ISSN: 2320-5407 Int. J. Adv. Res.

11(02), 203-211

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/16241
DOI URL: http://dx.doi.org/10.21474/IJAR01/16241

RESEARCH ARTICLE
PREVALENCE OF STRESS AND ITS ASSOCIATION WITH RESILIENCE AMONG MEDICAL
STUDENTS IN A TERTIARY CARE CENTER, AURANGABAD, MAHARASHTRA, INDIA

Dr. Jyotsna S. Waghmare1, Dr. Arvind V. Gaikwad2, Dr. Mohan K. Doibale3 and Dr. Pooja H. Roy4
1. Junior Resident-, Department of Community Medicine, GMCH Aurangabad.
2. Associate Professor, Department of Community Medicine, GMCH Aurangabad.
3. Head of the Department, Department of Community Medicine, GMCH Aurangabad.
4. Junior Resident-, Department of Community Medicine, GMCH Aurangabad.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Medical science is perceived as a stressful educational
Received: 10 December 2022 career, and medical students experience monstrous stress during their
Final Accepted: 14 January 2023 undergraduate studies and internships because of its depth and
Published: February 2023 competitiveness. Prolonged stress can cause health problems, hamper
academic achievements, and affect patient care.
Key words:-
Stress, Medical Student, Kessler 10 Objectives: The present study aimed to assess the prevalence of stress
Inventory, BRIEF Resilient Scale and its association with resilience, as well as the coping strategies
adopted by medical students.
Material & Methods: This was a cross-sectional study conducted
among medical undergraduate students studying at a tertiary care
hospital situated in Aurangabad, Maharashtra, between June and July
2022. Using Cochran's formula and the previous study's prevalence of
51.1%, 425 medical students from first year to internship were
included. A self-administered questionnaire consisting of
Sociodemographic characteristics, items from the Kessler 10 inventory,
and the BRIEF resilient coping scale were used.
Results: The overall response rate was 79.11%, with 380 out of 425
students returning the questionnaire. The study found that 57.6% of
medical students were suffering from high levels of stress, and the
highest prevalence was among the 1st year students, followed by the
internship students, and then the final year students. Stress was
classified as mild (13.9%), moderate (8.9%), severe (34.7%), or likely
to be well (42.4%) on the Kessler 10-item inventory scale. Academic
factors are a greater perceived cause of stress. The religion, present
address, medium of education and BRCS coping score had significant
impact on presence of stress.(p=0.027, p=0.03, p=0.001,p=0.001 )
Conclusion: The study recommended that consideration be given to
program decision-makers and health decision-makers to focus on
significant actions to reduce the academic stress perceived by medical
students. Preventive mental health services could be made an integral
part of routine clinical services for medical students, especially in the
initial academic years, to prevent such occurrences.
Copy Right, IJAR, 2023,. All rights reserved.

Corresponding Author:- Dr. Jyotsna S. Waghmare 203

Address:- Junior Resident-3, Department of Community Medicine, GMCH Aurangabad.
ISSN: 2320-5407 Int. J. Adv. Res. 11(02), 203-211

……………………………………………………………………………………………………....
Introduction:-
Studying medicine is stressful.Medical science is perceived as a stressful educational career, and medical students
experience monstrous stress during their undergraduate studies and internship because of its depth and
competitiveness.(1,2) Numerous studies have discussed the stressors that medical students must deal with. The body's
general reaction to demands placed on it or upsetting occurrences in its surroundings is called stress. (3, 4) It helps us
feel and respond to environmental hazards and difficulties. (5)

"Stressors" are situations that stress people out. The emotional changes or disturbances that stressors cause are
referred to as "stress." Stress comes in two forms. Positive stress encourages learning, whereas negative stress
prevents it. Depending on their innate abilities, medical students may interpret the same pressures in different ways.
Students' self-esteem, academic performance, and professional advancement are all negatively impacted by
excessive stress.(6,7)

Studies carried out in the United States have shown that studying medicine puts competent medical students at risk
for psychological morbidity, which occurs at various phases of training. (8-11) In a research study conducted in
Singapore, 57% of law students and 47.3% of medical students had experienced emotional disturbance based on
GHQ results.(12) Another study conducted in Turkey found that mental disorders were present in 47.9% of medical
students, compared to 29.2% of students in economics and physical education. (13)

These facts suggested a situation of elevated psychological pressure on medical students. Studies have also shown
that chronic exposure to stress is associated with anxiety and depression, interpersonal conflict, sleep disturbances,
and poor academic or clinical performance. (14,15) Stress was also found to decrease the quality of attention,
concentration, and decision-making and reduce the students‟ abilities to establish good relationships with patients.
(16)

Therefore, this study aimed to estimate the prevalence of stress and its association with resilience among medical
students in a tertiary care center in Aurangabad, Maharashtra.

Aim and objectives:-

1. To estimate the Prevalence of stress and its association with resilience.
2. To assess coping strategies adopted among Medical Students.

Material and Methods:-

Study design:
A Cross Sectional study.

Study setting:
The present study was conducted at a tertiary care center of Aurangabad city of Maharashtra, India.

Study duration:
1 Month (June 2022 to July 2022).

Sample size:
The sample size was calculated using purposive sampling and the prevalence of stress among medical students from
the previous study done by Goval P.et al(17) in South Gujarat, which was 51.1%.Using the Cochran formula, the
sample size was calculated to be 383 with a precision of 5%. The study included 425 students after accounting for
the nonresponse rate.

Study population:
The study included all MBBS and internship students studying in a tertiary care center.

Inclusion criteria:
All the MBBS students from their first year through their internship.

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Exclusion criteria:
1. Unwillingness to participate in the study; and 2. Incomplete answers.

Data Collection and Questionnaire:

A pre-tested and semi-structured questionnaire consisting of Sociodemographic characteristics, items from Kessler
10 inventory(18) and BRIEF Resilient coping scale (19)were used. To maintain data quality the questionnaire was
pretested on 30 medical students.

Study procedure:
A Google form consisting of all these items sent on whatsapp group of each batch after lectures. Also form was sent
on their groups twice in a week as a reminder to students during the study period. The students were allowed to
respond in their own time and privacy. The participation was entirely voluntary. Those who filled incomplete
questionnaire were excluded from study.

Study tools:
The study was conducted using Kessler10 psychological distress (K10) inventory developed by Kessler and
colleagues, which measures the level of stress according to none, mild, moderate, and severe categories. This
instrument has been used widely in population-based epidemiological studies to measure current (1-month) distress.
The World Mental Health Survey of the World Health Organization used it as a clinical outcome measure. (20)

The K10 consists of 10 questions in the form of “how often in the past month did you feel ...” and offers specific
symptoms, such as „tired out for no good reason‟, „nervous‟, and „sad or depressed‟. The five possible responses for
each question ranged from „none of the time‟ to „all of the time‟ and were scored from 1 to 5 respectively. All the
questions were collated to obtain a total score. The total score was interpreted as follows: a score of less than 20 was
considered not to represent stress of any level while a score of 20-24 represented mild stress, 25-29 represented
moderate stress, and 30- 50 represented severe stress.(21) The questionnaire also had additional questions relating to
academic achievement, sources of stress, and any perceived medical illness. The K10 questionnaire was observed to
have good psychometric properties with a Cronbach‟s alpha of 0.934. (18)

Another instrument used for measurement of resilience was BRIEF Resilient coping scaleby Sinclaire and Wallston
(2004).Resilience refers to the ability of people to „bounce back‟ when they encounter difficulties.It consists of 4
statements which consider how well the given statements describe participant‟s behavior and actions. The 5 possible
responses for each question ranged from „does not describe me at all‟ to „describe me very well‟ and were scored
from 1 to 5 respectively. Interpretation of this scale consist of score range from 4-13 points for Low resilient copers,
14-16 points for Medium resilient copers and 17-20 points for High resilient copers.(19)[Cronbach‟s alpha of 0.823]

Data entry and analysis:

The data were entered in Microsoft Excel and analyzed by using SPSS trial version 26. The outcome variable
"stress" was dichotomized as "yes" or "no." The three levels (mild, moderate, and severe) of stress were put into one
category and titled „presence of stress-yes‟. Descriptive statistics (mean, standard deviation, and percentages) were
used for summarizing the study and outcome variables. A univariate regression analysis was done for different study
variables. The Chi-square test determined that the correlation between various variables was significant when p
value <0.05.

Approval for the study:

Written approval from the institutional ethics committee was obtained beforehand. After obtaining informed verbal
consent from all MBBS students and interns studying in a tertiary care center, they were included in the study.

Results:-
The overall response rate was 79.11%, with 380 out of 425 students returning the questionnaire. The students' mean
age was 21.6 (2.1) years, with a range of 18-32 years. Out of the total 380 students, 198 (52.1%) were female and
182 (47.9%) were male. Among all respondents, 106 (27.9%) were first-year MBBS students, 48 (12.6%) were
second-year students, 48 (12.6%) were third-year students, 87 (22.9%) were final-year students, and 91 (23.9%)
were interns.

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The mean score for the Kessler scale was 25.33±9.95. In the present study, the prevalence of stress at all levels was
about 57.6%. However, the prevalence of severe stress was 34.7%, moderate stress was 8.9%, and mild stress was
13.9%. (Fig. 1 & Fig. 2)

Fig. 1:- Prevalence of Stress among Medical students.

Fig.1 Prevalence of Stress among Medical students

No Stress

Presence of
Stress

42.4 %
57.6 %

Fig. 2:- Level of stress according to Kessler 10 inventory.

Fig.2 Distribution of students according to Level of Stress

34.7 %
Severe stress

8.9%
Moderate stress

Mild stress 13.9%

Likely to be well 42.4%

The Sociodemographic characteristics of the study participants and their association with the presence of stress are
shown in Table 1. The prevalence of stress was the highest (80%) among the students in the age group 26–30 years
compared to their counterparts without statistical significance (p=0.1). There was no significant association between
gender and the presence of stress. (p=0.06). Female students had a higher proportion of stress (62%) than male

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students (52.8%). Religion had a significant impact on the presence of stress. Students of the Muslim religion had
higher stress (78.3%) compared to students belonging to Hindu (56.2%), Buddhist (70.6%), and other religions
(45.2%).

Also, the present address of students had a significant impact on the presence of stress (p = 0.003). Students living in
flats or rooms experienced more stress (67%) than hostel residents (59.4%) or local residents (51.4%).The
association between the permanent addresses of the students and the rate of stress was not significant (p = 0.17). The
distribution of stress levels was found to be significantly associated with the level of education. The prevalence of
stress was the highest among the 1st-year students (64.1%), followed by the interns (58.4%), the final year (55.9%),
the 2nd year (53.5%), and the 3rd year (47.1%). There was no significant association between the study year and
stress levels. (p=0.49).

Table 2 shows the association of behavioral factors and resilience with the presence of stress. The presence of any
health issue, duration of sleep, and duration of work were not significantly associated with the presence of stress
among the students (p = 0.51, p = 0.05, p = 0.31). The students with health issues had 61.2 % more stress than
students without any health issues (56.9%). Stress was more prevalent in students who slept for 6 hours compared to
students who slept for 6–8 hours (54.3%) and 9–11 hours (66.7%). The prevalence of stress was higher in students
who worked for more than 13 hours per day (75%), followed by work durations of 8 hours (58.6%), 8–10 hours
(56.3%), and 11–13 hours (46.2%). The brief resilience coping scale score had a significant impact on the presence
of stress among medical students (p = 0.001). The mean score was 14.63.55. Students who experienced more stress
(68.8%) were less resilient than their peers. Students who were moderate copers experienced 67.5% stress, while
high copers experienced 38.5% stress.

Table 1:- Association of sociodemographic variables with the presence of stress.

Study variables Category Presence of stress Total Chi-square value
No[N (%)] Yes[N(%)] N (%)
Age <20 49 (48) 53 (52) 102 (100) X22=4.509, p=0.105
21-25 109 (41.4) 154 (58.6) 263 (100)
26-30 3 (20) 12 (80) 15 (100)
Gender Male 85 (47.2) 95 (52.8) 180 (100) X21=3.300, p=0.069
Female 76 (38) 124 (62) 200 (100)
Religion Hindu 123 (43.8) 158 (56.2) 281 (100) X23=9.215, p=0.027*
Muslim 5 (21.7) 18 (78.3) 23 (100)
Buddhist 10 (29.4) 24 (70.6) 34 (100)
Other 23 (54.8) 19 (45.2) 42 (100)
Present Address Hostelite 41 (40.6) 60 (59.4) 101 (100) X22=6.574, p=0.037*
Localite 87 (48.6) 92 (51.4) 179 (100)
Flat/room 33 (33) 67 (67) 100 (100)
Permanent address Rural 51 (37.8) 84 (62.2) 135 (100) X21=1.807, p=0.179
Urban 110 (44.9) 135 (55.1) 245(100)
Medium of Education English 132 (47.8) 144 (52.2) 276 (100) X22=14.924, p=0.001*
Semi English 13 (39.4) 20 (60.6) 33 (100)
Marathi/Hindi 16 (22.5) 55 (77.5) 71 (100)
Designation 1st year 37 (35.9) 66 (64.1) 103 (100) X24=3.383, p=0.496
2ndyear 20 (46.5) 23 (53.5) 43 (100)
3rd year 18 (52.9) 16 (47.1) 34 (100)
Final year 49 (44.1) 62 (55.9) 111 (100)
Intern 37 (41.6) 52 (58.4) 89 (100)
Figures in parenthesis indicate row wise percentages.

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Table 2:- Association of behavioral factors with the presence of stress.

Study variables Category Presence of stress Total Chi-square value
No N (%) Yes N (%) N (%)
Health issue Yes 26 (38.8) 41 (61.2) 67 (100) X21=0.423, p=0.516
No 135 (43.1) 178 (56.9) 313(100)
Sleep duration <6hr 25 (30.9) 56 (69.1) 81 (100) X22=5.950, p=0.051
6-8hr 134 (45.7) 159 (54.3) 293 (100)
9-11hr 2 (33.3) 4.0(66.70) 6 (100)
Work duration <8 hour/day 84 (41.4) 119 (58.6) 203 (100) X23=3.559, p=0.313
8-10hour/day 59 (43.7) 76 (56.3) 135 (100)
11-13 hour/day 14 (53.8) 12 (46.2) 26 (100)
>13 hour/day 4 (25) 12 (75) 16 (100)
BRCS (Brief Resilience High (17-20) 83 (61.5) 52 (38.5) 135 (100) X22=31.369,
Coping scale) Moderate (14-16) 39 (32.5) 81 (67.5) 120 (100) p=0.000**
Scoring Low (4-13) 39 (31.2) 86 (68.8) 125 (100)
Figures in parenthesis indicate row wise percentages.

Table 3:- Different sources of stress in medical students.

Different sources of Stress in medical students Frequency (n) Percent (%)
Academic Vast syllabus for study 214 56.3
Difficulty in understanding 152 40
Lack of appreciation 124 32.6
No time for recreational activities 95 25
Preparation of future exam 276 72.6
Psychosocial Worried about future 132 34
Fear of failure in exam 170 44.7
Conflicts with colleague 87 22.8
Relationship problems 98 25.7
Family obligations 56 14.7
Loneliness/Home sickness 89 23.4
Financial problems 70 18.4
Environmental Living condition in Hostel 145 38.1
Quality of food in mess 124 32.6
Adjustment with Roommates 112 29.4
*Multiple responses are considered.

Table 3 shows different sources of stress among medical students. They are classified as academic, psychosocial,
and environmental stressors. The top three sources of stress among all students are exam preparation (72.6%), exam
failure (44.7%), and living conditions in the hostel (38.1%) in all three categories. Figure 3 shows various coping
strategies adopted by students to tackle this stress. Students' most common strategies were listening to music
(67.6%) and watching movies (48.9%). Others were meditation/yoga/gym (41%), sleeping (32.3%), talking with
parents (20.5%), etc.

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Fig. 3:- Various coping strategies adopted by students to tackle stress.

Fig.3:Various coping strategies adopted by students to tackle stress

Alcohol intake/Smoking 9%

Binge eating 12.1 %

Painting 22.3 %

Talking with Parents 20.5 %

Long driving 17.1 %

32.3 %
Sleeping

Meditation/Yoga/Gym 41 %

48.9 %
Watching Movies 67.6 %
Listening Music

Discussion:-
A high prevalence of stress among medical students is a cause for concern as it may impair their behavior, diminish
their learning, and ultimately affect patient care after their graduation. The overall prevalence of stress in this study
(57.6%) is similar to the Wahed WY et al. (21) study (62.4%)and Abdulghani H. et al (22) study (63%) but higher than
a study by Goyal P. et al (17) in South Gujarat (51.1%) and lower than a study by Chandalwala U. et al in Mumbai
(91%).(23)The present study revealed females were more stressed than males. This result was similar to the study
done by Chadalawada U.et al in Mumbai (23) and Sadiq A.et al in Faisalabad. (24)

In the present study, first-year students were more stressed, then stress decreased for the 2 nd and 3rd years gradually
and increased during the final year and internship. Similar results were observed in the Abdulghani H. et al study (22)
and the Attiya M. et al study. (25) However, contrary results were observed, i.e., 2ndand 3rd-year students had a
higher prevalence of stress than others in the studies done by Yusoff M. et al (26)andSani M. et al. (27)In the present
study, stress levels were higher among hostel students than in the locality, which was similar to the study by Shah C.
et al. (28) They discovered that students who spoke Marathi or Hindi had more stress than English-medium students.
These findings contradict those of the Supe AN et al study. (29)

The BRCS score revealed that 68.8% of students were low-resilient, which was found to be significant in this study.
Academic factors, such as exam preparation (72.6%) and a large study syllabus (56.3%), are the main sources of
stress in the present study. Similar results were reported by the Rock B. et al. study (30) and the Joseph N. et al.
study.(31) Listening to music and watching movies are the most common coping strategies adopted by students to
tackle stress. The Chadalawada U et al. study found similar results. (23)

Since stress affects students' behavior, learning, and patient care after graduation, it is concerning that medical
student‟s experience such a high prevalence of stress. To help the student‟s better handle the demanding professional
course, a variety of stress management techniques should be offered. Encourage students to participate in
extracurricular activities to reduce their stress levels.(32)

This was a cross-sectional study conducted using a self-administered questionnaire; hence, there is a chance of
information bias. Furthermore, because the study was restricted to a single medical college, it is possible that the
results cannot be generalized. The possibility of reporting bias exists, and students self-reported its causes. Despite
the provision of confidentiality, medical students may have exaggerated or underreported stress or coping
mechanisms out of fear of being singled out.

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Conclusion:-
The prevalence of stress was high in our study subjects with low resilience.One of the most effective ways to
prevent stress is by helping students in developing resilience. As resilience is a dynamic process, it is very essential
to include resilience-building strategies in the medical curriculum like mental health screening, sensitive workplace
infrastructure, peer support, nutrition, etc.Ongoing needs include reframing the academic curriculum, as well as
examination and evaluation patterns, incorporating extracurricular activities, and establishing counseling cells in
campus.

Acknowledgment:-
We would like to thank medical students of Government Medical College Aurangabad, Maharashtra who
participated in this study and given their valuable time for completing the questionnaires.

Financial support and sponsorship:

Nil.

Conflicts of interest:
There are no conflicts of interest.

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