|Year : 2015 | Volume
| Issue : 1 | Page : 29-34
Prevalence of stress, stressors and coping strategies among medical students in a Nigerian medical school
Afiong Oboko Oku1, Eme Theodora Owoaje2, Oboko Oboko Oku3, Bassey Monday Ikpeme1
1 Department of Community Medicine, University of Calabar, Calabar, Cross River State, Ibadan, Nigeria
2 Department of Community Medicine, University College Hospital, Ibadan, Nigeria
3 Department of Anaesthesia, University of Calabar, Calabar, Cross River State, Ibadan, Nigeria
|Date of Web Publication||17-Mar-2015|
Afiong Oboko Oku
Department of Community Medicine, University of Calabar, Calabar, Cross River State
Source of Support: None, Conflict of Interest: None
Introduction: Several international studies suggest that medical school training is associated with high levels of stress. Although stress is peculiar to the medical profession, it is rarely given the desired attention, especially in resource-constrained settings. This study was therefore conducted to determine the prevalence of stress stressors, coping strategies of medical students in the University of Calabar, Nigeria. Materials and Methods: A cross-sectional descriptive survey of 451 medical students was conducted on available classes during the study period. A semi-structured self-administered questionnaire was used to elicit information from respondents. Data were summarized using proportions, and Chi-square test was used to explore associations between categorical variables. Level of significance was set at P < 0.05. Results: Majority (94.2%), of undergraduate medical trainees perceived the training as stressful. The major stressors identified were excessive academic work load (82.3%), inadequate holidays (76.4%), and insufficient time for recreation (76.2%). Feeling depressed, sleeping problems and anxiety were the most common effects of stress reported by the respondents. The coping strategies adopted by the students were mainly positive. Perceived stress was significantly associated with being in the clinical level of study, residing on campus and a higher monthly allowance (P < 0.05). Conclusion: Majority of the students interviewed perceived their training as stressful. There is, therefore, an urgent need for medical educators to introduce of stress management courses or programs into the curriculum.
Keywords: Coping strategies, medical students, South-east Nigeria, stress, stressors
|How to cite this article:|
Oku AO, Owoaje ET, Oku OO, Ikpeme BM. Prevalence of stress, stressors and coping strategies among medical students in a Nigerian medical school. Afr J Med Health Sci 2015;14:29-34
|How to cite this URL:|
Oku AO, Owoaje ET, Oku OO, Ikpeme BM. Prevalence of stress, stressors and coping strategies among medical students in a Nigerian medical school. Afr J Med Health Sci [serial online] 2015 [cited 2019 Mar 26];14:29-34. Available from: http://www.ajmhs.org/text.asp?2015/14/1/29/153384
| Introduction|| |
Stress has been defined as the body's nonspecific response to demands made upon it, or to disturbing events in the environment, thus it is not just a stimulus or a response, but rather a process by which we perceive and cope with environmental threats and challenges.  An optimal level of stress may enhance learning. However, excessive stress has been shown to cause physical and mental health problems, reduced self-esteem, and may affect academic achievement, personal and professional development. Every individual has a certain number of coping resources, and once these coping resources are challenged or exceeded, stress usually results. A tremendous amount of stress medical students encounters in the course of their training have been attributed to the vastness in the academic curriculum, length of the course and consequent financial burden. 
Tertiary medical training across the globe has been regarded as being highly stressful. Dahlin et al. rightly observed that promoting and nurturing well-being students during medical training is a necessity. The equipping of undergraduates with the skills necessary to recognize personal distress (to determine when they need to seek assistance) and to develop strategies to promote their own well-being is fundamental to promoting professionalism.  Medical training has long been recognized globally as involving numerous stressors that can affect the well-being of students.  In addition to coping with stressors of everyday life, medical students must deal with stressors specific to medical education which includes; information overload, financial indebtedness, inadequate leisure time, pressures of work, work relationships and career choices.  These students also face social, emotional, physical and family problems that may affect their learning ability and academic performance. Consequently, it is commonly observed that medical students and resident doctors experience high rates of psychological morbidity when compared with students in other disciplines. ,,
Globally, studies have shown reported levels of stress among medical students range anywhere from 25% to 75%. , Similar studies conducted on medical students in the United states, Malaysia and Saudi Arabia have reported stress levels of 26%, 29.6% and 57% respectively and were related to their academic environment. ,, Another study conducted in Pakistan revealed that two out of every five respondents reported that work/study at medical school affected their personal health and well-being. This stress had led to grave consequences such as depression, substance misuse, poor academic performance, sleep problems, low self-esteem and other stress-related outcomes.  Obviously, such distress could have adverse effects on students and their professional development. Other studies have documented that this distress has further contributed to marital discord, poor physical health/self-care  and in some cases suicide. 
Although, several reports have been documented on stress among medical students in developed countries, limited information exists in Nigeria pertaining to this important global phenomenon. , In view of the current national and international initiatives to improve medical education, it is important that medical educators take into cognizance the causes of student's distress, potential adverse personal and professional consequences and institutional factors that can positively or negatively influence student's well-being. This study, therefore, aimed to identify possible stressors, associated consequences and coping strategies adopted to deal with the identified stressors.
| Materials and methods|| |
The study was carried out among medical students at the College of Medical Sciences, University of Calabar. The university is located in Calabar South Local Government Area of Cross River State. The College of Medicine was established in 1975. It is one of the largest undergraduate medical training institutions in the south-south zone of Nigeria. The institution produces an average of 80 medical doctors annually. In their first year, the students are exposed to premedical sciences, thereafter basic medical sciences in the second and third levels of study. From the fourth to the sixth levels, they are exposed to clinical courses. Students from this institution come from mainly from the south-south and south-west region of the country.
In 2010, the total number of medical students was 917.
Medical students in the University of Calabar.
A Descriptive cross-sectional study.
Sample size calculation
The appropriate sample size formula for a single proportion (Kish and Leslie sample size formula) was used to calculate the sample size. The minimum sample size calculated was approximately 451.
All medical students undergoing training in the University of Calabar at the time of the study were eligible to participate.
The third and final year students were on vacation at the time the study was conducted and thus were excluded from the study.
Medical students from all levels of study were recruited into the study. However, at the time of the study only four levels of study were available (1, 2, 4 and 5). This was because the third level students had just written their professional examination and was on vacation. Similarly, the final year students had just graduated from the medical school. All medical students who were available at the time the study was conducted were eligible to participate. The class representative of each class was consulted a day before and informed in preparation for the data collection exercise. Immediately after their lectures, a brief explanation of the survey and its instruments were given to the students. Thereafter, a self-administered questionnaire was distributed by the investigator and two trained research assistants. The questionnaires were retrieved immediately following completion, and this was repeated for the rest of the classes visited. The students were asked to give their honest responses to each question and were not allowed to discuss with one another while completing the questionnaires. A total of 451 questionnaires were administered, and all were returned.
Data were collected using a semi-structured, self-administered questionnaire which was divided into sections to elicit information on socio-demographic characteristics, Stressors affecting their well-being divided into 6 domains to include; (academic, accommodation, relationships, transportation, utilities and other), consequences of stress and coping mechanisms employed by the medical students.
Questionnaires were inspected daily so as to detect errors, and omissions to ensure that it was properly filled. Thereafter, the data were entered into the computer for statistical analysis using IBM Statistical Package for Social Scientists SPSS for windows version 19.0. Frequency, proportions, means and standard deviation were generated to summarize variables. Chi-square test was used to test associations between categorical variables.
Ethical approval was sought for and obtained from the University Of Calabar Teaching Hospital Ethical Review Committee before data collection commenced. Careful explanation of the purpose, content and implication was made known to the participants. Informed consent done in writing was obtained from each respondent after careful explanation of study objectives had been made. Students who were stressed were offered counseling services.
| Results|| |
Four hundred and fifty-one, undergraduate medical trainees from the University of Calabar were studied. The mean age of respondents was 23.4 ± 2.44 years. Majority, 200 (62.1%) were in the age group 20-24 years, male 288 (63.8%) and were currently single 437 (96.9%). More than half (51.7%) resided on campus and in their clinical levels 294 (65.8%). More students, 167 (37%) had a monthly allowance of N10,000 < N20,000 [Table 1] and [Figure 1].
The vast majority (94.2%) of respondents perceived their training as being stressful with over three-fifth (70.3%) perceiving it as being very stressful. The major stressors identified by the respondents [Table 2] and [Table 3] were related to the academic and social environments. They include; excessive school work 371 (82.3%), lack of holidays, 344 (76.4%), lack of time for recreation 343 (76.2%), poor learning environment 338 (74.9%) and lack of electricity 336 (74.7%).
[Table 4] shows the consequences arising as a result of stressful conditions experienced by the students. Being depressed, 342 (71.8%) sleeping problems 270 (59.8%) and anxiety 230 (51%) were the most common reported. Coping mechanisms adopted by the students when faced with stress were mainly positive. Majority coped with stressful situations by solving the problem 389 (86.2%) and belonging to peer discussion groups 305 (67.6%) [Table 5].
Factors found to be significantly associated with perceiving one's training as stressful [Table 6] were; being in the clinical level of study, residing on campus and receiving a monthly allowance of at least N10,000 (P < 0.05).
|Table 6: Socio-demographic characteristics of respondents and perception of medical school as stressful|
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| Discussion|| |
Stress has been described as an unavoidable experience for undergraduate medical trainees. It has long been recognized as a cause for concern in both developed and developing countries. Stressors experienced especially during the undergraduate medical training if not addressed early, may have dire consequences on them as professionals, their patients and the society as a whole.
Over four out of five of the students, rated their medical training as stressful. This finding was in keeping with the reports of some other studies conducted in Pakistan and Saudi Arabia, ,, but higher than reports from other studies that ranged from 75% to 90%. ,,, These studies probably used different instruments to measure stress. This, therefore, limits the comparability among these studies. One possible reason for the perceived high stress could be due to the fact that most of the students are not adequately prepared on what to expect during the medical training and so may not be able to cope effectively when faced with pressures and expectations of being a medical student.
The top five stressors identified by the students interviewed in this study were academically related. This finding is consistent with findings from similar studies conducted in Pakistan. ,,, A major stressor identified by three-quarters of the respondents was the epileptic electricity supply. This situation is peculiar to low-income countries like Nigeria where the provision of regular electricity supply is still a major problem. Considering that these students have to master a large volume of information in a short period, it is not surprising that the absence of regular electricity is considered to be a major stressor. This finding is in contrast to a similar study conducted among medical students in south western Nigeria, where the major stressor identified was overcrowded accommodation.  This difference could be attributed to the difference in time (10 years ago) when the study was conducted, and electricity supply has become more epileptic in Nigeria since then.
Consequences of identified stressors to psychosocial well-being
Exposure to stressors often exerts negative effects on students' academic performance, physical health, and psychological well-being, making them more susceptible to depression.  In this study, a major consequence of stress was depression and was reported by 70%. This finding is slightly lower than what was observed in a previous study in southwestern Nigeria, where 80% of clinical students interviewed admitted that they were depressed at one point or the other in the course of their training.  The main causes of depression identified by the students in this study included; lack of money, fear of failure of the examination, and family problems. These responses are similar to those reported by Omohkodion and Gureje in their study.  The least reported negative consequence of stress was tobacco smoking by only < 5%. However, this figure was slightly higher than what was reported by other studies conducted in Nigeria. ,,,,,,,,,, Coping strategies most students adopted were positive coping strategies including; problem-solving, belonging to a peer discussion group and positive reinterpretation of criticism. This finding was in agreement with a recent study by Sami-Abdo et al. in Malaysia  and another in Nepal.  Studies from the United Kingdom have reported that medical students often resort to alcohol, tobacco and drug use as a coping strategy. ,, However, in this study alcohol/drug use was the least adopted coping strategy and same was reported in India. 
Factors associated with perception of stress amongst undergraduate medical trainees
Medical students in the clinical levels of study were more likely to report their training as stressful compared those in the nonclinical level. This could be attributable to the fact that in the clinical years, the students undergo clinical rotations that include clinical teachings, numerous hours of patient clerking, observation and investigations on the wards. Furthermore, the work-load of the clinical students involves hours of clinical schedules in the hospital after the routine working hours. These activities ensure that the students are undergoing the clinical clerkship required for the acquisition of the requisite knowledge and skills for future medical practice. The clinical rotations also tend to highlight deficiencies of the students more compared to preclinical training where the mode of instruction is in groups with little one on one interaction with trainers.  However, this finding is in contrast to a study conducted in Iran, which reported no difference in perceived stress between preclinical and clinical medical students. 
Similarly, medical students residing on campus were more likely to perceive medical training as stressful. The explanation for this would be the overcrowded nature of university hostels because of extra number students staying in the rooms without the knowledge of the authorities. Consequently, these students have to relate with too many roommates and share the already inadequate sanitary facilities. This is further compounded by inconsistent water and epileptic power supply.
| Limitations|| |
The cross-sectional nature of this study did not allow for results to be generalized for the medical undergraduate population. The classes included in the study were those available at the time the study was being carried out. The problem of recall bias cannot be overlooked, and the issue of over-reporting may have constituted a problem in this study.
| Conclusion|| |
This study showed that the majority of the undergraduate medical trainees had perceived their training as stressful. The major stressors identified by the students were related to the academic domain. Consequences arising from encountering these stressors were self-reported depression, sleeping problems and feeling of anxiety. However, most of the students adopted positive coping methods when faced with stress. The authors, therefore, recommend that efforts should be targeted at providing a well-equipped library, efficient and reliable transport system to convey students to lecture venues, as well as conducive lecture halls and decent accommodation. In view of the fact that medical training is intrinsically stressful and some of the stressors are unavoidable, a review of undergraduate medical curriculum to include stress management courses is also recommended.
| References|| |
Sami-Abdo R, Redhwan A, Mustafa A, Krishna G. Stress and Coping Strategies of Students in a Medical Faculty in Malaysia. Malaysian J Med Sci 2011;18:57-64.
Yusoff MS, Abdul Rahim AF, Yaacob MJ. Prevalence and sources of stress among Universiti Sains Malaysia medical students. Malays J Med Sci 2010;17:30-7.
Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ 2005;39:594-604.
Supe AN. A study of stress in medical students at Seth G.S. Medical College. J Postgrad Med 1998;44:1-6.
Stecker T. Well-being in an academic environment. Med Educ 2004;38:465-78.
Stewart SM, Lam TH, Betson CL, Wong CM, Wong AM. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ 1999;33:243-50.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73.
Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: A prospective study in Antalya, Turkey. Med Educ 2001;35:12-7.
Mosley TH Jr, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping, and well-being among third-year medical students. Acad Med 1994;69:765-7.
Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: Psychological morbidity in first year medical students. Med Educ 1995;29:337-41.
Abdulghani HM. Stress and depression among medical students: A cross sectional study at a medical college in Saudi Arabia. Pak J Med Sci 2008;24:12-7.
Yousafzai AW, Ahmer S, Syed E, Bhutto N, Iqbal S, Siddiqi MN, et al.
Well-being of medical students and their awareness on substance misuse: A cross-sectional survey in Pakistan. Ann Gen Psychiatry 2009;8:8.
Ball S, Bax A. Self-care in medical education: Effectiveness of health-habits interventions for first-year medical students. Acad Med 2002;77:911-7.
Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al.
Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008;149:334-41.
Omohkodion FO, Gureje O. Psychosocial problems of preclinical students in the University of Ibadan Medical School. Afr J Med 2003;32:55-8.
Omigbodun OO, Odukogbe AT, Omigbodun AO, Yusuf OB, Bella TT, Olayemi O. Stressors and psychological symptoms in students of medicine and allied health professions in Nigeria. Soc Psychiatry Psychiatr Epidemiol 2006;41:415-21.
Babar TS, Arsalan K, Muhammad K, Hamza K, Kiran N, Nadia AK, et al
. Students, Stress and Coping Strategies: A Case of Pakistani Medical School. Education for Health 2004;17:346-53.
Sheikh BT, Kahloon A, Kazmi M, Khalid H, Nawaz K, Khan N, et al.
Students, stress and coping strategies: A case of Pakistani Medical School. Educ Health (Abingdon) 2004;17:346-53.
Ofili AN, Oriaifo I, Okungbowa E, Eze EU. Stress and psychological health of medical students in a Nigerian university. Niger J Clin Pract 2009;12:128-33.
Saipanish R. Stress among medical students in a Thai Medical School. Med Teach 2003;25:502-6.
Koochaki GM, Charkazi A, Hasanzadeh A, Saedani M, Qorbani M, Marjani A. Prevalence of stress among Iranian medical students: A questionnaire survey. East Mediterr Health J 2011;17:593-8.
Habeeb KA. Prevalence of stressors among female medical students Taibah University. J Taibah Univ Med Sci 2010;5:110-9.
Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al.
Depressive symptoms in medical students and residents: A multischool study. Acad Med 2009;84:236-41.
Makanjuola AB, Daramola TO, Obembe AO. Psychoactive substance use among medical students in a Nigerian University. World Psychiatry 2007;6:112-4.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes RG. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ 2007;7:26.
Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: A five-year prospective longitudinal study. J R Soc Med 1998;91:237-43.
Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc 2005;80:1613-22.
Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc 2005;80: 1613-22.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]