Perceived stress, anxiety, and coping states in medical and engineering students during examinations

Abstract

Aim:

This study aims to study the factors associated with stress, anxiety, and coping states in students of 1^st and 2^nd year in medical and engineering colleges during examinations.

Materials and Methods:

This prospective, longitudinal study was conducted on 200 undergraduate medical and engineering students from 1^st to 2^nd year (50 in each year), after obtaining ethical approval from the institutional ethics committee. All the participants gave written informed consent. All students filled a questionnaire which consisted of a general information sheet, perceived stress scale, Hamilton Anxiety Rating Scale, brief COPE inventory, and sources of stress questionnaire 1 month before and 1 month after their university examinations. Data were analyzed using t-test, Mann–Whitney U-test, Kruskal–Wallis test, and Chi-square test as appropriate.

Results:

In medical students, perceived stress was significantly higher in those in the management quota (both years), living in shared accommodation and from nuclear family (1^st year) and male (2^nd year). Only accommodation had a statistically significant relationship with perceived stress in 2^nd year engineering students. A statistically significant association of perceived stress and anxiety with academic performance was observed. Anxiety in students was significantly more before the examination compared to after the examination. The association of all the coping strategies used, with the academic performance, was statistically significant.

Conclusions:

In both medical and engineering students, there was a significant association of perceived stress and anxiety with academic performance. Both medical and engineering students used active coping a little more than avoidant coping strategies during the examination time. The association of all the coping strategies used, with the academic performance, was statistically significant, thereby proving the importance of coping states in academic performance.

Stress can be defined as “any challenge to homoeostasis,” or to the body's internal sense of balance.[1] Modern life is full of hassles, deadlines, frustrations, and demands. Stress has affected people of all the professions at one point or the other. National Health Survey states that 75% of the general population experiences at least some stress every 2 weeks.[2] The stress experienced by students may adversely affect their academic achievement, personal well-being, and long-term professional capabilities. Like all young adults, undergraduate students need to cope with the academic and social demands of university studies in preparation for professional careers.[3] Joining medical and engineering courses involves many stressful changes in a student's life. Living away from home and making the transition to a more independent but less supported condition is stressful for young people.[4] Apart from these, high parental expectations and huge fees are additional pressures on the students. However, majority of stressful incidents in traditional curricula are related to academic training rather than to personal problems.[4] Academic reasons including the large and difficult syllabus requiring long hours of preparation along with emotional factors such as little peer support, an extremely competitive environment, combined with authoritative and officious faculty, financial difficulties, lack of facilities for recreation, staying in hostels away from home, cultural and minority issues, and uncertain future are some reasons for stress and anxiety among medical and engineering students.[5] In addition, medical students have other significant academic sources of stress including disillusionment with medical course and realities of medical curriculum along with perception of hurdle jumping, relationships with faculty, and additional burden of ragging in the campus, in case of recently joined candidates.[4] Similar kind of stressors exist in the engineering stream as well, excluding factors related to the medical stream in particular like dealing with patients, disease, and death and the effects of being a medical student on personal life and social issues such as managing leisure activities and social relationships. Engineering students also have additional significant stressors such as career insecurity, stiff competition due to surplus of engineers in the country, and reduced demand due to the recent economic recession in the software stream.

Previous studies have shown high levels of stress among students of professional courses.[4] Although some stress is expected in college and it can be a motivation to study and learn, too much stress can deter learning. In fact many students said that the stress that they experienced, strengthened their commitment to their professional education and achievement.[1] Some studies have observed that medical students undergo greater distress when compared to their engineering counter parts, but there are few from India.[6]

Stress and anxiety tend to occur together. Anxiety is also associated with feeling of loneliness, peer competition, long hours, and loss of social time.[7] Anxiety plays a significant role in damaging the confidence of the student and thereby affecting his/her academic performance. In view of the adverse consequences of stress and anxiety, it is imperative to develop appropriate coping mechanisms to help students achieve academic success and preserve their mental health. In the developed countries, attempts have been made to tackle the problem at an earlier stage by undertaking prevention in the form of health promotion programs. These have been shown to reduce the effects of stress on medical student's health and academic performance.[4] In India, there is a paucity of literature in this area. Given the importance of stress on medical and engineering students, the present study has been undertaken to understand the level of stress and anxiety along with the significant stress factors and how they affect their academic performance and also the coping mechanisms adopted by them.

MATERIALS AND METHODS

This prospective, longitudinal study was conducted on undergraduate medical and engineering students from September 2012 to September 2014. The study was conducted after ethical approval from the institutional ethics committee.

Sample

The sampling frame consisted of 200 students of a total of 365 students, from both medical and engineering colleges, by employing simple random sampling method. From the medical stream, 100 students, that includes 50 from each batch, of total 165 students in both 1^st and 2^nd MBBS were taken from Santhiram Medical College. Similarly, in engineering, 100 students, that includes 50 from each batch, of total of 200 students was taken from RGM Engineering College.

Inclusion criteria

1. 1^st and 2^nd year students of Medical and Engineering College

2. Both male and female sexes

3. Students who give voluntary consent

4. Students who are appearing for examination.

Exclusion criteria

1. Those who are not giving voluntary consent

2. Those that are already on psychiatric interventions.

Tools used in the study

General information sheet

A semi-structured schedule to collect sociodemographic information, socioeconomic class by Revised Prasad's classification[8] (Sharma 2013), and relevant clinical information (physical illness and mental illness).

Perceived Stress Scale (PSS-14)

This 14-item scale is widely used tool for measuring the degree to which situations in one's life are appraised as stressful. The scores range from 0 to 56, with the higher scores indicating higher levels of perceived stress. The scale has Cronbach's α coefficient of 0.85 and a test–retest reliability of 0.85.[9]

Hamilton Anxiety Rating Scale

The 14-item Hamilton Anxiety Rating Scale is widely used in both clinical and research settings. It has acceptable inter-rater reliability. The total score ranges from 0 to 56, where <17 indicates mild severity, 18–24 mild to moderate severity, 25–30 moderate to severe, and >30 very severe.[10]

Brief COPE inventory

This 28-item scale is used to assess a broad range of coping behaviors among adults. Each item is rated on a 4-point Likert scale; higher the score greater is the coping. The items were scored to produce 14 dimensions, each reflecting the use of a coping strategy. The Cronbach's alpha values range 0.50–0.90, with only 3 coping strategies falling below 0.60.[11]

Sources of stress questionnaire were designed after a detailed interview with a few of medical and engineering students, to find their source of stress. It has four parts:

1. Academic factors: frequent examinations, more assignments, patient care responsibilities

2. Physical factors: inadequate hostel facilities, environmental factors, and insomnia

3. Social factors: interpersonal relations problem, language barrier, financial problems

4. Others: career insecurity, professional identity, discrimination.

Each source of stress that a particular number of people felt was calculated in the form of percentage in both medical and engineering streams.[1]

Methods

All the participating students were informed about the objectives of the study, assured of full confidentiality, and written informed consent was obtained. Each batch of students was handed over a self-administered questionnaire 1 month before their university examinations. The same questionnaire was filled again by the same students, 1 month following their university examination.

Statistical analysis

Data thus obtained were analyzed with SPSS version 17 (IBM, USA). using t-test, Mann–Whitney U-test, Kruskal–Wallis test, and Chi-square test as appropriate.

RESULTS

The demographic characteristics of 200 students included in the study are given in Table 1. Perceived stress was significantly higher in 1^st MBBS students living in shared accommodation, from nuclear family, while in 2^nd year medical students, there was a significant association of male gender with stress. In both 1^st and 2^nd year medical students, perceived stress was significantly higher in those in management quota. Only accommodation has a statistically significant relationship with stress in 2^nd year engineering students [Table 2]. A statistically significant relationship between anxiety and category of seat, accommodation, and the type of family was present in 1^st year medical students, but with only age and category of seat in the 2^nd year medical students [Table 3]. Anxiety was not associated with demographic factors in engineering students [Table 4]. The sources of stress reported by the students are given in Table 5. Comparison of pre- and post-examination perceived stress in medical and engineering students revealed a statistically significant difference in 1^st year medical students [Table 6]. Perceived stress was significantly associated with academic performance in all the batches [Table 7]. The distribution of anxiety in the students is shown in Table 8. The association of anxiety with academic performance is statistically significant in all the batches [Table 9]. Pre- and post-examination coping strategies in 1^st and 2^nd year medical and engineering and their association with academic performance are given in Tables 10 and 11, respectively. All the coping states are statistically significantly associated with academic performance.

Table 1.

Sociodemographic profile of medical and engineering students

Variable	Medical		Engineering		Total, n (%)
	1st year, n (%)	2nd year, n (%)	1st year, n (%)	2nd year, n (%)
Age (years)
16-18	24 (48)	47 (94)	25 (50)	3 (6)	99 (49.5)
19-21	26 (52)	0	25 (50)	47 (94)	98 (49)
22-24	0	3 (6)	0	0	3 (1.5)
Gender
Male	26 (52)	21 (42)	14 (28)	18 (36)	79 (39.5)
Female	24 (48)	29 (58)	24 (48)	32 (64)	121 (60.5)
Category of seat
Free	22 (44)	27 (54)	38 (76)	30 (60)	117 (58.5)
Payment	4 (8)	13 (26)	0	7 (14)	24 (12)
Management	24 (48)	10 (20)	12 (24)	13 (26)	59 (29.5)
SES
I	0	2 (4)	0	0	2 (1)
II	2 (4)	2 (4)	4 (8)	0	8 (4)
III	22 (44)	24 (48)	11 (22)	8 (16)	65 (32.5)
IV	26 (52)	22 (44)	31 (62)	40 (80)	119 (59.5)
V	0	0	4 (8)	2 (4)	6 (3)
Accommodation
Dayscholar	8 (16)	0	44 (88)	45 (90)	97 (48.5)
Hosteller	42 (84)	50 (100)	6 (12)	5 (10)	103 (51.5)
Type of accommodation
Single	6 (12)	5 (10)	37 (74)	9 (18)	57 (28.5)
Sharing	44 (88)	45 (90)	13 (26)	41 (82)	143 (71.5)
Type of family
Joint	4 (8)	12 (24)	6 (12)	5 (10)	27 (13.5)
Nuclear	46 (92)	38 (76)	44 (88)	45 (90)	173 (86.5)

SES – Socioeconomic status

Table 2.

Association of perceived stress with demographic variables in 1^st and 2^nd year medical and engineering students

Variables	Medicine 1st year		Medicine 2nd year		Engineering 1st year		Engineering 2nd year
	MR	Z-ratioa (P)	MR	Z-ratioa (P)	MR	Z-ratioa (P)	MR	Z-ratioa (P)
Age (years)
16-18	21.58	−1.831 (0.06)	-	−0.596 (0.55)	25.52	−0.010 (0.99)	37.83	−1.516 (0.129)
19-21	29.12		25.81		25.48		24.71
22-24	-		20.67		-		-
Gender
Male	26.81	−0.662 (0.50)	31.29	−2.402 (0.01*)	23.93	−0.477 (0.633)	23.97	−0.558 (0.577)
Female	24.08		21.31		26.11		26.36
Accommodation
Dayscholar	28.75	−0.690 (0.490)	21.10	−1.073 (0.28)	25.02	−0.629 (0.529)	24.11	−2.028 (0.043*)
Hosteller	24.88		26.60		29.00		38.00
Type of accommodation
Single	12.17	−2.396 (0.01*)	31.10	−0.911 (0.363)	26.65	−0.944 (0.345)	28.50	−0.684 (0.494)
Sharing	27.32		24.88		22.23		24.84
Type of family
Nuclear	45.50	−2.870 (0.00*)	28.17	−0.731 (0.465)	23.17	−0.420 (0.675)	35.00	−1.865 (0.062)
Joint	23.76		24.66		25.82		23.95
Category of seat
Free	20.23	15.050 (0.00*)	24.85	5.291 (0.07*)	23.82	2.129 (0.145)	24.40	0.729 (0.695)
Payment	8.50		20.23		-		29.57
Management	33.17		34.10		30.83		25.85
Economic status
I	-	2.473 (0.290)	23.75	2.124 (0.547)	25.50	0.085 (0.994)	-	1.802 (0.406)
II	2		31.00		25.45		25.81
III	22		28.08		25.26		26.11
IV	26		22.34		27.50		12.00
V	-		-		-		-

*Significant. ^aMann–Whitney U-test except caregory of seat and economic status with Kruskal–Wallis test. MR – Mean rank

Table 3.

Relationship of demographic variables with anxiety in 1^st and 2^nd year medical students

Variables	HAS scores medicine 1st year						HAS score medicine 2nd year
	<17, n (%)	18-24, n (%)	25-30, n (%)	>30, n (%)	Total, n (%)	χ2, P	<17, n (%)	18-24, n (%)	25-30, n (%)	>30, n (%)	Total, n (%)	χ2, P
Age (years)
16-18	14 (53.3)	8 (33.3)	0	2 (8.3)	24 (100)	5.929, 0.11	0	0	0	0	0	16.35, 0.00
19-21	14 (53.3)	8 (30.8)	4 (15.4)	0	26 (100)		37 (78.7)	10 (21.3)	0	0	47 (100)
22-24	0	0	0	0	0 (100)		2 (66.7)	0	0	1 (33.3)	3 (100)
Gender
Male	14 (53.8)	6 (23.1)	4 (15.4)	2 (7.7)	26 (100)	6.931, 0.07	16 (76.2)	4 (19)	0	1 (4.8)	21 (100)	1.413, 0.493
Female	14 (53.8)	10 (41.7)	0	0	24 (100)		23 (79.3)	6 (20.7)	0	0	29 (100)
Category of seat
Free	14 (63.6)	6 (27.3)	2 (9.1)	0	22 (100)	3.504, 0.743	21 (77.8)	6 (22.2)	0	0	27 (100)	10.479, 0.03
Payment	2 (50)	2 (50)	0	0	4 (100)		13 () 100	0	0	0	13 (100)
Management	12 (50)	8 (33.3)	2 (8.3)	2 (8.3)	24 (100)		5 () 50	4 (40)	0	1 (10)	10 (100)
SES
Class II	0	0	0	2 (100)	2 (100)	55.49, 0.00 (S)	2 (100)	0	0	0	2 (100)	2.929, 0.818
Class III	12 (54.5)	10 (45.5)	0	0	22 (100)		2 (100)	0	0	0	2 (100)
Class IV	16 (61.5)	6 (23.1)	4 (15.4)	0	26 (100)		19 (79.2)	4 (16.7)	0	1 (4.2)	24 (100)
Class V	0	0	0	0	0 (100)		16 (72.7)	6 (27.3)	0	0	22 (100)
Accommodation
Dayscholar	6 (75)	0	2 (25)	0	8 (100)	7.483, 0.05	9 (90)	1 (10)	0	0	10 (100)	1.106, 0.575
Hosteller	22 (52.4)	16 (38.1)	2 (4.8)	2 (48)	42 (100)		30 (75)	9 (22.5)	0	1 (2.5)	40 (100)
Type of accommodation
Single	6 (100)	0	0	0	6 (100)	5.357, 0.147	3 (60)	2 (40)	0	0	5 (100)	1.453, 0.484
Sharing	22 (50)	16 (36.4)	4 (9.1)	2 (4.5)	44 (100)		36 (80)	8 (17.8)	0	1 (2.2)	45 (100)
Type of family
Joint	0	2 (50)	2 (50)	0	4 (100)	12.63, 0.00	10 (83.3)	2 (16.7)	0	0	12 (100)	0.461, 0.794
Nuclear	28 (60.9)	14 (30.4)	2 (4.3)	2 (4.3)	46 (100)		29 (76.3)	8 (21.1)	0	1 (26)	38 (100)

SES – Socioeconomic status; S – Significant; HAS – Hamilton Anxiety Scale

Table 4.

Association of anxiety with demographic variables in 1^st and 2^nd year engineering students

Variables	HAS score engineering 1st year						HAS score engineering 2nd year
	<17, n (%)	18-24, n (%)	25-30, n (%)	>30, n (%)	Total, n (%)	χ2, P	<17, n (%)	18-24, n (%)	25-30, n (%)	>30, n (%)	Total, n (%)	χ2, P
Age (years)
16-18	18 (72)	5 (20)	0	2 (80)	25 (100)	2.473, 0.290	1 (33.3)	0	2 (66.7)	0	3 (100)	9.400, 0.024
19-21	13 (52)	10 (40)	0	2 (8)	25 (100)		22 (46.8)	20 (42.6)	4 (8.5)	1 (2.1)	47 (100)
22-24	0	0	0	0	0		0	0	0	0	0
Gender
Male	3 (21.4)	7 (50)	0	4 (28.6)	14 (100)	18.041, 0.000	12 (66.7)	4 (22.2)	2 (11.1)	0	18 (100)	5.415, 0.144
Female	28 (77.8)	8 (22.2)	0	2 (2)	36 (100)		11 (34.4)	16 (50)	4 (12.5)	1 (3.1)	32 (100)
Category of seat
Free	30 (78.9)	6 (15.8)	0	2 (5.3)	38 (100)	19.475, 0.000	10 (33.3)	15 (50)	4 (13.3)	1 (3.3)	30 (100)	6.297, 0.391
Payment	0	0	0	0	0		5 (71.4)	2 (28.6)	0	0	7 (100)
Management	1 (8.3)	9 (75)	0	2 (16.7)	12 (100)		8 (61.5)	3 (23.1)	2 (15.4)	0	13 (100)
SES
Class I	0	0	0	0	0	13.62, 0.03	0	0	0	0	0	4.152, 0.656
Class II	2 (50)	0	0	2 (50)	4 (100)		0	0	0	0	0
Class III	9 (81.8)	2 (18.2)	0	0	11 (100)		5 (62.5)	2 (25)	1 (12.5)	0	8 (100)
Class IV	18 (58.1)	11 (35.5)	0	2 (6.5)	31 (100)		18 (45)	16 (40)	5 (12.5)	1 (2.5)	40 (100)
Class V	2 (50)	2 (50)	0	0	4 (100)		0	2 (100)	0	0	2 (100)
Accommodation
Dayscholar	29 (65.9)	13 (29.5)	0	2 (4.5)	44 (100)	6.399, 0.04	23 (51.1)	16 (35.6)	6 (13.3)	0	45 (100)	14.44, 0.00
Hosteller	2 (33.3)	2 (33.3)	0	2 (33.3)	6 (100)		0	4 (80)	0	1 (20)	5 (100)
Type of accommodation
Single	25 (67.6)	12 (32.4)	0	0	37 (100)	12.377, 0.00	5 (55.6)	2 (22.2)	2 (22.2)	0	9 (100)	2.260, 0.520
Sharing	6 (46.2)	3 (23.1)	0	4 (30.8)	13 (100)		18 (43.9)	18 (43.9)	4 (9.8)	1 (2.4)	41 (100)
Type of family
Joint	4 (66.7)	2 (33.3)	0	0	6 (100)	0.595, 0.743	5 (71.4)	0	2 (28.6)	0	7 (100)	6.425, 0.09
Nuclear	27 (61.4)	13 (29.5)	0	4 (9.1)	44 (100)		18 (41.9)	20 (46.5)	4 (9.3)	1 (2.3)	43 (100)

SES – Socioeconomic status; HAS – Hamilton Anxiety Scale

Table 5.

Distribution of Sources of stress in medical and engineering students

	Source of stress	Medical	Total	Engineering	Total	Significance
Academic factors	Frequent examinations	41	69	44	71	Fisher’s exact test P=0.014 (S)
	More assignments	21		27
	Patient care responsibilities	7		NA
Physical factors	Inadequate hostel facilities	2	55	7	74	χ 2=4.03 P=0.133 (NS)
	Environmental factors	32		31
	Insomnia	21		36
Social factors	Interpersonal relation problems	45	68	34	69	χ 2=5.30 P=0.705 (NS)
	Language barrier	16		19
	Financial problems	7		16
Other factors	Career insecurity	3	7	7	10	Fisher’s exact test P=0.715 (NS)
	Professional identity	2		1
	Discrimination	1		1
	Miscellaneous	1		1

S – Significant; NS – Not significant

Table 6.

Distribution of pre- and post-examination perceived stress in medical and engineering students

Course	Mean (SD)		P
	Preexamination perceived stress scale score	Postexamination perceived stress scale score
Medical - 1st year	26.16 (7.68)	22.48 (6.23)	0.001 (SS)
Medical - 2nd year	23.68 (6.55)	23.76 (6.63)	0.923 (NS)
Engineering - 1st year	25.04 (5.27)	25.14 (4.26)	0.915 (NS)
Engineering - 2nd year	24.50 (5.57)	25.24 (4.87)	0.470 (NS)

SS – Statistically significant; NS – Not significant; SD – Standard deviation

Table 7.

Association of perceived stress with academic performance in 1^st and 2^nd year medical and engineering students

Course	Evaluation	Mean (SD)	t	P
Medicine 1st year	PSS	26.16 (7.68)	31.55	<0.0001
	Academic performance	65.68 (4.41)
Medicine 2nd year	PSS	23.68 (6.54)	33.59	<0.0001
	Academic performance	63.56 (5.26)
Engineering 1st year	PSS	25.04 (5.27)	34.22	<0.0001
	Academic performance	68.70 (7.32)
Engineering 2nd year	PSS	24.50 (5.57)	28.21	<0.0001
	Academic performance	66.50 (8.93)

SD – Standard deviation

Table 8.

Distribution of anxiety in 1^st and 2^nd year medical and engineering students before and after examination

HAS	Mild, n (%)	Moderate, n (%)	Severe, n (%)	Very severe, n (%)
Medical - 1st year preexamination	28 (56)	16 (32)	4 (8)	2 (4)
Medical - 1st year post examination	40 (80)	10 (20)	0	0
Medical - 2nd year preexamination	39 (78)	10 (20)	0	1 (2)
Medical - 2nd year postexamination	39 (78)	10 (20)	0	1 (2)
Engineering - 1st year preexamination	31 (62)	15 (30)	0	4 (8)
Engineering - 1st year postexamination	31 (62)	8 (16)	9 (18)	2 (4)
Engineering - 2nd year preexamination	23 (46)	20 (40)	6 (12)	1 (2)
Engineering - 2nd year postexamination	28 (56)	12 (24)	6 (12)	4 (8)

HAS – Hamilton Anxiety Scale

Table 9.

Association of anxiety with academic performance in 1^st and 2^nd year medical and engineering students

Course	HAS score	Academic performance based on marks secured in exams, n (%)			Total, n (%)	P
		40-60	61-80	>80
Medicine 1st year	<17	0	28 (100)	0	28 (100)	0.03 (SS)
	18-24	2 (12.5)	14 (87.5)	0	16 (100)
	25-30	2 (50)	2 (50)	0	4 (100)
	>30	0	2 (100)	0	2 (100)
Medicine 2nd year	<17	4 (10.3)	35 (89.7)	0	39 (100)	0.00 (SS)
	18-24	8 (80)	2 (20)	0	10 (100)
	25-30	0	0	0	0
	>30	1 (100)	0	0	1 (100)
Engineering 1st year	<17	0	29 (93.5)	2 (6.5)	31 (100)	0.00 (SS)
	18-24	5 (33.3)	10 (66.7)	0	15 (100)
	25-30	0	0	0	0
	>30	0	4 (100)	0	4 (100)
Engineering 2nd year	<17	3 (13)	19 (82.6)	1 (4.3)	23 (100)	0.38 (NS)
	18-24	7 (35)	13 (65)	0	20 (100)
	25-30	0	6 (100)	0	6 (100)
	>30	0	1 (100)	0	1 (100)

SS – Statistically significant; NS – Not significant

Table 10.

Pre- and post-examination coping strategies in 1^st and 2^nd year medical and engineering students

Coping	Medical 1st year, mean (SD)			Medical 2nd year, mean (SD)			Engineering 1st year, mean (SD)			Engineering 2nd year, mean (SD)
	Pre	Post	t, P	Pre	Post	t, P	Pre	Post	t, P	Pre	Post	t, P
Self-distraction	4.77 (1.68)	4.93 (1.50)	0.65, 0.514	4.62 (1.06)	4.26 (1.33)	1.38, 0.17	5.02 (1.51)	4.22 (1.26)	2.82, 0.00 S	4.98 (1.07)	4.60 (1.30)	1.664, 0.10
Active coping	5.7 (1.50)	5.55 (1.45)	1.34, 0.185	4.94 (1.20)	5.16 (1.34)	0.98, 0.33	5.06 (1.70)	5.38 (1.24)	1.21, 0.22	6.00 (1.44)	5.82 (1.61)	0.560, 0.57
Denial	4.48 (1.86)	4.81 (1.53)	1.19, 0.237	3.94 (1.44)	3.94 (1.46)	0.00, 1.00	3.24 (1.27)	3.98 (1.31)	4.26, 0.00 (S)	4.10 (1.19)	4.20 (1.44)	0.415, 0.68
Substance use	2.97 (1.73)	4.61 (1.49)	5.11, 0.00 (S)	2.56 (0.97)	2.14 (0.49)	2.72, 0.00 (S)	2.54 (1.14)	2.36 (1.12)	1.70, 0.09	2.060 (0.61)	2.24 (0.89)	1.102, 0.27
Emotional support	4.93 (1.58)	4.87 (1.58)	0.24, 0.810	4.74 (1.57)	4.76 (1.27)	0.06, 0.94	5.56 (1.73)	4.44 (1.24)	4.07, 0.00 (S)	5.00 (1.44)	4.48 (1.38)	2.156, 0.03 (S)
Instrumental support	4.81 (1.88)	4.530 (1.93)	0.96, 0.339	4.94 (1.42)	4.80 (1.32)	0.65, 0.51	5.42 (1.59)	4.56 (1.57)	3.40, 0.00 (S)	5.18 (1.39)	4.96 (1.53)	1.278, 0.20
Behavioral disengagement	4.28 (1.87)	4.36 (1.53)	0.32, 0.746	3.84 (1.36)	3.74 (1.12)	0.42, 0.67	3.62 (1.22)	3.88 (1.09)	1.21, 0.22	4.20 (1.30)	4.56 (1.48)	1.487, 0.14
Venting	4.40 (1.54)	5.48 (1.45)	3.75, 0.00 (S)	4.76 (1.13)	4.34 (1.31)	1.82, 0.07	4.14 (1.97)	4.42 (1.69)	0.85, 0.39	4.48 (1.24)	3.76 (1.17)	3.982, 0.00 S
Positive reframing	5.12 (1.62)	4.75 (1.46)	1.86, 0.069	4.90 (1.51)	4.64 (1.77)	0.79, 0.43	4.86 (1.56)	5.38 (1.66)	2.18, 0.03 (S)	5.48 (1.51)	6.14 (1.39)	2.622, 0.01 (S)
Planning	5.26 (1.87)	4.81 (1.66)	2.22, 0.03 (S)	5.14 (1.45)	4.78 (1.50)	1.085, 0.28	5.16 (1.40)	5.24 (1.50)	0.34, 0.73	5.26 (1.33)	5.50 (1.58)	0.960, 0.34
Humor	3.71 (1.83)	4.28 (2.07)	1.85, 0.070	4.04 (1.66)	3.52 (1.14)	1.93, 0.05 (S)	3.90 (1.72)	3.68 (1.43)	0.85, 0.39	4.60 (1.30)	4.62 (1.38)	0.085, 0.93
Acceptance	5.71 (1.80)	4.63 (1.57)	3.89, 0.00 (S)	5.52 (1.63)	4.52 (1.43)	3.59, 0.00 (S)	4.10 (1.96)	5.02 (1.65)	2.92, 0.00 (S)	5.28 (1.62)	5.38 (1.67)	0.386, 0.70
Religion	4.16 (1.37)	4.28 (1.39)	0.64, 0.523	4.44 (1.59)	4.18 (1.71)	0.83, 0.41	4.78 (1.48)	4.76 (1.33)	0.07, 0.94	5.32 (1.92)	5.28 (1.77)	0.191, 0.85
Self-blame	4.71 (2.08)	4.75 (2.00)	0.15, 0.881	4.18 (1.69)	3.92 (1.41)	0.92, 0.36	3.88 (1.64)	3.48 (1.31)	1.31, 0.19	4.62 (1.44)	4.08 (1.45)	2.001, 0.05 (S)

S – Significant; SD – Standard deviation

Table 11.

Association of coping and academic performance in 1^st and 2^nd year medical and engineering students

Coping	n	Medical 1st year		Medical 2nd year		Engineering 1st year		Engineering 2nd year
		Mean (SD)	t, P	Mean (SD)	t, P	Mean (SD)	t, P	Mean (SD)	t, P
Self-distraction	50	4.74 (1.68)	91.24, <0.0001	4.94 (1.20)	76.82, <0.0001	5.02 (1.51)	60.24, <0.0001	4.98 (1.07)	48.36, <0.0001
Active coping	50	5.76 (1.51)	90.89, <0.0001	3.94 (1.44)	77.30, <0.0001	5.06 (1.70)	59.88, <0.0001	6.00 (1.44)	47.29, <0.0001
Denial	50	4.52 (1.85)	90.43, <0.0001	2.56 (0.97)	80.64, <0.0001	3.24 (1.27)	62.30, <0.0001	4.10 (1.19)	48.97, <0.0001
Substance use	50	2.96 (1.72)	93.69, <0.0001	4.74 (1.57)	75.76, <0.0001	2.54 (1.14)	63.14, <0.0001	2.06 (0.61)	50.90, <0.0001
Emotional support	50	4.96 (1.57)	91.72, <0.0001	4.94 (1.42)	76.07, <0.0001	5.56 (1.73)	59.35, <0.0001	5.00 (1.44)	48.07, <0.0001
Instrumental support	50	4.80 (1.87)	89.87, <0.0001	3.84 (1.36)	71.21, <0.0001	5.42 (1.59)	59.73, <0.0001	5.18 (1.39)	47.97, <0.0001
Behavioral disengagement	50	4.36 (1.92)	90.14, <0.0001	4.76 (1.13)	77.28, <0.0001	3.62 (1.22)	62.01, <0.0001	4.20 (1.30)	48.81, <0.0001
Venting	50	4.38 (1.53)	92.88, <0.0001	4.90 (1.51)	75.79, <0.0001	4.14 (1.97)	60.22, <0.0001	4.48 (1.24)	48.64, <0.0001
Positive reframing	50	5.16 (1.63)	91.02, <0.0001	5.14 (1.45)	75.71, <0.0001	4.86 (1.56)	60.31, <0.0001	5.48 (1.51)	47.64, <0.0001
Planning	50	5.28 (1.86)	89.23, <0.0001	4.04 (1.66)	76.30, <0.0001	5.16 (1.40)	60.28, <0.0001	5.26 (1.33)	47.96, <0.0001
Humor	50	3.68 (1.83)	91.82, <0.0001	5.52 (1.63)	74.52, <0.0001	3.90 (1.72)	60.93, <0.0001	4.60 (1.30)	48.50, <0.0001
Acceptance	50	5.74 (1.79)	89.05, <0.0001	4.44 (1.59)	76.07, <0.0001	4.10 (1.96)	60.27, <0.0001	5.28 (1.62)	47.69, <0.0001
Religion	50	4.16 (1.36)	94.26, <0.0001	4.18 (1.69)	75.99, <0.0001	4.78 (1.48)	60.52, <0.0001	5.32 (1.92)	47.36, <0.0001
Self-blame	50	4.70 (2.06)	88.58, <0.0001	4.18 (1.69)	75.99, <0.0001	3.88 (1.64)	61.10, <0.0001	4.62 (1.44)	48.37, <0.0001

SD – Standard deviation

DISCUSSION

In the present study, the age of the students ranged from 16 to 24 years, and age was significantly associated with perceived stress and anxiety. In an earlier study on medical students, the mean age of the individuals was 21.3 years.[12] As the previous study was conducted on all students of the medical college, the mean age of 1^st and 2^nd year students in their study would probably be close to our study. Stress and anxiety was more in the 1^st and 2^nd year students. The reason cited was complexity and exorbitant material to be learned, in 1^st year students. Fatigue is often cited as a stressor at the end of 1^st year and all through 2^nd year.[12] In another comparative study, the medical students were <20 years of age indicating that most of them may have been in 1^st or 2^nd year of their course, while engineering students age ranged from 20 to 25 years, probably it included the students of all the years. However, stress levels were almost equal in both medical and engineering students, suggesting that stress occurs irrespective of the age factor.[6] Similarly, in another study, with an equal representation of students from all the years, mean age was 20.36 years. The association of age with stress and anxiety was statistically not significant.[13]

Gender and its association with stress and anxiety

The number of females in the present study was 57.8% in the medical stream and 35.4% in the engineering stream. The reduction of the gender gap was because of changing social perceptions and societal beliefs regarding gender roles, due to which females are becoming emotionally equally competent.[5] The association of male gender with stress and anxiety was statistically significant only in 2^nd year medical students. One earlier study reported that girls have higher level of stress than their male colleagues[8] while few other studies reported no significant gender differences in anxiety.[5,14]

Association of stress and anxiety to the socioeconomic status

Association of socioeconomic status (SES) with stress and anxiety was statistically significant. In contrast to our study, an earlier study observed that financial problems, were among the least source of stressors.[1] According to certain studies, parents' SES has a direct influence on their children's internalizing disorders such as anxiety though other reported no association or mixed results.[15]

Role of accommodation in causing stress and anxiety

Stress was associated with living in shared accommodation in 1^st MBBS and staying in hostels in 2^nd year engineering students. In agreement with the above, a study on stress in professional college students revealed that living in hostel was a major stressor (odds ratio 2.28, 95% confidence interval 1.12–10).[1] A study in UG medical students in Malaysia, also found a significant association between stress and accommodation.[16] Psychosocial factors such as “quality of food in mess,” “lack of entertainment,” “feeling of loneliness” were the factors linked to staying in hostels that played an important role in causing stress.[17]

Distribution of stress and anxiety according to the type of family

The association of type of family with stress and anxiety was found to be statistically significant in our study. This is in agreement with an earlier study which found that stress level was more in case of nuclear families, as joint families offered emotional and financial stability.[18]

Sources of stress in medical and engineering college students

Academic stressors were a little less in medical students when compared to engineering stream, probably because of frequency of examinations which is less when compared to engineering stream [Table 5]. The increased frequency of examinations, especially in the newly entered students, cause increased stress and anxiety, as it does not give enough time for students to adjust themselves to the changes in curriculum, environment, physiological changes, and the transition period from adolescent to early adulthood. In convergence with our findings, a study among UG students in Nepal, found that vastness of academic curriculum/syllabus, frequency of examinations, quality of food in mess, worries about the future, and high parental expectations were rated as most severe sources of stress.[17] In contrast to our study, a study on medical students in Malaysia, reported that important sources of stress were worries of the future (71%), financial difficulties (68.6%), study in general (64.6%), hearing bad news (58.5%), and interpersonal conflicts (54.3%). The least was trouble with faculty (22.6%).[3] On the other hand, poor communication skills by faculty, careless marking by them, and added responsibilities in the family cause stress and anxiety in engineering students.[19]

Perceived stress levels, preexamination and postexamination in medical and engineering students

Among the medical 1^st year students, preexamination stress was significantly higher than the postexamination stress. The reasons for increased stress could be due to exposure to a new environment that is totally different from the protected environment at home or residential junior colleges. The unbridled freedom that they get, after being under the watchful eye of their parents and teachers until then, would sometimes lead to forming of new habits that would be detrimental in the long run and cause undue stress in many aspects. Forming of new relationships with colleagues and faculty and attempting to establish a rapport with them causes added stress to them.

A new academic curriculum that has enormous syllabus, demands a change in their study style and needs adequate adjustments to be made, which, if not taken care of would cause immense burden on the minds of the students. There is also that additional factor of personal competence. There are also other factors such as financial burden, accommodation in hostels/outside stay, ragging in colleges, and lack of proper infrastructure in the private colleges.

In making adjustments to the above factors, almost a little more than half-year is spent and very little time was left for preparation. Apart from this, the added stress of losing a year and falling back causes immense stress on the students during the examinations. In accordance to our study, earlier studies also found that stress was higher in 1^st year medical students when compared to 2^nd year. The reasons cited were problems with adjustment and students' perception of academic overload.[17,20,21] However, one study found that stress was more significant in 2^nd and 3^rd year levels.[22] Coming to the preexamination stress levels, in contrast to our study, a previous study found the mean stress levels of preexamination and postexamination in 1^st year medical students to be 2.41 and 4.39, respectively.[23] Probably, the fear of failure and falling back are reasons for increased stress post examination and also new exposure to the clinical postings.

In the engineering 1^st year, pre-and post-examination stress score were not significantly different. In contrast to our findings, another study found that 1^st year engineering students have more academic load which in turn leads to increased examination stress.[24]

Distribution of perceived stress within groups and between groups

To obtain the association of stress levels within the group, i.e., students of both batches belonging to a same course and between the group, i.e., medical and engineering courses, the scores of all the batches preexamination and post examination were analyzed using the two-way ANOVA test. The association was not statistically significant. The probable reason could be that with drastic changes in lifestyle and diminishing of the cultural values, students appear to be under constant pressure irrespective of the situations and circumstances, and therefore, the stress levels do not vary much. Another reason could be that with the advancing technology, there are applications (apps) developed for educational purposes that help the students to grasp more information in lesser time. Internet usage effectively using search engines helps the students with instant information and thus saves much time taken to refer to books. All these factors play a role in reducing stress in students, especially during examination times. On the other hand, an earlier study on differences in perceived stress in professional college students reported that medical curriculum was slightly more stressful than engineering. The mean perceived stress scale scores of medical and engineering are 27.0 and 26.6, respectively.[1]

Perceived stress and academic performance

The association of perceived stress and academic performance was found to be statistically significant, implying that greater the stress, lower was the performance. The probable reason could be that impaired concentration, difficulty in retrieval of the learned information, slowing of the cognitive processes, and other psychological and physiological changes reduce the performance levels in examinations and thus reduce academic performance. The above findings are supported by few studies on stress and academic performance.[25,26] Although stress has a negative impact on academic performance, it is poorly related.[27] In contrast to the above findings, few studies conducted in medical students reported that higher the stress, better was the academic performance. The reason cited by them was that many students felt that more stress motivated them to perform better.[16,28]

Interestingly, in a study conducted on 1^st year medical college students, it was reported that male students' cumulative grades and stress were found to be inversely correlated. This finding can be explained on the basis of the fact that higher stress impairs the performance which is due to the deterioration of higher cognitive functions, for example, impaired concentration, poor retention and poor recall, startle response, and mental fatigue.[29] In contrast to this finding, in our study, it was observed that in female students, increasing amount of stress had a beneficial effect on cumulative grade points. An explanation for this contrary finding in female students can be based on the phenomenon of “eustress” wherein stress motivates an individual to move to action to get things accomplished and is in agreement with a recent study where stress was associated with improved performance.[30]

Anxiety in students of medical and engineering colleges

This study reveals that 1^st year medical students had increased preexamination anxiety but not in 2^nd year. The probable reason in increased anxiety preexamination in 1^st year students was the fear of failure and losing 6 months, that makes them to be separated from the main batch for the rest of the study period. Most of the students being in the adolescent age have greater adjustment problems with their environment, apart from the extensive syllabus and complexity of the subjects like anatomy, that cause lot of concern to the students. With many implications attached to the success in examinations, students feel more anxious before examinations.

An earlier study on medical students reported that the prevalence of examination anxiety in 1^st year was 73.46%, while in 2^nd year students, it was 54.90%. The factors contributing to examination-related anxiety were inadequate rest, irrational thoughts largely based on the examination-related stories narrated by senior students, extensive course load, long duration of examinations, and inadequate preparation.[31] In addition to the above factors, female gender appeared more vulnerable to stress and anxiety. The reason cited by them was that girls are more likely to be afraid of failure; males are more defensive about admitting anxiety as it may be a threat to their perceived masculinity; and females have a tendency to overreport their problems.[32] However, another study found no significant relationship of anxiety with gender.[33]

In the 2^nd MBBS medical students gradually acclimatize to the curriculum and stress levels so that the preexamination anxiety would be less. Moreover, students have enough time to adjust and learn the subjects as 2nd MBBS has a duration of 1½ years. Moreover, students learn much in their clinical postings, if they regularly attend and actively participate in case discussion. The role of attendance was confirmed by another study on stress and academic performance.[29] In line with our study, another study on patterns of anxiety in medical students, revealed that symptoms of anxiety do exist in students but as they gain more experience and familiarity with the routines and schedules, this apprehension and anxiety greatly reduces.[34]

In case of engineering stream, an interesting finding in this study was that preexamination anxiety levels in 2^nd year engineering were highest among all the batches. On interviewing engineering students, it was found that they needed minimum credit points to get promoted to the next year. These credit points were taken into account at the end of 2^nd year, wherein failure to earn adequate credit points would mean losing 6 months and falling back from the main batch. This could be one of the reasons that might lead to high anxiety in these students, and the role of parental pressures could not be downplayed. This system allows the students to be promoted to the 2^nd year inspite of failing in all the subjects in 1^st year, which could be the reason for lesser preexamination anxiety than 2^nd year students. Till date, minimal number of studies was done on the examination anxiety in engineering students, especially 1^st and 2^nd year separately. Therefore, it opens new areas of research so that better methods of overcoming the stress and anxiety could be advised to the students.

Role of anxiety with respect to academic performance

Examination anxiety is the emotional reaction that some students face before examinations is termed as “exam anxiety” and is a major problem faced by students of all age and field of education. Although the fear is rational, it is excessive and interferes with academic performance. While a little worry is helpful to keep students task oriented, excessive worry, unless managed appropriately, is detrimental to academic performance.

In the present study, the association of anxiety levels and academic performance was statistically significant except in engineering 2^nd year. Therefore, a negative relationship was found, wherein increased anxiety caused decreased performance. The probable reason could be increased anxiety affects the speed of cognitive processing, process of registration, and retrieval during the examination time. There is also impaired concentration and difficulty in reading for long number of hours. These factors lead to frustration, loss of confidence in self, and the inability to handle the situation. In addition, these mal- adaptive coping strategies in turn causes increased stress and anxiety. Other factors include lack of a proper study habit, faulty reading techniques, inability to recognize the salient points and retain them.

The findings in our study were convergent with few earlier studies which revealed a significant negative correlation between anxiety and academic achievement. The reasons cited were that students under anxiety are not able to recognize relevant information, are unable to integrate their knowledge into their long-term memory, do not possess the skills to self-evaluate their learning state and use faulty coping techniques. On the other hand, less anxious students sustain their focus throughout information processing and retrieval, and build up acceptable study habits. They stay on task and perform well in examinations because they have less disruptive thoughts and less cognitive breakdowns.[5,26,32,33] In contrast to our findings, few studies have reported that anxiety caused better performance in the students.[16,28]

Coping strategies in medical and engineering streams

Coping strategies are behavioral and psychological techniques utilized by persons to lessen, endure, or master stressful events. They are mainly of two types, i.e., active coping and avoidant coping. Active coping constitutes mainly four important strategies: active coping (making efforts to remove or circumvent the stressor), planning, acceptance, and positive reframing. Avoidant coping also constitutes four important strategies: denial, behavioral disengagement, venting, and humor.[35] In the present study, active coping strategies were used more than avoidant strategies by the students of medical and engineering streams which is in agreement with few earlier studies.[17,32,36] In the medical stream, strategies such as active coping, positive reframing, planning, and acceptance were used most frequently, while avoidant strategies like substance abuse was least used as a coping mechanism. Similar results were found in a Malaysian study on stress and coping in students, wherein the students used more active coping mechanisms, and substance abuse was used least of all the mechanisms.[3]

In contrast to this study, studies from U.K. have reported use of alcohol, tobacco, and drugs as common coping strategies adopted by medical students.[37] A study of stress, course work, and coping strategies in medical students revealed that most of the students in the study belonging to 1^st, 2^nd, 3^rd, 4^th year have used wishful thinking and problem-focused coping equally. However, wishful thinking or emotion-focused coping (wherein the students try to reduce the negative emotions associated with the stress) is used frequently by 1^st year students, while the problem focused coping (wherein the students tries to deal with the root cause of the problem) is used more by the final year students.[38]

Coping strategies and its role on academic performance

Almost all the coping strategies in all the batches have a statistically significant association with academic performance. Similarly, according to an earlier study, students used problem-solving strategies or active coping strategies for coping across time, situations, and contexts. The problem-solving strategy leads to attainment of higher level of academic achievement and success.[39] In contrast to the above, a study from China reported that that the association between coping strategies and academic performance is not significant.[40]

Limitations

The sample size in this study was modest and from a single center which could result in difficulty in generalization of certain parts of the study. The students with any psychiatric morbidity could not be properly evaluated to exclude them from the study. The cultural parameters were not considered while assessing gender-based differences in morbidity.

CONCLUSIONS

Academic factors, environmental factors, and interpersonal relationships seem to be highly stressful to the medical and engineering students. Perceived stress was significantly more in the preexamination time in only 1^st year medical students, but the prevalence of moderate and severe anxiety was more before examinations and reduced significantly post examination. There was a significant association of perceived stress and anxiety with academic performance. Both medical and engineering students used active coping a little more than avoidant coping strategies during the examination time. The association of all the coping strategies used with the academic performance was statistically significant, thereby proving the importance of coping states in academic performance.

Recommendations

Stress and anxiety are ubiquitous and seen in all ages and gender. However, the student community seems to be more affected by stress and anxiety due to a multitude of stressors. Therefore, it is imperative to understand the sources of stressors and deal with them effectively. In our study, we found that academic factors, environmental factors, and interpersonal relationships seem to be highly stressful to the students. Hence, dealing with these primarily could alleviate stress in the students and thereby improve their academic performance that could increase a student's confidence and help in making a better professional. To reduce academic pressures, students should be counseled regarding attending the classes regularly, daily reading along with adequate relaxation. They should be taught good reading techniques and better ways of improving their memory. Physical exercise should be actively promoted, as it helps in release of endorphins that naturally reduces stress and improves circulation to the brain. Efforts should be made to provide a student-friendly environment. If possible, students with frequent family conflicts should be advised to stay in hostels. Better coping strategies like active coping should be taught to the students during times of stress and educating them of the effects of avoidant coping techniques. Interpersonal relationships can be improved by teaching effective communication and social skills. The faculty should also be counseled about ways of effectively communicating with the students and should be taught about new learning techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.