Perceived stress, sources of stress and coping strategies among undergraduate medical students of Nepal: a cross-sectional study

Study design, participants, and sample size

This is a cross-sectional study conducted from 15 November 2019 to 14 December 2019 among undergraduate medical students of PAHS, a government medical school of a non-Western low-income country, Nepal. PAHS has adopted several new and innovative approaches in its medical curriculum. These include Problem-Based Learning (PBL) in the first two years of integrated basic science study, and the Clinical Presentation Curriculum (CPC) in third to final years of clinical clerkship.

The study is based on self-administered questionnaires. Written informed consent was obtained from the participants. The study included all medical students of the four batches currently in School of Medicine of PAHS. These batches consist of two groups in initial basic sciences years of medical school and two groups in later clinical clerkship years of medical school. Consenting students were asked to fill out the questionnaire together in class. Students not giving consent and students among the researcher team were excluded from the study. A total of 231 students from four batches were initially considered for inclusion in this study.

As there were no previous estimates of the prevalence of stress among medical students in Nepal, a conservative assumption of a prevalence of 50% was made, with a 10% margin of error, and a 5% level of significance. After adding a 10% non-response rate, the final sample size targeted for the study came out to be 106. To select study participants, a two-stage stratified random sampling method was employed. Stratification was based on the year of study and gender. Within each stratum, students were randomly selected using the lottery method. Out of the 106 sample of randomly selected students, 101 completed the questionnaire and provided consent.

The questionnaires administered to the students consisted of four parts: Demographics, Medical Student Stressor Questionnaire (MSSQ),¹² Perceived Stress Scale (PSS),¹³ and Brief-COPE (Coping Orientation to Problems Experienced).¹⁴ All questionnaires were in English language. Ethical approval was taken from the institutional research committee of the Patan Academy of Health Sciences [Ref no: std1506111071] and research was carried out per relevant guidelines and regulations.¹⁵

Description of tools

Demographic questionnaire

A demographics questionnaire was developed for this study. It comprised of questions pertaining to various demographic details such as age, gender, address, year of study, weather the participant resided in PAHS hostel or not, etc. These questionnaires were compiled in Microsoft Word (Microsoft Office Professional Plus 2019 version 2112) and discussed in the research group and reviewed by the research advisors to establish content validity. Finalized questionnaire were distributed among all respondents.

Perceived Stress Scale questionnaire

Perceived stress level was measured using the PSS-14.¹³ PSS-14 is a pretested and pre-validated questionnaire designed to assess an individual’s perception of stress. This questionnaire comprises 14 questions with responses varying from “never,” “almost never,” “sometimes,” “fairly often,” and “very often” labeled as 0-4 respectively. It is designed to assess the degree to which participants evaluate the stress levels in their lives over the previous month.¹³

PSS-14 scores were obtained by reversing the scores on positive items, following a pattern where 0 was converted to 4, 1 to 3, 2 to 2, and so on, and then summing across all 14 items. The scale yields a single score where high scores meant higher perceived levels of stress and lower scores meant lower perceived levels of stress. The PSS-14 has a range of scores from 0 to 56. A cut-off value of 28 (equivalent to 50%) was used, and the scores were labeled as “stressed” or “not stressed” depending on weather their scores exceeded of fell below this threshold, respectively. This specific cut-off value was selected from a similar study done in Pakistan.⁵

Medical Student Stress questionnaire

In this study, the MSSQ was used to assess sources of stress and their severity.^12,16 The MSSQ as well is a pretested and pre-validated questionnaire. It comprises 40 questions. Respondents were asked to rate this set of forty items or stressors using a scale of 0 to 4 where 0 = causing no stress at all, 1 = causing mild stress, 2 = causing moderate stress, 3 = causing high stress, and 4 = causing severe stress. These stressors encompass a wide array of challenges commonly faced by medical students, including examinations, heavy workload, lack of time to review what has been learned, etc.¹⁶

The MSSQ grouped stressors in six domains based on an underlying theme.¹² The six domains are: 1. Academic Related stressors (ARS), 2. Intrapersonal and interpersonal Related Stressors (IRS), 3. Teaching and Learning-related stressors (TLRS), 4. Social Related Stressors (SRS). 5. Drive and desire Related Stressors (DRS), and 6. Group Activities Related Stressors (GARS).¹² Total scores in individual domains were calculated by using weighted means. Stressors with scores of 0 – 1.00, 1.01 – 2.00, 2.01 – 3.00, and 3.01 – 4.00 were graded as mild, moderate, high, and severe respectively.¹⁶

Brief-COPE questionnaire

The Brief-COPE-28 scale, a pretested pre-validated questionnaire, was used to assess coping strategies used by students in response to their stress.¹⁴ It contains 28 items and is rated on a four-point Likert scale; 1 = I haven’t been doing this at all, 2 = I’ve been doing this a little bit, 3 = I’ve been doing this a medium amount, 4 = I’ve been doing this a lot. In total, this scale covers 14 dimensions. These are grouped into maladaptive coping strategies denial, self-distraction, behavioral disengagement, venting, self-blame, and substance use and adaptive coping strategies active coping, instrumental support, planning, acceptance, emotional support, humor, positive reframing, and religion.¹⁴

Data collection and analysis

A total of 106 students were randomly selected from the sample using two-stage stratified random sampling based on the year of study and gender, followed by the lottery method for each stratum to ensure a representative sample. The selected students were given questionnaires with written instructions. Informed consent was taken from all the participants in written form. The questionnaire was distributed amongst students and the researchers collected the completed questionnaires researchers for analysis.

Data were entered into Microsoft Excel (Microsoft Corporation, 2018, Microsoft Excel) (RRID: SCR_016137). It was analyzed using Statistical Package for Social Sciences (SPSS) 13.0 (SPSS Inc. Released 2005. SPSS for Windows, Version 13.0. Chicago) (RRID: SCR_002865).

To assess the perceived stress levels, the mean score of perceived stress was calculated and the number and percentage of stressed cases were determined according to demographic variables. We used Pearson’s Chi-Square tests to examine associations between categorical variables like gender and stress or phases of study and stress levels. Six different domains of MSSQ, namely, ARS, IRS, TLRS, SRS, DRS and GARS, were calculated, and we used descriptive statistics to measure the severity of stressors within these domains. Spearman’s correlation was applied to test the correlation between perceived stress (PSS score) and coping strategies among students. When comparing means across different groups, such as stress levels across academic years, we employed ANOVA. Furthermore, we utilized t-tests to compare the stress levels between students in initial basic science years and later clinical clerkship years. The p-value<0.05 was considered significant.

Perceived Stress Scale (PSS)

As shown in Table 2, among 101 students, 55 of them were stressed based on a cut-off score of 28, while 46 of them were not stressed. Consequently, the prevalence of stress in among our study participants was found to be 55%. Notably, female students exhibited a slightly higher prevalence of stress compared to their male counterparts (60% vs 52%) but the difference was not statistically significant (p < 0.05).

Similarly, an analysis of stress levels across different academic years reviled a trend with decreasing stress in senior years. However, the difference among different years was not significant (p > 0.05). In contrast, as shown in Table 2, on regrouping students by the phase of study, a notable finding emerged. Students in initial basic science years were significantly more stressed compared to students in later clinical clerkship years (66.7% vs 42%, with p-value < 0.05).

When considering the accommodation status of students, it was observed that 33 (52.4%) students staying at the PAHS hostel were stressed, while only 22 (57.9%) students not staying in the hostel were stressed. Despite this the difference was not statistically significant (p = 0.10). There was also no significant difference in the presence of stress among local students from within Kathmandu or outside Kathmandu (p > 0.05).

Medical Student Stressor Questionnaire (MSSQ)

The mean and standard deviation of stressors score are shown in Table 3 below.

Academic Related Stressors (ARS) scores were present amongst both male and female students as seen in Table 3. Social Related Stressors (SRS) was higher among male students, while other stressors were higher among female. When analyzing students’ accommodation status, it was observed that, apart from Intrapersonal and interpersonal Related Stressors (IRS) scores, other stressors were higher in those students staying outside the hostel. However, none of these differences were statistically significant.

The top ten stressors with their mean values are presented in Table 4. Eight of the top ten stressors are ARS. The most common stressors are test examinations, lack of time to review what has been learned, getting poor marks, an extensive amount of content to be learned, and the need to do well (self-expectation).

ARS scores (2.22 vs. 2.14) and GRS scores (1.82 vs. 1.61) were higher in basic science students but other domains were higher in clinical clerkship. Stressors were highest in basic science first-year students while lowest in clinical clerkship second-year students. However, the differences were not statistically significant.

Brief-COPE

In this study, we observed that the five most common coping strategies used by students during the event of stress were active coping, acceptance, planning, self-distraction, and instrumental support, with mean scores of 5.86, 5.67, 5.64, 5.05, and 4.85 respectively among all students. However, when we focused on stressed students, we noted slightly lower mean scores for these strategies compared to their non-stressed counterparts. Conversely, the least common coping mechanism was substance use. The mean scores of coping mechanisms used by students are presented in Table 5.

There were significant differences in coping strategies used according to gender, phase of the study i.e. basic science or clinical clerkship (p < 0.05), location of accommodation i.e. hostel or outside hostel (p < 0.05), and stress. Interestingly, substance abuse, a maladaptive strategy for coping was significantly more prevalent among male (mean score 3.07) compared to their female counterparts (mean score 2.05), and the difference was statistically significant (p < 0.05).

Coping strategies varied based on the phase of study as well. Positive reframing, planning, religion, and self-blame as a coping mechanism was significantly more prevalent among basic science students compared to clinical clerkship students and the difference were statistically significant. Furthermore, when we considered the year of study, we found that planning decreased significantly (p < 0.05) over the years of medical school, mean score being 6.11, 5.66, 5.66, and 5.04 in basic science year 1, basic science year 2, clinical clerkship year 1, and clinical clerkship year 2 respectively. The strategies that were significant among different groups of respondents are presented in Table 6.

These results highlight the diversity in coping strategies among students, shedding light on how different factors such as gender, academic phase, and academic year influence their choices in handling stress.

Limitations

Our findings may not be generalizable to other medical schools in Nepal since PAHS has a unique teaching-learning strategy. The cross-sectional design of our study is another limitation since associations could not be calculated. Prospective studies are necessary to study the associations between stressors and the incidence of stress. Since we did not evaluate the level of stress with academic performance, we cannot comment on the association between the two. The questionnaires were used as it is in the English language, potentially causing issues with students as this may not be their first language. The systematic translation, cultural validation, and adaptation in the local language of Nepalese medical students was not done.

Underlying data

Figshare: Underlying data of “Perceived Stress, Sources of Stress and Coping Strategies among Undergraduate Medical Students of Nepal”. https://doi.org/10.6084/m9.figshare.c.5757833.v1.²⁹

The project contains the following underlying data:

Extended data

Figshare: Underlying data of “Perceived Stress, Sources of Stress and Coping Strategies among Undergraduate Medical Students of Nepal”. https://doi.org/10.6084/m9.figshare.c.5757833.v1.²⁹

The project contains the following extended data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).