INTRODUCTION:

A growing concern globally on the mental health of medical students has been well documented in academic health professions literature over the past twenty-five years. A spectrum of effects has been identified ranging from stress, anxiety, depression leading to suicidal tendencies. The common factors identified have been academic pressure, environmental changes, obstacles encounter in achieving their goals, transition from a school to university life and role change from medical student to a knowledgeable physician^1-3.

In the past, several studies have identified three major areas of stress namely; academic pressure, social issues and financial problems^4-6 . In more recent publications, academic stressors have been documented to be the major problem^7-11

All these studies have either looked at medical student stress in comparison with the general population, or inclusion with other academic students or studied public and private university medical student stress individually. Other studies have focussed on medical student stress related to professional and academic life with various combinations of quantitative and qualitative methodologies that may not have been consistent in measuring the effects of the stressors. Several studies have reported only on particular years of the medical programme giving different findings. There is lack of focused objective to study this topic using a common instrument or theoretical framework and looking at all years of the medical programme. There were a vast variety of survey instruments used on stress studies in medical education namely the General health Questionnaire, Depression, Anxiety and Stress Questionnaire, Perceived Stress questionnaire, Kessler Psychological Distress Scale and many more^1,
12-16.

Since there are adequate publications reporting that academic pressure is the main source of medical student stress, in 2010, Yusoff et all developed a Medical Student Stress questionnaire exclusively evaluating medical student stress and published it, testing its validity and reliability^11,17-20. Equipped with the validated common questionnaire for the Malaysian medical student population and to avoid all the limitations described earlier, the author decided to study and compare the prevalence of stress and associated stressors between public and private medical university students in Malaysia. The rationale to conduct such a comparative study was to identify whether there were differences in the prevalence and stressors and initiate collaborative research between the public and private university which was conveniently placed within ease access of the author. The public health significance of this study would contribute to identifying stress levels, stressors in both universities using a common validated questionnaire which would also facilitate collaboration and sharing of information to initiate strategies to reduce stress among these students, working together as a team.

Based on current available literature search in comparing stress levels and stressors between a public and private university, a paper has been published recently where only the stress levels were compared, other parameters were studied using the combined private public sample as one dataset, in Bangladesh²¹ The objective of the study was to identify and compare the prevalence of stress and associated stressors among medical students in a private and public medical university in Malaysia.

MATERIAL AND METHODS:

Study design and sampling:

A cross-sectional study was conducted on undergraduate medical students of all five years (year 1-5) at University Sultan Zainal Abidin (UniZSA), Kuala Terengganu and UCSI University (UCSI), Marang, Terengganu. A universal sampling method was used for both universities due to easy access and it was conducted between 2015-2016. The inclusion criteria were all medical student of both mentioned universities and who voluntarily gave consent. The exclusion criteria were those students who were absent with permission during data collection, who refused to provide consent and those with known psychiatric illnesses.

Instruments:

There were 3 sections to the questionnaire which comprised of 6 items in the sociodemography profile, validated 12-item General Health Questionnaire and the validated 40 item- Medical Student Stress Questionnaire. The sociodemographic data included age, gender, ethnicity, marital status, year of study and source of tuition fee.

One of the most widely used tools to measure stress levels is the 12-item General Health Questionnaire (GHQ-12), an extensively used tool to measure stress levels. Various studies have demonstrated the internal consistency of the GHQ-12 coefficients ranging from 0.78 to 0.95. The items on the GHQ-12 represent 12 manifestations of stress, and respondents were asked to rate the occurrence of each of the manifestations in themselves during the recent week preceding the data collection. Subjects responded to each question by choosing from four typical responses: ‘not at all’, ‘no more than usual’, ‘rather more than usual’ and ‘much more than usual’. A binary scoring method was used to evaluate responses. This method assigns a score of zero to the two least symptomatic answers and a score of one to the two most symptomatic answers; thus, responses can only be scored as zero or one. The minimum GHQ-12 total score was 0 and the maximum of 12. Participants who scored GHQ-12 equal to 4 and above were considered as having significant stress and taken as ‘caseness’ in this study^22-24.

The MSSQ is a comparatively new validated instrument used to identify sources of stress²⁰. The items in MSSQ represent 40 possible sources of stress in medical students identified from the literature grouped into six main domains:

Academic Related Stressor (ARS) with items like ‘Tests/examinations’, ‘Getting poor marks’, ‘Large amount of content to be learnt’, and ‘Having difficulty understanding the content’.

Intrapersonal and Interpersonal Related Stressor (IRS) with items like ‘Conflicts with other students’,‘Verbal or physical abuse by teachers’, and ‘Conflict with personnel’.

Teaching and Learning Related Stressor (TLRS) with items like ‘Lack of guidance from the teacher’, ‘Uncertainty of what is expected of me’, and ‘Lack of recognition for work done’,

Social Related Stressor (SRS) with items like ‘Facing illness or death of patients’, ‘Talking to patients about personal problems’, and ‘Being unable to answer questions from patients’.,

Drive and Desire Related Stressor (DRS) with items like ‘Unwillingness to study medicine’, ‘Parental wish for you to study medicine’, and ‘Family responsibilities’ and

Group Activities Related Stressor (GARS) with items like ‘Participation in class discussion’, ‘Need to do well (imposed by others)’, and ‘Feeling of incompetence’.

Respondents were requested to rate each source by choosing from five responses, ‘causing no stress at all’, ‘causing mild stress’, ‘causing moderate stress’, ‘causing high stress’ and ‘causing severe stress’. The scoring method assigned marks from 0 to 4 to each of the responses respectively. A response of ‘causing no stress at all’ would be scored as zero and a response of ‘causing severe stress scored as four. The internal consistency Cronbach’s Alpha coefficients of the stressor groups ranged from 0.64 to 0.92²⁰.

Data was collected far in advance of examination dates, to avoid measurement bias due to examination stress. This ensured the stress levels measured reflected the natural stress levels experienced on any academic day. The questionnaire was distributed to students in a lecture hall. A short briefing was done with an information sheet distributed to the students to read and keep. Written informed consent was obtained from all the medical students in both universities and it took approximately 25 minutes to fill in the questionnaire. Students were assured of confidentiality. Approval was obtained from the UniZSA Medical Faculty to conduct the study among their students and ethical clearance was obtained from the UCSI University Research Ethics Committee

Statistical Analysis:

Data were analysed using Statistical Package for Social Sciences (SPSS) version 20.0 software. All data were entered into SPSS, checked, explored and cleaned. Descriptive statistics was applied for analysis of the demographic data, the students’ stress prevalence based on GHQ-12 score, and the stressor items. Stress was dichotomised into 2 categories namely ‘stress’ and ‘no stress’. Binary Logistic Regression was used to determine the stressors associated with stress.The researcher interpreted data with an alpha (α) set at 0.05 and confidence interval of 95%.

RESULTS:

The response rate from UniZSA medical students was 90% (245 out of 273 students). The response rate from UCSI medical students was 100% and 4 responses were discarded, out of 319, due to missing values.The demographic characteristics of the respondents in this study are presented in Table 1.

Table 1: Socio-demographic characteristics of medical students

	UniZSAMS (n = 245)		UCSIMS (n = 315)
Variables	Mean (SD)	Frequency (%)	Mean (SD)	Frequency (%)

Age	21.8 (1.50)		23.02 (1.78)
Gender Male Female		71 (29.0) 174 (71.0)		123 (39.0) 192 (61.0)
Ethnicity Malay Chinese Indian Others		163 (66.5) 42 (17.2) 36 (14.7) 4 (1.6)		83 (26.3) 164 (52.1) 53 (16.8) 15 (4.8)
Marital status Single Married		238 (97.1) 7 (2.9)		306 (97.1) 9 (2.9)
Year of study Year 1 Year 2 Year 3 Year 4 Year 5		61 (24.9) 57 (23.3) 37 (15.1) 51 (20.8) 39 (15.9)		52 (16.5) 64 (20.3) 49 (15.6) 77 (24.4) 73 (23.2)
Source of tuition fee Parents Scholarship Loan Combination		10 (4.0) 205 (83.7) 9 (3.7) 21 (8.6)		67 (21.2) 143 (45.4) 33 (10.5) 72 (22.9)

Table 2: Comparison of total stress scores between UniSZA and UCSI (n= 560)

Variable

Medical students

Mean difference

(95% CI)

t statistic (df)

p-value*

UniSZA

Mean (SD)

UCSI

Mean (SD)

Stress scores

2.91 (2.98)

4.66 (3.4)

-1.75 (-2.28, -1.22)

-6.49 (550.24)

< 0.001

*Independent t test

Table 3: Stressors ranked by severity between UniZSA and UCSI University medical students

Variables	UniZSA			UCSI University
Variables	*Mean (SD)	Severity	Rank	*Mean (SD)	Severity	Rank
Academic related stressor (ARS)	2.50 (0.6)	High	1	2.74 (0.59)	High	1
Interpersonal & Intrapersonal related stressor (IRS)	1.79 (1.04)	Moderate	4	1.48 (1.07)	Moderate	5
Teaching & Learning related stressor (TLRS)	1.88 (0.79)	Moderate	3	1.74 (0.85)	Moderate	3
Social related stressor (SRS)	1.78 (0.72)	Moderate	5	1.68 (0.79)	Moderate	4
Drive & Desire related stressor (DRS)	1.28 (0.96)	Moderate	6	1.36 (1.02)	Moderate	6
Group Activity related stressor (GARS)	2.03 (0.86)	High	2	2.22 (0.88)	High	2

*Degree of stress classification: 0-1.00: nil to mild stress, 1.00-2.00: mild to moderate stress, 2.00-3.00: moderate to high stress, 3.00-4.00: high to severe stress

Table 4: Multivaraible analysis of the association between stressors and stress among UniSZA and UCSI medical students

Variable	*Crude OR^a* (95% CI)	*Adjusted OR^b* (95% CI)	*Wald Statistics^b(df)*	P Value^b
UniZSA Medical students
Academic related stressor (ARS)	1.10 (1.06, 1.15)	1.08 (1.03, 1.13)	11.15 (1)	0.001
Interpersonal & Intrapersonal related stressor (IRS)	1.09 (1.05, 1.13)	1.05 (1.01, 1.10)	5.10 (1)	0.024
UCSI Medical students
Academic related stressor (ARS)	4.88 (3.01, 7.91)	1.92 (1.04, 3.52)	4.40 (1)	0.036
Social related stressor (SRS)	2.65 (1.90, 3.71)	1.51 (1.02, 2.23)	4.22 (1)	0.040
Group Activity related stressor (GARS)	3.54 (2.50, 5.00)	2.37 (1.56, 3.59)	16.27 (1)	<0.001

Only significantly associated stressors with stress are shown in Table 4.

^aSimple logistic regression, ^bMultiple logistic regression (Backward LR method was applied)

The model reasonably fits well. Model assumptions are met. There are no interaction and multicollinearity problems

The overall stress prevalence reported among UCSI medical students was 42.2% while UniZSA medical students was 33.1%. Similarly, the mean stress score for UCSI medical students was (higher) 4.66 compared to UNiZSA medical students 2.91.

DISCUSSION:

This study had a better response rate from UCSI medical students (100%) compared to UniZSA medical students (90%). The could be explained by the fact that the author had better access to UCSI medical students compared to UniZSA medical students. However, the non-respondents from UniZSA was due to students having classes in different disciplines and could not come for the data collection or were on leave or medical leave and the response rates very still very good.

The USCI medical students reported a prevalence of 42.2% compared to UniZSA medical students 33.1% which was reflected similarly through the mean stress levels estimated as 4.66 for UCSI students compared to UniZSA students which was 2.91. UCSI Medical students’ stress being high could be explained by their university campus and teaching hospital being far compared to UniZSA where it is just within walking distance. The relationship between a government medical university UniZSA and Ministry of Health Hospital where the students receive their clinical skills may be more conducive compared to USCI private students. UniZSA is a completely government sponsor institute compared to UCSI.

Among the six main domains of stress, Academic Relates Stressor (ARS) stressors followed by Group Activity Related Stressors (GARS) were ranked first and second, as causing high levels of stress based on the cut off values set for the degree of stress classification. Similar findings were reported by a study done in Malaysia among 4 public universities and another study done in another northern Public University and University Putra Malaysia (UPM)^24-26. Similar findings have been reported in several foreign medical schools in Thailand, India, Saudi Arabia, Turkey and Pakistan^{17, 27-30}. Studies done among private medical students also have reported that academic stressors contributed most to their stressful life in Medical University^31-33. This reconfirms the factor that academic stressors are a major contributor to stress in Medical Academia.

The Group Activity Related stressor also contributed significantly as high to the stress of medical students which was similarly reported by other studies in four public universities in Malaysia and USM^24,
26. The study in Kolkata, India showed 70% of stress contributed from GARS³⁴. Malaysian student selection is solely on merit from Malaysian schools and these students may be lacking in group dynamics and teamwork which explains the high ranking of this stressor. Comparing the findings of this study with medical schools who use specific selection criteria which Malaysian medical universities don’t include, may throw light on the stress levels in such medical students.

It is interesting to note that the first three stressors Academic Relates Stressor (ARS), Group Activity Related Stressors (GARS) and Teaching and Learning Related Stressor (TLRS) were ranked first to third in the same order as stressors, between the public and private university. This goes to show that irrespective of the type of university and type of curriculum implemented (public or private), the stressors that students face are not different and thus measures to prevent stress arising from these stressors need to be focused on. IRS (Interpersonal and intrapersonal) and SRS ( Social) both switched placed in the ranking as fourth and fifth stressor in UniZSA and UCSI medical students. IRS (Interpersonal and Intrapersonal related stressors) SRS (Social related stressor), TLRS (Teaching) and DRS (Drive) contributed moderately to the stress levels of the medical students in both universities. This is in contrast to a study reported in a public university in Malaysia, where the SRS (social) and DRS (drive) contributed none or mild stress to medical students while in an Indian medical college in Kolkata, prevalence of DRS was 50%. In the same Kolkata Medical College, prevalence of IRS (Interpersonal and intrapersonal), TLRS (Teaching), and SRS (social) were approximately 78%, 74% and 73% respectively. A study in a Pakistan Private Medical School found ARS (Academic) to be the primary stressor followed by SRS (Social) and GARS (Group Activity), while DRS (Drive) was the least contributor to stress³⁵.

Another interesting point was that among all the stressors ranked in this study, none were found to cause no or minimum stress, which shows that every type of stressor has a significant contribution towards medical student stress, just that the severity of the stressor varied.

There were 2 stressors namely; ARS (Academic) and IRS (Interpersonal and Intrapersonal), significantly associated with stress at UniZSA while ARS (Academic), SRS (Social) and GRAS (Group activity) were significantly associated with stress at UCSI. As both universities found Academic stressor to be a significant contributor, it reinforces the fact that Academic stressor needs to be adequately addressed to implement measures to reduce stress due to this domain. A study in a Malaysian Public University found that ARS (Academic) and GARS (Group activity) were significantly associated with stress among the medical students²⁶. The Malaysian school curriculum in Malaysia may not have enough on group activity and thus this may be a problem for medical students who lack this quality which is much required in delivering presentations and seminars in groups in the Academia. SRS (Social) as a significant predictor in UCSI medical students, relates to communication with patients, exposure to deaths, and answering patients queries, which may not come with ease with medical students who are learning novice in this field. UniZSA medical students reported significant association between IRS (Interpersonal) which encompasses conflicts with other students, verbal or physical abuse by teachers or conflict with other personnel. In the medical academia, the cultural and hierarchical nature of the medical academia explains why students may find this a significant stressor where the expectations of the clinicians and academicians may cause interpersonal and interpersonal related problems.

Both these medical schools have counsellors and mentor-mentee sessions for students to approach during times of stress. However, there are no studies done to evaluate these strategies and it is highly recommended that intervention programmes are explored to address the prime stressor; academic stressor. Student peer- support groups should be established and made avail to students who can seek help when needed. An intervention stress management programme should be considered as conducted in a public university called ‘Medical Students Well-being Workshop^36,
37. This was a pre-post intervention programme which proved to be beneficial with a marked decline in stress levels. To ensure constructive approaches are taken to implement such programmes, firstly the duration (1/2 day) in conducting this should be looked into, in a busy academic curriculum, which must not be delivered on weekends which may add to their stress, reducing their leisure time to recuperate from academic stressors during weekdays. Since this is collaborative research, it would be a worthwhile effort to share experiences and look into implementing such a stress management programme. Other studies in Australia and New Zealand reported well-being workshops incorporating students’ view on support services, stigma related to being stressed and receiving teaching on well-being, to ensure a good stress management programme was instituted³⁸.Other approaches published are; an USA University which developed a elective programme which included a wellness elective which focused on stress reduction and personal wellness³⁹. This explored students’ perceptions of medical school stress and assessed their perspective on the wellness elective. Another ‘Mindfulness-based stress reduction’ (MBSR) educational intervention designed to improve coping skills and reduce emotional distress has been published⁴⁰. Such stress management programmes can be explored taking into account students background, believes and religious acceptance to programmes discussed above, as Malaysia is a multicultural and multi-ethnic country.

Limitations of the study:

Though this comparative study on stress between 2 universities is a first attempt with a good response rate, the cross-sectional nature of the stress does not allow a cause effect relationship to be studied. Having studied this only in one state, the findings of this comparative study, cannot be generalised to medical student stress in other states or for the whole nation. Underscoring or providing socially desirable answers may have led to response bias which requires caution in interpreting the findings.

CONCLUSIONS:

The prevalence of stress among medical students was higher in the private university compared to the public university. Both universities documented Academic Related Stressor and Group Activity Related Stressor as of high severity. Academic related stressors were found to be significantly associated with stress among UniZSA and UCSI University medical students. Review of the academic curriculum to reduce stress, strengthening student support groups and stress management programmes, (Medical Student Well-being Workshops) to inculcate good inter and intrapersonal cum teamwork skills, are highly recommended.

ACKNOWLEDGMENTS:

We wish to thank the Dean of the Faculty of Medicine and Health Sciences, University of Sultan Zainal Abidin (UniZSA), Terengganu, for allowing us to conduct the study at the university.

This study was made possible with the University Research Grant from UCSI University – Proj-In-FMS- 025.

Conflict of interest:

‘The Authors declare that there is no conflict of interest’.

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Received on 20.02.2018 Modified on 22.03.2018

Research J. Pharm. and Tech 2018; 11(6): 2531-2537.

DOI: 10.5958/0974-360X.2018.00467.5