Stress is an unpleasant state of emotional arousal that occurs in people when experiencing threatening situations. Environmental and personal factors that cause stress are attributable to as stressors 1. Excessive stress can lead to mental and physical health problems 2. Several studies have revealed that medical students experience high levels of stress compared with other profession students 3–6. Medical students from different countries have been found to have high risk of stress and decreased life satisfaction 7,8. The prevalence of stress was reported at 65% among medical students in the United Arab Emirates University, Al-Ain 9; 30.9% among Egyptian medical students 10; 57% among medical students in King Saud University, Riyadh, Saudi Arabia 11; 61.4% among medical students in a Thai Medical School 12; 41.9% among medical students in a Malaysian Medical School 13; more than half among Bangladeshi medical students 14 and 31.2% among medical students in three British universities 15. This could be justified because medical students are more exposed to work overload in a competitive manner with constant pressure of examinations and regular assessment 16. The environment around medical student also encourages competition rather than cooperation, which brings stress 6. This, in turn, usually makes medical students to stop themselves from socializing and enjoying extracurricular activities 17. The excessive stress among medical students was found to be associated with sleep disturbance 2, poor academic performance 18,19, and a negative effect on cognitive functioning and learning 20 and even substance abuse 21. Moreover, medical school stress is likely to be a risk factor for mental health problems 2. It can reduce students’ self-esteem 22. Many studies have shown high levels of depression among medical students compared with general population 23–25. In a Swedish study, the prevalence of depressive symptoms among Swedish medical students was 12.9%, and a total of 2.7% of medical students had made suicidal attempts 20. The stress during the undergraduate medical study may continue during the internship and into the physician practical life and may reach burnout levels 26–28. Studies have shown that a higher prevalence of depression and suicide among physicians compared with other professions may be a reflection of untreated depression during the undergraduate period 29. Therefore, stress among medical students not only affects their mental health and academic achievement but also reflects on the patients’ care, which the medical students will provide to their patients later on. Although many studies pay attention on the factors associated with stress among medical students, which is very valuable, as a proper treatment of these factors will decrease the stress, few studies, especially in Arab countries, assess the stress among medical students based on sex differences. Studying the factors associated with stress among medical students based on sex differences is extremely valuable to expand our vision about these factors and to manage these factors in a more professional way. To the best of our knowledge, this is the first study that assesses the effect of social support on stress among medical students based on sex differences in Saudi Arabia. The current study was conducted to assess the differences between male and female medical students regarding (a) the level of perceived stress and (b) the factors associated with the perceived stress.
Participants and methods
Study design and participants
This cross-sectional study was conducted at the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, to compare the differences between male and female medical students (all years) regarding the level of stress and the factors associated with the perceived stress. The study was conducted from October 2013 till May 2014. Students were selected through a stratified random sample with proportional allocation for different academic years (all years). The sample size was estimated to be at least 170 males and 170 females for a power of 80% and confidence interval 95%. Moreover, 10% was added to the estimated sample to overcome dropout to get a final total sample size of 187 males and 187 females. The sociodemographic data of the students were recorded. Informed consent was obtained from the medical students to participate in this study, and ethical approval was obtained from the Local Ethics Committee of Faculty of Medicine, King Abdulaziz University.
Perceived stress was measured by using the Perceived Stress Scale (PSS) 30. The PSS comprises 14 items, with responses varying from 0 to 4 for each item and ranging from never, almost never, sometimes, fairly often to very often correspondingly on the basis of the occurrence during 1 month before the survey. The PSS has shown good internal consistency and test–retest reliability (Cronbach α=0.84 and 0.85, respectively) 30. PSS assesses the degree to which participants evaluate their lives as being stressful during the past month. PSS scores are obtained by reversing responses (e.g. 0=4, 1=3, 2=2, 3=1 and 4=0) to the positively stated items (seven positively stated items) and then summing across the scale items. Higher scores indicate higher levels of stress. The PSS has a possible range of score from 0 to 56.
The Multidimensional Scale of Perceived Social Support (MSPSS) 31 was used to assess the perceived social support. The MSPSS is a 12-item questionnaire on a seven-point Likert-type scale ranging from 1 ‘very strongly disagree’ to 7 ‘very strongly agree’. The scale has three subscales, each of which consists of four items that are used to determine the support from family, friends, and significant others. Subscale scores are calculated by summing the scores obtained from the four items of each subscale. The score range for the subscales is between 4 and 28 31. The total score of the scale is calculated by summing the scores obtained from all the subscales (range: 12–84). Higher scores reflect more perceived social support. Cronbach α for the three subscales are 93 for friends, 92 for family, and 93 for significant others 32.
The statistical package for the social sciences, version 20 (SPSS Inc., Chicago, Illinois, USA), was used for statistical analysis and sample size estimation. Descriptive data were analyzed using mean, SD and percentage. t-Test was used to compare quantitative parameters. The χ 2-test was used to compare categorical parameters. Regression method was used to develop predictive model. A P value less than 0.05 was considered to indicate statistical significance.
Sociodemographic and clinical parameters
The final sample size of the studied groups was 173 male medical students (group I) and 173 female medical students (group II), with dropout of 14 male and 14 female students. No statistically significant differences were found between the two groups regarding age, nationality, marital status, employment status, family monthly income, presence of financial problems, presence of family problems, relationship with staff members, living situation, rate of success across the previous years, presence of medical disorders, receiving current medications, family history of psychosis, family history of depression, family history of anxiety, past history of psychosis, past history of depression, past history of anxiety, presence of current psychosis, presence of current depression, and presence of current anxiety (Table 1). The severity of perceived stress was significantly higher among female medical students compared with male medical students (P=0.005). Female medical students showed a significantly poor friend (with their female friends) social support (P=0.001) compared with male medical students (Table 1).
Results of regression analysis
Multiple regression analysis showed that poor friend (with their female friends) social support was the only significant predictor for increased perceived stress among female medical students (B=−0.24 and P=0.002) (Table 2).
Medical education is found to be a very stressful factor that enhances the level of academic pressure and workload. Several longitudinal studies have reported that medical students’ emotional status, upon entering the medical school, is not significantly different from that of the general population, but levels of stress and depression increase thereafter, reflecting the negative effect of medical education on the students’ mental health 33–35. Identifying the modifiable risk factors associated with stress among medical students based on sex differences gives us a broad view of these risk factors for proper management. In the current study, female medical students showed a significant higher level of perceived stress when compared with male medical students. Consistent with our results, some western data reported higher levels of perceived stress among female medical students compared with males 20,36–38. Iqbal et al. 39 reported a higher level of stress, anxiety, and depression among female medical students compared with their male counterparts. Moreover, other studies demonstrated that female students have more depressive symptoms compared with male students 40–42. The possible reasons reported by these different studies were (a) females are more likely to complain about the volume and complexity of the material they have to cover, (b) they are more likely to report stress 42, and (c) females have a tendency to over report their psychological symptoms 43. Contrary to the findings of the current study, an Egyptian study reported that female medical students reported slightly higher level of perceived stress; however, the difference was not statistically significant 44. However, the disparity between their results and those of the current study could be explained by the difference between Egyptian and Saudi cultures regarding the nature of stresses faced by Egyptian and Saudi medical students. El-Gilany et al. 10 studied the effect of sociodemographic factors on the perception of stress among male medical students in Egypt and Saudi Arabia and found significant differences. They reported that Egyptian students were more likely to cite relationship, academic and environmental problems than Saudi counterparts. The top four stressors in Egyptian students were congested classrooms, troubles with the instructors, fear of the future, and limited time for recreational activities, all of which lie in the academic domain, whereas the Saudi students had a higher socioeconomic status compared with Egyptian students. A study performed in Saudi Arabia 45 reported that the prevalence of stress was higher among the female students compared with their male counterparts, which is consistent with our results. They justify the difference by the fact that as male and female students study in separate campuses, and as female campus has poor learning environment and less educational facilities and recreation opportunities, it could be one of the reasons for having higher stress in female than male. However, they reported that this issue could not appropriately be explained by their results and requires further investigations. However, in their study, there was a solid explanation for the higher levels of stress among female medical students, which is supported by our results. Our results demonstrated that female medical students showed a significantly lower levels of friend support (with their female friends) compared with male medical students, and the lower level of friend support was the only factor that was associated with higher levels of perceived stress among female medical students. Interpersonal social support raises one’s ability to cope with problems that affect one’s mental health by buffering the pathogenic effect of stress 46,47. This finding could be explained by cultural and social reasons, as parents of female students in Saudi culture may apply some unjustified severe restriction on their daughters. Parents would not allow their daughters from going out freely to meet their female friends at any time like males and not allow their daughters to stay longer with their female friends as males do. All these factors lead to losing a great part of social support that helps much in alleviating the stress, especially at times of stressful conditions. Social support makes individuals feel loved, cared for, valued, esteemed and connected to a group of people 48. It might be beneficial for students to get support from several sources rather than depending on one 49. Jeong et al. 3 demonstrated that low levels of perceived interpersonal support increase the risk of depression among medical students by more than 10 times. In dealing with stress and emotional disturbances among medical students, common coping strategy is obtaining support from family and friends, and it is reported to have positive effects 50. Hanging out with friends is an important coping mechanism against stress 51. Thus, this restrictive approach should be prevented. Rather, parents should be advised to allow free contact of their daughters with their female friends at all times.
Limitations of the study
The information collected from this cross-sectional study was self-reported by the students, with some potential for reporting bias. Moreover, the study was done on students in one university in Saudi Arabia, so the results may not be generalized to other universities in Saudi Arabia. However, this is an important study that has attempted to evaluate sex differences toward stress and the factors associated with stress among medical students. We believe that our findings will be a basis for further investigations.
Taken together, our study demonstrates that stress is significantly higher among female medical students compared with male medical students. Poor friend-perceived social support was the only significant predictor for increased perceived stress among female medical students. Social support is a buffer against stress. Parental restrictions from free contact of their daughters with their female friends may be a factor that explains this poor friend support among female medical students in Saudi Arabia. Thus, this highly restrictive approach is an inappropriate way and should be prevented. Rather, parents should be advised to allow free contact of their daughters with their female friends at all times.
Conflicts of interest
There are no conflicts of interest.
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