Self- perceived stress in relation to anxiety, depression and health-related quality of life among health professions students: A cross-sectional study from Bosnia and Herzegovina

The beginning of university life represents an important period of transition from adolescence to young adulthood that could be very often difficult due to interactions between individual psychological characteristics and common stressors, such as academic demands, changes in lifestyle, moving away from home, separating from family, inadequate living conditions, physical and emotional problems, and financial concerns (1-3). Stress in university students may also be related to examination (4), pressure of expectation to succeed or to be competitive, and an uncertain future (5, 6). Numerous studies analysed the correlation between exposure to aforementioned stressors and students’ health (7, 8). It has been shown that stress has a significant, negative impact on overall health (7-9) and may cause mental problems, deleterious dietary changes (10) as well as generate poor coping skills leading to aggressive behaviour and somatic disorders (11).

Although it is not well-known whether health professions education differs from other higher education, it is generally considered as highly demanding, and students perceive it as a source of significant psychological and emotional distress (12-20).

Previous studies have shown that students who chose medical profession because they wish to help people have greater predisposition to the stress over the students driven by professional respect or material benefit (21). Besides being exposed to academic-related stress, caused by curriculum overload, constant assessments, little time available or variable hour shift for clinical rotations (22), health professions students also encounter occupational stress because they deal with people, their health and their lives. In order to reach the personal and professional maturity the health professions jobs require, the students partake of handling their own mind, attitudes or emotions, and coping with the stress in different, sometimes even difficult, clinical situations (23). Inadequate teaching methods or lack of mentor’s support often unable students to adopt required skills, empathy and professionalism manners, ultimately leading to poor coping mechanisms and greater proneness to stress (24).

Increased perception of stress might be associated with moderate level of anxiety, depression symptoms, interpersonal sensitivity, frustration and powerlessness (25). When associated with anxiety and depression, occupational stress, as experienced by the student, can influence his or her quality of life and decrease his or her academic performance due to anxiety-induced difficult cognitive functioning, such as memory disorders, blockage, incapacity to make decisions, and increased sensitivity to appraisals of others (26, 27). Previous research found that the students and residents who frequently experience stress, also exhibit higher degree of burnout (20, 28) and future professional impairment (29).

As a psychological and physiological state, anxiety is considered to be a normal response to stress, but prolonged exposure and higher levels of perceived stress may lead to adverse consequences, including the development of anxiety disorder (30). When experiencing high levels of anxiety during their studies, the students are frequently inclined to achieve lower quality of total performance, which usually makes them feel that the situational demands exceed their competences, which further deepens perceived stress, ultimately resulting in the individual’s psychological distress (31). Situational stress, showed to be a factor that elevates state anxiety, probably because students realise that they will be judged and that their achievements will be compared with the achievements of others. Highly trait-anxious students often experienced stronger state-anxiety compared to low trait-anxious students, which implies that students with anxiety tendencies are more predisposed to state anxiety in stressful situation (32).

Very little is known about perceived stress among health professions students in Bosnia and Herzegovina (BiH), especially students of medicine. At the Faculty of Medicine, University of East Sarajevo, the study programme of medicine still has traditional curriculum. The students begin their training with three years of pre-clinical course, involving the basic medical sciences. This is followed by the three years of clinical courses and clinical rotations. Students attend lectures on all aspects of medical practice during the whole training. The programme is considered demanding, but up to now, aspects of study stress and generally students’ health and behaviour have not yet been studied much (33).

The purpose of the present study was to examine perceived stress of students at the Faculty of Medicine Foča, and to explore its association with anxiety, depression, and health-related quality of life. The questions were formulated into the following hypothesis. The symptoms of depression and anxiety among undergraduate students are associated with perceived stress and self-perceived health. The perceived stress in students of medicine differs from that in the students of similar study programmes, such as dentistry, nursing, and speech language therapy.

The study involved 426 students with the mean age of 21.5±2.26 years. Most students were female (69.2%), born in an urban place (75.8%), and had good financial status (86.9%).

A high degree of stress was reported by 1.6% of students, while the majority of students had either a moderate (70.6%) or low degree (27.5%) of stress. There was a tendency toward higher stress ratings by female students, and this was statistically significant (p=0.046). Statistically significant difference in degree of stress was also found between four study programmes. Students of medicine reported moderate and high degree of stress more frequently as compared to dentistry, speech therapy and nursing students (p=0.035). No significant difference was detected in the perceived stress degree among different years of study (p=0.313) (Table 1).

Table 1

Degree of perceived stress assessed by 14-item Perceived Stress Scale, depending on different characteristics of examined students.

The students with moderate and high perceived stress degree reported a significantly lower quality of life assessed by EQ-5D (p<0.001). However, statistical difference between the groups with low, moderate, and high degree of perceived stress was not found in general self-assessment of HRQoL, as measured with EQ-5D VAS (p=0.161) (Table 2).

Table 2

Perceived stress degree of examined students depending on quality of life, depression and anxiety symptoms.

We compared the frequency of depression symptoms in students with different perceived stress degrees. Only 16 (3.7%) students scored positive for the presence of depression (mild), whereby the frequency of symptoms increased with the increase of the perceived stress degree (p=0.019) (Table 2). Females reported depression more frequently compared with their male counterparts (p=0.042).

The majority of students reported either mild (50%) or moderate (38%) levels of trait anxiety. Similarly to depression symptoms, there was an apparent stepladder appearance in distribution of trait anxiety levels according to perceived stress degree (p<0.001) (Table 2).

The state scale was used to assess how students anticipate their feelings in a variety of hypothetical situations. Students with higher levels of stress scored higher in the Stale Anxiety Scale than the students with low stress levels (p<0.001) (Table 2). Unlike trait anxiety, none of the students reported state anxiety level as severe.

A weak, statistically significant correlation (r=0.245, p<0.001) was found between state and trait anxiety. Greater elevation of state anxiety was detected in moderate and severe trait-anxious students.

The multivariate linear regression analysis was used to find independent factors associated with the following outcome variables: perceived stress score, self-reported depression score, self-reported anxiety score, and HRQoL score. The results of the analysis presented in Tables 3 and 4 shows that the sociodemographic factors were not associated with any of analysed variables (p>0.05).

Table 3

Factors associated with perceived stress, depression, and HRQoL score (Multivariate linear regression analysis).

Table 4

Factors associated with trait and state anxiety score (Multivariate linear regression analysis).

The significant independent factors associated with perceived stress were trait anxiety (OR, 0.339; CI 95%, 0.276-0.403, p<0.001) and EQ-5D score (OR, 0.044; CI 95%, 0.033-0.085, p=0.036). The presence of anxiety was the only significant determinant of depression score (OR, 0.085; CI 95%, 0.054-0.115, p<0.001) (Table 3). EQ-5D score was associated with perceived stress degree (OR, 0.243; CI 95%, 0.16-0.467, p=0.036) and high trait anxiety level (OR, 0.220; CI 95%, 0.053-0.386, p=0.010). Poor general health assessment was a risk factor for health-related quality of life (OR, -0.604; CI 95%, -0.833-0.374, p<0.001).

A high degree of perceived stress (OR, 0.624; CI 95%, 0.507-0.704, p<0.001), the presence of depression (OR, 0.800; CI 95%, 0.513-1.087, p<0.001), and low quality of life were predictors of the trait anxiety (OR, 0.073; CI 95%, 0.018-0.128, p=0.020). State anxiety was a strong risk factor for trait anxiety (OR, 0.046; CI 95%, -0.084-0.007, p<0.001).

Perceived stress degree had a significant impact on the state anxiety level (OR, 0.696; CI 95%, 0.579-0.812, p<0.001) among Bosnian health professions students. A significant association was found between trait and state anxiety score (OR,-0.351; CI95%, -0.546--0.157, p=0.002).

The current study was conducted to assess the perceived stress and its association with anxiety, depression, and HRQoL in health professions students. As presented in Table 2, the majority of students perceived moderate stress (70.6%) and only 1.6% of them perceived a high degree of stress. This is consistent with the results of other studies demonstrating that university students around the globe are exposed to high levels of stress (38, 39). The reported prevalence of perceived stress among health professions students ranged from 31.2% in the United Kingdom (12) to 83.9% in Australia (39). This difference in the prevalence between the countries is considered to be the result of culturally different perception of stress or stressful event, but also of environmental factors, such as economic burden of studying, very high tuition fees, lack of family support, and higher or lower ‘readiness’ to report the stress or any other complaint (7).

Perceived stress was significantly associated with anxiety levels in the current study (Table 3 and 4), and was an independent determinant of both, state and trait anxiety. This is in line with the study of Bunevicius et al., showing independent association of anxiety symptoms with higher vulnerability to stress and lower level of emotional stability in medical students (40). High, significant correlation between perceived stress and anxiety level was also found in the study of Heinen at al., conducted on the sample of 385 first-year medical students (19), as well as in the studies carried out among dentistry (41) and nursing students (42). High trait-anxiety could have led to greater sensitivity to stress because of students’ attention being aimed toward threats to self-worth and self-esteem (43), while negative relationship between state and trait anxiety might have exacerbated the encumbrance of manifest anxiety (32). The results of the aforementioned research emphasise that counselling focusing on anxiety during health profession education might be a possible option for stress reduction. The autogenous training and progressive muscle relaxation showed to be effective in reducing trait and state anxiety levels in medical students (44).

Although ANOVA analysis showed that the frequency of depression symptoms increased with the increase of stress (Table 2), the association between self-rated depression and perceived stress was not found, as presented in Table 3. This is contrary to several other studies reporting very strong associations between these two outcome variables (10, 26, 45). However, merely 3.7 % of students examined here fulfilled the criteria for self-rated depression, in all cases it was rated as mild, which could explain why depression was not found to be the determinant of perceived stress.

A strong association was found between trait anxiety and depression score (Tables 3 and 4). Living in a constant state of anxiety can make the individual feel there is no hope for ever getting better and that life is not good, which creates a direct path to depression. Having depression during undergraduate studies can cause academic, psychosocial, physical, or academic related hindrances, as it is has been previously detected (46).

Regarding the role of quality of life, its relatedness to perceived stress, trait anxiety, and self-assessment of general health was demonstrated in the current study (Table 3). A portrait of stress levels and HRQoL has been provided in previous analyses, accentuating that higher vulnerability to stress in health professions students may be a predisposing risk factor for mental distress and poor physical heath (47). Our findings further support the necessity of providing predisposed students with programmes to alleviate their stress and boost their overall health (47).

ANOVA analysis showed higher levels of perceived stress in females than in males, and in medical students than in those of other programmes (Table 2). However, in a multivariate regression analysis neither gender nor study programme appeared as significant independent factors associated with perceived stress (Table 3). No association between gender and perceived stress was also reported in studies from Norway (48) and Germany (49), but studies from Sweden (14), Ethiopia (45), and Middle East (50) reported gender difference regarding stress perception. Different results in the studies may be subjected to a different degree of female discrimination, community pressure, and cultural habits.

The perceived stress in students of medicine did not differ from that in the students of dentistry, nursing, and speech language therapy. Controversial results were published on the relationship between health professions programmes of study and students’ stress perception. Some found higher incidence of stress in medical students than in dental and nursing students (51), but the other reported lower stress levels in medical than in dental students (52, 53). These inconsistent findings indicate that in addition to the study programme, there are other independent factors that might increase one’s proneness to stress.

Higher levels of perceived stress predispose students for anxiety and lower HRQoL. Although medical students reported higher levels of stress compared to the students of dentistry, nursing, and speech language therapy, the study programme was not a significant determinant of perceived stress score. The screening of stress among health professions students should become a regular practice, and those students experiencing high levels of stress should be undergoing screening for anxiety and depression. Interconnection of stress, trait and state anxiety, and HRQoL merits further investigation and development of appropriate interventions.