|Year : 2015 | Volume
| Issue : 1 | Page : 92-95
Factors causing stress among students of a Medical College in Kolkata, India
Soma Gupta1, Supriyo Choudhury2, Manisha Das2, Aparna Mondol3, Richeek Pradhan4
1 Department of Biochemistry, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
2 Department of Pharmacology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
3 Department of Physiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
4 ESI - Post Graduate Institute of Medical Sciences and Research, Kolkata, West Bengal, India
|Date of Web Publication||31-Jul-2015|
Head, Department of Biochemistry, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Medical students feel a significant amount of stress due to a variety of factors. Few studies have explored the relative size of these various stressors to identify which are most important. This study was undertaken to quantify the magnitude of various sources of stress among students of a medical college at Kolkata, West Bengal, and also to assess the reliability of Medical Students' Stressor Questionnaire (MSSQ-40) in this context. Methods: We evaluated the degree of stress along various dimensions using the MSSQ-40, a scale to measure stress among medical students that has been validated in other countries. Differences in stress and its causal factors were analyzed across demographic subgroups. The reliability of the MSSQ-40 was evaluated using Cronbach's alpha. Results: The overall prevalence of stress was 91.1% and the vast majority of students (94.9%) were stressed due to academic reasons. Academic related stress was found to be higher among students who are not conversant with the local language, experienced a change in medium of teaching from secondary school to medical school, and resided in a hostel. The MSSQ-40 in general, and its academic-related stress domain specifically, were found to be reliable in our setting. Discussion: Early detection and remedying stressors will help to build physical and mental health in medical students. Language training early during the medical course might reduce academic stress among our students. Further studies should relate individuals' stress with their academic performance.
Keywords: Academic stress, factors of stress, MSSQ-40, stress, undergraduate medical education
|How to cite this article:|
Gupta S, Choudhury S, Das M, Mondol A, Pradhan R. Factors causing stress among students of a Medical College in Kolkata, India. Educ Health 2015;28:92-5
| Background|| |
Medical education has been reported to be one of the most stressful academic curricula worldwide, negatively affecting the physical and mental health of medical students. Examination fear, high parental expectations, peer pressure, lack of leisure time, financial problems, relationship disharmony, and aspirations for higher studies are some of the many factors known to contribute to the development of stress among undergraduate medical students. , Early identification and necessary interventions targeting the alleviation of modifiable stressors might result in a less stressful academic life for students, which in turn could enhance their academic performance and skill development as medical graduates.
Studies investigating stress among Indian medical students report wide variations in the prevalence of stress (37.3-97%). This observed inconsistency can be explained by demographic differences in the samples, different academic years of the students studied, varying case definitions, and nonuniformity in measuring tools.  Supe  identified academic, physical, emotional, and social factors as the principal stressors in a cohort of medical students in Maharashtra, India. In contrast, Muhamad and colleagues reported six principal domains of stressors using the Medical Students' Stressor Questionnaire (MSSQ-40), a validated instrument.  Ours is the first study using MSSQ-40 to assess stress among Indian medical students. India is a country with considerable heterogeneity in language, ethnicity, culture, religion, and socio economic distribution, making it a unique setting to assess stress among medical students. Students qualify for medical college through nationally administered merit tests. Thus, besides dealing with the stress of studying medicine, students that come from other parts of the nation to their medical institution must also must also make cultural, linguistic and environmental adjustments, all contributing to their overall stress.
With this backdrop we conducted a pilot study to identify the prevalence and demographic correlates of stress among students of a Government Medical College in West Bengal. The reliability of measuring tool (MSSQ-40) was also evaluated in our setting.
| Methods|| |
This cross-sectional study was conducted in a government medical college of West Bengal in September 2013. During a Pharmacology lecture class of one hour, students of the 5 th semester were introduced briefly to the objectives and the methodological workflow of the study. A semi-structured anonymous questionnaire was administered to consenting students to capture personal data as well as their responses to a validated instrument called the MSSQ-40. Prior permission was obtained from the Head of the Department of Pharmacology, College of Medicine and Sagore Dutta Hospital. The students were not informed about the session beforehand. All students present on the schedule date were approached to participate in the study. Estimated time to respond to the entire questionnaire was approximately 30 min. Approval from the Institutional Ethics Committee of College of Medicine and Sagore Dutta Hospital, Kolkata, India was obtained.
Information was obtained regarding students' gender, their fluency in the local language, the medium of education at the school level (immediately prior to medical school), family income, number of family members, religion, and whether or he/she currently resided in a hostel (other generally resided with parents). The socioeconomic status of students was classified using the B.G. Prasad scale. 
The MSSQ-40 is a rating instrument developed in a medical school in Malaysia and validated to measure stress and its sources within students.  It consists of 40 items collectively addressing six domains of stressors:
- Academic-related stressors, 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 stressors: with items like 'Conflicts with other students', 'Verbal or physical abuse by teachers', and 'Conflict with personnel';
- Teaching and learning-related stressors, 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 stressors, 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 stressors, with items like 'Unwillingness to study medicine', 'Parental wish for you to study medicine', and 'Family responsibilities'; and
- Group activities related stressors, with items like 'Participation in class discussion', 'Need to do well (imposed by others)', and 'Feeling of incompetence'.
The complete MSSQ-40 is provided in Appendix-1. Participants had to respond to each item along a five point Likert scale (0-4) with anchors reflected an increasing level of severity in stress. All items encompassing the six stressor domains collate to measure the overall stress of the medical student. The mean score (after summation of scores from all the items and division by 40) was taken as the indicator of overall stress. Mean item scores for individual students were calculated and graded into mild (0.01-1), moderate (1.01-2), high (2.01-3), and severe (3.01-4) categories of stress. Mild stress means no stress or insignificant stress. Moderate stress signifies reasonable stress. Severe and high indicate reasonably significant emotional disturbances with and without perturbation of daily activities respectively.
The sample size calculation was performed using online survey sample size calculator, Raosoft, which for the present study was 60. The point estimate of stress among medical students was anticipated to be 94%. With the survey population of 2000, confidence level of 90%, 5% margin of error and an assumed nonrespondence rate of 25%, we aimed to collect data from 80 respondents.
The summary statistics were presented using frequencies with 95% confidence intervals for categorical variables and median with interquartile ranges for numerical, nonparametric variables. Differences between subgroups in the prevalence of stress were assessed using Fisher's exact test of significance. A P value of 0.05 was considered as statistically significant. Statistical calculations were performed using SPSS V-20 (©IBM Inc.) and Vassar stats (©Richard Lowry).
MSSQ-40 had been developed in Malaysia in English. In our setting, we administered the questionnaire in English, as the latter is the medium of instruction used in our institution. We tested the reliability of this score in the present setting by calculating Cronbach's alpha coefficient using SPSS V-20.
| Results|| |
A total of 83 5 th semester students were present for the scheduled class, 81 of whom provided near complete responses to the questionnaire (response rate 95.2%). The median age of the respondents was 21 years (Interquartile range 25-75: 20-22 years). Male students comprised 55.7% of the sample. Demographic parameters of the study population are presented in [Table 1].
All of the students reported some degree of overall stress. Students with mean domain score above 1-i.e., those that reported scores reflecting moderate, high and severe stress-were considered to be under stress. None were found to have severe stress. The prevalence of moderate and high stress among the participants were 55.7% (95% CI 44.74-66.14%) and 35.4% (95% CI 25.79-46.44%), respectively. Hence, the overall prevalence of stress was estimated as 91.1% (95% CI 88.82-95.64%). Most of the students (94.9%) reported stress due to academic-related factors. The frequency of students found to be stressed in each domain and the median score of each stressor domain are presented in [Table 2].
The degree of stress along the various domains within the various student subgroups was compared using Fisher's exact test of significance. The percentages of students suffering from academic-related stressors was significantly higher among students who (a) spoke languages other than the local language (100% vs 97%, P = 0.0001); (b) experienced a change of medium of teaching from school level (100% vs 89.7%, P = 0.0001), and (c) resided in the college hostel (98.5% vs 78.6%, P = 0.016).
Percentages of students affected due to social-related stressors and overall stress were significantly higher among residents of the college hostel than those who lived elsewhere (80% vs 42.9%, P value 0.008 and 95.4% vs 71.4%, P = 0.17, respectively).
Testing the reliability of MSSQ-40, the Cronbach's alpha coefficient was found to be above 0.8 for the academic-related stressor domain and total score of the 40 item scale. Intrapersonal and interpersonal-related stressors, teaching and learning-related stressors and group activities-related stressors revealed a Cronbach's alpha 0.5-0.8. The same for social-related stressor, drive and desire-related stressors was less than 0.5.
| Discussion|| |
The prevalence of stress among first year students in our setting was found to be 91.1%, which is similar to that reported from other medical colleges in India (Agartala [94.52%] and Surat [96.5%]), although different rating scales were used in these studies. ,
Academic stressors pose the major contribution to the overall stress in our study, in concurrence with reports by other investigators from India and abroad. , Limited reports are available exploring effects of various socio-demographic correlates of stress among medical students. A considerable cultural and language variation exists among students of our college. Students coming from other states are typically not conversant in the local language, bring considerable pressure to adjust and function within the college environment. On the other hand, local students who had most of their schooling in Bengali, the prevalent local dialect, often face difficulties adjusting to the change in language of teaching learning to English, as is standard in the medical curricula across India.
In this study, the degree of academic stress was found to be greater among students who are not conversant with the local language. This might reflect a communication gap due to language barrier with teachers, peers, and patients. Adjusting to the local language might add to overall stress. Academic stress was also found to be significantly higher among students for whom the English language basis of their medical curriculum was a change from of language they were used to through their school years. Shah et al. had a similar finding.  Further, students who resided at our college's hostel experienced relatively greater academic and social stresses than those who lived with parents or in other settings, which is unlike the research findings of Supe et al.  Perhaps inter-institutional differences in the living conditions of hostels, their infrastructure (e.g., size of rooms, number of roommates, cleanliness of the hostel, canteen facilities), social support systems and social environment of the hostels explain the differences found across schools for stress related to living situations. Student groups varying by gender, religion, and socio economic strata were found not to significantly differ in their stress along any of its causes in our setting.
The MSSQ-40 stress measurement tool was found to be reliable in our Indian setting through a high Cronbach's alpha for the 40 item overall stress scale and its subscale measuring academic stress of medical students. To our knowledge, this is the first report of the evaluation of stress among Indian medical students using the MSSQ-40 rating scale. However, the low reliability of the social and drive/desire-related stressor subscales reflect the particular focus of some their component items and point to a need for further evaluation and perhaps modification for use in India and relatively junior medical students. Three of the six items in the social-related stress domain pertain to difficulties handling patient-related situations, something that the present student cohort had not yet encountered. On the other hand, the items within the drive/desire-related stress area include students' unwillingness to study medicine and parental pressure to do so-stressors that become fully evident only in the final years of medical the curriculum and may not be yet found in this study's 5 th semester students.
A few shortcomings of this pilot study require mention. The pilot survey sampling does not encompass representation across semesters. Also, criterion validity of MSSQ-40 was not assessed in this study. Correlating the degree of stress with outcome measures, such as students' academic performance, may substantiate the validity of this measuring tool for future studies.
| Conclusion|| |
A significant number of medical students in our setting suffer from moderate to high stress, but none had severe stress. Academic stress has maximum was the most broadly source of stress found and thus most often contributed to overall stress scores. Communication gaps due to students' deficiencies in English and the local language might induce academic-related stress. This suggests the need for basic English instruction early in our school's undergraduate medical curriculum. Given that those who lived in the college hostel reported greater academic stress, the school might assess and address the issues within the hostel, and promote a caring attitude among teachers and the college authority.
| Acknowledgment|| |
The authors would like to acknowledge the whole hearted support of students of our college and Prof. Debasis Bhattacharya, Principal, College of Medicine and Sagore Dutta Hospital.
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[Table 1], [Table 2]