Prevalence of stress among third year medical students at Gulf Medical University

Transcription

1 Prevalence of stress among third year medical students at Gulf Medical University Mehdi Saeedan 1, Yasmin Ghazvini Kor 1*, Zahra Saeed 1, Rizwana B. Shaikh 2, Shatha Al Sharbatti 2, Faheem Khan 2 1 Third Year MBBS Students, 2 Department of Community Medicine, Gulf Medical University, Ajman, UAE * Presenting author ABSTRACT Objectives: To identify prevalence of stress among third year medical students of Ajman Gulf Medical University, to determine leading sources of stress based on six main stressor groups, and to explore association between stress and socio-demographic factors, past life experiences, social support system and coping mechanism. Materials and Methods: A cross sectional study was conducted by the use of self-reported questionnaire to assess prevalence of stress among third year M.B.B.S students at Gulf Medical University during November, Prevalence of stress and leading stress inducing factors were analyzed on the basis of gender, ethnicity, age group, past experiences and social support system. Data was analyzed using Excel and SPSS software. Appropriate tests (Kruskal-Wallis and Mann Whitney U) were used find any association. Descriptive statistics were used to summarize the results. Results: Medical students of third year Gulf Medical University suffer from moderate degree of stress with median score of 2.77 (on a scale of 0 to 4). Academic related stressors with median score of 3.03 shows the highest level of stress among all and teaching and learning related stressors shows the lowest stress with the median score of Major stress inducing factors were lack of time for family and friends, heavy workload and tests/examinations. Maximum amount of stress is seen in students from the American region with median score of Those students without family support showed more stress with median score of 3.04 however students with more support from their friends showed a higher stress score with a median score of Conclusion: Medical students in third year of Gulf Medical University suffer from moderate degree of stress. Academic related stressors induce the highest level of stress. There were statistically significant association between stress and ethnicity and between stress and type of accommodation. Keywords: stress prevalence, medical student, stress inducing factors, Ajman, UAE INTRODUCTION Some amount of stress is acceptable and constructive throughout education as far as it is under control. Stress among medical students is increasing and this is a matter of great concern 1,2. As per World Health Organization, stress is the body s response to a change that requires a physical, mental or emotional adaptation and stressors are the parameters & factors leading to stress that cannot be avoided but can be managed 3. Many studies on medical students revealed extreme rates of mental and emotional morbidity 3-5. Such as a study in Nepal 6,7, Putera University 8,9, three universities in England and Swistzerland Since stress is known to have a negative impact on student s academic performance, it is the responsibility of medical professionals and educators to find out the prevalence of stress among medical students and detect the source and main contributory factors 10,11,13,14. Recent studies show that high levels of stress can affect professional maturation. 18

2 The victim would lose his attention and concentration making him/her incapable of making effective decisions. They apparently show lack of desire to help patients, and this makes it a matter of great concern with regards to patients care and safety It is crucial that stress in medical students should be recognized, and appropriate strategies should be developed to deal with it. This study was conducted to assess the prevalence of stress among third year medical students in Gulf Medical University and assess the level of stress based on different stressor groups. An effort is also made to explore association between stress and socio-demographic factors, past life experiences, social support system and coping mechanism. MATERIALS AND METHODS A cross sectional study was conducted using a self-administered questionnaire to assess prevalence of stress among third year M.B.B.S students at Gulf Medical University. All students who participated in the study were informed about the objectives of the study and data was collected after taking a written consent. The students were informed for voluntary participation and anonymousness. Approval for conducting the study was obtained from the research and ethics committee of Gulf Medical University. The questionnaire was developed based on a validated instrument the MSSQ questionnaire which has Cronbach alpha value of The modifications were reviewed by two subject experts in medical education. The first portion of the questionnaire involved socio-demographic data and past life experiences and second part composed of 31 statements regarding stress inducing factors. Six main stressor groups in this questionnaire comprised 31 statements, each statement is considered as one stress inducing factor categorized in terms of six domains or stressor groups namely Academic Related Stressors (ARS), Intrapersonal and Interpersonal Related Stressors (IRS), Teaching and Learning Related Stressors (TLRS), Social Related Stressors (SRS), Drive and Desire Related Stressors (DRS), and Group Activities Related Stressors (GARS). Participants were asked to choose nil, mild, moderate or severe based on their degree of stress perception for each statement. Rating scale used to rank the answers is from one to four respectively. Total score for each stressor group is divided by number of statements in each stressor group to make them comparable. This gives the score of each stressor group for each participant. Scores are ranked according to following range: 0-1(no stress), (mild stress), (moderate stress), and (severe stress). Average of all 31 statements scores is taken to get the total stress for each participant. The analysis is done using median of total stress score. Prevalence of stress and leading stress inducing factors were analyzed on the basis of gender, ethnicity, age group, past experiences and social support system. Data was analyzed using Excel and SPSS software. Kruskal-Wallis and Mann Whitney U tests were used to find any significant association. Descriptive statistics were used to summarize the results. RESULTS Reliability analysis of 31 stress-associated questions shows that the Chronbach alpha value for the Questionnaire is A total of 60 medical students in third year of Gulf Medical University were approached, out of which 52 took part in this survey, the response rate is approximately 86%. The self- reported stress among participants is classified as moderate severity with median score of (on the scale of 0-4) as seen in figure 1. 19

3 Self Reported Severity of Stress 17.3% 7.7% 75.0% Mild Moderate severe Figure 1: Stress frequency based on total stress scores Table 1 shows the different factors associated with stress among the participants. There is no significant difference between male and female perception of stress with both the groups showing moderate stress. Participants age ranged from with mean age of 22 years (SD =2.722 years). There was no significant difference present between stress score in the different age groups. 86.5% of the participants were unmarried, both married and single participants show the same degree of stress with a slight predominance in the unmarried group. There is a significant association between nationality and amount of stress (P< 0.05), maximum amount of stress is seen in students from American region with median score of 2.9 when compared with students from other regions. There is a statistically significant association between type of accommodation and amount of stress (P< 0.05), students who reside with their families showed a considerably higher median stress score of 2.86 when compared to those who stayed on their own, in hostels and in sharing accommodations. According to this survey Table 1: Factors Associated with stress based on total stress scores Age Group 21 >21 Sex Male Female Marital status Married Single Nationality AFRO AMRO EMRO SERO Accommodation Hostel Single Accommodation Sharing Accommodation With Family Mode of transport Own Vehicle College Transport Public Transport Smoking Yes No * Not Significant Variables No. Of cases Median of stress p value AFRO: African region AMRO: American region EMRO: Eastern Mediterranean region SERO: South Asian region NS* NS NS NS NS 20

4 Unapproachable teacher(s) Family responsibilities Not enough study material Having difficulty understanding due to language problem Verbal abuse by teacher(s) Working with computers Not enough feedback from teacher(s) Lack of guidance from teacher(s) Verbal or physical abuse by other student(s) Unable to answer the teachers questions Inappropriate assignments MBBS program - wrong choice Conflicts with other students Feeling of incompetence Participation in class discussion Teaching not understandable Uncertainty of what is expected of me Having difficulty understanding the content Unfair dealing by teachers The need to do well on performance (self-expectation) Quota system in examinations Academic competition among students Parental wish for you to study medicine Need to do well (expected by others) Falling behind in reading schedule Grading process Large amount of contents to be learnt Getting poor marks Tests/examinations Heavy workload Lack of time for family and friends Figure 2: Perceived causes of stress All 31 statements regarding stress inducing factors are listed in figure 2. participants who have their own vehicle had a higher median stress score than those who did not have a vehicle although this finding was not statistically significant. In present research the ratio between smokers to non-smokers was 1 to 4.2. Non-smokers had a higher median stress score of 2.80 when compared to smokers who showed a median score of Table 2 lists those factors that have a median stress score of more than 3.00 which indicates severe stress. Most of the stressors were associated with Academic Related Stressors (ARS). Students at both extremes of stress i.e. those who had no stress or severe stress in their past life, had a higher total stress score. Participants ability to deal with past stressful circumstances seems to have no specific effect on their level of stress or coping capacity in medical course now. Those students without family support showed more stress with median score of 3.04 when compared to students with absolute family support; however students with more support from their friends showed a higher stress score with a median score of 2.72 when compared to those without any friend support. 21

5 Table 2: Main stress inducing factors among those with severe stress Stress Inducing Factors Stressor* domain Median of Stress Lack of time for family and friends SRS 3.76 Heavy workload ARS 3.69 Tests/examinations ARS 3.68 Getting poor marks ARS 3.68 Large amount of contents to be learnt ARS 3.67 Grading process TLRS 3.67 Falling behind in reading schedule ARS 3.58 Need to do well (expected by others) DRS 3.47 Parental wish for you to study medicine DRS 3.47 Academic competition among students ARS 3.44 Quota system in examinations ARS 3.24 The need to do well on performance (self-expectation) ARS 3.17 Unfair dealing by teachers IRS 3.15 Having difficulty understanding the content ARS 3.03 *SRS : Social Related Stressors ARS : Academic Related Stressors TLRS : Teaching And Learning Related Stressors DRS : Drive And Desire Related Stressors IRS : Inter And Intra Personal Related Stressors DISCUSSION The present research is conducted among third year students of Gulf Medical University in Ajman. The aim of the study is to assess the prevalence of stress in the mentioned population and its associations with age, ethnicity and gender. The response rate in this study was approximately 86%. Overall this survey shows that moderate severity of stress is present among participants with Median score of The results of three studies in Islamic Republic of Iran show levels of stress among medical students in Isfahan to be as 61.3% and other university as 31.1 % and among medical students in Gorgan it was reported as 60.6% 19. All show moderate degree of stress 19, 22. This study shows severe stress as 15.4%, much less than Great Britain reports from three universities which show the level of severe stress to be 31.2 % on average 21. Medical students severe stress prevalence ranges from 30% to50% globally The level of severe stress in medical students is higher when compared to general population as well as student in higher education courses. This signifies the urgent need for early detection and management of medical students who are suffering from severe stress. 23 Self reported severe stress prevalence in this research is less than what is seen in Saudi Arabia with 57% 12 and Thai with 61.4% 20, Malaysian 20 and British study with 41.9%and 31.2% respectively 19. Overall there are 3 main domains suggested by literature to be common cause of medical professionals stress: these are listed as academic stressors, social stressors, and financial difficulties 25. Present research shows academic related stressors had the highest median score of 3.03 among all the stressors. Most of participants in present research believe that medical students stresses stem in specific factors, table 2 and figure 2 show that lack of time for family and friends and heavy work load and test and examination were rated as highest stressors. Jizan University of Saudi Arabia report from 2012 shows a long hour of study, examinations and compact study plan as major stress inducing factors 26. Other universities mention sources for stress similar to this study 27,28 for example Iran-Isfahan medical school declares that those students who entered medical school under the pressure of their parents are the most stressful. 22

6 Similar to our research finding, one medical university reports high amount of knowledge to be learnt, no free time to enjoy and so much work to be done among major sources of stress chosen by participants, even some students believe that medicine is the wrong choice for them 22,24. There are some other researchers who reported that education and performance related forces count for major part of stress. Most of the medical students refer to overwork (47.4%) and interpersonal relations with students (13.5%) and professors (11.9%) as the core stressors in their universities. These findings are similar to the BMA survey in UK Pakistani medical students choose workload during exam preparations to be the major stress inducing parameter 27,28. But contrary to most published surveys, American medical students never chose heavy work load, instead they declare that feeling useless is the main thing which bothers them 18,25. In this research participants were mostly unmarried (86.5%) with mean age of 22 years (SD =2.77year), age does not contribute to any significant alteration in stress level; there was little more stress prevalent in people below 21 of age. One study suggests that being young about 18.3 years, by itself makes student prone to stress, especially if it is being accompanied by less social support 30. In this survey there is no difference in the stress level between married and unmarried participants, although stress is slightly higher in the unmarried students. This finding is similar to reports from Saudi University of Jizan 26. In this research gender has no specific role in stress prevalence, with slightly more stress reported in male population. Contrary to present research findings some surveys show more stress in females 31. One Swedish study 24, a study in Brazil Federal University of Ceará (UFC) 23,25, and a survey from Middle Eastern by Esfandiyari 22, 32, report that females are under great stress and pressure that can be truly destructive for their psychological health 31,32. Sources of males and females stress are different. It is mentioned that female do not get stressed due to heavy workload, but lack of self-esteem and high selfexpectation make them stressful. 31 But overall, studies show that male and female medical students are significantly more stressful than students of other courses 24,32. One recent survey done within America confirms this finding 27. In this study people from America region (AMRO) have the highest prevalence of stress among other ethnicities with median of 2.90.This report is unlike some studies from Midwestern USA that suggest no association between ethnicity and level of stress. 33 Another American study states that culture and ethnic background plays crucial role in stress perception 24. The role of family support as one of the main social support system is tested in this research. It is found that those participants with no family support have more stress with median score of Students who lack friend support system have less stress with median score of 2.65 and they believe they can better deal with stressful situations. It is unlike the earlier hypothesis which states that friend support system plays major role in stress reduction 30 as they are far from strict rules of their parents; they describe hostel life to be happy and cheerful 34. Contrary to this survey, there are some other researches that prove students who are with family have significantly less stress than their counterparts living in the hostel, 24% and 68% respectively. It is reported that people with family have no homesickness and are under less risk of depression and stress 25. Overall it is reported through literature that 15-26% people living outside home are in urgent need for psychiatric consultancy 25. Self-reported questionnaire cannot evaluate negative behaviors such as smoking accurately 25,27. In this research out of every four students one chooses smoking as coping mechanism, With 23

7 stress median of 2.80 in nonsmokers and median score of 2.65 in smokers. Some studies report that 74% of males smoke to decrease the study pressure 12, 28. American medical association suggests that this unhealthy coping system would decrease level of professionalism in future 25. Unlike this research findings Malaysian university reports that smokers (71.4%) have more stress than non-smokers (43.7%) 35,36. One survey from Pakistan reports 90% of students choose educational stress as cause of smoking and drug abuse 28. Another Pakistani study believes that it is alarming that almost 39.2% of students are smoking in the college 31. Reports show that doctors drug addiction accounts for 80%-90% of all iatrogenic disasters in hospitals and this make it a great matter of concern 29. A survey done in an Indian Medical College reports that social support system such as peers and family, seniors and even religious groups can increase resilience and decrease pressure on students to great extent 29. Owing to the small sample size these findings cannot be generalized. Research team did not have the opportunity to compare present research findings with those in other medical schools in the region as there was no published local research in terms of medical students stress prevalence in UAE. CONCLUSION This study found that medical students in third year of Gulf Medical University suffer from moderate degree of stress with median score of 2.77 (in the scale of 0 to 4).There is no significant difference between male and female perception of stress, median stress score was higher in people 21 of age. Among the six stressor groups, academic related stressors median had the highest stress score of 3.03 shows the highest level of stress among all. Maximum amount of stress is seen in students from the American region with median score of There is significant association between stress and ethnicity and between stress and type of accommodation. ACKNOWLEDGEMENTS Deep appreciation goes to the Gulf Medical University third year medical students who participated in this study. REFERENCES 1. Ross S, Cleland J, Macleod MJ. Stress, debt and undergraduate medical performance. Med Edu.2006;40: E Grebot, B Paty and N Girarddephanix. Relationships between defense mechanisms and coping strategies, facing exam anxiety performance. Unbound Medline. 2006;32(3): Johari AB, Hassim NI. Stress and coping strategies among medical students in national university of malaysia, malaysia university of sabah and universiti kuala lumpur royal college of medicine perak. Journal of Community Health. 2009;15:2. 4. Myers D.G. Stress and Health, in: Exploring Psychology (6th edn), pp New York: Worth Publishers, Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a crosssectional study. Med Educ. 2005;39: Griffith CH, Wilson JF. The loss of idealism throughout internship. Eval Health Prof. 2003;26: Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. March ;136: Willcock S, Daly MG, Tennant CC, et al. Burnout and psychiatric morbidity in new medical graduates. Med J Aust 2004;181: Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: a multicentre study. Medical Education, 2009; 43(3): CT Sreeramareddy, PR Shankar, VS Binu, et al. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Medical Education, 2007;7: Health and Safety Executive. Tackling work related stress: A manager s guide to improving and maintaining employee health and wellbeing [pamphlet]. Suffolk: Health and Safety Executive; Abdulghani HM, AlKanhal AA, Mahmoud ES, et al. Stress and Its Effects on MedicalStudents: A Cross-sectional Study at a College of Medicine in Saudi Arabia. J Health Popul Nutr oct;29(5): MacLeod R, Parkin C, Pullon S, et al. Early clinical exposure to people who are dying: learning to care at the end of life. Med Educ. 2003;37:

8 14. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38: Voltmer ER, Kieschke U, Schwappach DL, et al. Psychosocial health risk factors and resources of medical students and physicians. BMC Medical Education, 2008;8: Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety and other indicators of psychological distress among US and Canadian medical students. Academic Medicine, 2006; 81(4): Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64: Saiful Bahri M, Abdul Rahim A, Yaacob M. The development and validity of the medical student stressor questionnaire (MSSQ). ASEAN Journal of Psychiatry 2010;10(1). 19. Marjani A, Gharavi AM, Jahanshahi M, et al. Stress among medical students of Gorgan (South East of Caspian Sea),Iran. Kathmandu University Medical Journal 2008;6(3):Issue 23, White M. Stress management medical students [Internet]. [Accessed on Oct 2012] Available from: Management_Medical_Students 21. Assadi SM, Nakhaei MR, Najafi F, et al. Mental health in three generations of Iranian medical students and doctors. A cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 2007;42(1): Koochaki GM, Charkazi A, Hasanzadeh A, et al. Prevalence of stress among Iranian medical students: a questionnaire survey. Eastern Mediterranean Health Journal 2011;17(7): Aguiar SM, Vieira AP, Karine MF, et al. Prevalence of stress symptoms among medical students. Jornal Brasileiro de Psiquiatria [online]. [Accessed on Oct 2012];58(1): Available from: scielo.php?script=sci_arttext&pid=s &lng=en&nrm=iso 24. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students. Med Educ 2005;39: Dyrbye LN, Thomas MR, Eacker A, et al. Race, ethnicity, and medical student wellbeing in the United States. Arch Intern Med 2007;167(19): Sani M, Mahfouz MS, Bani I, et al. Prevalence of stress among medical students in Jizan University, Kingdom of Saudi Arabia. Gulf Medical Journal 2012;1(1): Yusoff MSB, Rahim AF. The Medical Student Stressor Questionnaire (MSSQ) Manual. First ed. Kelantan, Malaysia. KKMED Publications;2010. ISBN Shaikh BT, Kahloon A, Kazmi M, et al. Students, stress and coping strategies: a case of Pakistani medical school. Educ Health (Abingdon) Nov;17(3): Mahajan AS. Stress in Medical Education: a global issue or Much Ado About Nothing specific? South East Asian Journal of Medical Education 2010;4(2): Wilks SE. Resilience amid Academic Stress: The Moderating Impact of Social Support among Social Work Students. Advances in Social Work 2008;9(2): Inam SNB, Saqib A, Alam E. Prevalence of anxiety and depression among medical students of private university. J Pak Med Assoc Feb;53(2): Morrison J, Moffat K. More on medical student stress. Medical Education 2001;35: Ware J, Kosinski M, Dewey J, et al. How to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8 Health Survey. Lincoln, RI: Quality Metric Incorporated; Pani S. Life in a college hostel [internet]. [Accessed on Oct 2012], Available from: resources/92832-life-college-hostel.aspx 35. Al-Dubai SAR, Al-Naggar RA, Alshagga MA, et al. Stress and Coping Strategies of Students in a Medical Faculty in Malaysia. Malays J Med Sci Jul-Sep;18(3): Yusoff MSB, Rahim AF. Prevalence and sources of stress among postgraduate medical trainees: Initial findings. ASEAN Journal of Psychiatry. 2010;11(2). 25