J Med Allied Sci 2017; 7(1):41-47 DOI: https://doi.org/10.5455/jmas.252925

Original article

Perceived stress in Saudi undergraduate medical students

Aesha Farheen Siddiqui1, Saad Abdullah Al-Amri2, Assaf Abdullah Al-Katheri2, Khalid Hussain Mohammed Al-Hassani2

Affiliation(s):

1Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia.

2Medical Interns, College of Medicine and Associated Hospitals, King Khalid University, Abha, Saudi Arabia.

Corresponding author: Dr. Aesha Farheen Siddiqui, Assistant Professor, Department of Family and Community Medicine, King Khalid University, Abha, Saudi Arabia.

Phone: +966-591472255 Email: ashfarheen_zsh@yahoo.com

Abstract

This study aimed to assess the prevalence and magnitude of stress in Saudi undergraduate medical students and its associated socio-demographic factors using a cross-sectional design. It was conducted at King Khalid University Medical College during September-October 2016, including 267 students of both sexes and all study levels. Data was collected using an anonymous self administered questionnaire including socio-demographic information like participant details and family details, along with the Kessler -10 scale for measuring stress. Data analysis was carried out using SPSS 17.0. Results were described as frequencies, percentages, meanĪSD. Independent samples t test and ANOVA were used to study the relationship of stress with various social and demographic factors. A mean stress score of 23.46Ī7.77 was observed. This is graded as mild stress according to Kessler scale classification. Forty four students, i.e. 16.5% reported perception of high stress, while 23.6% students perceived mild and 26.6% reported moderate stress. Students who perceived no stress comprised one third (33.3%) of the study population.A significant relationship of female gender with stress was observed (p˂0.0001). It was concluded that most of the medical students undergo some degree of stress during their study period and female students have significantly more stress than their male counterparts.

Keywords: Female students, Medical education, Saudi Arabia, Stress

Running title: Stress in medical students

Introduction

Study of medicine is life-long and boundless. It has been described as a path that never ends and places the student under heavy stress and burnout1. A negative effect is exerted on the psychological health of the medical students as medical school is the place where for the first time they come into contact with serious illnesses and death2. The stressful environment during medical studentís life in medical college often negatively affects the academic performance, physical health and psychological well-being of the student. Compared to students of other academic streams, medical students face higher stress3. Medical students seem to have increased rates of depression and suicidal ideation compared to the general population; unfortunately they are no more likely to seek treatment4. The prevalence of emotional disturbance found in different studies on medical students is higher than that in the general population. In a large USA study of over 4000 medical students, undergraduate medical students were found to be under psychological stress to the extent of burnout and suicidal ideation5. In three British universities the prevalence of stress was 31.2%6, it was 41.9% in a Malaysian medical school7 and 61.4% in a Thai medical school8. Stress in medical school is likely to predict later mental health problems9. In a Swedish study, the prevalence of depressive symptoms in medical students was 12.9%, and 2.7% of students had made suicidal attempts10. Studies from developing countries like Thailand, Malaysia, Pakistan and India have reported stress among medical students and have underscored the role of academics as a source of stress7,8,11,12. A study from the United Kingdom on first year medical students in a new problem-based medical curriculum has reported a higher rate of psychological morbidity and stress13.

More and more medical educators are trying to look into the prevalence, causes and levels of stress in students, which not only affect their health but also their academic achievements. In Saudi Arabia, studies on epidemiological data about stress among medical undergraduate students are few and far between. There is no such study in Aseer region which is home to King Khalid University (KKU); a center that has one of the highest intake of medical students in the country. Hence, the objective of this study is to measure the stress in medical students and also to study possible social and demographic factors related to stress.

Material and methods

Ethical consideration:The study was conducted consequent to ethical approval by the Institutional Ethical Committee (REC#2016-05-18).

Setting and participants: A cross-sectional study was undertaken in King Khalid University Medical College during September-October, 2016. Every year KKU admits two batches of male and two batches of female students each for MBBS course in January and August, totaling approximately 200 males and 70 females. Basic sciences are taught in the first two years while medical courses (pre-clinical) start from third year onwards. Hence only the students who have completed at least one semester (16 weeks) of medical teaching in their third year (i.e. currently in level 6) were involved. Students from pre-clinical as well as clinical years were included in the study. Previous studies have reported prevalence of stress as 63.8% in Saudi Arabia14. Hence, based on 63.8% prevalence of stress, at 95% confidence interval and margin of error as 5%, the target sample size was calculated as 350 students. The final sample was constituted by 267 students who returned completely filled-in questionnaires.

Study tool: The study used an anonymous self-administered questionnaire. The questionnaire included general information of students. The socio-demographic variables included were; respondentís age, gender, academic level, fatherís education level and occupation, motherís education level and occupation and family monthly income. For assessing stress we used the Kessler-10 Psychological Distress instrument (K10) developed by Kessler and colleagues15. This instrument has been used widely in population-based epidemiological studies to measure current (1-month) distress.

Description of the study instrument: Kessler scale is a 10-item questionnaire intended to yield a global measure of distress based on questions about anxiety and depressive symptoms that a person has experienced in the most recent 4 week period. For each question, respondents mark the option that best describes the amount of time they have felt that way on a one to five point scale ranging from ďNone of the time ď to ďAll of the timeĒ. Scores of the 10 responses are added up and the total score is calculated. Scores range from 10 to 50. The total score is interpreted as follows: a score of less than 20 is considered not to represent stress of any level while a score of 20-24 represents mild stress, 25-29 represents moderate stress, and 30-50 represents severe stress. The K10 questionnaire was observed to have good psychometric properties with a Cronbachís alpha of 0.89 [95% confidence interval (CI): 0.88-0.90]15.

Data collection: Each group of students (in the academic level) was briefed about the purpose and objective of the study. Using a convenient sampling procedure, those students who agreed to participate were included in the study. Verbal consent was sought to participate in the study. The students were assured about anonymity and confidentiality of the responses given in the questionnaire and handed out the instrument. The questionnaires after completion were collected on the same day.

Statistical analysis: SPSS 17.0 was used for analysis. Descriptive results were presented as frequencies and percentages, while stress score was described as mean Ī standard deviation. Independent samples t-test and one-way ANOVA were used to study the relationship of stress with various social and demographic factors. All results were considered significant at (p˂0.05).

Results

Out of a total sample of 350 students, 267 students (76.28%) returned completely filled-in questionnaires, which were included in the final analysis. The incomplete questionnaires were discarded.

Table 1 presents baseline information of the respondents. The mean age of study group was 22.9Ī1.41 years. Male students formed 68.2% of our study sample. Most of the students belonged to the clinical years (88.8%). A good proportion of respondentsí fathers (45.7%) had university education while among mothers it was 27.3%. Illiteracy was not commonly reported. Among the reported fathersí occupation, 27.7% were military personnel, and 36% were retired, while almost two third of mothers (64.8%) were housewives. Most students reported a family income more than 10,000 Saudi Riyal / month (68.5%).

Table 1: Baseline characteristics of the respondents

Variable

 

N (%)

Age (Years)

<22

94 (35.2%)

 

≥22

173 (64.8%)

Gender

Male

182 (68.2%)

 

Female

85 (31.8%)

Academic level

Pre-clinical

30 (11.2%)

 

Clinical

237 (88.8%)

Fatherís education

Primary school

44 (16.5%)

High school

84 (31.4%)

 

Bachelor / Diploma

70 (26.2%)

 

Postgraduate

52 (19.5%)

 

Illiterate

17 (6.4%)

Motherís education

Primary school

89 (33.3%)

High school

53 (19.9%)

 

Bachelor / Diploma

47 (17.6%)

 

Postgraduate

26 (9.7%)

 

Illiterate

52 (19.5%)

Fatherís occupation

Teacher

46 (17.2%)

Professional

23 (8.6%)

 

Businessman

28 (10.5%)

 

Retired

96 (36.0%)

 

Military / Police

74 (27.7%)

Motherís occupation

Teacher

59 (22.1%)

Professional

3 (1.1%)

 

Businesswoman

4 (1.5%)

 

Housewife

173 (64.8%)

 

Retired

13 (4.9%)

 

Other services

15 (5.6%)

Monthly income

(Saudi Riyals)

<5000

16 (6.0%)

5000-10000

68 (25.5%)

 

10000-20000

105 (39.3%)

 

>20000

78 (29.2%)

 

Table 2 shows the distribution of students based on their responses to questions assessing stress. The various questions to assess stress among students and the proportion of students who opted for the frequency of times which they felt a certain way shows that all items were responded as less frequent (none of the time, a little of the time or some of the time) by majority of thestudents. Few of the students responded ďall the timeĒ to items on tiredness, nervousness, restlessness, hopelessness, depressive feelings, or feelings of worthlessness.†††††††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††††††††

Table 2: Distribution of study group based responses to items assessing stress

Items concerning feelings during the last 30 days

Frequency of feeling

None of the time

n(%)

A little of the time

n(%)

Some of the time

n(%)

Most of the time

n(%)

All of the time

n(%)

How often did you feel tired out for no good reason?

60(22.5)

65(24.3)

80(30.0)

44(16.5)

18(6.7)

How often did you feel nervous?

24(9.0)

76(28.5)

105(39.3)

41(15.4)

21(7.8)

How often did you feel so nervous that nothing could calm you down?

111(40.5)

80(30.0)

49(18.4)

19(7.1)

8(3.0)

How often did you feel hopeless?

85(31.8)

85(31.8)

60(22.5)

27(10.1)

10(3.8)

How often did you feel restless or fidgety?

58(21.7)

80(30.0)

78(29.2)

36(13.5)

15(5.6)

How often did you feel so restless you could not sit still?

89(33.3)

85(31.8)

57(21.4)

24(9.0)

12(4.5)

How often did you feel depressed?

69(25.8)

76(28.5)

80(30.0)

28(10.5)

14(5.2)

How often did you feel that everything was an effort?

57(21.3)

97(36.3)

65(24.4)

32(12.0)

16(6.0)

How often did you feel so sad that nothing could cheer you up?

82 (30.7)

100(37.5)

48(18.0)

23(8.6)

14(5.2)

How often did you feel worthless?

120(44.9)

67(25.1)

47(17.6)

19(7.1)

14(5.3)

 

Based on the information generated through the responses to the stress scale, the stress scores of students and their descriptive statistics were obtained and the stress grades were computed. This information is detailed in table 3 and table 4.The stress scores obtained by the students were normally distributed, with a skewness of 0.78 (SE=0.14) and kurtosis of 0.97(SE=0.29). The mean stress score was 23.46Ī7.77. The maximum and minimum score was 50 and 10 respectively. Depending on the Kessler scale the stress scores were graded into four categories. The results are displayed in table 4. A little more than one third of the students perceived no stress, while about 24% students perceived mild stress, 26.6% reported moderate stress. Forty four students i.e. 16.5% reported perception of high stress.

Table 3:Descriptive statistics of the stress score (Kesseler-10 score)

N

Range

Min.

Max.

Mean

SE

SD

Var.

Skewness(SE)

Kurtosis(SE)

267

40.00

10.00

50.00

23.46

0.48

7.77

60.4

0.78(0.14)

0.97(0.29)

SE= Standard error, SD= Standard deviation, Var. = Variance

 

Table 4: Respondentís distribution by their stress grades

Stress Grade

Frequency (%)

No stress ˂ 20

89 (33.3)

Mild stress 20-24

63 (23.6)

Moderate stress 25-29

71 (26.6)

High stress ≥30

44 (16.5)

 

We examined the relationship between the stress scores with student characteristics and parental variables using the t test and the one-way ANOVA. The results are presented in table 5 and 6. Examination of the relationships between the demographic variables collected and stress scores did not result in significant relationships associated with age and level of study. In contrast to this finding, the relationship between gender and stress score were significant (df =265, t=16.25, p˂0.0001). Examination of the relationships between the parental variables like education, occupation, monthly family income and stress scores did not result in any significant relationships. The detailed results are described in table 6.

Table 5: Relationship of student characteristics with their stress scores

Variable

 

Stress score

Mean Difference

95% CI of the difference

df

t value

P value

Mean

SD

Age

˂ 22

23.12

7.16

-0.23

-2.20,1.74

265

-0.23

0.81

 

≥ 22

23.35

8.17

 

 

 

 

 

Gender

Male

21.99

6.82

-4.03

-5.99,-2.06

265

16.25

˂0.0001

 

Female

26.02

9.07

 

 

 

 

 

Academic level

Preclinical

22.10

5.57

-1.32

-4.31,1.65

265

-0.87

0.38

 

Clinical

23.42

8.05

 

 

 

 

 

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Table 6: Relationship of parental variables and studentís stress scores

 

Variable

Mean

SD

partial η2

df

F value

p

Fatherís education

Primary school

23.09

8.75

0.008

4,262

0.55

0.69

 

High School

23.94

8.02

 

 

 

 

 

Bachelor/Diploma

23.45

6.96

 

 

 

 

 

Postgraduate

22.86

7.31

 

 

 

 

 

Illiterate

21.00

9.39

 

 

 

 

Motheríseducation

Primary school

21.32

7.58

0.03

4,262

2.25

0.06

 

High School

24.43

6.59

 

 

 

 

 

Bachelor/Diploma

23.55

7.23

 

 

 

 

 

Postgraduate

24.73

7.85

 

 

 

 

 

Illiterate

24.46

9.35

 

 

 

 

Fatherís occupation

Teacher

23.23

5.91

0.02

4,262

1.36

0.24

 

Professional

22.00

6.98

 

 

 

 

 

Businessman

25.07

9.40

 

 

 

 

 

Retired

24.12

9.03

 

 

 

 

 

Military/Police

21.91

6.57

 

 

 

 

Motherís occupation

Teacher

24.18

5.94

0.03

5,261

1.64

0.15

 

Professional

26.00

1.73

 

 

 

 

 

Businesswoman

28.50

14.70

 

 

 

 

 

Housewife

23.33

8.36

 

 

 

 

 

Retired

20.53

6.94

 

 

 

 

 

Other services

19.46

5.73

 

 

 

 

Monthly income

< 5000

19.68

9.77

0.02

3,263

1.99

0.11

 

5000-10000

24.63

8.84

 

 

 

 

 

10000 to 20000

22.77

6.83

 

 

 

 

 

> 20000

23.51

7.53

 

 

 

 

 

Discussion

In the current study, most of the students reported stress, and the average stress score was found to be 23.46Ī7.77. Sixteen percent students reported very high stress. These findings are in concordance with multiple studies that have reported a high prevalence of stress among medical students. A study in Riyadh, Saudi Arabia using the same scale as used in the current study reported a mean stress score of 26.03Ī9.7. Students with severe stress constituted 33.8% of the study group in that study16. Another similar study in Bangladesh found that the overall prevalence of stress scores was 54%17. Almost all Malaysian medical students (as high as 93.9 %) reported some degree of stress, and only 6.1% students reported no stress18. A study in India also identified that a high level of perceived stress is present among the medical students19. These findings can be explained by contextualizing them with the structure of the medical course in general, and particularly in KKU, Saudi Arabia. The study group, i.e. the medical students at KKU, is exposed to a rigorous training program. The typical medical program at KKU spreads over six-years. The students study an orientation (1st) year together with other health specialties (such as pharmacy and nursing). After that, medical students study separately for two pre-clinical (2nd and 3rd) years, followed by three clinical (4th, 5th and 6th) years. Each year is composed of two semesters. Each semester is further divided into two 8-week blocks. Students at medical faculties at KKU take multiple quizzes and examination that start from 4th to 6th week of each semester and continue, until semesterís final exams. Some courses are completed within the 8 week blocks and include quizzes, assignments and final exams comprised of theory as well as practical exams. Most of the courses incorporate teaching strategies that include self-directed learning, seminars and assignments that place increased demands on the studentís time and resources. The academic factors thathave been reported to be behind medical studentsí poor psychological health are, a high workload, future study concerns, the long duration of academic days and a high number of examinations20-22. These problems are compounded by the fact that the medium of instruction of the medical course in KKU is English, while the first language of the students is Arabic. Many of the students have only basic knowledge of English language and are exposed to medical and technical terms which pose a challenge to their comprehension abilities. Scrutiny of the sociodemographic factors, to study their association with stress revealed absence of any relation with student factors like age and academic level, or parental variables like education, occupation and family income. An important finding was a significant association of stress with female gender. This gender difference in stress is well known in general and among medical fraternity in particular. Studies have reported a higher prevalence of stress among female medical students16,17; although some studies have refuted this difference13. Some studies have also reported differences in stress degree by level of study, namely, higher stress level in preclinical or junior level as in the Saudi study16, while some studies have reported higher stress in senior levels13. Any such association was not found in our study. There was also no association of stress with other factors like age, parental education or occupation and family income. This could be because medical education in Saudi Arabia enjoys government patronage. Saudi Arabia has a nationwide educational system that provides free training from preschool through university to its citizens23.

Conclusion

Majority of medical students experiences stress of some degree. Stress cuts across all ages and study levels as well as socioeconomic variables like family income. This study also strengthened the theory that female gender is particularly vulnerable to stress during all stages of life including college life. There is a need to look deeply into stress as well as the coping mechanisms to improve studentís psychological health. The students should be taught different stress management techniques to improve their ability to cope with a demanding professional course.

Study limitations

This cross-sectional study was based on self-reported information provided by students. There may have been some misinformation. As English is not the first language of the students, therefore, there is some possibility of bias which may have occurred because of the respondentsí interpretation of the questions. Also, because of the nature of questions, students may be prejudiced to report their emotions in a certain way.

Recommendations

It is recommended to study this subject more deeply in order to evaluate the existing patterns of stress in students and its associated factors. A longitudinal study, with a cohort of students to investigate the levels of stress and coping mechanisms among students in all the five years of undergraduate medical years could go a long way in providing the much needed answers.

Acknowledgments: None

Conflict of interest: None

Source of Funding: None

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