Psychological well-being in medical undergraduates in a rural medical college in South India.

BACKGROUND: Medical colleges strive to create a learning environment best suitable for undergraduate medical education. In this process, measures taken can affect and influence the medical undergraduate psychological well-being. The demands of medical education lead to a psychological distress far beyond that experienced by the students of other specialties. AIMS: The aim of this study is to study the levels of psychological well-being in medical under graduates.
MATERIALS AND METHODS: Using a cross-sectional design, 402 medical students were surveyed using the Ryffs's Psychological Well-being Scale.
RESULTS: Low psychological well-being is evident in most of the medical undergraduates with the presence of stressors playing a significant role on psychological well-being with academic stress taking a major role.
CONCLUSION: As depicted from the current study, academic stress plays a role in low psychological well-being of medical students. Copyright:

Psychological well-being is about the lives going well. It is the combination of feeling good and functioning effectively.[1] The “feeling good” component encompasses emotions such as happiness, contentment, interest, engagement, confidence, and affection. While the component of “functioning effectively” involves the utilizing one’s potential to the fullest, exercising control over one’s life having a sense of purpose and experiencing positive relationships.

Psychological well-being is viewed as a combination of positive affective states such as happiness and functioning with optimal effectiveness in individual and social life.[2] Some individuals demonstrate the high level of well-being despite adverse circumstances, whereas others show low levels of well-being despite favorable conditions.[3]

Medical students face various challenges to their well-being during medical training.[4] Persistent worries and fear of not achieving set objectives have a negative impact on a medical student’s perception of well-being.[5] Psychological well-being is beneficial for adults to live a healthy life, especially its importance in the college years cannot be undermined.[6] As Ryff proposed psychological well-being as “the striving for perfection that represents the realization of one’s true potential” is easier said than done in medical students who face gamut of problems that stem from personal, academic, and socio-cultural factors.[78]

Late adolescence is considered to be a transition period of giving up the childhood ties to forming an identity apart from social and familial norms. In addition, medical undergraduates have to deal with a new environment, to relate to other students, enduring a competitive threat, adjust to new teachers and teaching methods. To top it, medical students additionally have to cope with the issues of life and death within the context of their relationship to patients.[9] These problems that are unique to the medical undergraduates can have damaging effect not only on their adaptive skills in the studentship but also long-standing effects on the wellbeing even as medical professionals.[10]

Earlier research focused on the psychopathology and mental disorders and positive aspects of human functioning was neglected.[3] In recent decades, there has been a paradigm shift from disease and deficit model to examine how individuals can be well and happy and to understand what makes an individual flourish and function optimally.[11] This new focus has necessitated further research in how well medical under graduates perceive their well-being. In this context, the present study aimed to (1) to study the levels psychological well-being in medical under graduates.

MATERIALS AND METHODS

This is a cross-sectional descriptive study conducted in PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. Convenience sampling technique was used. Participants included the 1st, 2nd, 3rd, and 4th year M.B.B.S students. Students were prior notified of the study and were motivated to participate, with the understanding that the study was of voluntary nature. Students were approached during one of their regular lectures, with prior permission from the principal and consent of the concerned faculty. Directions to fill the sociodemographic questionnaire and rating scale were given verbally. The purpose of the study was explained, those who were willing to participate in the study were distributed hard copy of the questionnaire and scales along with the informed consent and the responses were collected. All participants were assured of confidentiality of the data provided. Maximum participation was encouraged by emphasizing that the questionnaire was anonymous and would not be revealed to parents or faculty. Students took 30–40 min to complete the questionnaire. The completed questionnaires were collected for the data analysis. The data were collected in the mid–academic year to ensure that exam stress will not affect the analysis.

Those participants who gave written informed consent were included in the study. Students with preexisting medical or psychiatric illnesses were excluded. Incomplete questionnaire was excluded.

The approval of Institutional Ethics Committee was obtained before initiation of the study.

Statistical analysis

The data will be entered into MS Excel 2007 version and further analyzed using the SPSS software version 20 (IBM corp., Armonk, N.Y., USA). For descriptive analysis, the categorical variables will be analyzed by using percentages, and the continuous variables will be analyzed by calculating mean ± standard deviation (SD). For inferential analysis, the numerical data were analyzed using t-test; categorical data were analyzed using the Chi-square test. Logistic regression will be used to study the association between various factors studied and the outcome and P < 0.05 will be considered as statistically significant.

Instruments

Ryff scales of psychological well-being

This study used the 42-item version. It consists of consist of a series of statements reflecting the six areas of psychological well-being: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Participants rate statements on a scale of 1–6, with 1 indicating strong disagreement and 6 indicating strong agreement. Responses are totaled for each of the six categories. Prior to the totaling, items with negative content were reverse scored so that high values indicated psychological well-being. The scale has sound psychometric properties and has been used as a comprehensive and reliable measure of well-being in several contexts. All six scales have demonstrated excellent internal consistency, with Cronbach’s alpha values of 0.93 (self-acceptance), 0.91 (positive relations with others), 0.90 (environmental mastery), 0.90 (purpose in life), 0.87 (personal growth), and 0.86 (autonomy). Test-retest reliability coefficients ranged from 0.81 to 0.85. Research done previously focusing on the reliability and validity of the scale in different cultural contexts supports the six factor model.

RESULTS

A total of 402 medical under graduates participated in the current study to assess the levels of psychological well-being. The age of the participants ranged from 18 to 25 years with most of the study participants (59.7%) belonged to <20 years of age. Majority of the medical undergraduates (35.07%) were in the 1st year of their medical education. While the least participation in the study belonged to the 4th year (16.92%) [Table 1].

Table 1

Sociodemographic profile of medical undergraduates

Sociodemographic variable	Frequency, n (%)
Age (years)
<20	240 (59.70)
21-22	140 (34.83)
>23	22 (5.47)
Total	402 (100.0)
Sex
Female	251 (62.44)
Male	151 (37.56)
Total	402 (100)
Year of MBBS
1	141 (35.07)
2	97 (24.13)
3	96 (23.88)
4	68 (16.92)
Total	402 (100.00)
Father’s occupation
Business	140 (34.83)
Farmer	51 (12.69)
Government employee	121 (30.10)
Private employee	90 (22.39)
Total	402 (100)
Mother’s occupation
Business	5 (1.24)
Farmer	6 (1.49)
Government employee	76 (18.91)
Private employee	26 (6.47)
House wife	289 (71.89)
Total	402 (100)
Stressors if any related to
Family	22 (5.47)
Friends	24 (5.97)
Hostel	58 (14.43)
Studies	96 (23.88)
Others	64 (15.92)
Nil	138 (34.33)
Total	402 (100)
Income per month
10,000-50,000	220 (54.73)
50,001-100,000	144 (35.82)
100,001-200,000	32 (7.96)
200,001-500,000	4 (1.00)
>500,000	2 (0.50)
Total	402 (100)

Low psychological well-being was evident in 203 of the respondents (50.5%), with a mean and SD of 172.8 and 23.9, respectively, for the total score of psychological well-being. While on the sub-scales, the mean and SD were as follows: autonomy (M - 27.02, SD - 6.44), environmental mastery (M - 27.25, SD - 4.60), personal growth (M - 30.04, SD - 5.53), positive relations with others (M - 29.4, SD - 6.19), purpose in life (M - 30.62, SD - 5.55), and self-acceptance (M - 29.34, SD - 6.14). When the subscales were considered, majority of the students scored less on the dimensions of autonomy, positive relations with others, environmental mastery, and personal growth. Students have done reasonably well on the self-acceptance and purpose in life dimension.

Out of the 251 female participants, 63.3% (n = 126) experienced high psychological well-being Table 2.

Table 2

Correlation of clinical variables with psychological well-being in medical undergraduates

Sociodemographic variables	Low psychological score, n (%)	High psychological score, n (%)	Total, n (%)	χ2	P
Sex
Female	125 (61.58)	126 (63.32)	251 (62.44)	0.1298	0.719
Male	78 (38.42)	73 (36.68)	151 (37.56)
Total	203 (100.00)	199 (100.00)	402 (100.00)
Age (years)
<20	116 (57.14)	124 (62.31)	240 (59.70)	1.4114	0.494
21-22	74 (36.45)	66 (33.17)	140 (34.83)
>23	13 (6.40)	9 (4.52)	22 (5.47)
Total	203 (100.00)	199 (100.00)	402 (100.00)
Year of MBBS
1	66 (32.51)	75 (37.69)	141 (35.07)	4.4498	0.217
2	49 (24.14)	48 (24.12)	97 (24.13)
3	57 (28.08)	39 (19.60)	96 (23.88)
4	31 (15.27)	68 (18.59)	68 (16.92)
Total	203 (100.00)	102 (100.00)	402 (100.00)
Father’s occupation
Business	81 (39.90)	59 (29.65)	140 (34.83)	8.8994	0.031*
Farmer	18 (8.87)	33 (16.58)	51 (12.69)
Government employee	56 (27.59)	65 (32.66)	121 (30.10)
Private employee	48 (23.65)	42 (21.11)	90 (22.39)
Total	203 (100.00)	199 (100.00)	402 (100.00)
Mother’s occupation
Business	3 (1.48)	2 (1.01)	5 (1.24)	2.4086	0.661
Farmer	3 (1.48)	3 (1.51)	6 (1.49)
Government employee	33 (16.26)	43 (21.61)	76 (18.91)
Private employee	12 (5.91)	14 (7.04)	26 (6.47)
House wife	152 (74.88)	137 (68.84)	289 (71.89)
Total	203 (100.00)	199 (100.00)	402 (100.00)
Stressors if any related to
Family	12 (5.91)	10 (5.03)	22 (5.47)	18.2354	0.006*
Friends	17 (8.37)	7 (3.52)	24 (5.97)
Hostel	25 (12.32)	33 (16.58)	58 (14.43)
Studies	46 (22.66)	50 (25.13)	96 (23.88)
Others	44 (21.67)	20 (10.05)	64 (15.92)
Nil	59 (29.06)	79 (39.70)	138 (34.33)
Total	203 (100.00)	102 (100.00)	402 (100.00)
Income per month
10,000-50,000	107 (52.71)	113 (56.78)	220 (54.73)	3.1221	0.344
50,001-100,000	79 (38.92)	65 (32.66)	144 (35.82)
100,001-200,000	16 (7.88)	16 (8.04)	32 (7.96)
200,001-500,000	1 (0.49)	3 (1.51)	4 (1.00)
>500,000	0 (0.00)	2 (1.01)	2 (0.50)
Total	203 (100.00)	199 (100.00)	402 (100.00)

In male participants 38.42% (n = 78) of the 151 reported of low psychological well-being which was statistically not significant. High psychological well-being was evident in 62.3% (n = 124) of the medical students aged < 20 years. Majority of the 1st year MBBS students (37.7%) showed high psychological well-being which is statistically not significant.

Out of the 402 respondents, 138 (34.3%) reported of no stressors. High psychological well-being was evident in 39.8% (n = 79) of respondents who had no stressors which was statistically significant. Those who scored high on environmental mastery, positive relations, and self-acceptance subscales exhibited least stressors which are statistically significant [Tables 3-5]. Females also scored high on personal growth subscale (67.51%) which is statistically significant Table 6.

Table 3

Differences in stressors and Self-acceptance subscale

Socio demographic variables Stressors if any related to	Low self-acceptance, n (%)	High self-acceptance, n (%)	Total, n (%)	χ2	P
Family	9 (4.64)	13 (6.25)	22 (5.47)	17.6783	0.007*
Friends	13 (6.70)	11 (5.29)	24 (5.97)
Hostel	24 (12.38)	34 (16.35)	58 (14.43)
Studies	44 (22.68)	52 (25.00)	96 (23.88)
Nil	59 (30.41)	79 (37.98)	138 (34.33)
Others	45 (23.20)	19 (9.13)	64 (15.92)
Total	194 (100.00)	208 (100.00)	402 (100.00)

Table 5

Differences in stressors and environmental mastery subscale

Sociodemographic variables Stressors if any related to	Low environmental mastery score, n (%)	High environmental mastery score, n (%)	Total, n (%)	χ2	P
Family	11 (5.12)	11 (5.88)	22 (5.47)	14.0100	0.030*
Friends	13 (6.05)	11 (5.88)	24 (5.97)
Hostel	32 (14.88)	26 (13.90)	58 (14.43)
Nil	71 (33.02)	67 (35.83)	138 (34.33)
Studies	42 (19.53)	54 (28.88)	96 (23.88)
Others	46 (21.40)	18 (9.63)	64 (15.92)
Total	215 (100.00)	187 (100.00)	402 (100.00)

Table 6

Differences in gender and personal growth subscale

Sex	Low personal growth score, n (%)	High personal growth score, n (%)	Total, n (%)	χ2	P
Female	118 (57.56)	133 (67.51)	251 (62.44)	4.2422	0.039*
Male	87 (42.44)	64 (32.49)	151 (37.56)
Total	205 (100.00)	197 (100.00)	402 (100.00)

High psychological well-being was observed in medical students whose father’s occupation being a government employee (32.7%) and being self-employed doing business (29.7%) which is statistically significant. As the students progressed in the year of their MBBS education, it was noted that they scored less on the purpose in life subscale which is statistically significant Table 7.

Table 7

Differences in Purpose in life subscale in the year of MBBS

Year of MBBS	Low purpose in life score, n (%)	High purpose in life score, n (%)	Total, n (%)	χ2	P
1	61 (31.77)	80 (38.10)	141 (35.07)	12.0483	0.007*
2	45 (23.44)	52 (24.76)	97 (24.13)
3	60 (31.25)	36 (17.14)	96 (23.88)
4	26 (13.54)	42 (20.00)	68 (16.92)
Total	192 (100.00)	210 (100.00)	402 (100.00)

DISCUSSION

The current study set to assess psychological well-being in 402 medical undergraduates in a tertiary teaching hospital in South India. Low psychological well-being was evident in 50.5% of the medical students. This is similar to a study done in Saudi Arabia where medical students showed high psychological distress indicative of low psychological well-being.[12] Another study exhibited high psychological wellbeing in college students.[13]

Overall, psychological well-being did not significantly differ across most of the socio demographic characteristics inclusive of age and gender. This aspect echoes the findings in a study done in Nigeria where sociodemographic data in comparison with the level of psychological well-being was not statistically significant.[14] However, females scored high on the personal growth subscale from the Ryff’s scale of psychological well-being. This is comparable to a study which observed that females scored higher than males in four of the subscales-personal growth, positive relations with others, purpose in life, and self-acceptance.[15] Women across all age groups consistently scored high on positive growth and positive relations with others,[16] in fact women have greater psychological strength than men at least in certain aspects of the well-being and comparable profiles with regard to other dimensions.[17]

In terms of the impact of parents’ occupation on psychological well-being of the students, the results indicate that there were differences between well-being of students in relation to the occupation of their fathers but mothers’ occupation did not significantly affect their well-being. These findings echo a similar study done in Mysore, India.[18] This study also states that students who had the low family income also showed the low levels of well-being which is in contrast to the current study where no significant relationship was found between the income of parents and student well-being.

The current study emphasized the relationship between stress and psychological well-being. Significant proportion of the medical undergraduates who reported of no stressors also demonstrated high psychological well-being. Furthermore, noteworthy is the finding that these students scored high on environmental mastery, positive relations, and self-acceptance subscales. While another study done in medical students highlights a different conclusion in which though the students exhibited moderate-to-high levels of stress, they also were able to maintain the high level of psychological well-being. The authors in this study state that in spite of their findings of stress seemingly not affecting the global well-being, it could be short term and to proactively address the issue before the students become distressed and experience low psychological well-being.[19] Significant finding of the present study is that students who experienced some form of stress during their study tenure reported of low psychological well-being. Interestingly, enough greater proportion of these students reported of academic stress. Based on this finding, it can be stated that students who are less stressed about their academic workload experience better well-being.

Considering the complex information to be learned, the large workload, and the academically stressful and competitive environment of medical school, this finding may not be surprising. Research that can identify the specific academic stressors that affect health and well-being during medical school is recommended. Furthermore, it would be helpful if coping strategies that promote an awareness of academic stress and its consequences be developed and incorporated into medical education and student counseling services. The cross-sectional design limits the capacity to identify causality in relation to psychological well-being. To build on the present findings, the researchers also might consider a longitudinal approach to identify the specific causes of medical student well-being and to ascertain if, and how, well-being changes over time.

Future directions

The present study throws the spotlight onto the type of academic environment that medical fraternity should visualize and work toward to facilitate better opportunities for medical students to fulfill their aspirations of finishing their graduation and become competent doctors. Every attempt be made to help the students with their psychological well-being, academic pursuits should incorporate various innovative methods to impart knowledge going beyond the conventional mode of teaching and addressing causes of academic stress by mentoring programs can go a long way in alleviating students fears and anxiety. Appropriate training for future teachers on diverse teaching methods that are less detrimental to student’s psychological wellbeing is crucial in providing less stressful academic environment. New curriculum for the medical undergraduates rolled out by the Medical Council of India which is competence based will hopefully bring about the much anticipated change in the levels of academic stress and its effect on the psychological well-being of the students. Higher levels of psychological well-being among students would result in happier students who enjoy their learning process.

CONCLUSION

This study concludes that low psychological well-being was evident in most of the medical undergraduates. Students who reported of stress had low psychological well-being, especially academic stress played an important role. Females were better in psychological well-being levels than their male counterparts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 4

Differences in stressors and positive relations subscale

Sociodemographic variables Stressors if any related to	Low-Positive Relations, n (%)	High-Positive Relations, n (%)	Total, n (%)	χ2	P
Family	16 (7.69)	6 (3.09)	22 (5.47)	16.7352	0.010*
Friends	16 (7.69)	8 (4.12)	24 (5.97)
Hostel	29 (13.94)	29 (14.95)	58 (14.43)
Nil	60 (28.85)	78 (40.21)	138 (34.33)
Studies	45 (21.63)	51 (26.29)	96 (23.88)
Others	42 (20.19)	22 (11.34)	64 (15.92)
Total	208 (100.00)	194 (100.00)	402 (100.00)