study dentistry in 2012 means the majority of BDS4 have significantly more debt than BDS5 who paid the previous rate of £3,290. The self-reported mean level of debt for BDS4 is £41,000-50,000; whereas for both BDS5 and DCTs it is £21,000-£30,000. The disparity of up to £30,000 is likely to have led to the increased level of worry amongst BDS4 students. As can be seen in Table 2, BDS4 were the group most likely to stress over their student debt with 50% agreeing/strongly agreeing that their total student debt causes them stress, compared with 37% of BDS5. Fifty-nine percent of BDS4 disagreed/strongly disagreed with the statement that 'their total student loan does not cause them to worry', compared with only 36% of BDS5.

The difference in total level of debt between BDS4 and BDS5 was found to be highly significant (P <0.001), demonstrating the rise in tuition fees in 2012 has had a profound effect on the debt levels of dental students. BDS4 were most likely to worry about their total student loan followed by BDS5 then DCTs; this difference between BDS4 and DCTs was highly significant (P <0.001). BDS4 strongly agreed/agreed the most that their total amount of student loan causes them stress with a higher proportion of BDS5 and DCTs disagreeing; this was highly significant (P <0.001). BDS4 were the most worried about paying off their student debt with DCTs the least worried (P <0.05) and BDS4 were the least likely to participate in voluntary work with BDS5 the most likely (P <0.05).

From the data in Table 3 the following statements can be made: students with higher levels of debt were more likely to be stressed about their total student loan(s) (P <0.001). Students with higher levels of debt were more likely to worry about their total student loan(s) (P <0.001). And students with a higher level of debt are also less likely to participate in voluntary work (P <0.05)

To the statement 'having no student debt would reduce my level of stress' 61% of those with debt >£40,000 strongly agreed with it, in contrast to 48% of those with debt <£40,000. The study also showed that BDS4 were significantly more worried about paying off their student debt than DCTs (P <0.05).

Figure 1a shows the participants' responses to the question, 'has having your parents or close family help you financially reduced your level of stress?' Seventy-seven percent said parental/family support has helped to reduce their level of stress. This was found to be highly significant (P <0.001).

Figure 1
figure 1

Participants' responses relating to reduction in stress

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Figure 1b shows the participants' responses to the question, 'has having access to savings reduced your level of stress?' Fifty-four percent said access to savings had reduced their level of stress. Those who have access to savings are less likely to worry about their total student loans (P <0.001).

Figure 1c shows the participants' responses to the question, 'has having a job before coming to or whilst at university reduced your level of stress?' Only 38% agreed with this statement, with the majority suggesting it had not decreased their level of stress.

The study also revealed that participants who attended a private school had less debt than those who attended a state comprehensive (P <0.01).

Figure 2 shows that just over half of participants (54%) think it will take 13 years or more to pay off all their student loans; this suggests the effects of student debt will be long lasting and could continue to have an effect on dentists throughout their early practising career. When a comparison is made between BDS4 and BDS5 on how long they estimate it will take to repay their student loans, on average BDS4 thought it would take longer, this is indicative of the higher average debt of the BDS4 cohort.

Figure 2
figure 2

Estimated number of years to re-pay student loans

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As can be seen in Figure 3, applications to study dentistry at the University of Birmingham have fallen by 42% since the rise in tuition fees. Apart from 2012 the applications to study dentistry are all below the 2011 level when fees were nearly two thirds lower.

Figure 3
figure 3

Total number of applicants to study dentistry at the University of Birmingham

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Overview of participants

There were 134 questionnaires distributed with four rejected due to them being incorrect or incomplete. Of the 130 questionnaires accepted, 48 respondents were male and 82 were female, with 70 respondents from BDS4, 38 from BDS5 and 22 DCTs. There were 66 participants with a debt of less than £40,000 and 64 participants with a debt greater than £41,000 (This reflects the fact that more fourth years completed the survey than fifth years and DCTs). Regarding the respondents' schooling; 54 had attended a state school, 35 a grammar school and 30 a private school, with 11 having attended a combination of the above schools.

Discussion

The rationale behind selecting BDS4, BDS5 and DCT students was because they have already accumulated a substantial amount of debt, and can therefore respond to the questions with more sincerity as they do not have to estimate the debt they may have in years to come. An estimation by junior years may make their answers less reliable. DCTs were included as they have already had a minimum of one year earning a salary, with the intention being to determine whether earning a salary has affected their levels of stress or career aspirations.

This study has shown that debt has a statistically significant impact on student stress levels, with higher debt correlating to a higher stress level regardless of gender or year group. Having no student debt was also found to reduce stress levels, although to what extent is undetermined.

Dentists and dental students who attended a private school reported to have less debt than those who attended a state grammar or comprehensive. Therefore, attending a private school may suggest that the participant's parents/family are in a position to contribute more to student expenses, hence reducing their level of debt (and stress).

Despite DCTs and BDS5 graduating with approximately the same level of debt, BDS5 reported to be more stressed than the DCTs; this could suggest that earning money helps to relieve the stress of student debt.

Students with a higher level of debt were found to be less likely to participate in voluntary work. A study by Nicholson et al.5 identified that dental students with higher levels of debt were less likely to specialise and more likely to enter into private practice. This suggests that in the future the number of specialists and NHS dentists could decline as dentists seek jobs in the private sector with higher remuneration to help them repay their student loans. This study also showed that women reported to be more deterred by student debt than men from undertaking further study.

Debt aside, dentistry has been found to be a stressful profession, with studies from all around the world, including; the United States, Denmark, Thailand and the UK verifying this.7 Factors reported to be stress inducing include; running a business, changes to the NHS, the NHS payment system and managing stressful patients.7 In a study by Hill et al.,7 depression/psychological illness (stress or anxiety) was found to be the single biggest reason for premature retirement. With student debt on the rise,8 this is likely to add to the increased level of stress dentists face throughout their career, potentially leading to greater levels of ill health retirement.

Despite a net increase in the total number of students to attend university since the 2012 rise in tuition fees,9 the number of applications to study dentistry has decreased dramatically year on year, with a 42% decrease in applications to study dentistry compared with the lower tuition fees in 2011. It is likely the increased cost and, therefore, student debt has played a part in this reduction, however, it is the authors' opinion that the proposed changes to the NHS dental contract and a decrease in earning potential of dentists has led to people choosing to study other courses. In the future, it will be interesting to see if the numbers stabilise or continue to fall.

Conclusion

Student debt has affected student stress levels, with individuals who possess a greater debt identifying greater levels of stress and concern regarding paying off their student debt. Moreover, having no student debt would reduce stress levels. Gender was found to be non-significant on the whole with the only exception being that student debt was found to be more likely to deter females from undertaking further studies than males. Parental/family financial support and having access to savings were both found to significantly decrease student stress, however, having a job before or during university did not.

Applications to study dentistry have decreased since the rise in tuition fees. This suggests that increasing debt has deterred people from choosing to study dentistry; however, to what extent is difficult to determine.