Level of stress among undergraduate, intern and postgraduate medical students measured using perceived stress scale-10: a cross-sectional study

INTRODUCTION

Stress among under-graduate medical students is increasingly reported in the published literature recently. These under-graduate medical students are subjected to the pressure of academic activities with an obligation to succeed, an uncertain future and hurdles of integrating into the system. They also face social, physical, emotional and family problems which may affect their learning ability and academic performance. The potential negative impact of emotional distress on undergraduate medical students, include impairment of functioning in classroom and clinical performance. Perceived stress has been linked to current mental distress and forthcoming health problems.¹ Medical education is perceived as being very stressful. Due to this many psychological changes occur among the students.²

Multiple studies done in India have shown significantly high stress levels among medical students. Self-rated depression is also found to be significantly higher among Indian medical undergraduates.³ Medicine study is perceived as being stressful and this is attributed to the vastness of the medical syllabus that needs to be learned and the ongoing various forms of assessments. Increased levels of stress, anxiety and depressive symptoms have been reported among medical students due to rigorous and demanding nature of medical curriculum. Medical students, both under and postgraduate encounter different types of stressors during their course. As per the various studies, it is estimated that the prevalence of stress among medical students is 28.5-78%.⁴

Chronic stress can disturb personal life, academic performance and overall development among medical students. Stress can cause fatigue, inability to concentrate and irritability among both under and postgraduate medical students.⁵ Medical education is perceived as a stressful training and medical students experience lot of stress during their undergraduate studies, internship and residency training which affects their cognitive function, practical life and patient care.⁶ Medical interns are subjected to stress due to direct involvement in the treatment of patients, increased risk of infection, fear of transmission of infection to their closed ones and working under extreme pressure. Stress among medical interns should be focused and tackled in time to protect their health.⁷

Postgraduate medical students suffer from higher stress due to challenging nature of medical education that affects their mental wellbeing. This stress is an external constraint which upsets an individual both mentally and physically.⁸ Medical education is broad, stressful and challenging which can lead to many psychological problems among postgraduate medical students. These students are at risk of developing stress due to their professional duties, workloads, peer pressure, academic activities.⁹ Stress, anxiety, worry and aggression have significantly increased among postgraduate medical students in recent years.¹⁰ So, the study was planned to assess the level of stress among undergraduate, intern and postgraduate medical students.

METHODS

This cross-sectional study was conducted among undergraduate, intern and post-graduate medical students of Rajiv Gandhi medical college located in Mumbai metropolitan region in the month of June 2024, following purposive sampling method. Necessary permissions and approvals were obtained. PSS-10 scale was used to assess the stress level among the subjects. The purpose of the study was explained to all the subjects. Google form containing relevant variables was sent to 583 medical students of which 400 (68.61%) were undergraduates, 87 (14.92%) were interns and 96 (16.47%) were postgraduate medical students. Consent form was included in the Google form itself. Total 288 subjects responded to the Google form of which 150 (52.08%) were under-graduate, 50 (17.36%) were intern and 88 (30.56%) were post-graduate medical students. Data was entered in Microsoft excel and analysed. Descriptive and inferential statistics was applied. Statistical significance level was fixed at p<0.05.

RESULTS

Google form was distributed to all (n=583) undergraduate, intern and post-graduate medical students of the medical college of which 400 were under-graduates, 87 were interns and 96 were post-graduate medical students. Of the 400 under-graduate medical students, 150 (37.50%), of the 87 interns, 50 (57.47%) and of the 96 post-graduate medical students, 88 (91.67%) responded to the Google form. Total 288 (49.40%) subjects took part in the study. The overall response rate among the study subjects was 49.40%. The response rate among postgraduate medical students was highest (i.e. 91.67%). Among 288 subjects, 150 (52.08%) were under-graduate medical students, 50 (17.36%) were interns and 88(30.56%) were post-graduate medical students of non-clinical and clinical subjects. The mean PSS score of the study participants was 20.80±7.35. The mean PSS-10 score of post-graduates was more (i.e. 23.04±7.24) compared to under-graduate students and interns. The 52 (59.09%) post-graduate students were from clinical while 36 (40.91%) were from non-clinical subjects.

The mean PSS-10 score of postgraduate subjects belonging to clinical subjects (i.e. 20.74±7.34) was slightly higher compared to the PSS-10 score of postgraduate subjects of non-clinical branches. The mean PSS-10 score of post-graduate student from physiology department was 33.00±0.00, which was higher among the subjects of all other departments. The lowest mean PSS-10 score (i.e.13.00±7.20) was of subjects from anesthesiology department. The mean PSS-10 score of subjects belonging to >20-24 years age group was highest (i.e. 22.04±7.24) compared to subjects belonging to other age groups. Female subjects were having higher PSS-10 score (i.e. 21.98±7.36) compared to male subjects (p<0.05).

The mean PSS-10 score was highest among divorced subjects (i.e. 24.00±7.33) compared to subjects belonging to single, married and in relationship group. The hostelite subjects have more stress (i.e. PSS-10 mean score 21.41±7.32) compared to non-hostelite subjects. The distribution PSS-10 score of the study participants is represented in Table 1.

The 67 (44.67%) under-graduates, 30 (60.00%) interns and 42 (47.73%) post-graduates were having very high (PSS-10 score ≥21) stress level. The 26 (49.06%) postgraduate students from clinical and 16 (45.71%) from non-clinical branches were having PSS-10 score ≥21 i.e. very high stress level.

The 55 (53.92%) subjects from >20-24 years age group were having very high stress level (i.e. PSS-10 score ≥21). The 60 (43.48%) male subjects while 79 (52.67%) female subjects were having very high stress (i.e. PSS-10 score ≥21).

Two (66.67%) divorced subjects were having high stress level. The 86 (49.14%) hostelite subjects were having PSS-10 score ≥21 i.e. very high stress compared to the subjects staying in rented house or with own family (Table 2).

Academic burden, financial issues, working conditions, health problems, relation with seniors and family issues are some of the reasons for stress among the subjects as mentioned by them. The 46 (30.67%) under-graduates mentioned academic burden is the reason of stress for them while 52 (34.67%) mentioned family and personal issues are responsible for stress among them. The 26 (52.00%) interns said they suffer from stress due to academic burden. 25(28.41%) post-graduates also mentioned that the academic burden is the cause of stress among them (Table 3).

DISCUSSION

In the present study we observed mean PSS score of 20.80±7.35 among the study participants. The mean PSS-10 score of post-graduates was more (i.e. 23.04±7.24) compared to under-graduate students and interns. Among postgraduates, 59.09% were from clinical while 40.91% were from non-clinical subjects. The mean PSS-10 score of post-graduate medical student from physiology department was highest compared to the subjects of all other departments. The lowest mean PSS-10 score was of postgraduate subjects from anesthesiology department. Anuradha et al in their study in Tamil Nadu among undergraduate medical students observed, mean perceived stress score of 25±5.44.¹ The mean perceived stress score among female and male medical students was 26.19±5.57 and 24.83±5.15 respectively. Academic stressors were the most important reason for increased stress among undergraduate medical students. They observed, vast syllabus, fear of failure and lack of recreation were important determinants of stress. They also observed that the major significant psychosocial stressors were loneliness and family problems.

Abdulghani et al in their study in Saudi Arabia among medical students observed, the total prevalence of stress was 63.00% and the prevalence of severe stress was 25.00%.² They also observed that the prevalence of stress was higher among females (75.70%) than among males (57.00%). In the present study, it is observed that the female subjects were having higher PSS-10 score compared to male subjects. The mean PSS-10 score was highest among divorced subjects compared to subjects belonging to single, married and in relationship group. The hostelite subjects have more stress compared to non-hostelite subjects. Garg et al in their study among medical students from North Indian medical university concluded that stress amongst medical students is a dynamic process as the stressors keep changing with the year of study and constantly changing expectations of students and system.³

In our study we observed, 44.67% under-graduates, 60.00% interns and 47.73% post-graduates were having very high (PSS-10 score ≥21) stress level. 49.06% postgraduate students from clinical and 45.71% from non-clinical branches were having PSS-10 score ≥21 i.e. very high stress level. We also observed, 30.67% undergraduates mentioned academic burden is the reason of stress for them while 34.67% mentioned family and personal issues are responsible for stress among them. The 52.00% interns said they suffer from stress due to academic burden. The 28.41% post-graduates also mentioned that the academic burden is the cause of stress among them. Ragab et al observed in their study in Sudan, the overall prevalence of stress among medical students was 31.70%.⁴ The main sources of stress were time pressure, heavy workload, fear of failure and frequency of examination. They also observed female medical students were more stressed due to academics than males. As per the various studies, it is estimated that the prevalence of stress among medical students is 28.50-78.00%.

AI Houri et al in their study in Syria among medical students observed, majority of the subjects had mild (50.60%) and moderate (37.00%) stress levels.⁵ Academic-related stressors were the most important causes of stress among undergraduate medical students. Abdulghani et al in their study in Saudi among interns observed, most of the interns were affected by a severe level of stress (34.90%), followed by mild (19.30%) and moderate (18.80%) levels of stress.⁶ The stress level was significantly higher (84.00%) among female interns in comparison with male interns (66.50%). Their study showed that nearly 73.00% of the interns were under stressed conditions. Gyan et al in their study observed, 62.47% medical interns and doctors posted in COVID duties were having moderate stress and 34.58% were having mild anxiety.⁷ The mean score of stress was 21.14 with SD of 7.45 measured with PSS-10 scale.

Anjali et al in their study observed, moderate level of stress among postgraduate medical students.⁸ They observed statistically significant difference in the stress level among clinical and non-clinical postgraduate medical students. They observed mean stress score of 15.30±3.93 measured with DASS-42 among postgraduate medical students. Rabha et al in their study in Assam observed 90.74%, 05.55% and 03.74% postgraduate medical students were having moderate, high and low level of stress respectively.⁹ The stress was associated with marital status, gender, residence and clinical and non-clinical departments. Gobbur et al in their study among postgraduate medical students in Kalaburagi observed, majority of the postgraduate medical students were suffering from stress due to various factors.¹⁰

CONCLUSION

The stress was found to be prevalent among undergraduate, intern and postgraduate medical students. Preventive mental health services could be made an integral part of routine clinical services for medical students. Medical students counseling center may be useful to help them to cope with the stress among them.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

1. 1. Anuradha R, Dutta R, Raja JD, Sivaprakasam P, Patil AB. Stress and stressors among medical undergraduate students: A cross-sectional study in a private medical college in Tamil Nadu. Indian J Community Med. 2017;42(4):222-5.
2. 2. Abdulghani HM, Alkanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: A cross-sectional study at a college of medicine in Saudi Arabia. J Health Population Nutrit. 2011;29(5):516-22.
3. 3. Garg K, Agarwal M, Dalal PK. Stress among medical students: A cross-sectional study from a North Indian medical University. Indian J Psychiatr. 2017;59(4):502-4.
4. 4. Ragab EA, Dafallah MA, Ahmed MH. Stress and its correlates among medical students in six medical colleges: an attempt to understand the current situation, Middle East Curr Psychiatr. 2021;28:75.
5. 5. Al Houri HN, Jomaa S, Latifeh Y. The prevalence of stress among medical students in Syria and its association with social support: a cross-sectional study. BMC Psychiatr. 2023;23:97.
6. 6. Abdulghani MH, Irshad M, Al Zunitan MA, Al Sulihem AA, Al Dehaim MA, Al Esefir WA, et al. Prevalence of stress in junior doctors during their internship training: a cross-sectional study of three Saudi medical colleges’ hospitals. Neuropsychiatr Dis Treatment. 2014;10:1879-86.
7. 7. Gyan NN, Prashanth C, Kumar RMP, Babu R. Stress and anxiety among medical interns and doctors deputed in COVID duties: a cross-sectional study. Telangana J Psychiatr. 2021;7(2):122-7.
8. 8. Anjali SN, Garkal KD. A study of stress, anxiety and depression among postgraduate medical students. CHRISMED J Health Res. 2015;2(2):119-23.
9. 9. Rabha AP, Das UB, Deka U. Assessment of level of stress among post-graduate trainees working in tertiary care hospital in a district of Assam. Int J Community Med Publ Heal. 2024;11(2):885-92.
10. 10. Gobbur SB, Nigudgi SR, Reddy S. Prevalence of stress among post graduate doctors at Mahadevappa Rampure Medical College, Kalaburagi, Karnataka. Int J Community Med Publ Heal. 2017;3(2):576-80.