Stress and Coping Mechanism among Students Residing in Private School Hostels

Background . Mental health problems can signi ﬁ cantly impact a student ’ s academic performance, career, health


Introduction
Adolescence (10 to 19 years) is a crucial period of human life as adolescent students are pressured to learn and develop them-selves physically, emotionally, socially, and educationally [1]. Mental health problems can significantly impact students' academic performance, career, health, and future if not identified and managed in time [2][3][4][5]. Stress and depression in adolescence were found to be associated with somatic ailments such as metabolic disorders and cardiovascular diseases, as well as greater welfare dependence, unemployment, and academic failure [3,6,7]. Furthermore, inappropriate handling or the inability to cope with stress can lead to depression, anxiety, suicide attempts, substance abuse, self-injury, and antisocial behaviour among adolescents [7]. Globally, the adolescent group represents one-sixth of the total population, and 14% are estimated to experience mental health disorders [8]. More than half of mental disorders are expected to start at adolescent age [9]. However, the majority of mental disorders, including children, lack proper care and management [10,11]. Analogously, a contemporary investigation conducted in the United Kingdom in 2022 substantiated the exigency for mental health assistance for an additional 500,000 adolescents compared to the data from 2017 [12]. The poor mental health of young people has been documented in many countries, including the Czech Republic, Indonesia, Malaysia, and Singapore [13][14][15][16]. Nepal is another example of poor youth mental health. Studies targeting adolescent students in Nepal reported high rates of mental health problems [17][18][19]. Academic stress is reported in one-fourth of high school students in Nepal [20]. Moreover, stress-related problems were commonly reported among undergraduate medical students in Nepal [21,22].
The environment of the educational site, living area, and surrounding people directly affect mental health and development. There is a practice of admitting school-level students to the hostel in Nepal. The hostel is an educational residence where students from different cultures, backgrounds, and areas gather and stay to enhance their academic careers. It is estimated that around 30,000 students of various educational levels live in a private hostel in Kathmandu, a hub of education and the capital city of Nepal [23]. However, living in a hostel is also reported to be associated with stress among adolescent students [19]. Family distance, inadequate facilities, interpersonal relationships, and academic workload were found to affect the mental health of the students of private school hostels [21,22,24,25]. On the other hand, parents, education institutions, teachers, and governmental authorities have demonstrated inadequate consideration for the stress experienced by children [26].
Therefore, determining the degree of stress and developing coping mechanisms for adolescents is crucial. There has not been any research done to look at stress among adolescent students residing in hostels in Nepal. Hence, this study aimed at determining the prevalence of stress, stressors, coping mechanisms preferred, and associated predictors of stress among the adolescent students residing in a hostel in the central region of Nepal. The findings of this study are expected to determine adolescent students' mental health issues, contributing to health practitioners and the government in developing suitable programs and strategies for addressing adolescent mental health in Nepal and other countries in similar social and cultural contexts.

Study Design and Setting.
A cross-sectional quantitative study design was employed. The study was carried out in Hetauda, a submetropolitan and capital city of Bagmati Province that lies in the central part of Nepal. It is a centre for higher education and good healthcare facilities for districts like Parsa, Bara, and Sindhuli. The study participants were students resided in private hostels of boarding schools.

Ethical
Approval and Informed Consent. Ethical norms were considered and followed throughout the study. Ethical approval was granted from the Institutional Research Committee (IRC) of Bharatpur Hospital Nursing College, Chitwan, Bagmati Province, Nepal (Ref: 077/78-035/BNS). Informed written consent was taken from all participants and their carer/hostel owner before the data collection. The study details were well informed, including that the participants could withdraw from the study at any time if they wished without having to give a reason.
2.3. Sample Size and Sampling. Initially, before estimating the sample size, the total number of the registered hostel and a number of adolescent students (grades six to ten) residing there were searched. A total of eight hostels were identified registered with the government of Nepal and Private & Boarding School Association (PABSON) in Hetauda, Bagmati Province, Nepal. As the number of registered hostels was limited, all the adolescent students (grades six to ten) residing in all hostels were recruited for the study. Self-administered questionnaires were provided to students after being informed about the study objectives and obtaining informed consent. Data collection took place for two months (October 11th to December 12th, 2020), and a total of 209 students living in the hostels participated.

Data Collection
Tool. The study tool was divided into two parts. The first part considered independent variables that were (i) sociodemographic-related questionnaires and (ii) stressors related to the hostel environment. The second part considered dependent variables that were (i) stress measurement-related questionnaires and (ii) coping mechanism-related questionnaires.

Stressors
Related to the Hostel Environment. Potential stressors related to the hostel environment were considered the independent variable of interest. The questionnaires related to stressors of the hostel environment were initially prepared by studying the previously published studies [21,24,27] and finalized by consulting with mental health researchers, subject lecturers, and colleagues. There is a total of 23 stressors finalized for the study. Participants were required to respond by indicating yes or no to each stressor question. Mental Illness

Stress Measurement-Related Questionnaires.
A selfreported Perceived Stress Scale (PSS) 10-item was used to assess stress [28]. This tool has been validated and widely used in determining stress levels in previous studies [19,29]. PSS-10 contains ten questionnaires with a Likert scoring system where the reversed scoring was made for 4, 5, 7, and 8 items. A cutoff value was set at 20 scores (half score) to determine the perceived stress prevalence. The cutoff score is designed referring to previous similar studies [18,29]. Therefore, the individual with a total score of ≥20 was considered perceived stressed. Oppositely, an individual with a total score lower than 20 was considered absent of perceived stress.

2.4.4.
Coping Mechanism-Related Questionnaires. Similarly, the questionnaires for the coping strategy were adopted from Wright et al. [30]. This tool has been validated among children [30]. Wright et al. [30] provide 29 coping strategies, which retain six constructs: problem-solving, seeking social support, externalizing, internalizing, trivialising, and distraction. Again, the Likert score system was used to measure the coping strategy of the patient. They are classified in this way, not at all, hardly ever, sometimes, most of the time, and all of the time with 1, 2, 3, 4, and 5 scores, respectively. Initially, an English version of the questions was translated into Nepali. Two independent personnel with good knowledge of English and Nepali speaking and writing worked in translation. After that, the questionnaires were pretested among sixteen students. Students' feedback and comments on the understandability, clarity, and comprehensibility were taken. Then, the translation wording accuracy, fluency, and cultural suitability were reviewed and adjusted through consultation with coauthors, experts, and colleagues. Both the English and Nepali versions of the questionnaires were included in the survey to aid students' understanding.
2.5. Data Collection Procedure. Nursing student with a clear understanding of research objectives, methodology, and ethical issues collected the data. All the students available at the study site were approached to participate in the study. Initially, the purpose, procedure, anonymity, and potential impacts of the study were informed to hostel owners/ student's carers and students in verbal and written form. After the carer and student's written and verbal approval, the designated questionnaires were administered to students. The data collector helped in clarifying the questions in case of confusion raised by the students. Students took 25 to 30 minutes to complete the questionnaires.
2.6. Data Analysis. Data were entered into Microsoft Excel 2010 software and transferred into SPSS version 25 for analysis. Descriptive statistics such as frequency, mean, median, standard deviation, and percentage were measured to summarise the data. Then, inferential statistics were evaluated. Univariate analysis was performed to assess the association between the study variables or possible predictor variables and stress variables. Variables statistically significant in the univariate analysis, i.e., P value < 0.05, were further sub-jected to multivariate logistic regression analysis. Multicollinearity among the predictor variables was checked using the variance inflation factor (VIF), considering the cutoff value < 3 [31]. In multivariate logistic regression analysis, the statistical significance was considered at a P value less than 0.05. The normality test of the numerical data was performed using the Kolmogorov-Smirnov test.

Results
3.1. Perceived Stress by the Respondents. All approached 209 students responded to the questionnaire. Among them, 108 (51.67%) respondents were determined to have symptoms of perceived stress. Most perceived scale questions have "sometimes" as a median response. Only 33.5% of the students were very confident about their ability to handle their problems, 35.4% of the students could cope with all the things they had to do, and 33% never felt that their difficulties were increasing so much that they could not overcome them. The summary of the students' responses on the PSS-10 scale is available in the supplementary file (available here).

Characteristics of Participants and Association with
Perceived Stress. A majority of participants were above 15 years old (55.5%), boys (75.6%), and representative of grade ten (23.9). Nearly half (49.8%) of the respondents belonged to the Madheshi ethnic group, and more than half of the students (63.6%) belonged to the Hindu religion. The majority of the respondent had literate parents. Respondents could not visit their families often (82.3%) but were actively involved in extracurricular activities. Grade (seven and eight), ethnicity (Madheshi), religion (Hindu and Christian), and father education (literate) were positively associated significantly with student-perceived stress (Table 1).   Table 3). The detail of the multicollinearity test is given in the supplementary file (available here).

3.5.
Coping Strategy of the Respondents. Although being in a hostel, most respondents (n = 103, 49.3%) reported receiving help from family members "all of the time." Seeking social support was the standard approach taken by the respondents. On the other hand, "I swear (use bad words) out loud" was the least approach taken by the majority of the respondents (n = 122, 58.4%). "Not at all" was the median response to the three externalizing coping strategies: yelling or  [32,33]; nonetheless, the observed statistics in our research surpass those delineated in the aforementioned studies, and the discrepancy may stem from variances in the age and locale of participants across the respective studies. However, a study conducted among adolescent students of a private school in the Chitwan district (attached district to Hetauda), irrespective of hostel residents, reported high and moderate stress levels in 48% and 14% of adolescent students, respectively [19]. On the contrary, a study among adolescent students in public schools in Kathmandu, Nepal, reported stress in only 27.5% of the students [34]. The variation among the findings of the same country could be due to differences in education settings, residency, and possibly study period. Similarly, determining possible stressors is essential to resolve students' perceived stress. On observing the possible stressors of hostel students, we found strict discipline in the hostel (77.3%) and worries regarding the future (71.29%) as the most common stressors experienced. Evidence also shows that future-oriented stress and academic stress are major stressors among students [21,22,35]. This highlights the value of providing school students with careeroriented assistance and counselling to lessen unneeded stress.

Factors Associated with Perceived Stress.
In multivariable logistic regression analysis, the presence of a mischievous element in the dorm (AOR 4.283) and rejection from friends due to physical appearance (AOR 3.063) were only found to be positively associated with perceived stress. The mischievous element and rejection of friends appeared to affect the stress by more than 3 odds, which is very high and complied with the previous studies that state the causation of emotional disturbance and stress by unequal behaviour and relationship and rejection by friends [36,37]. This finding reinforces the crucial point of students' behaviours towards each other, assessing the environment and situation to improvise. Developing a friendly and helpful we-ness environment within an accommodation area is very helpful to promote the psychological welfare of people [38]. Different levels and standards of school hostels are available in Nepal depending on their fees, which might have a good environment preventing potential stressors. However, most lowand middle-income families may be unable to afford the expensive ones in Nepal [39]. Hence, there is actually a need for a student-friendly qualitative student hostel at a reasonable cost. Furthermore, the appropriate steps taken in man-aging stress at the early stage of the student level are imperative as it can prevent the psychological, physical, academic, and self-harm-related stress consequences in students [40].
Former studies in Nepal found that pupils' gender, age, parent's education, and family structure, such as family type, family dispute, parent marital status, and living with parents, are strongly related to how much stress they felt [17][18][19]. However, our findings revealed no significant correlation between students' age and gender with perceived stress and only a correlation with the father's education, ethnicity, study grade, and home visit in univariate analysis. This difference may be due to students' residential and school environments, which has already been reported as one of the vital factors for causing perceived stress in students [22].

Students' Coping Mechanism for Perceived Stress.
Although most students reported experiencing stress symptoms, only around one-third of the students were very confident about their ability to handle their problems, said they could cope with all the things, and felt that their difficulties were not increasing so much that they could not overcome them. Moreover, most of them became upset, nervous, stressed, and angered to some level when things went out of control. Similarly, school students of Chitwan (a nearby city to Hetauda) were confident about their problem-handling ability, and most of the time, they also became upset, nervous, stressed, and angered by uncontrolled conditions [19]. On the contrary, physiotherapy students in Malaysia perceived themselves as less confident in handling and coping with their problems [41]. It is a positive finding that at least some students have a good attitude and confidence to solve their prob-lems. Also, the results suggested monitoring the change in students' behaviours (fear, nervousness, and anger) and providing appropriate knowledge and education on coping approaches to deal with the problem. Furthermore, the study found that most students tried to solve their problem themselves and sought social support to cope with their stress. Bhattarai et al. also reported spending time with close ones and looking at good things as a common coping strategy adopted by adolescent students [19]. Closeness, continuous provision of comfort and love, and proper education and counselling by the peer and parents were the fundamental approaches suggested to combat the stress-related problem in children [42][43][44][45]. Therefore, parents and caretakers should respond to them with good communication, affection, and respect whenever they need help and help them also to explore different coping strategies [46]. A few students also said they sometimes or hardly ever share their problems and feeling with their parents and friends. Thus, students should also be provided proper guidance and education to communicate effectively with their parents and friends. Family guidance and proper mental health education from their education institutions could contribute significantly in resolving mental health problems [47]. On the other aspect, there is still a challenge in providing emotional and mental health education and counselling to students at the school level due to the lack of particular regulations and policies in Nepal [48,49]. However, this study's finding greatly recommends academic institutions and residential institutions to develop and provide mental health care.
On the other hand, students rarely utilized externalizing strategies to deal with their stress. One potential explanation for it could be the dormitory's rigorous regulations because academic hostels mostly have strict rules; in this study, 77.03% of the students reported that. However, students' low externalizing behaviour may result from their desire to get occupied in socially and culturally acceptable activities and settings in which they were raised. Nevertheless, the lower externalizing behaviour is good as it indicates a lower possibility of the students' detachment to their education [50]. It is also revealed that students were likely to watch TV, read books, and think about something good to get distracted from stress. In contrast to our findings, Leonard et al. found that along with adaptive coping strategies, high school students in the USA were also using substance/alcohol abuse as a coping approach [51]. This discrepancy may be attributed to limited access to illegal substances for students living in hostels. Additionally, significant cultural and societal differences between the study site and the United States have also played a role in this discrepancy. Overall, the management of facilities for entertainment, refreshment, and distraction should be promoted in the student hostel in order to prevent students from using possible unhealthy coping mechanisms like substance abuse and bad behaviour [52].

Strength and
Limitations. This is the first study documenting the perceived stress, potential stressors, and coping strategies used and predictors of perceived stress in students residing in private educational hostels in Nepal. Also, it has given a baseline context of the stress situation and discussed the potential approaches to resolve their current stress problem. Further study is needed to investigate interventions that decrease stress levels and facilitate practical coping strategies among hostel students. A comparative study can be carried out between government school hostels and private school hostels, day-care and residential hostels, and home and hostels to better understand the prevalence and characteristics of stress and coping strategies of adolescent students. Along with that, the study retains some limitations. The study was limited to one metropolitan city in Nepal and was further constrained by the COVID-19 pandemic, which led to a reduced number of the students in hostels and hence in our study. Therefore, all the students living in the hostel were selected at the time of the visit. On the other hand, a large national-level study is recommended to determine adolescent students' stress status in a school hostel in Nepal. Secondly, the study is limited to being cross-sectional, which reported the perceived stress and coping strategy at the point of the visit. Therefore, any changes throughout the year nor the causal direction of these variables were not evaluated.

Conclusion
The study confirmed the presence of perceived stress among students living in the hostel, where hostel residential factors (mischievous element and rejection of friends) were the predominant predictors. Strict discipline in the hostel, worries regarding their future, and differences in language were the most common stressors reported by the students. However, the minority students could only cope with the situation and mainly sought social support to manage their stress. Therefore, proper educational counselling must be provided to students to cope with the mental pressure. Second, proper education and counselling must be provided to caretakers of the hostel and school delegates to monitor and evaluate the student's psychological health and provide appropriate care. In addition, the hostel administrators require to be concerned about establishing a friendly, mutually respectful environment. Hostel guardians must closely monitor students' relationships, behaviours, and their impact on their mates. Moreover, parents should monitor their children's psychological and emotional well-being and interact with them to help them cope with the stress experienced at their academic and residential sites. The governmental authorities and academic institutions are recommended to prepare a policy and practice of providing psychological care to adolescent students in educational institutions too.

Data Availability
Data is not publicly available but can be shared by the corresponding authors on reasonable request.

Conflicts of Interest
There is no potential conflict of interest reported by the authors.

Authors' Contributions
Rajeev Shrestha and ST conceptualized and designed the study. ST coordinated and monitored the data collection. Rajeev Shrestha conducted the data analysis. Rajeev Shrestha, ST, and Rajina Shakya wrote the draft of the manuscript. NS, YK, TH, and AO critically reviewed and edited the manuscript. All authors reviewed and approved the final manuscript. Rajeev Shrestha and ST contributed equally to this work. 8 Mental Illness