Abdulghani PDF
Abdulghani PDF
Abdulghani PDF
INTRODUCTION
1. Dr. Hamza Mohammad Abdulghani, DPHC, ABFM, MRCGP,
Assistant Professor,
Department of Family Physician and
Medical education is perceived as being
Community Medicine, stressful. It is characterized by many psycho-
College of Medicine, logical changes in students. Medical students
King Saud University,
Riyadh, encounter multiple anxieties in transformation
Saudi Arabia. from insecure student to young knowledgeable
Correspondence physician. There is a growing concern about
Dr. Hamza Mohammad Abdulghani, stress in medical training. Studies have ob-
MBBS, DPHC, ABFM, MRCGP (UK) served that medical students experience a high
Assistant Professor & Consultant Family Physician,
incidence of personal distress during their un-
Dept. of Family & Community Medicine,
College of Medicine, dergraduate course. High levels of stress may
King Saud University, have a negative effect on mastery of the aca-
P.O. Box: 230155,
Riyadh-11321, demic curriculum. Stress, health and emo-
Saudi Arabia. tional problems increase during the period of
Email: hamzaabg@gmail.com undergraduate medical education. This can
* Received for Publication: September 25, 2007 lead to mental distress and has a negative
* Accepted: December 1, 2007
impact on cognitive functioning and learning.1
In most medical schools, the environment been assessed with different tools like Beck’s
itself is an all prevailing pressure providing an Depression Inventory,12 General Health Ques-
authoritarian and rigid system; one that en- tionnaire (GHQ)11 and as well as well other
courages competition rather than cooperation common and less common instruments.1,15
between learners.2 Studies suggest that men- The instrument Kessler10 Psychological
tal health worsens after student begins medi- Distress (K10) has been developed by Kessler
cal school and remains poor throughout train- and colleagues, which widely used in popula-
ing. The majority of the studies on stress in tion-based epidemiologic studies to measure
medical education focus on the documentation current (1-month) distress. It has been shown
of stress and information on the correlation of to be without substantial bias with respect to
stress.3-6 It is not just undergraduate study pe- sex and educational level. It has been designed
riod which brings the stress but it may con- to measure the level of distress and severity as-
tinue later in internship, postgraduate study sociated with psychological symptoms in popu-
period and later in physicians’ practical life7-9 lation surveys. It is being used widely, includ-
and it may reach burnout level.10 The estimated ing in the World Health Organization World
prevalence of emotional disturbance was found Mental Health Survey, and as a clinical out-
in different studies higher than in general come measure.16-20 The K10 comprises 10 ques-
population. In three British universities, the tions of the form, “how often in the past month
prevalence of stress was 31.2%,11 in a Malay- did you feel ...” and offers specific symptoms
sian medical school 41.9%12 and 61.4% is a Thai such as “tired out for no good reason,” “ner-
medical school.13 Medical school stress is likely vous”, and “sad or depressed”. The five pos-
to predict later mental health problems, but sible responses range from “non of the time”
students seldom seek help for their problems.14 to “all of the time” and are scored from 2 to 5;
In a Swedish study, the prevalence of depres- the items are assumed to obtain a total score.
sive symptoms among students was 12.9% and A score of less than 20 was considered not to
a total of 2.7% of students had made suicidal represent a ‘case’ possibility of mental illness.
attempts.1 It is important for medical educa- A score of 20-24 was considered to present a
tors to know the prevalence and causes of stu- mild stress, 25-29 was considered to present
dent distress, which not only affects his health, moderate stress and 30-50 was considered to
but also his academic achievement at different represent as severe stress. These coding was
time points of their study period. used according to the instructions of the au-
An extensive electronic internet based search thors.21 This K10 questionnaire is observed to
failed to locate any study which shows the have good psychometric properties with
prevalence of stress in undergraduate medical Cronbach’s alpha of 0.8938 (95% Confidence
students in Saudi Arabia. This study was Interval (C.I.): 0.8793-0.9072).
carried out with the following objectives: Study Sample: All the five-year male under-
1. To determine the prevalence of self-per- graduate students in the College of Medicine
ceived stress among under graduate medi- were asked to complete the K10 self-adminis-
cal students. tered Arabic version questionnaires during the
2. To observe an association between the lev- academic year 2006. Filled questionnaires were
els of stress and study variables: (i) academic collected before one month of the examination
year (ii) academic grades (iii) regular to period so as minimize the extra stress symp-
course and (iv) physical problems. toms. Additional questions relating to academic
METHODOLOGY achievement, source of stress, medical illness
in past 4 weeks and how many days a student
Instrument: A wide range of different measures was not able to work were also collected. All
has been used to address stress and depressive students who participated in the study were
symptomatology in medical students. It has informed about the objectives of the study and
information about the instrument was Table-II: Distribution of variables of study sample
explained by well trained research assistants. Variables Number (%)
The students were allowed to respond in their Academic level (n = 494)
own time and privacy. The participation was First year 120 (24.3)
entirely on voluntary basis. All students were Second year 106 (21.5)
guaranteed the confidentiality. The study was Third year 148 (29.9)
approved by research ethical committee. Fourth year 69 (14)
Statistical Analysis: Data were entered in Fifth year 51 (10.3)
Microsoft Excel and analyzed using SPSS ver- Academic grades (n = 439)
sion 12.0 statistical software. Prevalence of an Excellent 224 (51)
outcome variable along with 95% confidence Very good 111 (25.3)
interval was calculated. Pearson’s chi-square Good 76 (17.3)
Poor 28 (6.4)
test and odds ratio were used to observe and
quantify an association between the categori- Regular to academic course(n = 480)
cal outcome and different study variables. Yes 432 (90)
Student’s t-test for independent samples was No 48 (10)
used to compare the mean values of study vari- Physical problems (n=450)
ables in relation to stress. A p-value of < 0.05 No 267 (59.3)
was considered statistically significant. The Mild to moderate 158 (35.1)
Severe 25 (5.5)
outcome variable stress was categorized into
dichotomous as stress (no/yes) by considering and the stress levels. As the year of study was
the three levels (mild, moderate and severe) of increasing, the prevalence of stress was
stress as presence of stress. decreasing, which is statistically significant
(X2 = 45.9, p <0.0001). The odds ratios 6.4(for
RESULTS 1st year), 5.2 (2nd year), 2.4 (3rd year) and 2.1
There were 494 responses from a total (5th year), when 4th year is considered as refer-
student population of approximately 600 with ence category also indicates highly statistically
the response rate of 83%. The mean (± stan- significant association. The odds of student hav-
dard deviation) age of study sample was 21.4(± ing stress is higher in 1st and 2nd year, where as
1.9) years. The prevalence of stress of all types the odds are decreasing in 3rd and 5th year.
was found to be about 57% (95% Confidence (Table-III)
Interval (C.I.): 52.6-61.4) and the severe stress The association between academic grades of
prevalence was 19.6% (95% C.I.: 16.1-23.1) study subjects and their stress levels is not sta-
(Table-I). The distribution of study variables tistically significant, as the distribution of preva-
are given in Table-II. lence of stress is not significantly different
The prevalence of stress was higher (74.2%) across each of the four academic grades (X2 =
in first year of study followed by second year 2.57, p =0.46). There is no statistical significant
(69.8%), third year (48.6%), fourth year (30.4%) association between the regularity (Yes/No) to
and 49% was observed in fifth year of the the academic course and the stress levels of
study. There is highly statistical significant study subjects. The distribution of stress levels
association between the year of study subjects is not significantly different, being a student
either regular or irregular to the academic
Table-I: Distribution of stress levels among course (X2 = 0.78, p =0.37). The corresponding
medical students. odds ratios also show non significant associa-
Not stressed : 43.1% tion. But the prevalence of physical problems
Mild : 21.5% is statistically significantly associated with the
Moderate : 15.8% stress levels (X2 = 19.78, p <0.001). The odds
Severe : 19.6% ratios 2.5 and 2.0 shows the odds of getting
into stress is higher with mild to moderate and An interesting finding of this study is that
severe physical problems when compared with the level of stress decreases as the year of study
no physical problems (Table-IV). The mean is increasing. This is contradicting to the find-
number of days unable to work(9.5 days) was ing of a study where the level of stress increased
higher in subjects who had stress, when com- progressively during the course, to as much
pared with the subjects with no stress (2.3 days) high as 40% by the end of the clinical training
which is statistically significant (t = 9.75, p< period.22 Other studies also suggest that men-
0.0001). The mean number of days cut down tal health worsens after students are admitted
(10.7 days) was higher in subjects, who had to medical school and remains poor through-
stress, when compared with subjects with no out the training23 especially in the transition
stress (5.2 days) which is statistically from basic science teaching to clinical train-
significant (t = 5.3, p<0.0001). ing.24 Only one study goes in line with our find-
The main source of stress stated by the study ing that, students found medical course stress-
subjects was their studies (60.3%), followed by ful during the first year but not in subsequent
home environment (2.8%) and 36.9% of study years.25 Our finding could be explained by
population did not mention any source of many factors. Our students may be able to de-
stress. velop coping mechanism with the help of our
DISCUSSION students support system. Other factor could be
that our education is free and a small amount
A descriptive self administered questionnaire of monthly stipend given to each student dur-
based study got a response rate of 83%, which ing their under graduate course. In many dif-
provides an adequate sample size to fulfill the ferent foreign schools students are plagued by
objectives of this study. The results of this study financial worries, which is an important cause
indicates higher prevalence of stress in our of their stress3,26 which is not the case in our
undergraduate medical students. The level of
stress or depression varied between stages of Table-IV: Association between stress and study
education. This increased level of stress variables (academic grades, regular to academic
course and physical problems)
indicates a decrease of psychological health in
Study Stress No. (%) Odds 95% CI’s
our students which may impair students’
Variables ratio of OR
behaviour, diminish learning, and, ultimately, No Yes (OR)
affect patient care. Overall prevalence of stress Academic grade*
in this study is 57% which is similar to the (n = 439)
Thai study; 61.4% 13 but higher than Excellent 91 (40.6) 133 (59.4) 1.23 0.5-3.1
Malaysian; 41.9%12 and British study;31.2%.11 Very Good 54 (48.6) 57 (51.4) 1.7 0.7-4.4
The increase in stress level in fifth year is Good 32 (42.1) 44 (57.9) 1.3 0.5-3.5
expected as it is the clinical teaching where Poor 10 (35.7) 18 (64.3) 1.0 --
students are loaded with clinical schedules at Regular to academic**
course (n=480)
the hospital.
Yes 187 (43.3) 245 (56.7) 1.39 0.7-2.7
Table-III: Association of stress and year of study No 17 (35.4) 31 (64.6) 1.0 --
Year of Stress No. (%) Odds 95% CI’s Physical problems***
study * ratio of OR (n = 450)
No Yes (OR) No 130 (48.7) 137 (51.3) 1.0 --
First year 31 (25.8) 89 (74.2) 6.4 3.2-13.1 Mild to 43 (27.2) 115 (72.8) 2.5 1.6-3.9
moderate
Second year 32 (30.2) 74 (69.8) 5.2 2.5-10.6
Severe 8 (32) 17 (68) 2.0 0.8-5.3
Third year 76 (51.4) 72 (48.6) 2.4 1.2-4.5
X2 - Value P- value
Fourth year# 47 (69.6) 21 (30.4) 1.0 -
Fifth year 26 (51) 25 (49) 2.1 0.9-4.9 * 2.57 0.46
** 0.78 0.37
* X2 = 46.99, p < 0.00001, # reference group *** 19.78 <0.0001
participation in the study. Also special thanks H, Akaydin M. Anxiety, depression and stressful life
to Dr. Sheikh Shafi Ahmad, Assistant Profes- events among medical students: a prospective study
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sor and consultant statistician in the depart- 16. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek
ment of family and community medicine, for DK, Normand SL, et al. Short screening scales to
his valuable analysis and advice on statistics monitor population prevalences and trends in non-
and reviewing whole manuscript. specific psychological distress. Psychol Med
2002;32(6):959-76.
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