Abstract
BACKGROUND:
The education environment of medical colleges is known to have a burdensome effect on the overall mental health of the students. This study aimed to investigate the immediate impact of the medical education environment on mental health and quality of life among Health Profession students and to identify various coping strategies used by students to mitigate the stress.
MATERIALS AND METHODS:
An online survey was conducted between April 1 and May 10, 2021, using a validated questionnaire based on DASS-42, employing a snowball sampling technique.
RESULTS:
A total of 338 students filled the questionnaire. The respondents had a high level of depression and anxiety scores, categorized as very severe which were significantly different among level of education (P < .05), for example, 88.9% of sixth year students had very severe depression compared to just 37% of first year ones. Gender-wise very severe scores varied from lowest 45.8% to 70.3% with comparable results for both males and females. Additionally, more than 30% of the students listed that the amount of material to be covered, lack of time to study the material to be tested, heavy demand to study, concern about trying to learn all the content, and competitiveness among students to be the top reason which affect their mental state of mental health.
CONCLUSIONS:
This study identifies the need to provide the free professional and psychological services to help cope with stress to the health profession students.
Keywords: Anxiety, DASS, depression, healthcare, mental health, stress
Introduction
Life of a University students is like a roller coaster ride—full of ups and downs constituting huge amounts of numerous varieties of stress.[1] University life of a student is subjected to various sources of stress emanating from academic pressures; peer pressures; personal, emotional, or social issues; environmental factors; and huge and rigorous curriculum. During the academic life, students must face all these issues and navigate carefully to succeed in this competitive world.[2] Health professions (HP) education usually is known to have one of the toughest and challenging curriculum which provides a highly toxic and unfavourable environment for the students, negatively affecting their mental health in numerous ways.[3,4,5]
Generally, students of HP have an additive stress of high academic burden, adjustment to the novel school environment, information overload, lack of quality relaxation time, huge amount of study material to be learned, repeated formative and summative examinations, maintenance of viable attendance, financial indebtedness, family-related stressors, pressures of work, work relationships, and future career choices.[5,6,7]
A number of studies have reported that the constant exposure to the various stressors primes the HP students to depression.[7,8,9] Additionally, the students who suffer from both anxiety and depression are usually at risk of poor academic performance with lower grade point averages.[10] A recent study identified the most common mental health problem among HP students to be anxiety (41.1%-56.7%), followed by depression (12%-30%) and stress (11.8%-19.9%).[3] Depression being a single most effect of various stressors in HP students' life is actually a multidimensional disorder that unfavourably affects interpersonal, social, and occupational domains of students' life.[11] However, it being modifiable and treatable, managing depression to improve academic performance has become the topmost priority for the medical educationist around the world nowadays.[7]
A number of techniques and strategies have been identified by psychologists to master, reduce, tolerate, or minimize the effects of stressors. All these are referred to as coping strategies and usually include mindfulness-based stress reduction classes, wellness electives, informal support groups, and mentoring programs.[12]
Coping methods often used by HP students include effective time management, social support, positive reappraisal, and engagement in leisurely pursuits.[13] Other studies have demonstrated that establishing a positive academic environment that is healthy and well-managed and overlapping it with stress management programs can potentially resolve the stress and enhance performances.[14]
Therefore, we designed this study to assess the perceptions of HP students toward various stress factors, their sources, and their severity. This study would also identify various coping strategies the HP students use and gauge their effectiveness.
Materials and Methods
Study design and settings
A cross-sectional study was conducted in between November 1 and February 9 at King Saud Bin Abdul Aziz University for Health Science (KSAU-HS), Jeddah. All HP students from College of Medicine, College of Applied Medical Sciences, and College of Nursing were included in this study and were selected by convenience sampling method to complete a self-administered validated questionnaire after being provided with an informed consent.
Study participants and sampling
Sample size was calculated by using the Raosoft software, with the following parameters—90% confidence level with an estimated 50% prevalence of awareness of mental state and a margin of error ± 5%. Total number of students studying in our University in Jeddah Campus being ~2500, a necessary sample size was calculated to be 245.
Data collection
A snowball sampling technique was used for the collection of the data. The data collection was continuous during this period solely focused to include as much participants as we can to have the appropriate sample size. A self-determined, predesigned questionnaire consisting of two tools was used to obtain a dataset composed of sociodemographic and physical characteristics. The survey-based study was conducted by using two tools: Tool 1 (attachment 1) is DASS-42 which is a freely available, standardized questionnaire to assess depression, stress, and anxiety. Participants answer this questionnaire by choosing one of the numbers (0, 1, 2, 3) that indicate how much has the sentence been applied to the participant over the past week. Tool 2 (attachment 2) is a validated questionnaire to assess various strategies used by students for coping the stress and answers were acquired through Likert scale. For qualitative data, frequencies and percentage and mean and standard deviation were used for quantitative variables.
Data analysis
Data were analyzed using SPSS version 22.0. For the quantitative variables, dispersion measures and central tendency were used. For the qualitative variables, data were tabulated and the results were expressed in relative frequencies and percentages. For the comparisons between the two groups, a contrast test for quantitative variables with parametric distribution using Student's t-test was carried out. The normal distribution with the Kolmogorov-Smirnov test was checked. For the comparison of categorical variables, Chi-square test was used. U Mann-Whitney test was used for nonparametric distributions. Correlation of quantitative variables was done by Spearman test. P value less than .05 was considered significant.
Ethical consideration
The study protocol and the questionnaire thereof was reviewed and approved by the Institutional Review Board of King Abdullah International Medical Research Centre (KAIMRC), a research wing of KSAU-HS, Jeddah (Reference No: RJ19/148/J; Dated: 24/05/2020).
Results
A total of 338 participants responded to the survey, of them, 220 (65.1%) were males, while 118 (34.9%) were females. Moreover, 333 (98.5%) of respondents were single, four (1.2%) of them were married, and one (0.3%) were divorced. Twenty seven (8%) of the students were first year, 28 (8.3%) were second year, 75 (22.2%) were third year, 180 (53.3%) were fourth year, 19 (5.6%) were fifth year, and nine (2.7%) were sixth year medical students. Additionally, based on the colleges, college of medicine represented around 34.32% of students, while college of nursing students were 29% [Table 1].
Table 1.
Demographics of the participants
| n | Percentage | |
|---|---|---|
| Gender | ||
| Male | 220 | 65.1 |
| Female | 118 | 34.9 |
| Marital Status | ||
| Single | 333 | 98.5 |
| Married | 4 | 1.2 |
| Divorced | 1 | 0.3 |
| Academic Year | ||
| First Year | 27 | 8.0 |
| Second Year | 28 | 8.3 |
| Third Year | 75 | 22.2 |
| Fourth Year | 180 | 53.3 |
| Fifth Year | 19 | 5.6 |
| Sixth Year | 9 | 2.7 |
| Health Profession Programs | ||
| College of Medicine | 116 | 34.32 |
| College of Nursing | 98 | 29.00 |
| College of Applied Medical Sciences | 69 | 24.41 |
| College of Health Professions | 55 | 16.27 |
| Total | 338 | 100.0 |
Analysis of DASS-42 scores [Table 2] revealed that male and female participants' results were comparable in depression, anxiety, and stress (P value > .05) as shown in Table 3 [Figure 1]. Based on the severity among males, 22 (10%) had moderate, 27 (12.3%) had severe, and 120 (54.5%) had extremely severe depression, while among females, 17 (14.4%) had moderate, 18 (15.3%) had severe, and 65 (55.1%) had extremely severe depression. As for anxiety, 19 (8.6%) of males had moderate, 16 (7.3%) had severe, and 149 (67.7%) had extremely severe anxiety, regarding females, seven (5.9%) were moderate, 13 (11%) were severe, and 83 (70.3%) were very severe.
Table 2.
Participants perceptions of depression, anxiety, and stress on the DASS-42 scale
| Item in DASS-42 | Questions | Did not apply to me at all | Applied to me to some degree or for some of the time | Applied to me to a considerable degree or for a good part of time | Applied to me very much or most of the time |
|---|---|---|---|---|---|
| 1 | I found myself getting upset by quite trivial things | 75 (22.2) | 137 (40.5) | 90 (26.6) | 36 (10.7) |
| 2 | I was aware of dryness of my mouth | 152 (45.0) | 84 (24.9) | 65 (19.2) | 37 (10.9) |
| 3 | I couldn’t seem to experience any positive feelings at all | 176 (52.1) | 100 (29.9) | 47 (13.9) | 15 (4.4) |
| 4 | [I experienced breathing difficulty (e.g. breathlessness or excessively rapid breathing in the absence of physical exertion) | 199 (58.9) | 74 (21.9) | 47 (13.9) | 18 (5.3) |
| 5 | I just couldn’t seem to get going | 136 (40.2) | 102 (30.2) | 66 (19.5) | 34 (10.1) |
| 6 | I tended to over-react to situations | 106 (31.4) | 128 (37.9) | 68 (20.1) | 36 (10.7) |
| 7 | I had a feeling of shakiness (e.g. legs going to give way) | 224 (66.3) | 68 (20.1) | 27 (8.0) | 19 (5.6) |
| 8 | I found it difficult to relax | 93 (27.5) | 119 (35.2) | 84 (24.9) | 42 (12.4) |
| 9 | I found myself in situations that made me so anxious I was most relieved when they ended | 76 (22.5) | 71 (21.0) | 115 (34.0) | 76 (22.5) |
| 10 | I felt that I had nothing to look forward to | 154 (45.6) | 73 (21.6) | 69 (20.4) | 42 (12.4) |
| 11 | I found myself getting upset rather easily | 92 (27.2) | 135 (39.9) | 66 (19.5) | 45 (13.3) |
| 12 | I felt that I was using a lot of nervous energy | 100 (29.6) | 97 (28.7) | 83 (24.6) | 58 (17.2) |
| 13 | I felt sad and depressed | 102 (30.2) | 110 (32.5) | 79 (23.4) | 47 (13.9) |
| 14 | I found myself getting impatient when I was delayed in any way (e.g. lifts, traffic lights, being kept waiting) | 113 (33.4) | 109 (32.2) | 71 (21.0) | 45 (13.3) |
| 15 | I had a feeling of faintness | 206 (60.9) | 79 (23.4) | 34 (10.1) | 19 (5.6) |
| 16 | I felt that I had lost interest in just about everything | 139 (41.1) | 98 (29.0) | 42 (12.4) | 59 (17.5) |
| 17 | I felt I wasn’t worth much as a person | 180 (53.3) | 70 (20.7) | 47 (13.9) | 41 (12.1) |
| 18 | I felt that I was rather touchy | 169 (50.0) | 95 (28.1) | 48 (14.2) | 26 (7.7) |
| 19 | I perspired noticeably (e.g. hands sweaty) in the absence of high temperatures or physical exertion | 218 (64.5) | 65 (19.2) | 33 (9.8) | 22 (6.5) |
| 20 | I felt scared without any good reason | 180 (53.3) | 96 (28.4) | 39 (11.5) | 23 (6.8) |
| 21 | I felt that life wasn’t worthwhile | 173 (51.2) | 85 (25.1) | 43 (12.7) | 37 (10.9) |
| 22 | I found it hard to wind down | 159 (47.0) | 117 (34.6) | 41 (12.1) | 21 (6.2) |
| 23 | I had difficulty in swallowing | 273 (80.8) | 44 (13.0) | 16 (4.7) | 5 (1.5) |
| 24 | I couldn’t seem to get any enjoyment out of the things I did | 146 (43.2) | 107 (31.7) | 54 (16.0) | 31 (9.2) |
| 25 | I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) | 157 (46.4) | 98 (29.0) | 51 (15.1) | 32 (9.5) |
| 26 | I felt down-hearted and blue | 186 (55.0) | 83 (24.6) | 40 (11.8) | 29 (8.6) |
| 27 | I found that I was very irritable | 129 (38.2) | 116 (34.3) | 58 (17.2) | 35 (10.4) |
| 28 | I felt I was close to panic | 159 (47.0) | 96 (28.4) | 43 (12.7) | 40 (11.8) |
| 29 | I found it hard to calm down after something upset me | 145 (42.9) | 93 (27.5) | 69 (20.4) | 31 (9.2) |
| 30 | I feared that I would be “thrown” by some trivial but unfamiliar task | 175 (51.8) | 91 (26.9) | 42 (12.4) | 30 (8.9) |
| 31 | I was unable to become enthusiastic about anything | 162 (47.9) | 77 (22.8) | 53 (15.7) | 46 (13.6) |
| 32 | I found it difficult to tolerate interruptions to what I was doing | 144 (42.6) | 114 (33.7) | 47 (13.9) | 33 (9.8) |
| 33 | I was in a state of nervous tension | 129 (38.2) | 112 (33.1) | 53 (15.7) | 44 (13.0) |
| 34 | I felt I was pretty worthless | 215 (63.6) | 55 (16.3) | 28 (8.3) | 40 (11.8) |
| 35 | I was intolerant of anything that kept me from getting on with what I was doing | 153 (45.3) | 107 (31.7) | 57 (16.9) | 21 (6.2) |
| 36 | I felt terrified | 193 (57.1) | 85 (25.1) | 31 (9.2) | 29 (8.6) |
| 37 | I could see nothing in the future to be hopeful about | 199 (58.9) | 73 (21.6) | 38 (11.2) | 28 (8.3) |
| 38 | I felt that life was meaningless | 195 (57.7) | 73 (21.6) | 38 (11.2) | 32 (9.5) |
| 39 | I found myself getting agitated | 165 (48.8) | 99 (29.3) | 48 (14.2) | 26 (7.7) |
| 40 | I was worried about situations in which I might panic and make a fool of myself | 157 (46.4) | 87 (25.7) | 49 (14.5) | 45 (13.3) |
| 41 | I experienced trembling (e.g. in the hands) | 224 (66.3) | 67 (19.8) | 26 (7.7) | 21 (6.2) |
| 42 | I found it difficult to work up the initiative to do things | 123 (36.4) | 99 (29.3) | 52 (15.4) | 64 (18.9) |
Table 3.
Frequency distribution of various scales of DASS-42 based on gender
| Normal |
Mild |
Moderate |
Severe |
Very severe |
P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | ||
| Depression | 0.275 | ||||||||||
| Male | 36 | 16.4% | 15 | 6.8% | 22 | 10.0% | 27 | 12.3% | 120 | 54.5% | |
| Female | 15 | 12.7% | 3 | 2.5% | 17 | 14.4% | 18 | 15.3% | 65 | 55.1% | |
| Anxiety | 0.299 | ||||||||||
| Male | 29 | 13.2% | 7 | 3.2% | 19 | 8.6% | 16 | 7.3% | 149 | 67.7% | |
| Female | 9 | 7.6% | 6 | 5.1% | 7 | 5.9% | 13 | 11.0% | 83 | 70.3% | |
| Stress | 0.106 | ||||||||||
| Male | 55 | 25.0% | 15 | 6.8% | 17 | 7.7% | 24 | 10.9% | 109 | 49.5% | |
| Female | 22 | 18.6% | 9 | 7.6% | 20 | 16.9% | 13 | 11.0% | 54 | 45.8% | |
Figure 1.
Distribution of participants on different depression, anxiety and stress scores
Finally, males' scores were 17 (7.7%) moderate, 24 (10.9%) severe, and 109 (49.5%) were very severe in stress. Also, 20 of females scored (16.9%) moderate, 13 (11%) severe, and 54 (45.8%) extremely severe in stress [Table 3]. Ten (37%) of first year, 17 (60.7%) of second year, 46 (61.3%) of third year, 92 (51.1%) of fourth year, 12 (63.2%) of fifth year, and eight (88.9%) of sixth year students have shown extremely severe level of depression. Nineteen (70.4%) of first year, 21 (75%) of second year, 56 (74.7%) of third year, 115 (63.9%) of fourth year, 13 (68.4%) of fifth year, and eight (88.9%) of sixth year students have shown extremely severe level of anxiety. Nine (33.3%) of first year, 16 (57.1%) of second year, 39 (52%) of third year, 80 (44.4%) of fourth year, 12 (63.2%) of fifth year, and seven (77.8%) of sixth year students have shown extremely severe level of stress [Table 4]. We also found that the most frequently used coping methods were listening to music, watching television, and social networking. The least used coping strategies were academic counselling, student rights, and identifying oneself with models of physicians who prioritize their quality of life [Table 5].
Table 4.
Participants overall scores on the DASS-42 scale based on the academic year and severity of depression, anxiety, and stress
| Normal |
Mild |
Moderate |
Severe |
Very severe |
P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | ||
| Depression | 0.028 | ||||||||||
| First Year | 1 | 3.7% | 0 | 0.0% | 7 | 25.9% | 9 | 33.3% | 10 | 37.0% | |
| Second Year | 5 | 17.9% | 0 | 0.0% | 2 | 7.1% | 4 | 14.3% | 17 | 60.7% | |
| Third Year | 10 | 13.3% | 5 | 6.7% | 6 | 8.0% | 8 | 10.7% | 46 | 61.3% | |
| Fourth Year | 33 | 18.3% | 12 | 6.7% | 20 | 11.1% | 23 | 12.8% | 92 | 51.1% | |
| Fifth Year | 1 | 5.3% | 1 | 5.3% | 4 | 21.1% | 1 | 5.3% | 12 | 63.2% | |
| Sixth Year | 1 | 11.1% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 8 | 88.9% | |
| Anxiety | 0.561 | ||||||||||
| First Year | 1 | 3.7% | 0 | 0.0% | 2 | 7.4% | 5 | 18.5% | 19 | 70.4% | |
| Second Year | 4 | 14.3% | 1 | 3.6% | 0 | 0.0% | 2 | 7.1% | 21 | 75.0% | |
| Third Year | 8 | 10.7% | 2 | 2.7% | 6 | 8.0% | 3 | 4.0% | 56 | 74.7% | |
| Fourth Year | 23 | 12.8% | 10 | 5.6% | 16 | 8.9% | 16 | 8.9% | 115 | 63.9% | |
| Fifth Year | 1 | 5.3% | 0 | 0.0% | 2 | 10.5% | 3 | 15.8% | 13 | 68.4% | |
| Sixth Year | 1 | 11.1% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 8 | 88.9% | |
| Stress | 0.011 | ||||||||||
| First Year | 3 | 11.1% | 2 | 7.4% | 10 | 37.0% | 3 | 11.1% | 9 | 33.3% | |
| Second Year | 5 | 17.9% | 2 | 7.1% | 3 | 10.7% | 2 | 7.1% | 16 | 57.1% | |
| Third Year | 16 | 21.3% | 3 | 4.0% | 5 | 6.7% | 12 | 16.0% | 39 | 52.0% | |
| Fourth Year | 49 | 27.2% | 14 | 7.8% | 19 | 10.6% | 18 | 10.0% | 80 | 44.4% | |
| Fifth Year | 3 | 15.8% | 3 | 15.8% | 0 | 0.0% | 1 | 5.3% | 12 | 63.2% | |
| Sixth Year | 1 | 11.1% | 0 | 0.0% | 0 | 0.0% | 1 | 11.1% | 7 | 77.8% | |
Table 5.
Participants stress factors and strategies for coping with it
| # | Questions | Strongly disagree | Disagree | Unsure | Agree | Strongly agree |
|---|---|---|---|---|---|---|
| 1 | The amount of material to be covered | 34 (10.1) | 49 (14.5) | 51 (15.1) | 76 (22.5) | 128 (37.9) |
| 2 | Lack of time to study the material to be tested | 34 (10.1) | 46 (13.6) | 50 (14.8) | 88 (26.0) | 120 (35.5) |
| 3 | Frequent tests/exams | 52 (15.4) | 51 (15.1) | 61 (18.0) | 74 (21.9) | 100 (29.6) |
| 4 | Many tests at the same time | 84 (24.9) | 67 (19.8) | 60 (17.8) | 53 (15.7) | 74 (21.9) |
| 5 | Test subject matter goes beyond what was covered | 54 (16.0) | 73 (21.6) | 63 (18.6) | 69 (20.4) | 79 (23.4) |
| 6 | Studying at night | 65 (19.2) | 49 (14.5) | 57 (16.9) | 66 (19.5) | 101 (29.9) |
| 7 | Dealing with new forms of assessment | 63 (18.6) | 38 (11.2) | 79 (23.4) | 87 (25.7) | 71 (21.0) |
| 8 | Missing classes | 98 (29.0) | 63 (18.6) | 77 (22.8) | 48 (14.2) | 52 (15.4) |
| 9 | Studying material that I consider unnecessary | 59 (17.5) | 54 (16.0) | 61 (18.0) | 66 (19.5) | 98 (29.0) |
| 10 | Amount of details required by teachers | 54 (16.0) | 57 (16.9) | 69 (20.4) | 74 (21.9) | 84 (24.9) |
| 11 | Amount of extracurricular activities | 110 (32.5) | 64 (18.9) | 72 (21.3) | 46 (13.6) | 46 (13.6) |
| 12 | Difficulty in memorizing the content | 54 (16.0) | 54 (16.0) | 60 (17.8) | 76 (22.5) | 94 (27.8) |
| 13 | Heavy demand to study | 36 (10.7) | 52 (15.4) | 54 (16.0) | 67 (19.8) | 129 (38.2) |
| 14 | Concern about trying to learn all the content | 33 (9.8) | 21 (6.2) | 55 (16.3) | 63 (18.6) | 166 (49.1) |
| 15 | Competitiveness among students | 45 (13.3) | 66 (19.5) | 55 (16.3) | 45 (13.3) | 127 (37.6) |
| 16 | Daily activities unrelated to school | 79 (23.4) | 70 (20.7) | 70 (20.7) | 60 (17.8) | 59 (17.5) |
| 17 | Teachers’ lack of time | 105 (31.1) | 79 (23.4) | 91 (26.9) | 35 (10.4) | 28 (8.3) |
| 18 | Feelings of guilt at giving more priority to personal life | 68 (20.1 | 45 (13.3) | 64 (18.9) | 65 (19.2) | 96 (28.4) |
| 19 | Waking up very early to go to school | 76 (22.5) | 59 (17.5) | 75 (22.2) | 52 (15.4) | 76 (22.5) |
| 20 | Family problems | 123 (36.4) | 68 (20.1) | 54 (16.0) | 36 (10.7) | 57 (16.9) |
| 21 | Marriage and children | 247 (73.1) | 24 (7.1) | 44 (13.0) | 11 (3.3) | 12 (3.6) |
| 22 | High parental expectations | 124 (36.7) | 41 (12.1) | 57 (16.9) | 59 (17.5) | 57 (16.9) |
| 23 | Identifying yourself with models of physicians who prioritize their quality of life | 105 (31.1) | 57 (16.9) | 85 (25.1) | 56 (16.6) | 35 (10.4) |
| 24 | Studying the minimum needed to pass subjects | 140 (41.4) | 66 (19.5) | 53 (15.7) | 43 (12.7) | 36 (10.7) |
| 25 | Respecting my physical limits, avoiding spending many hours without sleeping | 73 (21.6) | 54 (16.0) | 76 (22.5) | 67 (19.8) | 68 (20.1) |
| 26 | Avoiding comparing grades with other students | 67 (19.8) | 45 (13.3) | 57 (16.9) | 58 (17.2) | 111 (32.8) |
| 27 | Skipping classes to perform activities that give pleasure (sports, etc.) | 118 (34.9) | 72 (21.3) | 54 (16.0) | 41 (12.1) | 53 (15.7) |
| 28 | Going to the cinema/outings on weekends | 80 (23.7) | 46 (13.6) | 57 (16.9) | 57 (16.9) | 98 (29.0) |
| 29 | Going for long walks/trekking etc | 89 (26.3) | 64 (18.9) | 62 (18.3) | 49 (14.5) | 74 (21.9) |
| 30 | Getting together with family and friends | 31 (9.2) | 36 (10.7) | 73 (21.6) | 82 (24.3) | 116 (34.3) |
| 31 | Cooking | 129 (38.2) | 59 (17.5) | 64 (18.9) | 35 (10.4) | 51 (15.1) |
| 32 | Eating well | 78 (23.1) | 46 (13.6) | 64 (18.9) | 70 (20.7) | 80 (23.7) |
| 33 | Reading nonmedical literature/novels etc. | 106 (31.4) | 46 (13.6) | 56 (16.6) | 56 (16.6) | 74 (21.9) |
| 34 | Listening to music etc. | 42 (12.4) | 33 (9.8) | 50 (14.8) | 59 (17.5) | 154 (45.6) |
| 35 | Watching television for Dramas/Sports/Religious etc. | 55 (16.3) | 32 (9.5) | 52 (15.4) | 58 (17.2) | 141 (41.7) |
| 36 | Going out to dinner | 64 (18.9) | 42 (12.4) | 65 (19.2) | 71 (21.0) | 96 (28.4) |
| 37 | Social networking - Facebook, Instagram, Twitter | 54 (16.0) | 58 (17.2) | 66 (19.5) | 56 (16.6) | 104 (30.8) |
| 38 | Taking solace in Religion - Prayers and Quran | 45 (13.3) | 50 (14.8) | 63 (18.6) | 85 (25.1) | 95 (28.1) |
| 39 | Participating/Playing Sports | 79 (23.4) | 64 (18.9) | 60 (17.8) | 66 (19.5) | 69 (20.4) |
| 40 | Academic Counselling | 161 (47.6) | 78 (23.1) | 59 (17.5) | 22 (6.5) | 18 (5.3) |
| 41 | Student Rights | 143 (42.3) | 67 (19.8) | 75 (22.2) | 18 (5.3) | 35 (10.4) |
Discussion
HP students are more exposed to stressors due to the nature of their studies,[5,6,7] piling up these stressors play a significant role in developing depression and anxiety which end up being the cause of the drop in their academic performance.[7,8,9,10] Therefore, we here aim to discuss the various stressors and the degree of which they affect HP students' mental health, their coping mechanisms, and their effectiveness. In this research, we found that HP students suffered from different levels of depression, anxiety, and stress which they tried to handle in a variety of ways. We also found that the levels of these conditions were not affected by gender or academic year (P value > .05).
The outcomes showed higher levels in depression (84.9%), anxiety (88.8%), and stress (77.2%) in comparison to other studies from Syria and India,[15,16] although our findings did not show any significant difference in the levels of depression and anxiety in relation to gender. Al Saadi et al. results showed higher prevalence in females, while Iqbal et al. noticed higher levels of stress in females as well.[15,16] Our study also revealed same levels of mental morbidities across all academic years. This did not match the study from India that showed higher incidence in students in their fifth semester (third year) of their medical studies.[16]
Listening to music and social networking, which were of the most coping strategies our participants agreed upon, have been associated with aggravating negative feeling and tendency toward self-isolation in previous literature.[17] We noticed that students' behavior was not directed toward positive coping strategies like academic counseling and cooking.[18,19] In alignment with previous papers regarding this topic, our research has also shown high levels of mental morbidity that could be attributed to the stressful life of HP students. However, higher levels in these mental condition in our research might have been due to the fact that the students were surveyed during the beginning of the COVID-19 pandemic and quarantine. The impact of gender that has been demonstrated in other literature may have been caused by the male predominance in our sampling that could have affected the results. The inconsistency between our paper and Shawaz Iqbal's paper regarding the effect of the academic year also can be referred to the fact that their curriculum differs from ours.
DASS-42 was our first tool of data collection which has proven its effectiveness in measuring depression, anxiety, and stress levels.[20] The other tool that we used aimed to explore how the HP students coped with their psychological disturbances. Convenient sampling was the better available choice due to the low number of respondents. In spite of the relatively low number of participants, the study was able to yield a rough estimation of the psychological burden of students in KSAU-HS Jeddah.
Limitations and recommendations
This study has a number of weaknesses and limitations. The sampling was convenient and there were discrepancies in the participants in terms of gender, medical year, and marital status. Also, the respondents were surveyed during the pandemic which could have played a major role in their mental health status. In addition, the study was self-reported which could subject it to systemic bias. Data collection was via an online form which has a risk of the inherent recall bias.
Conclusion
This study identifies the need to provide the free professional and psychological services to help cope with stress to the HP students. We also identify dire need of implementation of an effective destressing and counselling programs, curricular activities, and awareness campaigns for HP to help them in strategizing their priorities in the demanding phase of their student life.
Ethical clearance
This study was approved by the Institutional Review Board of King Abdullah International Medical Research Centre (KAIMRC), a research wing of KSAU-HS, Jeddah (Reference No: RJ19/148/J; Dated: 24/05/2020).
Author contributions
S.S.A. conceptualized the project, designed the study questionnaire in its final form surveyed the existing literature, and wrote the entire manuscript.
Z.S.J.A., A.N.M.A., A.G.M.A., and O.G.M.A. collected the data of the study and equally contributed in writing the draft of this manuscript.
M.A.Q, S.S.A. and B.K. reviewed and revised the manuscript.
M.A.K. analyzed the collected data and made sense of it and reviewed the manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
I would like to express their deep gratitude toward all participating students of KSAU-HS, Jeddah campus who proactively participated in this study.
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