Stress levels in Portuguese 1st year medical students

Ana Filipa Marques; Ana Rita Soares; Carlos Filipe Neves; Emanuel Brilhante; Joana Filipa Tavares;

João Pedro Freitas; Mafalda Correia; Mariana Gomes; Pedro Tavares; Vítor Silva.

fmup21@gmail.com

Prof. Dr. Armando Teixeira-Pinto. Class 21

ABSTRACT

Stress is a problem that affects students, especially medical students who are known for their

stressful life. In the case of first year medical students, levels of stress may be in fact high. This study

may be considered innovative since it pretends to identify general causes of stress and not specific

factors related to school environment or type of learning. Besides that, we consider that focusing on

first year students, we may analyse the stress factors of a special population, in which is present an

important stress factor - the transition to college.

Therefore, this study pretends to assess stress levels among first year medical students and

identify some factors related to those levels.

Accordingly, we have defined the 280 first year medical students of Faculty of Medicine of

Porto University as our sample. To find out the incidence of stress in those medical students, they

were asked to complete a questionnaire – General Health Questionnaire-12 – and some questions

about factors related to stress. Then, the results of this cross-section study were statistically

analyzed, using SPSS program. Therefore, we created a histogram to evaluate if the variable stress

followed a normal distribution. As the results were unclear we proceeded with a Kolmogorov-Smirnov

test, and concluded that the data doesn’t follow a normal distribution. But, since Kolmogorov-Sminorv

test is very sensible we analyzed variables using t-tests. As we didn’t obtain any statistical significant

values, we decided to use non-parametric tests, namely Mann-Whitney U and Kruskal-Wallis. We

also didn’t obtain any results, so in our final analyses we categorized the levels of stress in three

categories (low, medium and high or very high stress). Finally we used frequencies tables as

summary measure and analyzed the results through crosstabs and chi-square tests, considering 0,05

our statistical significance level.

All the chi-square tests showed that there is no significant relation between the variables

(gender, attending for the first time to an undergraduate course, being away from home, living alone,

practicing extracurricular activities, having a boyfriend/girlfriend, being a part-time student, smoking,

hours of study, hours of sleep and zodiac sign) and the levels of stress, since p value is always

higher that 0,05.

In conclusion, the percentage of students with low and medium stress levels is higher than the

percentage of students with high or very high stress levels of stress and all the variables that were

analyzed didn’t show any significant relation with stress levels.

KEY-WORDS: Stress; Medical; Students; University; Porto.

INTRODUCTION

Stress is the body’s specific answer – emotional, physical or cognitive – when it is exposed to

an external stimulus, which requires a greater response than the one it is used to giving.

Nevertheless, stress can be a positive factor and it is always present, although its intensity changes:

it is very low when a person is resting or sleeping and extremely high after a severe accident.

In this manner, society’s concern about stress has been increasing because, nowadays, this

problem affects a very large number of people and is felt earlier in life. Therefore, it is in our best

interest to analyse this subject. In this way, this project will broach one of the most stressful factors in

young people – entering University.

In fact, it is important to study the levels of stress of first year university students because

entering and attending a degree at university implies huge changes concerning responsibility,

working habits as well as transformations in the youngsters’ social life. Considering all this, some

studies(1,2,3,4,5) point out the amount to learn, the time amounts of the course and examinations as

factors that increase stress levels. On the other hand, uncertainty about individual study behaviour,

fear of failure and inadequacy in social activities are considered important psychological factors.

Lastly, inadequate time for relaxation and for practising other activities is also considered by

university students as stressful factors. Considering all this, it is easy to understand the intimate

relation between high stress levels and mental diseases, such as depression(6,7), as well as with

weight changes(8), both loss and gain. Therefore, it is essential to know whether or not there are high

stress levels in first year university students.

On the other hand, we chose to focus only on medical students, since this course is, at first

glance, extremely stressful, because not only does it require many hours of study, but also because

students have to develop interpersonal skills and self-confidence, in order to be “fully”-qualified

doctors in the future.

In this way, there have been made, as we have already mentioned, several studies about this

subject in other countries. Also in Portugal, it has been made a study to evaluate the stress levels in

first year medical students of Faculdade de Medicina da Universidade do Porto(9). So, our work is

innovative not because it measures the stress levels of Portuguese students. It will be innovative in

the type of stress factors that are analysed. In fact, the study previously made measured not only

factors of a more general character, like sleeping hours and the changes associated to the transition

to college, concerning autonomy, demands and responsibility, but it also focused very specific

factors. Examples of these factors are the evaluation system, FMUP's environment and the fact that

the type of education/learning is focused on memorization. This is shown on the graphic below, which

is a synthesis of a graphic of this study.

So, our study is innovative because we analyse only general factors, which allow us to broad

the results to a larger population. This is very important because the study reaches and is interesting

to a large number of people.

Other than that, this study was about students of all years, while our study analyse only first

year students. We believe that focusing our study on this population, we will be able to analyse the

stress factors of a very unique population in which its present a very important stressor factor – the

transition to college.

RESEARCH QUESTIONS AND AIMS

The study that is being developed has two main objectives. The first one is to assess the stress

levels of first year medical students in a Portuguese medical school. The second objective is to

identify some factors that might be related to academic stress, namely: gender, being away from his

normal residency, attending for the first time to an undergraduate course, having extracurricular

activities, having a partner, being a part-time student, amount of study hours, smoking status, living

alone and sleeping hours.

Our study is of great interest because, although it has been made at least one study about

stress levels in Portuguese students, our project has specific characteristics that make it unique and

important to analyse a population that, according to our research, has never been properly studied.

PARTICIPANTS AND METHODS

Study participants

Regarding the participants, the target population is first year medical students. Accordingly, we

have defined the first year medical students of Faculty of Medicine of Porto University as our sample.

In what concerns sampling methods we chose a non-randomized method, specifically

convenience sampling. In our study the inclusion criteria was being a first year medical student. No

exclusion criteria was defined.

Study design

Concerning the study design, our study is a cross-sectional study.

Data collection methods

In order to collect the data, we used the General Health Questionnaire-12 (GHQ-12) (10). This

questionnaire is a resumed version of the General Health Questionnaire-28 and accesses the

general state of the health of an individual, being the majority of the questions about the

psychological state. The English version of this questionnaire was chosen since it is validated and

scored. The translation was made separately by two translators and then the two versions were

confronted with each other. The final translation was also compared with a translation that had

already been made in another study(9). Finally, we added to the questionnaire the general questions

related to the variables in study. Before the application of the questionnaire to the sample, it was

made a pilot-application in a sample of ten individuals that are not part of the sample.

Regarding the score of the questionnaire, the answers of every question are scored from 0 to

3. So, to obtain the level of stress we some them up. Than, the value obtained is put into one of the

three categories defined from the questionnaire: less or equal to 10 means low stress; from 11 to 15

means medium and more than 15 means high or very high stress.

Variables description

In relation to variables, the dependent variable is the stress level. In what concerns the

independent variables, our aim is to find out if they have a significative relation with stress levels.

Therefore, they can be considered either causes or consequences of stress. In fact, these

independent variables are factors as gender, being away from his normal residency, living alone,

being a part-time student, amount of study hours, attending for the first time to an undergraduate

course, smoking status and sleeping hours. Finally, having a partner and extracurricular activities are

factors that give us these two perspectives because, on one hand, they can be causes of stress by

demanding time and dedication and, on the other hand, they can be factors that minimize stress by

being a distraction, allowing the abstraction from questions related to the course. We also added to

the questionnaire a question about the zodiac sign that will work as a control factor.

We chose to apply the questionnaire during the class of Introduction to Medicine. In order to

do this, we asked the collaboration of the professors to deliver the questionnaire in the first three

minutes of the class. This application was made in the first two weeks of March.

Statistical Analysis

The statistical analysis was performed using SPSS for Windows. Descriptive methods were

used to summarize the data. Since all our variables are categorical, we used absolute and relative

frequencies.

Firstly, we wanted to find out if the variable stress could follow a Normal distribution. So, we

built a histogram and the result wasn’t conclusive enough. Thus, we applied to the Kolmogorov-

Smirnov test, which lead us to reject H0 (H0: the variable stress follows a Normal distribution),

because the value of p (significance level) was lesser than 0,05 (p=0,001). But due to the very high

sensibility of the Kolmogorov-Smirnov and the presence of some stress values that had great

deviation to the mean we analysed the stress level as a variable with a normal distribution. This

analysis didn’t show us any significant relation between the stress levels and the variables in study.

We also consider the variable as a categorical one, which was divided into four categories

accordingly to the questionnaire (low stress levels, medium stress levels, high stress values and very

high stress values). This way, we analysed the results through crosstabs and a chi-square. This

analysis showed that there was a significant relation between the stress levels and the variables

“Having a boyfriend/girlfriend” and “Hours of study”. But, due to the low frequencies of students in the

high and in the very high categories we decided to collapse these two categories in one category

(high or very high stress levels) so that the statistical analysis could be more solid and to prevent

statistical errors. Consequently we performed our analysis of the results through crosstabs and chi-

square tests, using only the final three categories.

Besides considering stress as a categorical variable, we decided to analyse it as a continuous

one, using non-parametric tests. Related to the variables gender, attending for the first time to an

undergraduate course, being away from his normal residency, living alone, having extracurricular

activities, having a partner, being a part-time student and smoking status, we used Mann-Whitney U

test to verify if there was any relation between these variables and the stress levels. To verify if there

was any relation between the variables amount of study hours, sleeping hours and zodiac sign and

the stress levels, we used Kruskal-Wallis test.

At the end, we verified that there was no relation in both situations. Thus, we decided to

consider the stress levels a categorical variable, with the high and the very high categories collapsed,

so that we could achieve more consistence in the applied method.

RESULTS, TABLES AND GRAPHICS

After the questionnaire delivery, there

were obtained 236 answered questionnaires,

out of the 280 first year medical students.

As mentioned before, the stress levels

were divided in three categories. The

distribution in these categories(Table 2 and

Graph 2) is: 38,6%(N=91) of the students

have low levels of stress, 37,3%(N=88) have

medium levels and 23,3%(N=55) have high

or very high levels of stress. Besides this

there were two missing values (0,8%).

Table 1 – Frequency of stress categories

GenderStarting by the variable gender, the frequencies table (Table 2) showed that 64.4% of the

students are female (N=152) and that 35.6% are male (N=84).

Frequency Percentage

Valid

values

Male 84 35,6

Female 152 64,4

Total 236 100,0

Frequency Percentage

Valid

values

Low levels of stress 91 38,6

Medium levels of stress 88 37,3

High or very high levels of

stress

55 23,3

Total 234 99,2

Missing 2 0,8

Total 236 100,0

Graphic 1 – Frequency of

stress categories

Table 2

Table 2 – Frequencies table concerning the sex

According to the crosstab (Table 13) we verify that the percentage of male and female per

each stress category is similar. Consistent with, the chi-square test showed that there is no

significative relation between the gender of an individual and the levels of stress, since p>0,05

(p=0,972). Therefore we accept the H0: Levels of stress on male are equal to levels of stress on

female.

Attending for the first time to an undergraduate course

Related to the variable attending for the first time to an undergraduate course, the frequencies

table (Table 3) showed that 86.4% of the students are away from home (N=204) and 13.6% are not

(N=32).

The crosstab (Table 13) allow us to verify that the percentage of students who aren´t for the

first time at an undergraduate course is higher in the low level of stress category. On the other hand,

the percentage of students who are for the first time at an undergraduate course is higher in the

category of medium levels of stress. In the high or very high category we observed that the

percentage of students who are for the first time at an undergraduate course or not is approximately

the same. The chi-square test shows that there aren’t significative differences, since p>0,05

(p=0,565). Therefore, we accept H0: Levels of stress on students that are attending for the first time to

an undergraduate course or not are equal.

Being away from home

Related to the variable being away from home, the frequencies table (Table 4) showed that

51,3% of the students are away from home (N=121) and 48,7% are not (N=115).

Frequency Percentage

Valid

values

Yes 121 51,3

No 115 48,7

Total 236 100,0

Frequency Percentage

Valid

values

Yes 204 86,4

No 32 13,6

Total 236 100,0

Table 4

Table 4 – Frequencies table concerning being

away from home

Table 3 – Frequencies table concerning attending

for the first time to an undergraduate course

The crosstab (Table 13) show us that there is a higher percentage of students who aren’t away

from home in low stress levels, however there is a higher percentage of students who are away from

home with high or very high levels of stress. In the medium category of stress the percentage of

students who are away from home or not is similar. The chi-square test allows us to verify that this

differences aren’t statistically significative, since p>0,05 (p=0,492). Therefore, we accept H0: Levels

of stress on students that are away from home or not are equal.

Living alone

In what concerns to this variable, the frequencies table (Table 5) showed that 10.6% of the

students live alone (N=25), while 89.4% don’t (N=211).

The crosstab (Table 13) allow us to verify that there are some differences between students

who live alone and not. There is a higher percentage of students who don’t live alone in the low level

of stress category. In the high or very high stress category there is a higher percentage of students

who live alone. In the medium stress level category the percentage of students who live alone and

those who don’t are approximately the same. The chi-square test showed us that those differences

are not statistically significant, because p>0.05 (p=0.543). So, we accept H0: the levels of stress on

students who live alone are equal to the levels of those who don’t.

Having an extracurricular activity

Regarding the variable having an extracurricular activity, the frequencies table (Table 6)

showed that 59,3% of the students practice an extracurricular activity(N=140), while 40,7%

don’t (N=96).

Frequency Percentage

Valid

values

Yes 140 59,3

No 96 40,7

Total 236 100,0

Frequency Percentage

Valid

values

Yes 25 10,6

No 211 89,4

Total 236 100,0

Table 5 – Frequencies table concerning

living aloneTable 6

Table 6 – Frequencies table concerning having

an extracurricular activity

Looking at the crosstab (Table 13), we see that the percentage of students who practice an

extracurricular activity and those who don’t per each stress category is similar. Consistent with, the

chi-square test showed that there is no significative relation between this variable and the levels of

stress, since p>0,05 (p=0,994). Therefore we accept the H0: Levels of stress on students who have

an extracurricular activity and on those who don’t are equal.

Girlfriend/Boyfriend

Related with the present variable, the frequencies table (Table 7) showed that 38.6% of the

students have a boyfriend/girlfriend (N=91) and that 61.4% have not (N=145).

Frequency Percentage

Valid

values

Yes 91 38,6

No 145 61,4

Total 236 100,0

The crosstab (Table 13) allow us to verify that there are a higher percentage of students who

have a boyfriend/girlfriend in the medium stress category. In contrast, the percentage of students who

haven’t got a boyfriend/girlfriend in low and in high or very high levels of stress categories is similar.

The chi-square test shows that there is no significative differences, since p>0,05 (p=0,739).

Therefore, we accept H0: Levels of stress on students that have a partner or not are equal.

Part-time studentRelated to the variable being a part-time student, the frequencies table (Table 8) showed that

3,0% of the students are part-time students (N=7) and that 97,0% aren’t (N=229).

The crosstab (Table 13) allow us to verify that the percentage of part-time students that have

low and medium stress levels is lower than the percentage of non part-time students. On the other

hand, the percentage of part-time students in the high or very high levels of stress category is higher.

However, the chi-square test showed that there is no significative relation between being a part-time

Frequency Percentage

Valid

values

Yes 7 3,0

No 229 97,0

Total 236 100,0

Table 7 – Frequencies table concerning

having a girlfriend/boyfriend

Table 8 – Frequencies table concerning being

a part-time student

student and the stress levels, because p>0,05 (p=0,471). But, since 50% of the cells expected count

less than 5, we chose to do an exact test. The result was p=0,543 (p>0,05). Therefore we accept the

H0: Levels of stress on part-time students are equal to levels of stress on non part-time students.

Smoking

Related to the variable being a smoker, the frequencies table (Table 9) showed that 8,1%

of the students are smokers (N=19) and that 91,9% aren’t (N=217).

Frequency Percentage

Valid

values

Yes 19 8,1

No 217 91,9

Total 236 100,0

The crosstab (Table 13) allow us to verify that there are some differences between students

who smoke and not. There is a higher percentage of students who don’t smoke with low stress levels.

On the other hand, in the high or very high stress category there is a higher percentage of students

who smoke. In the medium stress category the percentage of students who smoke or not is similar

However, the chi-square test showed us that those differences are not statistically significant,

because p>0.05 (p=0.650). So, we accept H0: the levels of stress on students who smoke are equal

to the levels of those who don’t.

Hours of study

Related to the variable hours of study, the crosstab (Table 10) showed that 50% of the students

study less than 2 hours (N=118), 47,9% between 2 and 5 hours(N=113), 2,1% between 5 and 8 hours(N=5).

Frequency Percentage

Valid

values

Less than 2 118 50,0

Between 2 and 5 113 47,9

Between 5 and 8 5 2,1

Total 236 100,0

The crosstab (Table 13) allow us to verify that there are some differences in the levels of

stress between the different groups. We noticed that in the low and medium stress categories there is

a higher percentage of students who study between 2 and 5 hours a day. On the other hand, in the

category of high or very high levels of stress, there is a higher percentage of students who study

Table 9 – Frequencies table concerning

being a smoker

Table 10 – Frequencies table concerning the

hours of study

between 5 and 8 hours a day. However the chi-square test told us that there are no statistically

significant differences, because p>0.05(p=0.407).

But, since 33,3% of the cells expected count less than 5, we did an exact test. The result was

p=0,513 (p>0,05). Therefore we accept the H0: levels of stress of the students who study less than 2

hours are equal to those of the students who study between 2 and 5 and equal to the levels of the

students who study between 5 and 8 hours.

Hours of sleep

Related to this variable, the frequencies table (Table 11) showed us that 3% of students sleep less

than four hours (N=7), 55,8% sleep between four and six (N=130), 30% sleep between six and eight (N=70)

and 11,2% sleep more than eight hours (N=26).

Frequency Percentage

Valid

values

Less than 4 7 3,0

Between 4 and 6 132 55,9

Between 6 and 8 70 29,7

More than 8 26 11,0

Total 235 99,6

Missing 1 0,4

Total 236 100,0

The crosstab (Table 13) allow us to verify that the percentage of students who sleep less than

four hours a day is higher in the low and high or very high levels of stress categories. However, the

percentage of students who sleep between six and eight hours a day is higher in the medium stress

level category. The chi-square test showed us that p=0,385 so, p>0,05. But, since 25,0% of the cells

expected count less than 5, we did an exact test. According to this test, p=0,379. Therefore, we

accept H0: Levels of stress on students that sleep less than 4 hours, sleep between 4 and 6 hours,

sleep between 6 and 8 hours and sleep more than 8 hours are equal.

Zodiac Sign

Analyzing the factor Zodiac signs, the frequencies table (Table 12) showed that 6,8% of the

students are Aries (N=16); 9,4% are Cancer (N=22); 7,7% are Libra (N=18); 10,3% are Capricorn

(N=24); 12,0% are Taurus (N=28); 15,8% are Leo (N=37); 3,0% are Scorpio (N=7); 3,8% are

Aquarius (N=9); 8,1% are Gemini (N=19); 7,7 are Virgo (N=18); 6,8% are Sagittarius (N=16) and

8,5% are Pisces (N=20).

Table 11 – Frequencies table concerning the hours of study

Frequency Percentage

Valid

values

Aries 17 7,2

Cancer 22 9,3

Libra 18 7,6

Capricorn 24 10,2

Taurus 28 11,9

Leo 37 15,7

Scorpio 7 3,0

Aquarius 9 3,8

Gemini 19 8,1

Virgo 18 7,6

Sagittarius 17 7,2

Pisces 20 8,5

Total 236 100,0

According to the crosstab (Table 13) of the variable Zodiac Signs, we verify that in the low

stress level category there is a higher percentage of students whose zodiac sign is Aries. We also

observed that in the medium stress level category there is a higher percentage of students whose

zodiac signs Libra. In the high and very high category we find a higher prevalence of students whose

zodiac sign is Scorpio.

Although the results observed in the crosstab, the chi-square (Table 35) showed that that is no

significative relation between the zodiac signs and the stress levels, since p>0,05 (p=0,376). Since

33,3% of the cells expected count less than 5, we did an exact test. However, the program was

enable to realize it, so we couldn’t obtain the p value. Therefore we used the result of the chi-square

test and accepted H0 (H0: the levels of stress of the students are equal in all signs).

Variable analysis

Stress Categoriesp value (chi-

square)P value (exact

test)

Low levels(%)

Medium levels(%)

High or very high levels (%)

Gender Male Female

39,338,7

38,137,3

22,624,0

0,972

Table 12 - Frequencies table concerning the

zodiac sign

First time on an undergraduate course Yes No

37,945,2

38,929,0

23,225,8

0,565

Being away from home Yes No

36,741,2

36,738,6

26,720,2

0,492

Living alone Yes No

32,039,7

36,037,8

32,022,5

0,543

Extracurricular activities Yes No

38,838,9

37,437,9

23,723,2

0,994

Boyfriend/girlfriend Yes No

37,439,9

40,735,7

22,024,5

0,739

Part-time student Yes No

28,639,2

28,637,9

42,922,9

0,471 0,543

Smoking Yes No

31,639,5

36,837,7

31,622,8

0,650

Hours of study <2h 2h-5h 5h-8h

38,540,220,0

37,638,420,0

23,921,460,0

0,407 0,513

Hours of sleep <4h 4h-6h 6h-8h >8h

57,140,032,942,3

14,333,848,634,6

28,626,218,623,1

0,385 0,379

Zodiac sign Aries Cancer Libra Capricorn Taurus Leo Scorpio Aquarius Gemini Virgo Sagittarius Pisces

68,850,022,229,228,637,814,333,347,438,937,550,0

12,531,855,645,850,040,528,633,342,133,337,520,0

18,818,222,225,021,421,657,133,310,527,825,030,0

0,376

DISCUSSION

During this study, we pretend to access stress levels of first year medical students (we defined

students of Faculty of Medicine of Porto University as the sample) and to identify some factors that

might be related to those levels. In spite of what was expected, we verified that the percentage of

students with low and medium stress levels (38,6% and 37,3%) is higher than the percentage of

students with high or very high stress levels (23,3%). Moreover, all the variables analyzed didn’t

show any significant relation with stress levels. Our results may be explained by some factors such

as, bad quality/wrong interpretation of the questionnaire, lack of encouragement to fill honestly the

questionnaire, incorrect choose of the variables or sample and difficulties to quantify stress.

Tabela 13 – Sum up table of the crosstabs, chi-square and exact tests, resulting from the variable analysis

In order to compare our results with previous studies, we decided to focus on “Estudo da

relação entre o stress e os estilos de vida nos estudantes de Medicina” (9) due to its similarity with our

study. Although this study involved students from every academic year and our study only focused on

first year medical students, both of them meant to measure stress levels in FMUP.

In opposition to that study, which found that 58,2% of medical population had high stress

levels, our results showed that just 23,3% of first year medical students have equivalent levels.

However, we were not able to compare the results between both studies, as the variables in study

were completely different.

Although we didn’t find any significant statistical results, this study can be an important tool in

the study of stress, since it shows the need to invest in the search of new variables that may explain

the stress levels among medical students.

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