Stress: Prevalence and correlates among residents of a suburban area.

BACKGROUND AND OBJECTIVES: Stress is a major concern in the present scenario as it is occurring in a big way involving all age groups. The objectives of this study were estimating the prevalence of stress, assessing the associated stress factors, and symptoms of stress among residents of suburban community.
MATERIALS AND METHODS: The community-based cross-sectional study was conducted in a suburban area in Delhi from June to August 2017. Adults and children aged 14 years and above permanently residing (1 year or more) in the area were included in the study. A sample size of 384 was calculated with the alpha error set to 05% and absolute error 05%, and to cater for refusals, a total of 400 participants were approached. A structured questionnaire was used for the study by interview method. To estimate the prevalence of stress, a standardized scale, depression, anxiety, and stress scale 21 was used.
RESULTS: The mean age of the participants in the study was 36.31 (±15.10), with 51.2% of males and 48.8% of females. Among the children, the leading factors associated with stress were studies (41.2%), poverty (22.1%), and competitions (16.2%). Among the adults, the leading factors were financial problems (35.2%) and children's studies (23.1%). The most common reported somatic symptom during stress was headache (59.8%) and psychological symptom was "unable to sleep" (47.5%). The prevalence of stress was 26% in a subset of sample in this study. There was a statistically significant association of stress with family size, the level of stress decreased with an increase in family size.
CONCLUSION: The study emphasizes the need for effective prevention and management of stress in the community and schools. Copyright:

Stress is a major concern of the modern era. It has been dubbed as “the health epidemic of the 21st century' by the WHO.[1] The term “stress” was derived from the Latin word “stringere,” meaning the experience of physical hardship, starvation, torture, and pain. Selye who coined it in 1936, defined it as a “nonspecific response of the body to any demand for change.”[2]

Acute responses to stress may be in the areas of feelings (anxiety, depression, irritability, fatigue), behavior (withdrawn, aggressive, tearful, unmotivated), and thinking (difficulties of concentration and problem solving) or physical symptoms (palpitations, nausea, and headaches).[3] Persistent stress might lead to changes in neuroendocrine, cardiovascular, autonomic, and immunological functioning, leading to mental and physical ill-health (anxiety, depression, heart disease, etc.).[3]

Previous studies on stress across the world have shown the prevalence and sources of stress to vary according to age[4] and gender.[45] A study in Delhi showed stress due to studies and examinations as reported by 71% of the school-going children.[6] Social and environmental factors also have an influence on stress levels. Low socioeconomic status (SES) is generally associated with distress, prevalence of mental health problems, and with health-impairing behaviors that are also related to stress.[7]

The present study was planned in a suburban area of Delhi with the objectives of estimating the prevalence of stress among suburban community, assessing the associated stress factors and symptoms of stress among families of the suburban community. The aim of this study was to accumulate evidence regarding stressors.

MATERIALS AND METHODS

Study setting

The present community-based cross-sectional study was conducted in Nangal, Delhi Cantt, the urban field practice area of Department of Community Medicine, ACMS, from June to August 2017.

Inclusion and exclusion criteria

Adults and children aged 14 years and above permanently residing (1 year or more) in the geographic area of Nangal were included in the study. Migrant population visiting their friends and relatives residing in this area >1 year) were excluded from the study.

Sample size

Since prevalence estimates of stressors in this community were not available, a hypothetical maximum prevalence of 50% was taken for this study. A sample size of 384 was calculated with alpha error set to 05% and absolute error 05%, and to cater to any refusal, a total of 400 participants were approached.

Data collection

A structured questionnaire was used for the study. A pilot study of 40 participants (10% of the proposed sample size) in the community was conducted to pretest the questionnaire, and necessary modifications were done. The major domains of the final questionnaire were: socio-demographic profile; factors leading to stress; symptoms; and response to stress. In addition, to estimate the prevalence of stress, a standardized scale, depression, anxiety, and stress scale (DASS 21) was used on a subset of sample. A total of 107 participants who were above the age of 45 years were offered to be part of this study. Of these, 100 participants agreed to respond to the DASS 21.

The DASS[8] is a 42-item self-report instrument developed by Lovibond and Lovibond. It is designed to measure the three-related negative emotional states of depression (D), anxiety (A), and stress (S). Scores for D, A, and S are calculated by summing the scores for the relevant items. In addition to the basic 42-item questionnaire, a short version, the DASS 21, is available with 7 items per scale[9] which was used in this study. The obtained score for each scale are multiplied by 2, to make them comparable to the full DASS score. The stress scale was utilized for this study. The severity rating for this scale is normal – 0–14, mild – 15–18, moderate – 19–25, severe – 26–33, and extremely severe – 34+. The reliability and validity of DASS 21 in measuring symptoms of D, A, and S have been well proven in previous studies.[10]

Higher DASS scores for stress required further assessment, thus those participants with higher scores on the DASS were referred for professional help. A trained medico-social worker from the Department of Community Medicine, ACMS conducted the survey by door-to-door visit in the field, after appropriate training and observation. The pretested structured questionnaire was administered using the interview method. Ethical clearance was obtained from the Institutional Ethics Committee before conduct of this study.

Statistical analysis

The Statistical Package for the Social Sciences (version 22 IBM Corp) was used for data analysis. Data were presented as frequencies (percentage). The Chi-square test was used to test the association of stress with sociodemographic factors. A value of P < 0.05 was considered as statistically significant.

RESULTS

The age of the participants ranged from 14 to 79 years, median-32, mean standard deviation - 36.31 ± 15.10, with 205 (51.2%) males and 195 (48.8%) females. About 67.5% were married and predominantly belonged to Hindus (94.2%) community with 3.3% Muslims. More than half of the participants belonged to a nuclear family (57.3%) and 48.8% of them belonged to lower SES (modified Kuppuswamy scale).[11] Among the participants, 11% consumed alcohol and 10.8% were smokers [Table 1].

Table 1

Sociodemographic profile of the participants

Profile	Group	n (%)
Age	<18	68 (17)
	18-48	238 (59.5)
	49 and above	94 (23.5)
Education status	Nil	69 (17.3)
	Up to middle	89 (22.3)
	Up to intermediate	60 (15)
	Graduate and above	43 (0.5)
SES	Lower	12 (3)
	Upper lower	183 (45.8)
	Lower middle	121 (30.3)
	Upper middle	84 (21)
Addictions	None	279 (69.8)
	Smoking	46 (10.8)
	Tobacco chewing	24 (6)
	Alcohol	44 (11)
	Others	7 (1.8)

SES – Socioeconomic status

The meaning of stress varied as 38.8% considered it to be mental tension. The opinion regarding stress and frequency of feeling stressed is in Table 2. To assess the stress factors, participants were stratified into children (14–< 18 years) and adults (≥18 years). Among the children, the leading factors associated with stress were studies (41.2%), poverty (22.1%) and competitions (16.2%) [Table 3]. Among the adults, the leading factors for their stress were financial problems (35.2%) and children's studies (23.1%) as per Table 4.

Table 2

Opinion and frequency of stress

Response	n (%)
Opinion regarding stress
Negative or unpleasant	43 (10.8)
Distress	47 (11.8)
Bad thing/uncomfortable	147 (36.7)
Mental tension	155 (38.8)
Good thing/motivator	8 (2)
Total	400 (100)
Frequency of feeling about stress
Never	16 (4)
Rarely	84 (21)
Sometimes	260 (65)
Very often	21 (5.25)
Always	19 (4.75)
Total	400 (100)

Table 3

Stress factors among children (age <18 years)

Response	1st choice, n (%)	2nd choice, n (%)	3rd choice, n (%)
School studies	28 (41.2)	4 (5.9)	1 (1.5)
Competitions/exams	11 (16.2)	21 (30.9)	2 (2.9)
Social media	-	2 (2.9)	-
Peer pressure	2 (2.9)	1 (1.5)	2 (2.9)
Fight/argument between parents	5 (7.4)	6 (8.8)	1 (1.5)
Fight/argument between parents and grandparents	1 (1.5)	-	1 (1.5)
Relationship with friends	4 (5.9)	3 (4.4)	3 (4.4)
Relationship with girlfriend/boyfriend	4 (5.9)	4 (5.9)	2 (0.5)
Behaviour of teachers	-	2 (2.9)	1 (1.5)
Addiction of parents	-	-	1 (1.5)
Poverty	15 (22.1)	8 (11.8)	15 (22.1)

Table 4

Stress factors among adult (age≥18 years)

Response	1st choice, n (%)	2nd choice, n (%)	3rd choice, n (%)
Children studies	77 (23.1)	51 (15.3)	21 (6.3)
Relationship problems with spouse	14 (4.2)	8 (2.4)	7 (2.1)
Relationship with problems in-laws	3 (0.9)	5 (1.5)	2 (0.6)
Relationship problems with neighbors	11 (3.3)	6 (1.8)	4 (1.2)
Financial problem	117 (35.2)	87 (26.2)	33 (9.9)
Medical problems-chronic illness/acute illness	5 (1.5)	10 (3.0)	6 (1.8)
Medical problems-self/spouse/children/in-laws/others	18 (5.4)	15 (4.5)	25 (7.5)
Problem of basic amenities (electricity, water, sanitation)	26 (7.8)	37 (11.1)	10 (3.0)
Security problem of children	21 (6.3)	23 (6.9)	16 (4.8)
Workplace problems	25 (7.5)	17 (5.12)	8 (2.4)
Death of spouse	6 (1.8)	2 (0.6)	2 (0.6)

The symptoms experienced by the participants during stress were categorized into somatic and psychological and shown in Table 5.

Table 5

Symptoms (feeling) during stress

Factors	Symptoms	n (%)
Somatic	Fatigue	37 (9.3)
	Headache	239 (59.8)
	Muscle stiffness	33 (8.3)
	Palpitations	37 (9.3)
	Dizziness	19 (4.8)
Psychological	Depression	56 (14)
	Unable to sleep	190 (47.5)
	Easily angered	120 (30)
	Frustration	112 (28)
	Poor concentration	72 (18)
	Excessive eating	9 (2.3)
	Preference for loneliness	51 (12.8)
	Breaking objects	23 (5.8)
Others	Shopping	8 (2)
	Listen to music/entertainment	32 (8)
	Crying	4 (1)

DASS 21, according to the scale, 26% (95% confidence interval, 17.74, 35.73) participants were found to be stressed (mild – 9, moderate – 13, and severe – 4). For the purpose of analysis, the participants were grouped into “normal” and “stressed.” There was a statistically significant association of stress with family size, those with a small family size of <4 members were more stressed than family size more than four (P = 0.017) [Table 6].

Table 6

Association of sociodemographic factors with stress (n=100)

Sociodemographic	Stress, n (%)	No stress, n (%)	P
Age
<14-<18	4 (23.5)	13 (76.5)	0.96
18-48	17 (26.6)	47 (73.4)
49 and above	5 (26.3)	14 (73.7)
SES
Upper lower	13 (37.1)	22 (62.9)	0.148
Lower middle	7 (17.5)	33 (82.5)
Upper middle	6 (24)	19 (76)
Gender
Male	12 (22.2)	42 (77.8)	0.351
Female	14 (30.4)	32 (69.6)
Number of family members
≤4	19 (35.8)	34 (64.2)	0.017
>4	7 (14.9)	40 (85.1)

SES – Socioeconomic status

DISCUSSION

More than half the participants described stress as a “mental tension” or a “bad thing, whereas only 2% considered it to be a good thing or a motivator.

In the current times, children are also vulnerable to stress as are the adults. The study revealed that major stressors among children were studies (41.2%) and competition (16.2%). This is similar to the Delhi study where stress due to studies and examinations were reported by 71% of the school-going children.[6] A study done in Greater Noida, UP among adolescent students belonging to affluent families found significantly higher DASS in students who had low academic marks in their last school exam.[12] According to a study on middle school-going adolescents in Los Angeles,[13] greatest stress was school related to school stressors being reported with the highest frequency.

Financial problems (35.2%) emerged as the major stressors for the adults in our study. A similar community-based study from Malaysia reported financial crisis (24.1%) as a major stressor besides family problems (25.2%).[14] However according to the National Institute of Occupational Safety and Health (NIOSH) report, job stress in American industries among workers is more strongly associated with health complaints than financial or family problems this may be due to our study population is mixed as all are not employed.[15]

Stress over the child's academic performance (23.1%), was the other major stressor among adults. In today's competitive environment, parent's desire their children to excel in studies and consequently tend to worry over their academic performance. It was worthwhile to note that stress due to relationship problems with in-laws was not an important factor found in our study, as is believed in our society. In our study, stress due to workplace problems was less (7.5%) as compared to other studies for example in NIOSH[15] report where 40% of workers reported their job was very or extremely stressful and 25% view their jobs as the number one stressor in their lives, this difference may be due to the fact that our study population was mixed and not all the persons in the study were working. Further we also found that stress due to problems related to basic amenities were also a major factor as it was mentioned by 7.8% of respondents as number one cause of their stress.

Headache was the most common somatic symptom reported by the participants (59.8%) in our study. Studies conducted in India on occupational stress among nurses revealed that somatic symptoms positively correlated with stress perception.[1617] According to NIOSH report, 13% worker believes that their headache is due to occupational pressure.[15] Among psychological symptoms, nearly half of the participants (47.5%) reported inability to sleep during stress. In a nationwide study conducted among adult Americans,[18] for nearly half of Americans (45%) lying awake at night for past 1 month was one stress outcome. “Problems with sleeping when worried” was a common symptom reported in studies conducted among medical students from Agartala in India (25.3%)[19] and a university in Malaysia (71%).[20] Sleep problem manifesting as a symptom may worsen the negative state of stress.

Overall, the prevalence of stress was found to be 26% in a subset of the sample. Of the 83 adults, 22 (26.5%) were suffering from stress. Higher percentage that is around 59% of stress were reported from a Sweden study among adults seeking primary care.[21] Of the adolescents, 4 (23.5%) of 17 were suffering from stress in our study. In the Delhi study, 87.6% school going students were positive for stress.[6]

The number of family members played a significant role on stress in our study, with The higher level of stress decreasing with increase in family members. The increased size of family has possibly acted as a buffer against various stressors in the family due to shared roles and support of the family members. The family constitutes an important source of “social support” which has been described as”A network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help” (www.cancer.gov). Social support may moderate genetic and environmental vulnerabilities and confer resilience to stress, possibly through its effects on the hypothalamic-pituitary-adrenocortical system, the noradrenergic system, and central oxytocin pathways.[22] On the contrary, a study from Korea observed the level of stress increased with increase in family members for the women. For men, the association of family members was not significant.[23]

In our study, stress was not found associated with age, gender, and SES of the participants. However in the America[18] and Sweden study,[21] women have reported higher stress than men. As with our study, there was no indication that experience of stress was related to age, in the Sweden study. It was partly explained in that study by the fact that all participants experienced a health problem, a stress exposure in itself.

CONCLUSION

Major stressor among children was studies and competition and among adults were financial problems and stress over children's study. Headache was the most common somatic symptom and “problems with sleep,” the most common psychological symptom, reported when experiencing stress. The prevalence of stress was 26% in a subset of sample. The level of stress decreased with an increase in family members. The study emphasizes the need for effective prevention and management of stress in the community and schools.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.