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Research Article: Observational Study

Prevalence and correlates of university students’ perceived stress in southwestern Saudi Arabia

Alsaleem, Mohammed A. SBFMa; Alsaleem, Safar A. SBFMa; Shehri, Sarah Al MBBS, DESb; Awadalla, Nabil J. MDa,c; Mirdad, Tarek M. FRCSCb; Abbag, Fuad I. FRCP(c)d; Mahfouz, Ahmed A. Dr. PH (Epidem.)a,e,∗

Editor(s): Tusconi., Massimo

Author Information
doi: 10.1097/MD.0000000000027295
  • Open


1 Introduction

Stress is a state of inadequacy between our needs and our capability and offers of our environments and demands from us.[1] The university period could be stressful for most students. It may be due to exposure to various stressors. These include separation from family support, high personal expectations, time urgency, academic overload, examinations, competitions, attempting to achieve educational goals despite financial limitations, and lack of leisure time activities.[2]

The prevalence rate of high perceived stress varies widely between different universities due to differences in the magnitude of university environment stressors, tools used in measurement, and target colleges.[3,4] Students in health care colleges could be at a greater risk of stress than those in other colleges. This may be due to exposure to a higher load of academic, social, and financial stressors.[5,6]

An acceptable level of stress could be a motivation for productivity and good performance. However, a high level that exceeds the personal capability to cope could be harmful. It may negatively impact physical and psychological wellbeing.[2,7] Stress among university students may also be associated with risky behaviors, including smoking and drug abuse.[8] Furthermore, it is correlated with low academic achievement.[9]

The objectives of the present study were to establish the prevalence and factors associated with high perceived stress among university undergraduates in south-western Saudi Arabia.

2 Materials and methods

2.1 Study design

A cross-sectional survey was conducted among male and female students at King Khalid University (KKU) during the academic year 2017-2018.

2.2 Target population and study setting

Undergraduates in health and non-healthcare colleges in KKU were the target population for the present study. KKU is situated in the Aseer region in south-western Saudi Arabia. The seer region population amounted to more than 1.6 million persons. The university encompasses five healthcare colleges and 24 non-healthcare colleges. The total number of male and female students in the academic year 2014 to 2015 was 60,312.

2.3 Sample size and sampling method

The sample size was calculated using Epi Info program version 7.2. The calculation was based onan anticipated occurrence of high perceived stress among university undergraduates of 33.8%,[3] 95% confidence level, and an acceptable margin of error of 3%. The estimated sample size was 912 undergraduate students. To consider the possibility of non-response, 1100 undergraduates were targeted at each health and non-healthcare college.

All health care colleges in KKU were involved in the study; namely, colleges of dentistry, nursing, applied medical science, pharmacy, and medicine. Four non-healthcare colleges were chosen using a random method. They were colleges of languages and translation, science, administrative and financial sciences, and education. The students included in the study were selected using the stratified cluster random sampling technique. In each college, students were stratified by academic level. For each level, a cluster (study section group) was selected. All listed undergraduates in each set were involved in the survey whenever possible. Inclusion criteria were students present at the university campus during the survey. Exclusion criteria were those who were not willing to participate in the study.

2.4 Study measures

A self-administered questionnaire was disseminated personally between the participants by medical students as part of their community medicine course teaching. The questionnaire comprises the following elements: a) personal data such as age, sex, marital status, smoking status, and family income; b) academic data, which include academic level, name of college, and grade point average (GPA) score; c) the Arabic version of Cohen's Perceived Stress Scale (PSS)[10] which has been translated and validated by a previous study.[11]

2.5 Data collection and ethical issues

Before data collection, written approvals were taken from the designated colleges’ authorities to perform the study in the setting. The medical students (data collectors) presented themselves to the participants at each level, notified them about the study objectives, and guaranteed data anonymity and confidentiality. Participation in the study was voluntary. The authors state that the study was conducted according to the ethical codes of the relevant national and institutional committees on human research and the Helsinki Declaration of 1975, as revised in 2008. KKU Ethical Committee approved the study. Informed consent was taken from participants.

All incomplete questionnaires were eliminated. The response rate was 87% in healthcare colleges and 92% in non-healthcare colleges. The reasons for non-response were lack of time and interest.

2.6 Data analysis

Data were entered, double-checked, and analyzed using the Statistical Package for the Social Sciences version 22 software package. The grading of PSS into low, moderate, and high PSS was based on Cohen et al.[10]. Using univariate and multivariable logistic regression analyses, the crude odds ratio and adjusted odds ratio (aOR) were estimated. The 95% confidence intervals (95% CIs) were used to identify significant factors associated with stress among university students. Statistical significance was set at P < .05.

3 Results

The current study was conducted among 2467 students (overall response rate of 91.37%) affiliated with King Khalid University's nine colleges. A total of 1342 students (54.4%) were selected from four non-healthcare colleges. These colleges include the college of languages and translation (313 12.9%), science (336, 13.6%), administrative and financial sciences (338, 13.7%), and Education (355,14.4%). The study also included 1125 students (45.6%) from five healthcare colleges. These were colleges of dentistry (155, 6.3%), nursing (164,6.5%), applied medical science (220, 8.9%), pharmacy (243, 9.8%), and medicine (343, 13.9%). The participants’ ages ranged from 18-to-36 years, with an average age of 21.58 ± 1.60) years. The distribution of students was proportional across the different academic levels of KKU colleges. Of the 2467 participants, 1353 (54.8%) were women.

In contrast to students in health care colleges, non-healthcare colleges contained more students with younger (≤ 20 years) age (32.1% vs. 20.9%), males (55.1% vs. 33.2%), married (7.2% vs. 4.8%), with unsatisfactory family income (8.6% vs. 3.5%), smokers (15.4% vs. 9.5%), and ex-smokers (9.2% vs. 4.2%), students in 1st to 6th academic levels (68.0% vs. 44.7%), and with GPA ≤ (4.1% vs. 1.8%). Hence, the two groups of students were unmatched concerning these personal and academic criteria (Table 1).

Table 1 - Characteristics of health and non-healthcare university students (n = 2467).
Factors TotalN = 2467n (%) Health care collegesN = 1125n (%) Non- health care collegesN = 1342n (%) P-value
Age (yr)
 ≤20 666 (27.0) 235 (20.9) 431 (32.1) .001
 + 20 1801 (911) 890 (79.1) 911 (67.9)
 Male 1114 (45.2) 474 (33.2) 740 (55.1) .001
 Female 1353 (54.8) 751 (66.8) 602 (44.9)
Marital status
 Married 150 (6.1) 54 (4.8) 96 (7.2) .01
 Single 2317 (93.9) 1071 (95.2) 1246 (92.8)
Smoking status
 Never smoker 1983 (80.4) 971 (86.3) 1012 (75.4) .001
 Ex-smoker 170 (6.9) 47 (4.2) 123 (9.2)
 Current smoker 314 (12.7) 107 (9.5) 207 (15.4)
Family income
 Satisfactory 2313 (93.8) 1086 (96.5) 1227 (91.4) .001
 Unsatisfactory 154 (6.2) 39 (3.5) 115 (8.6)
Academic level
 1–6 1416 (57.4) 503 (44.7) 913 (68.0) .001
 7–12 1051 (42.6) 622 (55.3) 429 (32.0)
GPA score
 ≤ 2.5 62 (3.1) 15 (1.8) 47 (4.1) .004
 + 2.5 1911 (96.9) 808 (98.2) 1103 (95.9)
P-value= Chi square test P value, GPA Grade point average.
= missed data for 604 students.

The average PSS score of university students was 19.13 (SD=6.56). Overall, the prevalence of severe perceived stress was 12.7%. High perceived stress was 13.6% in healthcare colleges and 12.0% in non-healthcare colleges. The average PSS score of health care students (19.45 ± 6.49) was significantly higher (P = .02) than that of non-healthcare students (18.85 ± 6.61).

Table 2 shows that the univariate and multivariable analysis of factors associated with high perceived stress. Multivariable analysis revealed that high perceived stress was significantly higher among female university students (aOR=2.35, 95% CI:167–3.30) than male students. Similarly, the following factors were found significantly associated with high perceived stress: being ex-smoker (aOR=1.63, 95% CI:1.04–2.56) or current smoker (aOR= 1.65, 95% CI: 1.01–2.77), perceiving unsatisfactory family income (aOR=3.10, 95%CI:1.94–4.89) and belonging to health care colleges (aOR=1.33,95%CI:1.01–1.77). High perceived stress was negatively associated with GPA score, which was used as a proxy of academic performance (aOR= 0.77, 95% CI:0.62–0.96). No significant relations were detected between high stress and participants’ age, marital status, and academic level.

Table 2 - Univariate and multivariable analysis of academic and personal factors associated with high perceived stress among study university students (n=2467).
Factors Totaln (%) High perceived stressn (%) cOR (95%CI) aOR (95%CI)
Overall 2467 (100) 314 (12.7)
Age (yr)
 ≤20 666 96 (14.4) Ref Ref
 + 20 1801 218 (12.1) 0.82 (0.631–1.06) 0.85 (0.60–1.21)
 Male 1114 100 (9.0) Ref Ref
 Female 1353 214 (15.8) 1.90 (1.48–2.45) 2.35 (1.67–3.30)
Marital status
 Married 150 22 (14.7) Ref Ref
 Single 2317 292 (12.6) 0.84 (0.52–1.34) 0.98 (0.56- 1.72)
Smoking status
 Never smoker 1983 244 (12.3) Ref Ref
 Ex-smoker 170 23 (13.5) 1.255 (0.89–1.76) 1.63 (1.04–2.56)
 Current smoker 314 47 (15.0) 1.11 (0.70–1.76) 1.65 (1.01–2.77)
Family income
 Satisfactory 2313 272 (11.8) Ref Ref
 Unsatisfactory 154 42 (27.3) 2.81 (1.93–4.10) 3.10 (1.94–4.89)
 Non- health colleges 1342 161 (12.0) Ref Ref
 Health colleges 1125 153 (13.6) 0.87 (0.86–1.10) 1.33 (1.01–1.77)
Academic level
 1–6 1416 188 (13.3) Ref Ref
 7–12 1051 126 (12.0) 0.89 (0.70 – 1.13) 1.01 (0.72 – 1.40)
GPA score
 ≤ 2.5 62 12 (19.4) Ref 0.77 (0.62–0.96)
 + 2.5 1911 232 (12.1) 0.57 (0.30–1.10)
GPA Grade point average.
= missed data for 604 students, 95%CI= 95% confidence interval, ref = reference group, cOR= crude odds ratio, aOR=adjusted odds ratio.
entered into the model as a continuous variable.

4 Discussion

The present study observed high perceived stress among 12.7% of university students in south-western Saudi Arabia. The literature reports varying rates of high stress among university students. A recent systematic review noted that the prevalence rate ranged widely from 14.3% to 56%.[4] Cultural differences may explain the differences.

The average students’ PSS in the current study was 19.13 ± 6.56 (19.45 and 18.85 for health and non- health care colleges, respectively). Our findings were similar to those reported among university students in India (19.2),[12] Nigeria (19.6),[13] and Iran (20.04)[14] and slightly higher than those reported in France (15.9),[8] the USA (16.0),[15] Romania (17.3)[16] and England (17.9).[17] The average score was markedly lower than that reported in universities in other regions of Saudi Arabia, including Jeddah (28.5)[18] and Riyadh (27.0).[19] It is also remarkably lower than that reported in Malaysia (27.5).[20] The wide variation in stress level could be related to the difference in stress study design being used in different populations and the differences in the magnitude of personal, family, academic, financial, and university environment stressors.[4,20]

According to our results, female students are exposed to a higher risk of perceived stress than males. This was reported by several studies conducted among university students in Saudi Arabia,[21] Malaysia,[22] Turkey,[23] Lebanon,[24] the UK,[17] and the USA.[25] The reason for the excess risk in female students is unclear. Although studies have found that female students do not have higher academic stressors than male students, they may perceive challenging and adverse events as more stressful than males.[26,27] Another study suggests that socially, male expression of emotions may be considered a symbol of weakness and low masculinity.[28]

The positive association between perceived stress and smoking in the present study confirms previous studies.[4,8] There is some evidence that stress may contribute to behavioral problems such as smoking and drug abuse.[8] Smokers believed that smoking helps cope with stressful events at university by brief social relations during the study day, non-verbal expression of distress, and stress relief.[29] Students’ tobacco smoking in response to stress can lead to a greater risk of lifetime nicotine addiction.[8]

The association between the higher risk of high perceived stress and students’ perception of insufficient family income observed in our study follows the findings of a previous study.[2] University time may be sufficiently stressful for students attempting to achieve academic goals despite their financial inadequacies.[9]

The higher risk of high perceived stress observed in the present study among health care students compared to students in other colleges is following previous reports.[4–6,20,30] Earlier studies found that healthcare students, particularly medical students, are exposed to more frequent stressors, including too many examinations, time urgency, shortage of leisure time, academic pressure, and work overload.[5,6,31]

In the current study, high perceived stress was negatively associated with the GPA score, used as a proxy for academic performance. A reasonable stress level is positive and helpful in making the student more energetic and a better performer. On the other hand, high-stress levels may negatively impact students’ physical and psychological wellbeing, leading to low academic achievement.[2,7]

The present study has several strengths. It included a large and representative sample of university students in south-western Saudi Arabia. It is also the first study to compare health and non-healthcare students regarding perceived stress. It could provide a deep insight into the relationship between high perceived stress and smoking, low academic achievement, and perceived insufficient family income.

However, this study had some limitations. First, the data were obtained using a self-administered questionnaire that may be affected by recall bias. Due to the study's cross-sectional nature, it was difficult to confirm the direction of the relationship between stress and other associated factors, such as smoking and GPA scores. Moreover, unevaluated factors could affect perceived stress at the time of the study, such as other academic, social, economic, and cultural criteria. The missing data for GPA in some instances was another limitation.

5 Conclusion

High perceived stress is a substantial problem among university students. Female students and students in health care colleges are at a greater risk of high perceived stress than other students. High perceived stress was correlated with smoking, lower GPA scores, and perceived insufficient family income. Our results can improve the stress prevention program by giving special attention to smokers, those with lower academic achievement, and inadequate family income. In addition, efforts should be directed toward improving the academic environment in health care colleges.


The authors would like to thank all students at the College of Medicine, KKU, for helping with the data collection.

Author contributions

Conceptualization: Nabil J. Awadalla, Ahmed A Mahfouz.

Data curation: Ahmed A Mahfouz.

Formal analysis: Nabil J. Awadalla.

Methodology: Nabil J. Awadalla.

Writing – original draft: Nabil J. Awadalla, Ahmed A Mahfouz.

Writing – review & editing: Mohammed A. Alsalem, Safar A. Alsaleem, Sarah Al Shehri, Nabil J. Awadalla, Tarek M. Mirdad, Fuad I. Abbag, Ahmed A Mahfouz.


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academic performance; health and non-healthcare colleges; perceived stress; smoking; University students

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