|Year : 2014 | Volume
| Issue : 3 | Page : 155-159
Perceived stress among medical students in preclinical years: A Saudi Arabian perspective
Ahmed Al Sunni, Rabia Latif
Department of Physiology, College of Medicine, University of Dammam, Dammam, Saudi Arabia
|Date of Web Publication||7-Oct-2014|
Department of Physiology, College of Medicine, University of Dammam, Dammam
Source of Support: None, Conflict of Interest: None
Context: The study of medicine is extensive, time-consuming, and highly stressful, especially during preclinical study period. Aim: To assess perceived stress in medical students studying in a medical college in Saudi Arabian Eastern Province and observe any gender-related variations in stress. Study and Design: Cross-sectional comparative study. Materials and Methods: The present study was carried out in College of Medicine, University of Dammam using Arabic version of Perceived stress scale-10 questionnaire. Eighty students (40 males and 40 females) studying in 2 nd year were included in the study. Statistical Analysis: Data were analyzed by using Microsoft Excel and SPSS version 19. Descriptive analyses were conducted to determine the frequency distributions of the study variables. Independent sample t-test was used to compare stress scores among male and female students. Stress level was analyzed by quartiles of perceived stress. Results: The overall prevalence of stress found in this study was 71.7%. Mean perceived stress score of all the students was 17.31 ± 5.31. There was no significant difference in the mean stress scores of males and females students. The percentage of students with no, mild, moderate, and severe stress was found to be 28.3%, 21.7%, 31.7%, and 18.30%, respectively. Conclusions: The present study indicates of high prevalence of stress in these medical students in the preclinical years. Hence, there is a need to take measures by the authorities to reduce stress among students.
Keywords: Medical school, stress, students
|How to cite this article:|
Al Sunni A, Latif R. Perceived stress among medical students in preclinical years: A Saudi Arabian perspective. Saudi J Health Sci 2014;3:155-9
| Introduction|| |
Stress is a term normally used in a variety of social, academic, and employment settings. A certain amount of pressure is essential for everyone to perform at his/her best. However, when this pressure surpasses a person's capability to cope, it results in stress. Besides, stress can lead to a vicious circle of distress and reduced ability to cope even in ordinary situations.
Recently, stress during medical training has been increasingly reported, and multiple studies have shown high levels of stress among medical students. ,,, The study of medicine is extensive, time-consuming, and highly stressful, especially during the preclinical study period. Students are subjected to endless working hours, and examinations. Peer, teacher, or parental pressures add an extra burden. With the intention of getting an outstanding grade-point-average (GPA), students often have to work over and above their threshold strength. Hence, medical students experience substantial stress. This stress can have negative academic, emotional, and health outcomes.
Based on their cultural background, personal traits, experience, and coping skills, similar stressors may be interpreted in a different manner by different individuals. Despite increased attention being paid worldwide to research about stress faced by medical students, ,,, there has been limited research on perceived stress in KSA. ,,] To the best of our knowledge, no study has investigated the perception of stress among Saudi medical students in preclinical years. Saudi students may have more stressors than other students. This may be related to their cultural aspects, learning medicine in a foreign language, extracurricular activities, transportation issues, etc., Since the beginning of the new millennium, 20 new medical schools have been established in Saudi Arabia bringing the total number of medical schools to 25.  This has resulted in an exponential increase in the number of medical students in a short period of time. Therefore, we find it necessary to look for the stress problems in medical community so that the students with high stress levels can be identified at an early stage and timely interventions can be made to reduce academic stress. It is essential for authorities to identify the prevalence and levels of stress among students, which affects not only their wellbeing but also their academic accomplishments at different points of time during their study period.
| Materials and methods|| |
The major objective of the current cross-sectional comparative study was to evaluate the level of perceived stress among Saudi medical students in preclinical years. Permission and Ethical Approval to conduct the study was sought and granted by the University Deanship of Scientific Research. Participants were drawn by nonprobability convenience sampling from students enrolled in 2 nd year medicine class in University of Dammam. Considering the total number of students enrolled in preclinical years (220), margin of error (±10%), Confidence Interval (95%), and degree of variability (0.5), the required sample size was estimated to be 85. Hoping to get a response rate of 90% and adding 10% for non-response, it turned out to be 93; however, only 80 students successfully returned the questionnaire. Participation into the study was solely voluntary, and students who volunteered were reassured that all information obtained will be kept confidential and secure.
Data collection was accomplished by using a questionnaire PSS-10 (Perceived stress scale) which is the most widely used psychological instrument for measuring the perception of stress. It consisted of 10 items that measured perceived stressful experiences over the previous month with a 5-point Likert scale ranging from never (=0), almost never (=1), sometimes (=2), fairly often (=3), and very often (=4).  PSS-10 has a possible range of scores from 0 to 40.
PSS is not a diagnostic tool; therefore, there were no cut-offs to identify stressed individuals,  and merely comparisons between subjects in the same sample were permitted. We used Arabic version whose internal consistency reliability assessed using Cronbach's α was reported to be 0.74.  Test-retest technique was adopted to check the reliability and validity of the questionnaire. Ten students were asked to solve the same questionnaire with a 2 weeks lag to see if they answered in the same manner.
The collected data was entered in Microsoft Excel. Coding of the variables was done. PSS scores were obtained by reversing responses (e.g. 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8)  and then summing across all scale items. The scale yielded a single score, with high scores indicating higher levels of stress and low scores indicating lower levels of stress. Statistical analysis of the coded data was done by using SPSS version 19. Descriptive analyses were conducted to determine the frequency distributions of the study variables. Independent sample t-test was used to compare stress scores among male and female students. Stress level was analyzed by quartiles of perceived stress.
| Results|| |
All our participants were 2 nd year students, 18-20 years age group. Mean age was 19.3 years. Half of them were males and remaining half were females. Mean PSS score in the study population was 17.31 [Table 1]. The response of the students to various questions has been summarized in [Figure 1]. The overall prevalence of stress found in this study was 71.7% (including participants with mild, moderate, and severe stress) [Figure 2]. The range of PSS scores was also divided into stratified quartiles. The first quartile represented students with a PSS score of less than 13, the second quartile had a PSS score of 13-17, the third quartile had a PSS score of 18-21, and the fourth quartile represented students with a PSS score of more than 21 [Table 2]. The 1 st , 2 nd , 3 rd , and 4 th quartiles were labeled as no, mild, moderate, and severe stress, respectively. The 1 st quartile served as the reference point for analysis. This method was selected in accordance to a recent similar study from France.  Independent sample t-test revealed insignificant difference among PSS scores of males and females students [Table 3].
| Discussion|| |
To the best of our knowledge, this is the first study mainly focusing on the perceived stress in preclinical year's medical students in KSA. The overall prevalence of stress found in this study was 71.7%. This stress prevalence is in accordance with a previous study conducted in KSA, which found out the perceived stress in Jazan University medical students to be 71.9%.  However, our reported stress prevalence is greater than that reported among European medical undergraduates. Levels of stress in a British and Swedish study have been reported to be 31.2%  and 12.9%,  respectively. The cause of decrease stress in these European medical students could be the presence of student support centers and medium of education being the native language, whereas in KSA, the medium of education is English-A language foreign to the Saudis. Eastern countries have reported higher stress prevalence than our country. A study conducted in Pakistan revealed that overall 85% of medical students felt stressed.  Other two studies from Pakistan found that more than 90% students experienced stress during their course. , A study conducted in Mumbai (India) reported that 73% of the students perceived stress during their medical schooling.  Multiple factors such as variations in the curricula and/or evaluation (examination) system, and use of a different instruments to measure stress may affect the amount and severity of stress experienced by medical students and limit comparability among these studies. The reason for less stress in Saudi medical students as compared to Indian and Pakistani medical students might be because in KSA, medical education is free and a small amount of monthly stipend is given to each student during their study. Contrary to that in other foreign medical schools, students are inundated by financial uncertainties, which may be an important cause of their stress. We selected the perceived stress scale since this instrument has been documented for its reliability and validity. , Moreover, PSS not only focuses on academic stress but also includes personal issues or reactions to stressful situations.
Mean PSS score in our study population was 17.31 (SD = 5.31), a score less than the PSS scores documented in the literature. In a study conducted in a medical school in Pakistan, the mean PSS score reported was 30.84 (SD = 7.01).  In a study conducted by Mane Abhay, using PSS in different disciplines, the mean PSS score among medical students was 27.0. 
Our study consisted of equal proportion (50:50) of the male and female students. Mean PSS scores among male students (17.9 ± 4.39) was slightly higher than that among female students (16.73 ± 6.11). However, the difference was statistically insignificant (P = 0.39). This is in agreement with previous studies. For example, Cohen documented that there was no significant difference in stress using PSS between male and female students.  Niemi and Vainiomaki reported the same. 
However, in a study conducted in India, females were more stressed than males.  Higher level of stress among female students was also reported by two studies: One conducted in a medical college in Indore, Madhya Pradesh  and the other conducted in Pakistan.  The reason behind significant gender differences found in other countries but not in our study might be the cultural difference. In Islamic society in general and in Saudi society in particular, women are highly valued and taken care of. Women in KSA have been enjoying the economic and social rights long before the Western women. Males are considered the guardians of females. All finances are strictly the man's responsibility, and there are no obligations to women. This might be the cause of less stress in females as compared to their male counterparts. However, two Saudi studies have reported that overall females perceived more stress than male students. , As male and female students in their studies have separate campuses in KSA, it could be speculated that relatively a poor learning environment may exist in some female campuses with lesser educational facilities and recreation opportunities leading to more stress in female students. We may say that in our university, female campus is having equal educational and recreational facilities as that of the campus, leading to no gender difference in perceived stress.
As the study findings showed 18.3% students suffering from high level of stress (4 th quartile), we suggest supporting them and taking care of this group by the student support system. Early interventions and effective psychological services at this stage will enable them to handle stress in a much better way in the coming future. Also, students with either mild (2 nd quartile) or moderate level (3 rd quartile) of stress need to be targeted to prevent the development of more serious conditions of stress. Western medical schools have introduced health-promotion programs and have stated encouraging results in decreasing the adverse effects of stress upon health and academic performance of medical students. ,, A similar line of action could be used for the students in our College of Medicine to reduce their level of stress.
Limitations of the study
Since our study was limited to the students from a single university in KSA, our findings cannot be generalized. The information was collected through a self-administered questionnaire; therefore, because of participants' understanding of the questions or merely because of inaccuracies of responses or desires to report their feelings in a certain way, we cannot exclude information bias. Last, but not the least, due to the cross-sectional design of the study, our results lack temporality.
| Conclusion|| |
Based on our results, almost 71.7% of the subjects experience stress (mild, moderate, and severe) irrespective of their gender. The authorities should address the stress among students by taking measures such as creation of a congenial environment, peer education, and counseling. The students should be taught different stress management techniques to improve their ability to cope with a demanding professional course. Prospective studies are necessary to identify the stressors whether these are academic, psychosocial, or health related.
| Acknowledgment|| |
The authors fully acknowledge the contribution of all the students who participated in the study and Deanship of Scientific Research, University of Dammam for funding this project.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]