ISSN- 0301-1216

Indian J. Prev. Soc. Med. Vol. 42 No.3, 2011

ASSESSMENT OF STRESS, COPING STRATEGIES AND LIFE STYLE AMONG MEDICAL STUDENTS Ipseeta Ray Mohanty1, Nimain Mohanty2, Padma Balasubramanium3, Daniel Joseph4, Yeshwant Deshmuk5
ABSTRACT
Background: The process of medical education can sometimes be stressful. Stress can have detrimental effect on students health, life style and academic performance. Objectives: The study intends to identify the stressors specific to the campus, analyze the stress, stress coping strategies, variables that influence stress levels, life style, health risk behaviors, its relationship with family support, hostel stay; and correlation with stress. Methods: Four previously validated instruments for evaluating the stress, stress coping behavior, personality type and life style scores were administered to 302 medical students belonging to 1 , 2 , 3 MBBS and internship. Results: Results indicate that degree of stress (physical, emotional, behavioral signs) was significantly higher among interns as compared to 1 , 2
st nd rd st nd st nd rd

and 3 MBBS students. Besides academic stressors, social and emotional stressors (1 and 2

MBBS), physical stressors (Internship) were the predominant factors contributing to stress in these groups as compared to the others. The avoidance type coping was the dominant coping mechanism employed by the interns to alleviate stress. A positive correlation between stress and personality type (p<0.01), stress coping behavior (p<0.01) was found. The FANTASTIC life style score 1 MBBS and 3rd MBBS students was higher than 2nd MBBS and internship (lowest). Social support (p<0.01) had a profound impact on FANTASTIC scores. Interpretation and Conclusions: Lower life style scores were strongly associated with increased stress and use of maladaptive coping strategies. Key words: Stress, life style, coping strategies, Stressors
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INTRODUCTION Medicine is a physically, emotionally demanding career and training. Several studies have documented that stress is prevalent among medical professionals and that is also true for the medical students who have very busy and demanding schedule with minimal opportunity to relax and recreate
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. The stress of medical training

stems from academic pressure, perfectionist standards and demanding nature of medical practice which requires involvement with the most personal or emotionally draining aspects of life (human suffering, death, sexuality, fear, medico-legal issues) .
_____________________________ 1. Associate Professor, Pharmacology, 2. Prof. Pediatric, , 3. Prof. Physiology, 4 &5 Prof. Pharmacology, MGM Medical College, Kamothe, Navi Mumbai
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Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol and Drug Abuse, National Database in TB
and Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

Ipseeta Ray Mohanty et al

Assessment of stress, coping strategies and life style among medical students

Stress can have detrimental effect on health, academic performance, memory and learning, problem solving abilities, medical decisions and ultimately, patient care . How well an individual copes depends on his personality, environment and physical well-being. Coping with the help of unhealthy life style choices such as nutrition, exercise, sleep pattern and health risk behaviors: alcohol, tobacco and drug abuse can be counterproductive and worsen stress. The study intends to identify the stressors specific to the campus, analyze the stress, coping strategies and life style patterns of medical students and explore the possibility of using the results, to improve their quality of life and reinforce a healthy life-style. The results will provide lead for future preventive interventions at the level of students, parents, teachers and administration with medical students in order to reduce the negative consequences of stress on their lifestyle choices and mental health.
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MATERIALS AND METHODS

The Survey was conducted among a total of 302 students belonging to 1st MBBS (Group 1), 2nd MBBS (Group 2), 3rd MBBS (Group 3) medical students and interns (Group 4) of MGM Medical College, Navi Mumbai. The sample size per group was Group 1: (N=78), Group 2: (N=77), Group 3: (N=87) and Group 4: (N=60). QUESTIONNAIRE Four previously validated instruments were used to collect study data. a) b) Stress {Stress Check List for Self (SCL-S)}: measures the intensity of stress . Stress Coping behavior {Coping Inventory for Stressful Situations (CISS-21)}: assesses cognitive appraisal, emotion-oriented and avoidance coping . c) d) Personality Type (Jenkins Activity Survey): assesses the personality type . Life style scores (FANTASTIC Lifestyle Assessment): contains items Family, Activity, Nutrition, Tobacco, Toxins Alcohol, Sleep/stress, Personality type, Insight and Career . Protocol and methods: The students of the four groups were administered the questionnaire. Student ID numbers as opposed to names was used to identify subjects while maintaining confidentiality. The students willing to participate in the study were enrolled. Informed consent was taken in writing. Analysis of the data: An analysis of variance was performed to compare the scores of 1st, 2nd, 3rd medical students and interns followed by the Bonferroni post hoc test and Pearson Correlation. Differences were considered statistically significant at p<0.05.
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RESULTS
Degree of Stress :The total mean stress scores, physical, emotional and behavioral signs of stress were significantly higher among the interns as compared to 1 , 2
st nd

and 3 MBBS students (Fig 1 & 2).

rd

Mean stress coping score : The total mean stress coping score was not statistically different among the groups. However, the avoidance type coping behavior was significantly higher among interns as compared to 1 , 2 students.
st nd

and 3 MBBS

rd

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Assessment of stress, coping strategies and life style among medical students

Figure 1: Stress levels among medical students. #p<0.001 Vs 1st, 2nd and 3rd MBBS

Figure 2: Categorization of Stress among medical students. Score more than 75 % of total stress score was considered as very severe, between 60 75 % as severe, 40-60% as moderate and 20 40 % as mild.

Variables that influence Stress levels i)

Gender, Residence and Family Income: There was no difference in the stress on the basis of gender, hostel stay, family income of the medical students. ii) Personality type: Among 1 MBBS 9.2%, 2 10.7%, 3
rd st nd

iii) Stress coping behavior: A positive correlation between stress and avoidance type coping behavior was found in the present study (r= 0.627) (Fig 3).

Stressors: Among the 1st and 2nd MBBS students, the social and emotional stressors (self expectation, parental expectation,
classroom relationships with peers, teachers) were significantly higher as compared to the 3
rd rd

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Stress score Figure 3: Type of Stress coping behavior among medical students. #p<0.001 Vs 1st, 2nd and 3rd MBBS MBBS MBBS 11.8% and Internship 33.3% belonged to Type A personality. A significant positive correlation (p<0.001) between stress and Type A personality was observed in the study. MBBS and Interns. Academic factors (Examination, Enormous syllabus, inadequate clinical exposure, lack of proper guidance, work over-load) were most significant for 3 MBBS students. Physical stressors (hostel food, residing away from home) were the dominant factor contributing to stress among interns.

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Assessment of stress, coping strategies and life style among medical students

FANTASTIC Life Style The fantastic life style score of 1 MBBS as well as 3 than 2
nd rd st

Table -1: Correlation between stress and life style among medical students Groups Mean 1 MBBS 2 3
nd rd st

N 302 78 77 87 60

MBBS was higher

Total Stress score 25.029.09 21.05 7.7 22.01 8.3 23.56 3.5 33.48 8.0

Life style score 38.22 6.20 39.12 6.03 37.95 5.16 39.36 5.19 35.73 8.10

Pearson Correlation Coefficient -0.466 -0.586 -0.545 -0.512 -0.390

Sig. (2tailed) 0.01 0.01 0.01 0.01 0.05

MBBS and internship (Fig 4). The

individual items of the FANTASTIC life style questionnaire were also ranked

MBBS MBBS

sector wise (Table 1).

Interns Influence of residence and family support on life style: There were no significant differences in life style a score positive based on residence. (r=0.625)

Figure 4: FANTASTIC Life Style Scores among medical students. st rd #p<0.05 Vs 1 and 3 MBBS

However,

correlation

40 39
Mean Score

39.12 37.95

39.36

between life style scores and social support was determined. Correlation between stress and life style: The FANTASTIC lifestyle score exhibited a significant (p<0.01) negative correlation with perceived stress across all curriculum years (Table 2).

38 37 36 35 34 33 1st MBBS 2nd MBBS 3rd MBBS Interns 35.73

DISCUSSION
In recent years, many segments of the medical establishment are becoming increasingly concerned about mental health of medical students and physicians. medical
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Life Style of Medical Students

Table- 2: Fantastic life style item ranking among medical students Items 1 Family Activity Nutrition Toxins Tobacco Alcohol Sleep/Stress Type B Personality Insight Career Rank
st

MBBS 2 1 3 2 2 4 4 2 1 2 3

nd

MBBS 3 MBBS Interns 3 2 3 1 3 2 3 2 3 4 2 1 4 4 2 3 1 3 1 1 4 4 1 3 1 1 4 4 4 2

rd

Few studies among physicians and projected higher stress and

students

frustration, poorer health, lack of positive health and coping behaviors besides engaging in inappropriate behaviors such as self-medication, delay in seeking care or frequent use of denial.
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However,

surprisingly there have been few published studies in India documenting hard and quantifiable data on the health habits and coping behaviors of medical students in different academic years of medical education.
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Group rank of individual item: 1= Max score, 4= Min score

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Assessment of stress, coping strategies and life style among medical students

The environment in which medical students live is quite different in respect of the sources of stress, such as continuous evaluation process, exhausting and demanding work hours, striving for excellence, constant efforts to earn high grades, higher setting of goals etc. . Stress may not only impair the quality of medical students but also influence patient care and the complex psychodynamics of the doctor patient relationship.
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As a consequence of increased stress, medical

students can experience an alarming amount of resulting depression, substance abuse and even suicide. Chronic stress is known to influence memory and learning, especially problem solving abilities which demands flexible thinking. Thus stress can affect medical decisions and ultimately patient care.
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Preventive intervention with medical students in order to reduce stress and improve their life style is a very important factor in achieving a holistic health. With this point in view, the study was designed to identify the stressors specific to the campus, analyze the stress, coping strategies and life style of medical students Results indicated that stress is prevalent among medical students. Out of 302 students, 54 % of the students had some degree of stress. The total stress scores as well as the physical, emotional and behavioral signs of stress were significantly higher among interns as compared to 1 , 2 , and 3
st nd rd

MBBS students. Clinical responsibilities, professional

accountability and competition for postgraduate seats could be the cause of high stress among interns. The mean total stress coping score was almost similar among the four study groups. However, a matter of concern is that the avoidance type coping behavior which is aimed at avoiding the stressful situation via distracting oneself with other situations or tasks is predominant coping strategy among the interns and significantly higher as compared to 1st, 2nd and 3rd MBBS. Interestingly, a positive correlation between stress and avoidance type coping behavior was found. Stress was least among medical students of cognitive appraisal type, as they accepted responsibility and planned to solve the problem themselves. A positive correlation between stress and Type A personality was observed in the study. Type A personality usually did not cope well with stress, prone to develop stress related illnesses such as cardiac problems and tend to respond to stressors far more quickly than Type B. medical check up.
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Stress management training is something they should consider, besides routine

Among the 1st and 2nd MBBS the social and emotional stressors were significantly higher as compared to the 3rd MBBS and Interns. This may be due to entry into a large professional college which made students feel insecure in the initial period. Academic factors were considered most significant to generate stress by 3rd MBBS students and Interns when given clinical responsibilities. Physical stressors were the dominant factor contributing to stress among interns as compared to other groups maybe because of clinical postings and frequently night duties warranting to stay back. Students suggestions for improvement in their external and internal environment to ameliorate stress were taken. To reduce academic stressors, many innovative suggestions were put forward. Students felt that the curriculum should focus more on problem oriented medical education approach. More emphasis should be laid on teaching of critical care and emergency medicine. Discussions on critical care areas (MI, PPH, Acute abdomen, medico legal cases, cardiopulmonary resuscitation, first aid etc) should be a part of curriculum. There should be periodic discussion on correlation of investigations and progress of cases throughout the clinical terms. Topics for vertical/horizontal integration, whichever feasible should be identified. Medical literature should be made available at various places (Wards, ICU, ICCU). To appreciate and acknowledge students in-house prizes for scoring highest marks in individual subjects, credit hours for small assignment may be desirable. Interns should be involved more in primary care, encouraged to write on case papers, given more responsibilities under direct

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Assessment of stress, coping strategies and life style among medical students

supervision of residents and lecturers.. Interns should attempt to do minor procedures so that transition from final MBBS to internship becomes smoother. To reduce physical stressors, improvement in the quality of hostel food, a lunch room where they can interact and have meals in a amicable environment, more recreational facilities like a literature club for light reading, ongoing social and extracurricular activity to help them unwind, distress and explore hidden talent were suggested. Emotional stressors can be possibly addressed by more frequent interactions of students with faculty and regular open houses with the concerned authorities which can be meeting grounds for solving problems of students: both personal and academic. System of mentorship and postgraduate career counseling must be introduced to ameliorate emotional stressors. The FANTASTIC life style score of students when they enter universities i.e., 1 MBBS and also during 3rd MBBS was higher than 2nd MBBS and internship. Largest proportion, which need to improve their life style i.e., from average or poor life styles categories were among interns. Abuse of drugs, excess intake of caffeine, tea was predominant among 1st and 2nd MBBS students. However smoking was more common among 3rd MBBS and interns as compared to 1st and 2nd MBBS students. The largest percentage of respondents who consumed alcohol on a regular basis were among interns, followed by 2nd MBBS, 3rd MBBS and 1st MBBS students in that order. These health risks behaviors may be the negative coping mechanisms developed among students over a period of time to overcome stress. This is indeed a matter of concern. Lower life style scores were strongly associated with increased stress and use of maladaptive coping strategies. The present study emphasizes the profound impact of stress on life style and health risk behaviors. In view of the potential long term benefits of managing stress in a more effective way, it may be important for students to develop some stress coping skills early in their medical career. If required, counseling may be introduced at an appropriate stage. In susceptible cases or obvious cases of stress voluntarily admitted by students in course of counseling may be started at an appropriate stage integrated with medical curriculum and extracurricular activities, sports, yoga etc in close association with parents, wherever required. Appropriate modification in teaching and evaluation time in medical education to reduce undue stress should be evolved. Through such intervention reduction of stress, perceived by students approaching exam can be planned while laying more emphasis on regular, day to day reading. Numerous authors have emphasized the role of positive mental health among students for their future growth [19-20]. It may not be possible to completely eliminate stress in our colleges, but it is important that stress intervention programs may be designed after the stressors specific to the college students are determined. There is an urgent need of intervention strategies for medical students in order to prevent the negative consequences of stress, improve their life style by promoting individual and social resources as well as the doctor patient relationship, at the formative period of the students career. Therefore, increased awareness about stress, its consequences, and introduction of early stress management techniques in the medical career is important. Acknowledgment: The authors sincerely thank the Foundation for the Advancement of International Medical Education Institute in Medical education and Research. The authors acknowledge the support and guidance from the clinical
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psychologist: Dr Pushplata and the statistician: Mr Pratap Yadav.

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