Anxiety and Stress Among Undergraduate Medical Students of Haramaya University, Eastern Ethiopia.

BACKGROUND: The perceived stress and anxiety among medical students have bleak consequences on their academic performances, physical, and psychological wellbeing. However, there is a dearth of reliable epidemiological studies in Ethiopia on medical student's experience of stress and anxiety. Therefore, this study was aimed to determine the prevalence and identify factors associated with stress and anxiety among undergraduate medical students of Haramaya University, Eastern Ethiopia.
METHODS: An institutional-based cross-sectional study was conducted from May 13 to June 12, 2019 among 523 participants selected by simple random sampling technique. Data were collected by using structured questionarie through self-adminstered method. Data were entered by Epidata version 3.1 and analyzed using Stastical Package for Social Science(SPSS) version 22. Bivariableand multivariable logistic regression analysis were conducted to identify factors associated with anxiety and stress. Adjusted Odd Ratio (AOR) and 95% Confidence Interval(CI) was used to show the strength of association, and P-value of 0.05 was used to declare statistical significance.
RESULTS: The prevalence of stress was 44% (95% CI: 40.2%-48.2%) and anxiety was 48.9% (95% CI: 44.6%-53.3%) among undergraduate medical students of Haramaya University. Being female (AOR=1.90, 95% CI: 1.28-2.81) and living off-campus (AOR=1.75, 95% CI: 1.12-2.73) were factors significantly associated with both stress and anxiety. Whereas, alcohol use (AOR=2.26, 95% CI: 1.50-3.50) and smoking cigarette (AOR=3.50, 95% CI: 1.58-7.73) linked with stress. The poor psychosocial support (AOR=1.93, 95% CI: 1.20-3.20) was significantly associated with anxiety.
CONCLUSION: Substantially a higher level of stress and anxiety was reported. Being female and living off-campus were linked with both stress and anxiety. Where as, alcohol use and smoking cigarette were associated with stress and poor psychological support was significantly associated with anxiety.

Introduction

Stress and anxiety often appear after one another.1 But stress is typically caused by an external trigger and it can be a short term.2 Anxiety, on the other hand, is defined by persistent excessive worries that do not go away even in the absence of stressors. However, their symptoms are nearly identical.2 In common, anxiety and stress results from an interaction between persons and their environment that are perceived as straining or exceeding their adaptive capacities.3 Constant exposure to anxious and stressful situations may increase susceptibility to a variety of health problems.4 Effects may range from mild, moderate to severe health problems and it depends onstressor’s duration and individual’s ability to cope.5

The medical school environment has been recognized as anxious and stressful for the students due to the curricular and extra-curricular situations.6 The perceived stress and anxiety among medical students have negative consequences on their academic performances, physical and psychological well-being.6

The prevalence of anxiety and stress among medical students has been reported higher compared to the general population and age-matched peers. Accordingly, the study results from different countries pointed out the prevalence of anxiety and stress among medical students is 37.2% and 47.1% in Brazil,7 50.6% and 32.8% in India,8 62.5% and 45.1% in Iraq,9 63% and 41% in Saudi Arabia,10 and 64.3% and 62.4% in Egypt11 respectively.

In Ethiopia, the reported prevalence of anxiety ranges from 30.1% among Addis Ababa University12 to 60.8% among Arsi University medical students,13 whereas, the stress ranges from 40.4% among Arsi university13 to 52.4% among Jimma university medical students.14

Studies showed the level of stress and anxiety experienced by students is elucidated by many factors. Living off-campus,15 higher body mass index,11 smoking, being female, being first and second-year Students linked with a higher level of both anxiety and stress.10,12,16 Likewise, stress among medical students associated with perceived sleeping problem,17 living situation, monthly income, and educational level.14 Students with poor social support, first and second-year educational levels were more anxious as compared to their counterparts.12

Failure to detect the psychological abnormality among medical students may lead to increased mental illness with unwanted outcomes throughout their careers and lives.18 Early detection and treatment of such problems will shorten the duration of illness and lessens the long-term social impairment.19

Despite few studies12,14,20,21 assessed the prevalence and identified risk factors of stress and anxiety among medical students, there is a lack of epidemiologically reliable and study with enough sample size in Ethiopia. Therefore, this study was aimed to determine the prevalence and identify factors associated with stress and anxiety among undergraduate medical students of Haramaya University, Eastern Ethiopia.

Method

Study Period and Area

The study was conducted at Haramaya University, College of Health and Medical Science, from May 13 to June 12, 2019. Haramaya University is located in the eastern part of the country at a distance of 510 km from the capital city, Addis Ababa. The university has two campuses and nine colleges. The Harar campus (College of Health and Medical Science) is found at a distance of 17kilometers away from the main campus. School of medicine emerged as an academic constituent in 2007 and currently, a total of 1315, students are following their education in 2019 (unpublished data. School of medicine, College of Health and Medical Science, Haramaya University).

Study Design and Population

Institutional based cross-sectional study design was used. All selected undergraduate medical students were included for study and students transferred from other universities and stayed for less than six months at the university were excluded.

Sample Size and Sampling Technique

Single population proportion formula was used to calculate sample size by considering the assumptions: ni: minimum sample size required for the study, Z= standard normal distribution (Z=1.96) with a confidence interval of 95% and α=0.05, P=the prevalence anxiety among medical students of Addis Ababa University, 30.1%,12 d=tolerable margin of error (d) =4%. The total sample size for this study was 556 with a 10% non-response rate added. The simple random sampling technique was used to select study participants after proportional allocation of the sample size according to the student's academic year.

Data Collection Tool and Procedure

The data was collected by using a standardized tool. The socio-demographic characteristics; age, sex, marital status, and living conditions were collected. ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), which was developed by the World Health Organization, was used to assess the psychoactive substance use (WHO).22

Depression, anxiety, and stress: Were measured by Depression, Anxiety, and Stress Scale (DASS-21) short form, which has 21 items and seven items each. It was the Likert scale ranges from zero to three,computed and multiplied by two. The sum scores of ten and above was indicative of depression, eight and above was indicative of anxiety since,15 and above was for the stress.23

Suicidal history: It was assessed by the module of the world mental health survey initiative version of the WHO and CIDI (Composite International Diagnostic Interview).24 Concerning the social support, the Oslo-three-item, social support scale was used.25 Four psychiatric nurses (bachelor of degree holder) were participated in data collection through self-administered technique and supervised by one psychiatrist (master’s degree holder).

Data Quality Control

Pre-test was done among Dire Dawa University medical students on 5% (28) of total samples, and relevant modification taken. During the data collection, the questionnaire was checked for its completeness on daily basis by supervisors and investigators. Double data entry was conducted by two independent data clerks, and the proper corrections were made based on the variation between two data clerks.

Data Processing and Analysis

The data was checked and entered to Epi-Data version 3.1 and exported to SPSS (Statistical Package for Social Science) version 22 for analysis. Descriptive statistics (percentage, mean and standard deviations), bivariable and multivariable binary logistic regression analysis was performed to identify factors associated with stress and anxiety. All variables with a P-value less than 0.25 at bivariable logistic regression analyses were entered into the multivariable logistic regression model, and variables with a P-value less than 0.05 at 95% confidence interval with their adjusted odds ratio were considered statistically significant.

Results

Socio-Demographic Characteristics of Participants

A total of 523 undergraduate medical students were included in the study with a response rate of 94%. The mean age of the students were, 23.62 years (±2.36SD) with ages ranging from, 19 to 34 years. The majority of the students, 362 (69.2%) were male, 266 (50.9%) orthodox by religion and, 393 (75.1%) were living in the campus. Regarding their cumulative grade point average, the mean grade of students was, 3.00 with grades ranging from, 1.83 to 3.87 and, 115 (22%) students were 6th year, followed by 5th year, 99 (19%) in the medical school (Table 1).

Table 1

Socio-Demographic Characteristics of Undergraduate Medical Students of Haramaya University, Eastern Ethiopia, 2019 (N=523)

Variables	Category	Frequency	Percentage
	Mean	Standard Deviation
CGPA	3.00	0.63
Age in years	23.6	2.36
Sex	Male	362	69.2
	Female	161	30.2
Marital status	Single/divorced	466	89.1
	Married	57	10.9
Living situation	In campus	393	75.1
	Off campus	130	24.9
Religion	Orthodox	266	50.9
	Muslim	135	25.8
	Protestant	104	19.9
	Others*	18	3.4
Educational level	First year	58	11.1
	Second year	78	15.0
	Third year	89	17.0
	Fourth year	84	16.1
	Fifth year	99	19.0
	Sixth year	115	22.0

Note: *Wakefata, Atheist, Catholic, Jehovah witness and Apostle.

Substance Use History

About,146 (27.9%) students have been consuming alcohol and, 41 (7.8%) students were smoking cigarette in the past, 3 months (Figure 1).

Figure 1

Substance use characteristics of undergraduate medical students of Haramaya University, Eastern Ethiopia, 2019 (N=523).

Clinical and Psychosocial Characteristics

A total of, 228 (43.6%) students had depressive symptoms, 120 (22.9%) had suicidal ideation, and, 22 (4.2%) had a suicidal attempt. Around, 223 (42.6%) students reported moderate perceived social support (Table 2).

Table 2

Clinical and Psychosocial Characteristics of Undergraduate Medical Students of Haramaya University, Eastern Ethiopia, 2019 (N=523)

Variables	Category	Frequency	Percentage
Depressive	Yes	228	43.6
	No	295	56.4
Suicidal ideation	Yes	120	22.9
	No	403	77.1
Suicidal attempt	Yes	22	4.2
	No	501	95.8
Family history of suicidal attempt	Yes	41	7.8
	No	482	92.2
Family history of committed suicide	Yes	22	4.2
	No	501	95.8
Family history of mental illness	Yes	57	10.9
	No	466	89.1
Perceived social support	Poor	192	36.7%
	Moderate	223	42.6%
	Strong	108	20.7%

Prevalence of Stress and Anxiety

The prevalence of stress was, 230(44%) (95% CI: 40.2%–48.4%) and anxiety was, 256(48.9%) (95% CI: 44.6%−53.3%) among undergraduate medical students (Figure 2).

Figure 2

Prevalence of stress and anxiety of undergraduate medical students of Haramaya University, Eastern Ethiopia, 2019 (N=523).

Among students with stress, 61% were males and, 60.5% were among those with anxiety (Table 3).

Table 3

Prevalence of Stress and Anxiety Among Undergraduate Medical Students of Haramaya University, Eastern Ethiopia

Characteristics		Stress	Anxiety
Sex	Male	61%	60.5%
	Female	39%	39.5%
Living situation	In campus	69.5%	66.7%
	Off campus	30.5%	33.3%
Marital status	Married	9%	12.5%
	Single	91%	87.5%
Current alcohol use	Yes	37.8%	33%
	No	62.2%	67%
Current khat use	Yes	23%	72.6%
	No	77%	27.4%
Current cigarette use	Yes	13%	9.3%
	No	87%	90.7%

Factors Associated with Stress and Anxiety

During the bivariable analysis; sex, marital status, living situation, family history of suicidal attempt, family history of mental illness, current alcohol use, current cigarette use, and current khat use fulfilled the minimum requirement (P-value less than 0.25) and were taken into a multivariable logistic regression model to control confounding factors.

From the multivariable logistic regression analysis being female, living off-campus, current alcohol use, current cigarette use, and poor social support were found to be statistically significant at P-value less than 0.05.

According to the current study female students experience stress; 1.9 times (AOR=1.90, 95% CI: 1.28–2.81) and anxiety; 2.1 times (AOR=2.10, 95% CI: 1.40–3.10) more likely than male students. The odds of having stress and anxiety among students who were living off-campus were 1.75 times (AOR=1.75, 95% CI: 1.12–2.73) and 2.21 times (AOR=2.21, 95% CI: 1.42–3.44) higher as compared to the students who were living in the campus respectively. Those students using alcohol were 2.28 times (AOR=2.26, 95% CI: 1.50–3.50) more likely to experience stress as compared to non-alcoholic students. Similarly, students who smoke cigarettes were 3.5 times (AOR=3.50, 95% CI: 1.58–7.73) more likely to have anxiety as compared to nonsmokers. Whereas, students with poor social support were 1.93 times (AOR=1.93, 95% CI: 1.20–3.20) more likely to have anxiety as compared with students with strong social support (Table 4).

Table 4

Factors Associated with Stress and Anxiety Among Undergraduate Medical Students of Haramaya University, Eastern Ethiopia, 2019

Characteristics		Stress		COR(95% CI)	AOR(95% CI)	Anxiety		COR(95% CI)	AOR(95% CI)
		Yes	No			Yes	No
Sex	Male	140	222	1	1	155	207	1	1
	Female	90	71	2.01(1.38–2.93)	1.90(1.28–2.81)*	101	60	2.25(1.54–3.30)	2.1(1.40–3.10)**
Living situation	In campus	160	233	1	1	171	222	1	1
	Off campus	70	60	1.70(1.14–2.53)	1.75(1.12–2.73)*	85	45	2.45(1.62–3.71)	2.21(1.42–3.44)*
Marital status	Married	21	36	1	1	32	25	1	1
	Single	209	257	1.40(0.80–2.50)	1.770.94–3.33)	224	242	0.72(0.42–1.30)	1.02(0.60–1.90)
Family history of suicidal attempt	Yes	22	19	1.53(0.80–2.90)	1.10,(0.52–2.30)	26	15	1.90(0.98–3.70)	1.28(0.60–2.80)
	No	208	274	1	1	230	252	1	1
Family history of mental illness	Yes	31	26	1.60(0.92–2.80)	1.75(0.92–3.32)	36	21	1.92(1.10–3.38)	1.90(0.90–3.64)
	No	199	267	1	1	220	246	1	1
Current alcohol use	Yes	87	59	2.40(1.63–3.60)	2.28(1.50–3.50)**	82	64	1.50(1.02–2.20)	1.50(0.94–2.21)
	No	143	234	1	1	174	203	1	1
Current khat use	Yes	53	52	1.40,(0.90–2.13)	0.75(0.45–1.25)
	No	177	241	1	1
Current cigarette use	Yes	30	11	3.85(1.90–7.86)	3.50(1.58–7.73)*	24	17	1.52(0.80–2.90)	1.10(0.53–2.20)
	No	200	282	1	1	232	250	1	1
Perceived social support	Strong					43	65	1	1
	Moderate					102	121	1.27(0.80–2.03)	1.30(0.80–2.10)
	Poor					111	81	2.07(1.28–3.35)	1.93(1.20–3.20)**

Notes: *p<0.05 and **p<0.001.

Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio.

Discussion

This study determined the prevalence and identified the factors associated with stress and anxiety among undergraduate medical students of Haramaya University. Hence, the overall prevalence of stress and anxiety was, 44% (95% CI: 40.2%-48.4%) and 48.9% (95% CI: 44.6%-53.3%) respectively. This is in line with the study finding from Turkey, 47.1% for anxiety,16 Hong Kong University, 54.4% for anxiety26 and Malaysia, 41.9% for stress.27 However, the current finding is lower as compared to the study finding by Abdallah et al (2014) with the prevalence of stress, 57.8%, and anxiety, 78.4%.28 Similar studies from other countries showed far higher rates of stress and anxiety among medical students; in Egypt, stress, 62.4% and Anxiety, 64.3%,11 in Saud Arabia, stress, 71.9%.17 This variation could be attributed to socio-cultural differences, and the tools used for the study.11

The study finding from Jordan29 and Michigan University reported a lower level of anxiety, 13.58% and 15.6% among university students respectively30 as compared to our study finding. This could be linked with the fact that students in a developed country may have less financial hardship compared to those students in low-income countries including Ethiopia.31

This study identified gender difference in the self-reported level of stress and anxiety with much higher among female students. This finding is in consonance with study results conducted among Egyptian and Turkish female students reporting a higher level of stress and anxiety.11,28 This is possibly due to the fact that females complain more about the high load of the curriculum and they are also more likely to report the stress, physical and psychological symptoms.32 Additionally, the study result conducted among a sample of college students in the United States of America outlined the body image and lower self-esteem was the significant contributor of stress and anxiety among females.15

Our current study suggests the living situation of students contributes to stress and anxiety. Students living off-campus were reported more stress and anxiety than those who are living in a campus dormitory. This is in agreement with previous study findings.30,33–36 This could be linked with the fact that students live off-campus were responsible to pay monthly house rent, prepare or buy daily meals and deal any issues raised related to the house or apartment they live in.15 There is also evidences that living alone is the risk factor for stress and anxiety.37,38 So the university has to give psychosocial support for students living off-campus. The students also need to get ready before they plan to live off-campus.30

Good social support is perceived to have a positive effect on health and defined as through which social relationships promote health and well-being.39 Our study finding also delineated students who have poor social support were more anxious than students who have good social support. This is in agreement with the previous study results.40,41 Hamadan et al (2008) also depicted that University students who have a lower perception of social support are expected to have a higher perception of life events as anxious situations.42

Both social cognitive and stress environment model emphasizes the reciprocated association among physiological, cognitive, behavioral, and socio-environmental factors that can both cause stress symptoms as well as mediate effective coping responses to stressors.43 Evidences also showed up the relationship between stress and alcohol looks like a vicious circle.44,45 Stress is a significant motivator for university students to drink alcohol or smoke cigarettes as a coping mechanism. Despite, it is not merely the reason, occasional celebration, peer pressure, and social acceptance were raised.46 Reciprocally the intended coping mechanism may lead to stress.

Our study finding also highlighted students who drink alcohol and smoke cigarette were more likely to experience stress than their counterparts. This is supported by previously conducted study results which revealed the excessive alcohol consumption and smoking cigarette, which is considered as a coping response, in turn, have exacerbated the stress symptoms.47 The ill-effects of the substance abuse among medical students, were not limited to the psychological stress but lead to physical impairment, poor interpersonal relationships and poor academic performance.46

This study was not without limitation. Its cross-sectional nature may fail to capture the long-term cause and effect relationship. The study was also conducted in one university and might not be generalized to whole university students. Despite these limitations, the study expanded our knowledge on the prevalence and factors associated with stress and anxiety among undergraduate medical students of Haramaya University. It also provides an insight for the Haramaya University administrators and stakeholders to tackle the problem. Additionally, the current finding might help as baseline data for further studies with advanced methods and multi centers.

Conclusion

The study depicted the higher prevalence of stress and anxiety among undergraduate medical students of Haramaya University. Being female gender, living off-campus, perceived poor social support, using alcohol and cigarette were associated with stress and anxiety. The establishment of students’ counseling, behavioral change, and communication unit in medical schools, promoting student wellbeing, providing supportive, preventive, and curative psychosocial services to enable students to cope with their new phase of life is recommended. Medical schools have to encourage students to spend more time on their social lives and provide them with coping tools to overcome stress throughout their medical education. There should be special attention given to female students and those living off-campus. Leisure activities should be included in the curriculum to promote better interaction between the students and their medical environment.