Sources of Stress and Coping Strategies among Undergraduate Medical Students Enrolled in a Problem-Based Learning Curriculum

1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia 2Department of Family Medicine and Primary Health Care, King Saud bin Abdulaziz University for Health Sciences and King Abdulaziz Medical City, Riyadh, Saudi Arabia 3Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia 4Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia


Introduction
Stress is increasingly becoming a part of our daily lives.Historically, the Latin word "stress" has been in common language since the seventeenth century and was used to address hardship, adversity, or affliction.However, stress is best described as a situation where environmental demands exceed the capacity for effective response by the individual and can potentially have physical and psychological consequences [1,2].Coping with stress, on the other hand, is important for human survival and can be defined as the process of managing external or internal demands that are perceived as taxing on personal capacities and resources [1].Globally, the incidences of stress and stress-related illnesses such as anxiety and depression among students, trainees, and qualified physicians have increased and received significant attention in literature [3][4][5][6][7].
Academic stress, among college students in particular, has been a topic of interest for many years [8].Indeed, there is evidence that medical students face unique academic challenges that render them more vulnerable to stress and anxiety than students of other disciplines [9][10][11].College students, especially freshmen, are particularly prone to stress due to the transitional nature of college life, where college life compels students to acquire entirely new social skills and also to take responsibility for their own personal needs [8,12].
In addition to academic requirements, relations with faculty members and time pressures are yet further sources of stress [13].On top of all, more strain comes from social adjustment, particularly adjusting to university life while separating one's self from family and friends [14].In addition, tests, grades, competition, time demands, professional class environment, and concern about future careers were found to be major source of academic stress [15].Academic pressures combined with emotional factors prevail during the first year, while reasons related to patient care and physical factors are more important in subsequent years.Additionally, there are long working hours, lack of peer support, lack of recreational activities, financial strains, life and death situations, and patient cultural and minority issues, which are all reasons for stress associated with medical education and training [16].
Another important point to consider is that stress is a matter of personal perception.Researchers have found that personality traits of medical students include being highly motivated and action oriented achievers, which helps them get high scores; yet same students cannot tolerate feelings of helplessness and dependency and therefore are more prone to stress or less capable of handling it [17,18].Reports have shown association of high level of stress among medical students with different types of academic stressors [19][20][21][22][23][24][25][26][27].Studies related to stress in medical education in Arab countries have also confirmed that stress, depression, and anxiety are common among medical students [6,28].It has also been reported that student's perception of high stress levels may lead to poor academic performance, depression, attrition, and serious health problems [13].A different study on stress management suggested that monitoring student-stress and the methods utilized to deal with it could have valuable implications for higher education administrators [29].With all the evidence presented above on how the medical student life is burdened with stress, failure to resolve student stress in the long-term could have serious professional and personal consequences [30].
Coping has been viewed as a stabilizing factor that may assist an individual in psychosocial adaptation during stressful events [31].Coping methods often used by students, to reduce level of stress include, effective time management, social support, positive reappraisal, and engagement in leisurely pursuits.There is also emotion-based coping that involves accepting responsibility and self-blame, and this type of coping is more useful in the first year of the medical school, while in later years the trend shifted towards confronting, cognitive, and planned problem solving [32][33][34][35].It has also been found that students with engagement strategy of coping are able to modify situations, resulting in a more adaptive outcome, and also have reported fewer symptoms of depression [20,33].
Studies on stress and coping strategies among medical students in Saudi Arabia are few and far in between.The aim of this study is to identify common sources of stress among medical students and to determine the coping strategies employed by the students.We also explored the associations between sociodemographic, stress sources, and perceived stress.

Study Design and Settings.
This cross-sectional survey study was conducted in the College of Medicine, King Saud Bin Abdul Aziz University for Health Science (KSAU-HS), Riyadh.All undergraduate medical students during the academic year 2012-2013 were included in the study.The college adopts problem-based learning medical education curriculum split into three phases (premedical, medical, and clinical), each of two years duration.

Ethical Considerations.
The study was approved by the Institutional Review Board (IRB) of King Abdullah International Medical Research Centre.Written informed consent forms were distributed to the students.Only those agreed to participate in the study were enrolled.Students were assured that participation would not affect their academic progress.Incomplete questionnaires were not included in the study.

Data Collection Instrument.
A self-administered questionnaire consisting of 34 items was manually distributed to the students.The data collection instrument included 6 sociodemographic variables: age, gender, enrollment year, marital status, smoking, and family income.Three additional sections were added on perceived stress, common stressors, and coping strategies.
The Perceived Stress Scale (PSS-10) of ten items, measuring occurrence by "never," "almost never," "sometimes," "fairly often," and "very often," rated on a scale from 0 to 4, respectively, assessed the stress perception.Scores were reversed for questions 4, 5, 7, and 8.A total score ranging from 0 to 40, with higher score meaning higher perceived stress by the medical student [33,36].
Coping strategies were assessed using the Brief COPE scale, which is an abbreviated version of the COPE Inventory [38].It consists of 28 items and the answer choices were on how frequently each of these coping mechanisms were applied by the student, that is, "never," "sometimes," "often," and "mostly," scored from 1 to 4, respectively.
To estimate sample size we assumed that nearly half (with 5% margin of error) of the students would feel stressed, and this yielded a sample size of 384, based on 95% confidence interval.Using the rule of 10 participants per item a sample size of 340 was considered optimum, which was rounded up to 350 for possible data losses.

Statistical Analysis.
Descriptive statistics were used to summarize data, including frequencies, percentages, means, and standard deviations for each item of the questionnaire.Total mean (sd) scores for perceived stress, sources of stress, and coping strategies were computed.An independent sample -test and ANOVA was used to compare continuous data.Stressors' responses were further grouped into two categorical responses: "agreeing" or "disagreeing" that a stressor was of concern to the student.Similarly coping strategies were further grouped into two categorical responses of "rarely" or "frequently" used coping method.The association between specific stressors and coping strategies were explored using chi-squared test.Odds ratios (OR) with 95% (CI) of using a particular strategy under a particular stressful situation were estimated.Relationships were explored between scores using simple linear regression.Principle Component Analysis was carried out to explore the common themes of 17 stressors and fewer dimensions of 28 coping strategies. values < 0.05 were considered statistically significant.Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 20.

Demographics.
From a total of 400 medical students who received the questionnaire, 378 completed the survey, yielding an overall response rate of 94.5%.Male students were 224 (59.3%) in the study sample.Majority of students were single (97.3%).Over 40% of the respondents were from the premedical year, 26% from preclinical year, and 33% from the clinical years, while 81 did not document their batch year.Tables 1, 2, and 3 show forms of stress as perceived by students, stressors, and coping strategies, respectively.Over half of the students (53%) often felt stressed, yet 53.8% often felt confidant as well.A third (32.1%) often felt that they could not cope with stress, 35.9% were unable to control, and 37.8% felt angered.The mean (sd) of total perceived stress score was 32.2 (4.1), range between 10 and 45.Female students had slightly higher perceived stress score compared to male students ( = 0.018).
Over 82% found studying stressful, nearly two thirds (64.3%) were not sleeping well, over three quarters (78.2%) worried about the future, and more than half (57.1%) were stressed by interpersonal conflicts, reported low self-esteem as stressing (51.7%), or had challenges with transport (56.2%).Total stressors were 17, with mean (sd) stressor score 41.4 (9.6) and range between 17 and 68.Female students had higher specific stressor score compared to male students ( < 0.001).
Total coping strategies applied by medical students were 28, with mean coping score of 64.6 (9.1) and range between 29 and 102.Female students had higher coping strategies mean score compared to male students with mean score of -test = 3.46,  = 0.001.
Regressing to coping strategies the score on total stressor score did not yield any significant relationship.Perceived stress score showed a marginal positive association with total stressor score, with  = 0.11 ( = 3.7,  = 0.052).Coping strategies score showed a mildly positive association with the perceived stress score, with  = 0.27 ( = 21.8, < 0.001), suggesting that the higher the perceived stress is, the more the coping strategies were applied (see Figure 1).
No statistically significant difference was found between stressors and coping strategies mean scores of premedical, preclinical, and clinical years.However, the perceived stress mean score increased as the students progressed from 31.1 to 33.8 ( = 7.2,  < 0.001) through the medical school years, with premedical mean score being significantly less   than the scores of all other years on Bonferroni posthoc test.Age of participants was not significantly associated with scores of perceived stress, stressors, or coping strategies.No significant difference of age was noted between genders.
On grouping the 17 stressors using the principle component analysis (Table 4), it was found that the stressors could be grouped into four areas of stress: social issues, personal challenges, somatic impact, and studying in general, with eigenvalues of 4.9, 1.8, 1.4, and 1.3 and with percent of variance of 29.1%, 10.9%, 8.2%, and 7.6%, respectively.Social issues included the stressors: financial difficulties, family problems, being away from family, trouble with parents, no parental support, trouble with teachers, trouble with friends, roommate conflict, and interpersonal conflicts.
Personal challenges included the stressors: hearing bad news, low self-esteem, and searching for a life partner; "somatic impact" grouped sleeping disorder and appetite change.Studying in general remained a major stress factor.KMO sampling adequacy was 0.899, of Bartlett Chi-Sq.= 1628.2,and of  < 0.001.Students were noted to use different coping strategies for different stressors (Table 5).

Discussion
According to a WHO report, medical students are more susceptible to stress as they encounter the highly competitive medical education environment.Different levels of stress including burnout have been reported among medical students and health care professionals in different countries [16,[25][26][27][28]. Studies have reported high level of stress particularly in students of medicine [5,19,39,40], dentistry [41], pharmacy [42], and physiotherapy [43] programs.The majority of students face high level of stress in the medical college [24,25,28].In two earlier studies the overall prevalence of stress in medical students was found to be 41.9% [37] and 29.6% [35], respectively, and in Saudi Arabia the figure reported is 57% [22].
It is notable that different studies used different tools to measure stress and this may account for the wide range of prevalence obtained.In current study, medical students that "felt stressed" (PS-Q3), "fairly often" and "very often," were nearly 53% of the participants.
An earlier study from Malaysia identified five significant predictor items for stress, namely, gender, family income, marital status, study program, and smoking [37].We found that female students scored higher on all three scales, suggesting that they perceived more stress than their male counterpart, and they have more stressors in their lives.Accordingly female students used more coping strategies to overcome the stress.This finding is similar to a previous study from Pakistan [26].We speculated that the deeply conservative nature of Saudi society could be the reason for the high score of stress among Saudi females, as women are not usually involved in a wide range of social activities, compared to males.However, data were insufficient in other variables such as family income, smoking, and marital status to allow further analysis, but only age was found not to be a significant factor.
Our study has also found the perceived stress score of students in the medical years to be higher than that of students in the premedical years.This is not unexpected and is similar to the finding of an earlier study where the level of stress was reported to increase gradually from premedical through medical years [38].This may attribute to the fact that premedical students have fewer study courses compared to those in medical years where students can hardly find time within a congested schedule to deal with the resulting stress.Other studies have reported that students found the medical course more stressful during the first year of study, but less so in subsequent years [22,40].
The main stressors in the current study for medical students were related predominantly to medical training and social and personal problems.A combination of academic, physiological, and health related stressors was also reported among students in Nepal [27].The significant stressors perceived by our students were "study in general," "worrying about the future," interpersonal conflicts," and "low self-esteem."The finding of "study in general" as a significant stressor was similar to previous finding in which academic/exams were common sources of stress and unsatisfaction among medical students [27,43,44].Worrying about future was identified as important stressor among medical students in Malaysia [37] and health-profession students in the Emirates [41].In earlier studies "low self-esteem" has been claimed to result from the high stress affecting student's academic achievement [18,19,21].
The widely employed original COPE questionnaire containing 14 domains of coping strategies [37] in our study were found to have 9 underlying domains of 28 item coping strategies (Table 4).Some strategies were used more often than others for a variety of stressors, while some coping mechanisms seemed less likely to be used when experiencing specific stresses.Also, multiple coping methods were used for a specific stressor.Blaming self-coping strategy was commonly employed in six different stressors.Seeking support from others was used in four different stressful situations, finding comfort in religion was also used for three stressors, while "concentrating effort," "distracting by work," "giving up," "being self-critical," "getting advice from others," "distraction in another activity," and "giving up to cope" were utilized more than once for specific stressors.
Earlier studies in Malaysia [37], United Arab Emirates [41], and Jordan [42] reported similar findings.Alcohol or drugs were hardly mentioned as a coping method in our study, as alcohol is prohibited in Saudi Arabia for religious reasons, and this is in line with the findings in study on stress of Malaysian medical students [37].In contrast, medical students in the United Kingdom used alcohol, tobacco, and drugs as common coping strategies [40,43].

Limitations
This survey was a cross-sectional and subject to recall bias.Moreover, the study was limited to one university campus in Saudi Arabia; hence, the results may not be generalizable to other institutions.Also, perceived stress and its causes were self-reported by students and that may have resulted in some reporting bias.Although confidentiality was assured, students may have exaggerated or underreported stress or coping strategies because of fear of being singled out.Lastly, the relationship between different levels of stress and outcomes such as academic performance was not explored.

Conclusions
The findings of this study led us to conclude that female students perceived stress more, faced more stressors, and applied more coping strategies than male students.Stress is very common among our medical students as stress was prevalent among over half of the participating students, and a third found it difficult to cope with it.The effect of stress on medical students well-being was far reaching, as nearly two thirds were not sleeping well, and half were stressed by interpersonal conflicts.Half were reporting low self-esteem as a reason.Self-blame and self-criticism were often the reactions to stressful situations.Distraction by work or other activity featured in specific stress conditions.As religious faith runs deeply in the Saudi society, refuge in religion was frequently sought; as a coping measure, some looked for advice and help from others, while use of alcohol or other drugs was rare.When the stresses perceived by the student were high as in studying in general, worrying about future, interpersonal conflict, and having a low self-esteem, the applied coping strategies were also high as a result.Interpersonal conflict triggered coping strategies significantly.Premedical students perceived less stress than medical students.Stressors could be grouped into four domains of social issues, personal challenges, somatic impact, and studying in general.Coping strategies could be grouped into nine themes: being selfcritical, denial, distracting oneself, humoring it, solace in religion, use of chemicals, acceptance, making personal effort, and seeking support from others.Stressors that required at least four different coping mechanisms were worrying about future, trouble with friends, room-mate conflict, hearing bad news, and low self-esteem.Coping strategies that were significantly applied more often were blaming self or being self-critical, seeking advice and help from others, finding comfort in religion, concentrating effort, distracting by work or activity, and giving up.

Recommendations
More attention should be paid to improve the methods of teaching and the quality of study environment within our college campus.Some form of student support should be available in the form of mentoring and guidance to help in coping with stress and to educate the students about unhealthy consequences of stress.Moreover students should construct an effective time management program for studying and pleasure activities during their study years, in addition to adopting a healthy life-style in the context of physical, psychological, and spiritual well-being.Establishing a wellness clinic within campus might help reduce some types of stress and its consequences.

Figure 1 :
Figure 1: Regression of coping strategies score on perceived stress score.

Table 1 :
Forms of stress as perceived by students.

Table 2 :
Specific stressors of students.

Table 3 :
Coping strategies used by students.
KMO sampling adequacy 0.715, Bartlett Chi-Sq.= 2541.7,and  value < 0.001.The coping strategies could be grouped into nine themes: being self-critical, denial, distracting oneself, humoring it, solace in religion, use of chemicals, acceptance, making personal effort, and seeking support from others.

Table 5 :
Specific coping strategies likely (or unlikely) to be applied by students for stressors.