Assessment of level of stress among post-graduate trainees working in tertiary care hospital in a district of Assam

INTRODUCTION

WHO, defined stress as a state of worry or mental tension caused by a difficult situation.¹ By Hans Selye, stress is the non-specific response of the body to any demand.² Stress is an automatic physical, mental and emotional response to a challenging event. “Stress” has been recognized as the “Health Epidemic of the 21^St Century” by the World Health Organization.³

Every human being experiences stress to some degree. Stress is a natural human response affecting both the mind and body. Too much stress can cause physical and mental health problem. Stress levels have a strong relationship with physical condition.⁴

Medical education is itself very vast, challenging, hectic and competitive to each and every medical professionals. Medical profession, itself leads to stressful condition to both medical undergraduate and postgraduate medical students. Stressful condition can lead to many psychological responses like, anxiety, depression, irritability, restlessness, insomnia, etc. Stress is a common problems among the medical professionals. Stress has been recognized for a long time among the medical students. The postgraduate students are at risk of developing stress due to their professional duties, workloads, peer pressure, academic activities, and so on. So, they are under pressure in relation to their duties and responsibilities of their own works which lead them psychological stress. The workload and their stress leads to psychological dysfunction. According to a study conducted by Indian Medical Association, it has been found that 82% of doctors in India experience high levels of stress.5 Stress in Postgraduate trainees has recently become a focus of concern globally. Thus , the study has been initiated to find out the level of stress and its related factors among the PG trainees working in a Tertiary care hospital of Assam. This study aimed to assess the level of stress among postgraduate trainees working in a tertiary care hospital and to find out the association between the factors leading to stress.

METHODS

The present cross-sectional study was conducted from March 23-June 2023 among the postgraduate trainees working in a tertiary care hospital in a district of Assam. All the postgraduates in different specialties pursuing their postgraduate had been included for the study. The participants had been explained about the objectives of the study and asked them to participate in the study. Those who were willing to participate in the study were included and those who were absent on the day of survey were excluded. After obtaining their informed written consent out of 138 postgraduates who were contacted only 108 responded and completed the questionnaire. The study was carried out among the post graduate trainees using Cohen’s perceived stress scale-10(PSS-10) to assess the perceived stress of the students.

Study populations and sample size

There are around 138 post graduate students working at the Tertiary care hospital. By convenient sampling 108 post graduate trainees who have given the written voluntary consent were included for the study. But during the day of survey, only 108 participants participated in the survey.

Inclusion criteria

Participants those who were present and agreed for the study included for the study.

Exclusion criteria

The participants absent during the survey had been excluded from the survey.

Data collection method

Questionnaire consisting of different study instruments. Study Instruments are follows 1. Socio-demographic data, 2. Perceived stress scale-10, 3.Self reporting questionnaire-20, 4.Insomania severity index scale.

Cohen’s Perceived Stress Scale-10 (PSS-10): It comprises of 10 questions with responses varying from zero(0) to four (4) for each item and ranging from zero (0)=never, one (1)=almost never, two (2)=sometimes, three (3)=fairly common and four (4)=very often (five point Likert’s scale) respectively on the basis of their occurrence during one month prior to survey.

Self-reportingquestionnaire-20 (SRQ-20): The Self Report Questionnaire-20 is a (screening) tool developed by WHO (1994) to assess psychological morbidity of the individuals. The tool comprises of twenty questions - four on physical symptoms and sixteen on psycho-emotional symptoms indicating presence of few symptoms yes (1) and no (0) points. The score range is from 0 to 20. Here, we divided into two groups; as those having scores >10 and <10, here indicating presence of positive symptoms if scores >10 and <10 indicating absence of symptoms.

Insomnia severity index (ISI): The scale has seven questions asking about insomnia problems. The items ranging from, none (0), mild (1), moderate (2), severe (3), and very severe (4). Total score categories, those who scores 0-7=no clinically significant insomnia, 8-14=sub-threshold insomnia, 15-21=clinical insomnia (moderate severity), 22-28=clinical insomnia (severe).

Statistical analysis

The data obtained was coded and entered in Microsoft Excel sheet and analyzed using the statistical software Statistical Package for Social Sciences (SPSS.16.0).Tests applied Chi-square tests, regression analysis, correlation coefficient, odds ratio for analysis.

RESULTS

In the present study, 75 (69.4%) male and 33(30.6%) female post graduates. According to the perceived stress scale, 6 (5.6%) of the study subjects were under high stress, 99 (91.7%) under moderate stress and 3 (2.8%) perceived low stress. Among males 72 (%) having moderate, 2 (%) high and 1 (%) low stress level. While female 27 (%) having moderate, 4 (%) high and 2 (%) low perceived stress. The difference between the male and females were found to be statistically significant. Average age of the PG students is 29 years. Among them, average age of males is 29.62 and females is 27.57 years. Most of the study participants i.e. about 97 (89.8%) are unmarried and 11 (10.2%) married; 88 (81.5%) from clinical and 20 (18.5%) were from non-clinical departments. The study participants mostly belonged to 29 (26.9%) from rural, 44 (40.7%) semi-urban and 35(32.5%) from urban area. There was significant differences among the students regarding their stress level according to their place of residence. The level of stress was highest among postgraduate students from semi-urban area compared to urban and rural area (Table 1 and 2).

Table 3 shows association between stress level with different variables. It shows significant association between gender and stress level. There was no significant association between marital status and stress level. Using Fisher’s exact test, p value=0.22 < 0.05, i.e. a significant difference could be seen among the students regarding their stress level according to their place of residence. P value for Fisher’s exact test is 0.03771<0.05, i.e. test is significant according to PG students from clinical departments compared to non-clinical departments.

Table 4 shows about the insomnia severity index with stress level among the participants. It was observed that about 64 (59.26%) having no clinical significant insomnia, 33 (30.56%) sub-threshold insomnia (low), 10 (9.25%) clinical insomnia (moderate), 1 (0.93%) clinical insomnia (severe) among the study participants

Table 5 shows correlation of insomnia and level of stress among the study participants. Spearman’s correlation coefficient has been found out to be 0.120, p value 0.216 which was found to be insignificant, i.e. there is no significant correlation between insomnia status and stress level among the PG students.

Table 6 shows the association between of the psychological morbidity with levels of stress among the study participants. It was observed that the level of stress found to be low with less psychological morbidity, moderate with less psychological symptoms and also less symptoms with high level of stress. By using Fisher’s exact test, p value=0.008 < 0.05, test was found to be significant regarding psychological morbidity and stress level among the study participants.

Table 7 shows the ordinal logistic regression analysis of level of stress with different variables and odds ratio. Results showed OR represents the odds of falling in to a higher or lower categories on the dependant variable with a unit change in the in dependant variable. With an increase in age, higher chances or higher odds of having higher stress. Clinical departments, married ones, semi-urban residents showed higher odds of having higher stress level. On the other hand, males had lower odds of being in higher stress of level than females and students belonged to rural area showed higher odds of having stress among them.

DISCUSSION

In the present study a total of 108 postgraduate students participated. The results of the present study revealed that most of the postgraduates 75 (69.45%) are male and 33 (30.55%) female having different levels of stress. Of which only 1 (33.3%) having low level 72 (68.8%), moderate 2 (33.3%), high among male and 2 (66.7%) low, 27 (27.3%) moderate and 4 (66.7%) high level of stress among female postgraduate students. Similar findings found by Anupama et al in their study where 69% had moderate and 11% severe level of stress with more in females compared to male students.⁶ By Gorantla et al and Joshi et al also observed moderate level of stress among postgraduate medical students.^7,8 Similar findings also found by Ameer RS and Ramya et al in their studies with moderate levels of stress among the study participants.^9,10 In a study done by Verma et al found most of the participants suffered from stress which were mostly related with somatic and cognitive symptoms.¹¹ By Shete et al also reported a high level of stress among postgraduate medical students.¹² In a study done by Aravind et al also reported 73% students having severe level of stress among the medical students compared to dental postgraduate students in Southern Asia.¹³ Studies of medical students from Saudi Arabia, Malaysia, identified a high frequency of stress.^14,15 In a study done by Abraham et al found about 68.5% were suffering from moderate level of stress and 25% having severe level.¹⁶ By Saini et al reported 17.7% had mild stress, 12.2% moderate and only 2.9% severe level of stress in their study.¹⁷ In a study done by Vasugi et al reported moderate level of stress and no significant differences for level of stress and anxiety and depression based on demographic factors (marital, gender and age) as seen by present study.^18,9 In a study conducted by Chandan et al mentioned prevalence of stress was 91.67%, among them 37.50% had mild and 22.50% had severe level of stress which was found to be more than the present study.¹⁹ In Malaysian study done by Yusuf et al, the prevalence of distressed postgraduate students was 36.4%.²⁰ and stress prevalence was 54.8% by Ismail et al in their study.²¹

In the present study, showed that there was significant difference between gender along with level of stress. Same findings also observed by Gorantla.⁷ By Salam et al also found a higher level of stress among females compared to male postgraduates.²² Same findings also found by Gobbur et al, Mangaiarkkarasi et al and Nayak et al where female students were more stressed than male students and found to be significant.^23-25 By Zegeye et al in their study found significant association between gender and stress among the study participants. The study done by Nazeer M et al²⁷ also found level of stress more among females than males in their study.²⁶ But by Chanadan et al reported that male postgraduates were almost two times more prone to stress compared to females.¹⁹ Same findings also reported from Arif et al where female predominance was seen in terms of stress 58 (55.7%) which was statistically significant.²⁸ From a study in Bangladesh by Sadiq et al reported to be severe to extremely severe stress disorders among residents where 10.5% residents having stress disorders.²⁹

Our study also revealed a significant difference in stress level between clinical and non-clinical departments. The findings from a study conducted by Chandan et al reported that 92.11% of postgraduates from clinical and 90.91% from pre and para clinical postgraduates had stress and there association was not statistically significant.¹⁹ In the present study, there was no significant difference between marital status and level of stress. The level of stress was found to be high among unmarried 97 (89.91%) compared to married 11 (10.18%) postgraduate students. Similar findings also reported by Aravind et al whereas unmarried postgraduates reported having more stress and association was non-significant.¹³ Stress level was found to be high in married students as compared to unmarried in a study by Guruprakash et al.³⁰ In a study done by Manpreet et al, married postgraduates had more stress compared to unmarried.³¹ By Koochaki et al, mentioned in their study that married students had significantly lower scores than single but there were no differences between the sexes.³² Overall prevalence of stress was 61.3% and no statistical significant differences in stress levels between preclinical and clinical phase.

This study also found out the association between the place of residence among the study participants with the level of stress.

The psychological morbidity like headache (42%), bad sleep (51%), feel unhappy (64%), easily tired (48%), study participants having complained in the present study. In a study done by Ramya et al also reported 53.0% suffering from headache, 28.8% poor appetite, 49.2% easily tired among study participants.¹⁰ The psychological morbidity with level of stress was found to be significant. Similar findings also found in a study done by Kavitha et al and by Datar et al and Abraham Zegeye et al in their study.^33,34,16 In a study done by Basheer et al found that 60.6% of the study participants developed symptoms related to exposure to stress, most common symptoms were gastrointestinal (67.19%).³⁴

In the present study, the insomnia severity index scale used to find out insomnia problems among the study participants. The study revealed that only 1 (0.93%) having severe clinical insomnia, 10 (9.25%) moderate severity and sub-threshold level 33 (30.56%) and around 64 (59.26%) were no clinical significant insomnia. Our Study showed no significant correlation between insomnia status and level of stress among the study participants. In a study done by Abdullal et al found poor sleep quality (76%) and 53% having stress among the study participants.¹⁴ No significant association was found between stress and gender. By Anupama et al, reported 62% of the study participants suffering from insomnia.⁶ Perceived stress scores had a significant correlation with insomnia scores. In a study done by Carpi et al identified insomnia subtypes characterized by high distress and psychological co-morbidities.³⁶ By Kusuma et al, in their study revealed that the students with poor sleep quality are 4.7 times higher risk of experiencing moderate-severe stress levels compared to students who have a good sleep quality.³⁷

This study has some limitations. The study was cross-sectional; so the findings cannot be generalised to all. Further the study focused on level of stress, other related factors did not covered.

CONCLUSION

In this study, stress level was found to be moderate in postgraduates trainees. Postgraduate trainees with gender, marital status, place of residence and clinical departments had higher stress levels. Stress was more prominent among males compared to females and more among unmarried than married postgraduates. The association between stress and psychological morbidity also found to be significant in this study.

ACKNOWLEDGEMENTS

We would like to thank all the study participants for successfully completion of the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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