Prevalence of stress and its associated factors among intern physicians in Bangladesh: a cross-sectional study

Abstract

Objectives

Stress is inherent in human life, and physicians by dint of their nature of profession are subjected to a high level of stress. Stress among intern physicians is a major concern that can lead to physical and mental illness and can harm the quality of patient care. This study assessed stress and its associated factors among intern physicians.

Design

A cross-sectional study.

Setting

This study was conducted among intern physicians of three medical college hospitals in Bangladesh. A self-administered questionnaire consisting of socio-demographic details, work-related questions, social and personal questions and the Kessler Psychological Distress Scale was used.

Participants

A total of 350 interns participated in this study.

Outcome measures

We measured the prevalence of stress and socio-demographic, work-related and social and personal factors associated with stress among interns.

Results

The prevalence of stress among medical interns was 65.7%. Most interns were affected by mild stress (27.1%), followed by moderate (20.9%) and severe (17.7%) stress. The stress level was significantly higher (76.9%) among interns who were posted in the gynaecology and obstetrics department compared with interns who were posted elsewhere (p=0.003). Stress was significantly associated with family income (p=0.001), hours of work per day (p<0.001) and per week (p=0.001), duration of sleep (p=0.004) and relaxation time (p<0.001). Higher stress levels were found in interns who feared hospital-acquired infections (p=0.001), missed social events (p=0.03), did not have a close friend in the same department (p=0.01), spent less time with friends and family (p=0.004), could not have a meal during work hours (p=0.008) and had conflicts with nurses (p=0.005) and patients or their attendants (p=0.022).

Conclusions

Stress was widely prevalent among the intern physicians. Excessive stress can impact cognitive abilities, education and patient outcomes negatively. Interventions targeting precipitating factors can reduce interns’ stress and enhance work efficiency.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Use of a reliable and validated instrument to measure the outcome.

• Risk of responder recall bias due to the self-report nature of the study.

• The cross-sectional design and use of convenience sampling may introduce selection bias and limit the ability to infer causality.

Introduction

The shift from being a medical student to becoming an intern physician has always been viewed as an important milestone.¹ This is their initial experience managing patients with accountability and putting knowledge into action. An internship bridges the gap between medical school and being eligible for medical specialty training. Research from around the world has shown that this change is often perceived as quite a difficult experience.2,4 Interns have to face and handle the primary responsibility of patient care in a hospital. Sudden leaps from studies into patient care, communication problems, work overload, patient responsibility, emotional investment towards patients and inadequate support as they start working in clinical settings have been recognised as factors that lead to this challenging transition period.⁴

In Bangladesh, medical education was inherited from the colonial education system, which occupied Bangladesh from 1757 to 1947. The current system includes a 1-year rotational internship period.⁵ This training year is required for interns to obtain a medical license and work as physicians.⁶ An intern physician develops the skills to interact with patients, understand and manage medical issues while being supervised by senior doctors. The major tasks assigned to medical interns are to register new admissions, provide patient care, prepare medical records and fine-skill the procedures of drawing blood, lumbar puncture aspiration, ascitic fluid tap, pleural fluid tap, etc. These invaluable experiences help the intern develop their skills and identify their future career interests.⁷

Stress is a personal experience caused by a situation that triggers either physical or emotional discomfort.⁸ Stress is a common aspect of daily life, and it can be either beneficial or harmful.⁸ In certain situations, a small amount of acute stress can benefit by enhancing immune protection and could be used to strengthen immune responses in instances of injury, illness, immunisation and certain cancers.⁹ However, excessive or persistent stress could lead to reduced job satisfaction and productivity. Other risks include depression, suicidal tendencies, cardiovascular disease, insomnia, anorexia, fatigue, etc.¹⁰ Several research studies have evaluated how a person’s stressful life impacts their career outcomes, particularly in the medical field, often in anticipation of future postgraduation years.11,13

Stress among undergraduate medical students14,17 and postgraduate students18,22 has been well studied. Yet, there have been limited efforts to investigate the stress levels and relevant factors that cause stress among recent medical school graduates. Interns have been found to experience more emotional distress than attending physicians and residents.²³ Abdulghani et al in their study in Saudi Arabia found that 73% of intern physicians were under stressful conditions.⁸ Another study in Kerala, India, found 85% of the interns were found to be stressed.²⁴ Female interns suffer more stress in comparison to their counterparts.^{8 25}

Stress and long-term stress effects, such as burnout, are primary reasons for physical and emotional illness, low job performance and satisfaction, along with reduced overall well-being and life satisfaction. This study is poised to make a meaningful contribution by shedding light on the prevalence and contributing factors of stress among intern physicians in Bangladesh, an area where such research remains notably scarce. By focusing on this critical transition period, the findings may offer valuable insights for medical educators, hospital administrators and policymakers to develop targeted interventions aimed at reducing stress, enhancing coping strategies and ultimately improving the well-being and professional readiness of future physicians.

Materials and methods

Settings and sample

Following ethical approval, this cross-sectional study was carried out in three medical college hospitals, namely Sylhet MAG Osmani Medical College Hospital (SOMCH), Jalalabad Ragib-Rabeya Medical College Hospital (JRRMCH) and Sylhet Womens’ Medical College Hospital (SWMCH). All the male and female intern physicians of the hospitals were selected as the study population. The minimum sample size was 350, calculated using the formula z²pq/d², with an expected prevalence of 34%,¹² 95% CI, and a relative precision of 5%. A total of 399 questionnaires were distributed using convenient sampling in all three hospitals, and 350 filled-in questionnaires were received from the participants the next day to meet the calculated sample size (190 from SOMCH, 91 from JRRMCH and 69 from SWMCH).

Data collection tool

The questionnaire had four parts—socio-demographic details, work-related questions, social and personal questions and the Kessler Psychological Distress Scale (K10). A pilot test on 15 intern physicians was done. Minor changes were made to the language of the questionnaire. The language of the questionnaire was kept in English and not translated into Bangla. During pre-testing, participants were comfortable answering in English as it is the medium of learning in medical education. The socio-demographic part of the questionnaire includes questions regarding age, sex, marital status, accommodation and family income. The work-related part of the questionnaire includes questions regarding department posted, hours of work per day and week, duration of sleep and relaxation time, number of night shifts in the past month and conflict with seniors, co-interns, nurses and patients or their attendants. Social and personal questions were regarding fear of hospital-acquired infection, close friends in the same department, ability to have a meal during work hours, a decision on the future field of career, missing social events, opportunity to spend time with friends and family and confidence in clinical decision-making.

K10 is a 10-item questionnaire intended to yield a global measure of stress based on questions about anxiety and depressive symptoms that a person has experienced in the most recent 30-day period. There are 10 questions like ‘During the last 30 days, how often did you feel tired out for no good reason?’ or ‘During the last 30 days, how often did you feel nervous?’. There are five options to choose from, which are—none of the time, a little of the time, some of the time, most of the time and all the time; which are scored as 1, 2, 3, 4, 5, respectively. The numbers attached to the 10 responses are added up, and the total score is the score on the K10 scale. A score on or above 20 indicates the presence of stress in the last 30 days. A score under 20 is likely to have no stress, scores 20–24 are likely to have mild stress, scores 25–29 are likely to have moderate stress and scores 30 and over are likely to have severe stress. Cronbach’s alpha (0.88) demonstrated strong internal consistency of the K10.²⁶ K10 has been used to assess stress among interns and junior doctors in similar studies in Saudi Arabia.^{8 14 15 18}

Data collection method

Data were collected in a self-administered way from the intern physicians of the three medical college hospitals using a prepared pre-tested questionnaire and scale. The questionnaire was distributed by researchers at the intern stations in the departments without disturbing their routine work. The purpose and objectives of the study were explained to the interns during the distribution of the questionnaire. Assurance was given regarding confidentiality and secrecy of the information they provide. No identifying information like names or addresses was collected through the questionnaire. An informed written consent was taken before handing over the questionnaire to each intern. Questionnaires were collected from the participants on the following day from their work stations.

Data analysis

For analysis, data were grouped using medians as follows—age into ≤24 and ≥25 years, family income into <52 000, 52 000–100 000 and >100 000 taka, hours of work per day into ≤7, 8–12 and >12 hours, hours of work per week into ≤72 and >72 hours, duration of sleep into <6 and ≥6 hours, duration of relaxation time into ≤2 and >2 hours and number of night shifts in past month into ≤7 and >7 shifts. Except for surgery, medicine and gynaecology and obstetrics, all other departments are grouped in ‘Others’ like Paediatrics, Orthopaedics, Ophthalmology, Otorhinolaryngology, etc. To assess or measure the objectives, descriptive statistics—frequency, percentage, mean and SD were used for socio-demographic and work-related factors. For the test of significance, the χ² test was used to see the relationship between dependent variables and independent variables. For all statistical tests used in this study, a statistically significant level was set as p≤0.05. Data were analysed with the Statistical Package for Social Science V.24.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Result

A total of 350 interns from the three different medical college hospitals who completed the questionnaire were included in the present study, with a response rate of 87.7%. All the participants ranged from 23 to 30 years, with a mean age of 24.86±1.03 years. Most of the interns were women (61.1%) and about half resided in the hostel (53.1%). Only 18.6% of interns were married, and most of them reported having a family income between 52 000 and 100 000 taka. On average, the interns worked 7.28±4.37 night shifts per month, with individual workloads ranging from 0 to 20 night shifts, indicating considerable variation. They also worked an average of 12.13±2.93 hours per day, with daily shifts spanning from 6 to 18 hours. Weekly working hours averaged 81.78±20.03 hours, with a minimum of 30 hours and a maximum of 126 hours per week, reflecting substantial differences in workload among interns.

The prevalence of stress among intern physicians was high (65.7%, n=230). Mild stress was experienced by 95 interns (27.1%), moderate stress by 73 interns (20.9%) and severe stress by 62 interns (17.7%), as shown in figure 1. The mean K10 score of the participant was 23.15±6.397.

Figure 1. Severity of stress among intern physicians. The total prevalence of stress. Stress category according to the Kessler Psychological Distress Scale.

Socio-demographic factors associated with stress are shown in table 1. Stress was higher in the older (≥25 years) age group. Female intern physicians were found to be slightly more stressed (68.2%) compared with their male counterparts (61.8%). Intern physicians who resided in a hostel were suffering more from stress (68.3%) than those who resided in their homes (63.3%) and rented rooms (60%). Married interns reported higher stress (73.8%) than unmarried ones (63.9%). Interns with lower family income (<52 000 takas) reported higher stress (74.5%), and it was statistically significant (p=0.001). Among the study centres interns from JRRMCH reported higher stress (72.5%) compared with interns from SOMCH (62.1%) and SWMCH (66.7%).

Table 1. Socio-demographic factors associated with stress.

Socio-demographic variables	Stress*		P value
	Present	Absent
Age (years)
≤24	84 (63.2)	49 (36.8)	0.43
≥25	146 (67.3)	71 (32.7)
Sex
Male	84 (61.8)	52 (38.2)	0.215
Female	146 (68.2)	68 (31.8)
Accommodation
Home	88 (63.3)	51 (36.7)	0.532
Hostel	127 (68.3)	59 (31.7)
Rented room	15 (60)	10 (40)
Marital status
Married	48 (73.8)	17 (26.2)	0.126
Unmarried	182 (63.9)	103 (36.1)
Family income (taka)
<52 000	82 (74.5)	28 (25.5)	0.001†
52 000–100 000	107 (68.2)	50 (31.8)
>100 000	41 (49.4)	42 (50.6)
Study centres
SOMCH	118 (62.1)	72 (37.9)	0.223
JRRMCH	66 (72.5)	25 (27.5)
SWMCH	46 (66.7)	23 (33.3)

^*Percentage in parentheses.

^†Statistically significant.

JRRMCH, Jalalabad Ragib-Rabeya Medical College Hospital; SOMCH, Sylhet MAG Osmani Medical College Hospital; SWMCH, Sylhet Womens’ Medical College Hospital.

Table 2 represents the work factors associated with stress among intern doctors. Interns working in the department of gynaecology and obstetrics reported the highest proportion of stress (76.9%), and it was statistically significant (p=0.003). The average duration of work hours was collected in terms of both per day and per week. The prevalence of stress increased with an increase in working hours. Interns who spent more than 12 hours per day and more than 72 hours per week in hospitals reported the most stress (71.2% and 70.7%, respectively), and both results were found statistically significant (p<0.001 and p=0.001). Duration of sleep was significantly associated with stress (p=0.004), as was the duration of relaxation time (p<0.001). The stress level difference between interns who did ≤7 shifts and >7 shifts per month was statistically insignificant (p=0.184). Intern physicians who were suffering from higher stress reported a history of conflicts with seniors (p=0.144), peers (p=0.278), nurses (p=0.005) and patients or their attendants (p=0.022).

Table 2. Work-related factors associated with stress.

Work-related variables	Stress*		P value
	Present	Absent
Department posted currently
Medicine	61 (62.9)	36 (37.1)	0.003†
Surgery	65 (72.2)	25 (27.8)
Gynae & Obs.	60 (76.9)	18 (23.1)
Others	44 (51.8)	41 (48.2)
Hours of work per day
≤7 hours	13 (35.1)	24 (64.9)	0.000†
eight to 12 hours	101 (67.3)	49 (32.7)
>12 hours	116 (71.2)	47 (28.8)
Hours of work per week
≤72 hours	49 (52.1)	45 (47.9)	0.001†
>72 hours	181 (70.7)	75 (29.3)
Hours of sleep per day
<6 hours	99 (75)	33 (25)	0.004†
≥6 hours	131 (60.1)	87 (39.9)
Hours of relaxation
≤2 hours	178 (73.6)	64 (26.4)	0.000†
>2 hours	52 (48.1)	56 (51.9)
Number of night shifts in the past month
≤7 shifts	170 (62.6)	17 (32.4)	0.184
>7 shifts	113 (69.3)	50 (30.7)
Conflict with seniors
Yes	83 (70.9)	34 (29.1)	0.144
No	147 (63.1)	86 (36.9)
Conflict with co-interns
Yes	104 (68.9)	47 (31.1)	0.278
No	126 (63.3)	73 (36.7)
Conflict with nurses
Yes	96 (75)	32 (25)	0.005†
No	134 (60.4)	88 (39.6)
Conflict with patients or their attendants
Yes	110 (72.4)	42 (27.6)	0.022†
No	120 (60.6)	78 (39.4)

^*Percentage in parentheses.

^†Statistically significant.

Gynae & Obs., gynaecology and obstetrics.

Table 3 demonstrates the personal and social factors associated with stress among intern physicians. Interns who had a fear of exposure to infectious agents reported more stress (72.5%), and the association was statistically significant (p=0.001). Interns who had a close friend in the same department they were posted reported lower stress (61%) in comparison to those who did not have one (74.8%), and it was statistically significant (p=0.010). The ability to have a meal during work hours was found to be statistically associated with stress (p=0.008), as interns who could have a meal during duty time reported a lower proportion of stress (55.3%). Respondents who had decided on their future field of career were suffering from lower stress (61.7%) than those who did not (70.7%). Having enough time to spend on social meetings was found to be a key factor in developing stress. Intern doctors who did not find enough opportunity to spend time with friends and family (p=0.004) and missed social events (p=0.030) reported a higher proportion of stress, with a statistically significant association. The proportion of stress among interns who had confidence in clinical decision-making and who did not was comparable, and the difference was statistically insignificant (p=0.252).

Table 3. Personal and social factors associated with stress.

Work-related variables	Stress*		P value
	Present	Absent
Fear of hospital-acquired infection
Yes	150 (72.5)	57 (27.5)	0.001†
No	80 (55.9)	63 (44.1)
A close friend in the same department
Yes	141 (61)	90 (39)	0.010†
No	89 (74.8)	30 (25.2)
Ability to have a meal during work hours
Yes	57 (55.3)	46 (44.7)	0.008†
No	173 (70)	74 (30)
Decision on the future field of career
Yes	119 (61.7)	74 (38.3)	0.076
No	111 (70.7)	46 (29.3)
Opportunity to spend time with friends and family
Yes	43 (52.4)	39 (47.6)	0.004†
No	187 (69.8)	81 (30.2)
Missed social events
Yes	178 (69)	80 (31)	0.030†
No	52 (56.5)	40 (43.5)
Confidence in clinical decision-making
Yes	155 (63.8)	88 (36.2)	0.252
No	75 (70.1)	32 (29.9)

^*Percentage in parentheses.

^†Statistically significant.

Discussion

Occupations that require a lot of responsibility, like healthcare, which involves human well-being, can be stressful. Physicians have varying responses to their work environment; some find it positive, appealing and invigorating, while others find it overwhelming. A high frequency of stress in medical interns is worrisome because it can impact interns’ behaviour, reduce learning and ultimately impact patient care. In this study, we assessed the prevalence of stress levels and influencing factors among physicians undergoing internship training in Bangladesh. To the best of our knowledge, this is novel research delving into the stress levels of the recently graduated doctors in Bangladesh.

This current study showed that 65.7% of intern doctors were suffering from stress. Abdulghani et al⁸ and Zolhavarieh et al²⁷ reported that 73% and 70% of medical interns were stressed in Saudi Arabia and Iran, respectively, which are similar to this study. However, Austoria et al reported that 85% of the interns in India were found to be stressed, which is higher than our findings.²⁴ In other studies, stress prevalence in medical students was found to be lower, but in residents, it was found to be higher compared with our findings.^{14 15 18} The difference in prevalence could be due to differences in research instruments, or it could be a real difference in different levels of medical education. Perhaps the stress level increases as a medical student becomes a doctor and further increases when entering into postgraduation studies. This rise in stress levels can be multifactorial, driven by academic pressures, performance anxiety, competitive examinations, clinical workloads, patient care responsibilities and decision-making pressures.^{28 29}

When categorised according to the K10 scale, 27.1% of interns were mildly, 20.9% interns were moderately and 17.7% interns were severely stressed in this study. A study done among interns in Kerala and residents in Delhi, India, found that 34% of interns and 17.7% of residents were suffering from mild stress, the highest in stress categories, which is consistent with our study.^{21 24} However, Abdulghani et al in two different studies in Saudi Arabia found that severe stress (34.9%) was most prevalent among interns, but mild stress (27.4%) was most prevalent among resident doctors.^{8 18}

Female interns were found to be more stressed than their male counterparts, but this was not significant. This is not different from the distribution of stress prevalence among these two genders in the general population.³⁰ Women tend to be more susceptible due to emotional sensitivity, societal pressures to excel in male-dominated environments, lesser ability to cope with stress and higher self-blame.^{30 31} A study among medical students in Saudi Arabia in 2011 also reported a significant association between females and stress.¹⁴ Interestingly, another study found that male intern doctors suffer mostly from mild stress, but female intern doctors suffer mostly from moderate-to-severe stress.⁸ In our study, we found that lower family income resulted in higher stress, and there was a positive association (p=0.001). This is understandable as a lower socioeconomic person experiences higher stress.³² Also, for added income, traditionally, interns in Bangladesh work extra hours in private hospitals and private chambers of senior doctors. This extra work explains how lower-income family backgrounds can influence higher stress prevalence among the participants.

Interns with the highest proportion of stress (76.9%) belonged to those who were working in the gynaecology and obstetrics department and had a significant positive relationship with stress (p=0.003). A similar finding was reported in Shiraz University of Medical Sciences, Iran, where 57.8% of interns in gynaecology and obstetrics were stressed and had the highest stress score among all the departments.²⁰ The gynaecology and obstetrics department provides service to a large number of patients as well as delivers many newborns in every shift. Higher psychological burdens in gynaecology and obstetrics compared with other departments are well documented.^{33 34} The average duration of work hours both daily (p<0.001) and weekly (p=0.001) was found to be significantly associated with stress in this study. Similar studies in India, South Africa and Iran among interns have established that prolonged working hour is a significant causative factor of stress.^{20 24 25 27} Long work hours cause a lack of time for recreation, socialisation, sleep and recovery, which adds even more stress on these interns. Research has found that the greatest risk of cardiovascular events occurred when individuals were both working long hours and not getting enough sleep.³⁵ We found that interns with reduced sleep (p=0.004) and relaxation time (p<0.001) had a significant association with stress. Previous studies with similar respondents have also found an association between duration of sleep and relaxation time with stress.^{15 24} Insufficient sleep and mental health are significant public health issues worldwide, as they both have a significant impact on individuals.³⁶ Inadequate sleep further burdens the already stressed interns. Intern physicians who reported a history of conflicts with nurses (p=0.005), and patients or their attendants (p=0.022) were suffering from higher stress. Austoria et al also found similar results among Indian intern doctors.²⁴

We found a significant association between a fear of nosocomial infection and stress (p=0.001). The fear of getting infected creates a high-stress environment in healthcare settings.³⁷ Anxiety associated with such exposures was considered ‘moderate’ by 34%, ‘significant’ by 45% and ‘overwhelming’ by 21% of interns in South Africa.²⁵ Since the coronavirus pandemic, this has become a new challenge for health workers, especially for interns who provide frontline service for patients in tertiary hospitals.³⁸ Interns with a close friend in the same department reported significantly lower stress (p=0.010). A study among Delhi residents also reported similar findings.²¹ According to Revicki et al, peer and workgroup support helps alleviate stress for healthcare professionals.³⁹ Intern doctors who spent less time with friends and family (p=0.004) and missed social events (p=0.030) had a significant association with stress. Studies among interns and residents in India also resulted in similar results.^{21 24} Sun et al²⁵ and Earle et al⁴⁰ also found that as a coping strategy, junior doctors typically sought support from their family and friends. These findings are attributed to the fact that family and friends are the primary sources of support in an individual’s life, offering both social and mental stability. We also found that interns who could not find time to have a meal during work hours had a significant association with stress (p=0.008). Other research has also referred to this lack of capability as a contributing factor to stress.^{20 24}

Limitations

This cross-sectional study relied on convenient sampling and self-reported data from interns who participated. Reporting biases could have arisen from how respondents interpreted questions or their emotional reporting preferences, indicating potential inaccuracies. This study did not explore the effectiveness of coping strategies for stress among intern doctors, and future studies can look at this and whether the findings of this study persist beyond the internship period, here in Bangladesh.

Conclusions

This research revealed a relatively high prevalence of stress among intern physicians. The results indicate that long working hours, lack of proper sleep as well as relaxation time, spending less time with friends and family, missing social events, workplace conflicts, etc, were contributing to this stress. This research could assist in creating strategies for offering psychosocial support and counselling in the workplace to decrease stress experienced during internships. This research helps motivate the staff and faculty at medical colleges to collaborate with interns and create support services during their internships. Lastly, it is necessary to conduct additional research to monitor the stress levels of interns in Bangladesh.

Data availability statement

Data are available upon reasonable request.