Self-perceived stress and associated factors among preclinical science students in a medical college in Central Nepal

Abstract

Background

Self-perceived stress is a common problem among university participants with relatively high-stress levels. This study aimed to determine perceived stress levels and associated factors among preclinical participants at a medical college in Central Nepal.

Methods

This study employed an analytical cross-sectional design. The participants were first- and second-year MBBS students studying in the second, third, and fourth semesters at the preclinical science premises of Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal. The Perceived Stress Scale was used to assess perceived stress levels. A medical participant stress questionnaire was used to identify the different sources of stressors. The associations between sociodemographic profiles and perceived stress and stressors were tested.

Results

The mean age of the 247 undergraduate medical participants was 20.61 years (SD ± 1.47), with the majority being male (70.9%) and Hindu (92.3%). Significant gender differences in stress levels were observed, with males reporting higher levels of low (24.6%) and moderate stress (69.1%) than females did (p-value = 0.009). The second-semester participants experienced the highest levels of moderate (74.1%) and high stress (14.1%), with significant semester-related differences (p-value = 0.027). Participants with a history of anxiety or depression had significantly higher stress levels (p-value < 0.001). The key stressors were academic-related, including lack of time for review and examinations, with gender (OR = 2.85, 95% CI: 1.15–7.02), semester (OR = 0.32, 95% CI: 0.13–0.76) and history of anxiety (OR = 5.29, 95% CI: 1.54–18.07) being significant predictors of stress.

Conclusions

High levels of stress among undergraduate medical students in Nepal are driven primarily by academic pressure, with second-semester participants and those with a history of anxiety or depression being the most affected. Compared with male participants, female participants experienced higher stress levels. These findings highlight the need for targeted stress management and mental health support for medical students.

Background

Self-perceived stress refers to the feelings a person has about how much stress they are experiencing at a certain point in time or during a period [1]. Among individuals, self-perceived stress among college participants is a significant concern because many participants experience high levels of stress due to academic pressures, financial concerns, personal relationships, etc. Different research findings show that the level of perceived stress differs depending on the course in which the participants are taking. [2,3,4,5]

Short-term stress may usually be manageable, but persistent and severe stress can lead to poor quality of life, burnout, and mental problems such as anxiety and depression [5,6,7,8]. As a result of stress, people might develop coping behaviours, which may include positive strategies such as problem-solving and even negative strategies such as avoidance and substance abuse [9]. The associations of perceived stress with depression and anxiety have been studied in previous studies, but the extent of perceived stress in preclinical science participants and associated factors and sources of stressors are not fully understood and have been less addressed in Nepal [10,11,12,13]. Therefore, this study aimed to investigate the level of perceived stress among undergraduate medical participants, associated factors, and sources of stressors.

Methods

Study design and study setting

An analytical cross-sectional study was conducted at the preclinical science block of the Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Kavrepalanchok, Nepal. The study duration was from July to August 2024.

Sampling and recruitment

Students enrolled in the first and second years of the MBBS program, specifically those in the second, third, and fourth semesters, were eligible to participate in this study. First-semester students were not included, as there were no students enrolled in that semester at the time of the study. A universal sampling approach was used, employing a non-probability sampling method. All students present in class were approached to participate, and those who were absent were invited to participate upon follow-up on three separate occasions.

Data collection tools

The questionnaire included two previously developed scales, i.e., Perceived Stress Scale- 10 [14], a Sociodemographic profile specifically developed for the study was also used and is available in the supplementary material (See additional file 1).

The PSS- 10 is a 10-item questionnaire used to assess stress levels in young people. It evaluates an individual’s perception of life as unpredictable, uncontrollable, and overloaded over the past month. Responses are scored on a Likert scale, and the perceived stress score is obtained by summing allitems. Higher scores indicate higher levels of perceived stress, while lowerscores indicate lower stress levels.The PSS- 10 has previously been used in Nepalese populations and demonstrated good internal consistency, with a Cronbach’s alpha of 0.78 (95% CI = 0.70–0.85), supporting its reliability in the Nepali context [14, 15].

The MSSQ is avalidated questionnaire comprising 40 questions. Respondents rate each item (or stressor) on a scale from 0–4, where 0 = causing no stress at all, 1 = causing mild stress, 2 = causing moderate stress, 3 = causing high stress, and 4 = causing severe stress. The MSSQ was grouped into six domains based on the underlying theme. The six domains were as follows: 1. Academic-related stressors (ARS), 2. Intrapersonal and interpersonal-related stressors (IRS), 3. Teaching and learning-related stressors (TLRS), 4. Social-related stressors (SRS) 5. Drive- and desire-related stressors (DRS), and 6. Group activity-related stressors (GARS).The MSSQ has shown high internal consistency, with a Cronbach’s alpha of 0.95, indicating strong reliability [16, 17]

Ethical consideration

This study was conducted as per the Declaration of Helsinki. Ethical approval for the study was obtained from the Institutional Review Committee (IRC) of the Kathmandu University School of Medical Sciences (reference number: 189/24). The participants were approached during break time, where information about the study, voluntary participation, and confidentiality were mentioned to the participants, and a questionnaire along with a consent form was distributed. Written informed consent was obtained from each participant before the beginning of data collection.

Data analysis

SPSS version 16 was used to analyze the data. For continuous data, the mean and standard deviation were used. For categorical data, frequencies and percentages were calculated. For bivariate analysis, a chi-square test was performed to find an association. Variables with p values < 0.2 in bivariate analysis were considered for multivariate analysis. For multivariate analysis, logistic regression was performed.

Results

A total of 300 students were eligible for the study, of whom 247 completed the questionnaire, 9 submitted incomplete questionnaires, and 44 could not be reached even after three attempts. The overall response rate was 82%. Table 1 shows the participants’ sociodemographic characteristics. The mean age of the participants was 20.61 years (SD ± 1.47). The majority of participants in the study sample were male (175, 70.9%), and Hindu (228, 92.3%). In terms of nationality, 81.8% of the participants (n = 202) were Nepalese, and 18.2% were Indian (n = 45). The participants were equally distributed in their academic semesters, with nearly one-third in each semester from the second to the fourth semester. More than half of the participants (139, 56.3%) lived in rented houses, and one (0.4%) with their family, while the rest lived in college or private hostels. Approximately one-fourth (55, 22.3%) of the participants reported a history of anxiety, with 2.8% of the participants reporting being under medication for anxiety or depression (n = 7). The majority of the participants (91.1%) considered their family income satisfactory (n = 225). Nearly three-quarters had moderate levels of stress (176, 71.26%).

Table 1 Sociodemographic characteristics of the participants (n = 247)

Table 2 presents the distribution of stress levels among participants, highlighting a statistically significant association. According to the bivariate analysis, female participants (55, 76.4%) presented with higher moderate levels of stress than male participants (121, 69.1%) (p-value = 0.009). Similarly, stress levels were significantly associated with academic semesters, with second-semester students demonstrating the highest proportion of moderate stress (63, 74.1%, p-value = 0.027). Additionally, a history of anxiety or depression was strongly associated with elevated stress levels, as 74.5% of participants (n = 41) with a history of anxiety or depression reported moderate levels of stress (p-value < 0.001). In the bivariate analysis, variables such as religion, nationality, residence, and family income did not show statistically significant associations with stress levels.

Table 2 Distribution of stress levels among medical participants (n = 247)

Table 3 shows the mean and standard deviation of the participants'stressor scores. Academic-related stressors (ARS), intrapersonal and interpersonal-related stressors (IRS), teaching and learning-related stressors (TLRS), social-related stressors (SRS), and group activity-related stressors (GARS) cause moderate stress, with mean scores ranging from 1.39–1.98. Drive- and desire-related stressors (DRS) cause only mild stress, with a mean score of 1.

Table 3 Mean ± S.D. and Inference of different domain stressors (n = 247)

Table 4 shows the top ten stressors among the participants with their mean values. Eight of the top ten stressors were ARS. The most common stressors among the participants were a lack of time to review content, test examinations, large amounts of content, poor marks, falling behind in reading schedules, and poor motivation to learn.

Table 4 Top 10 stressors among the medical participants (n = 247)

Table 5 shows the associations between stress levels and sociodemographic characteristics. There was a significant association between gender and the level of stress after adjusting for sociodemographic characteristics. The odds of experiencing stress were 2.85 times greater for female participants than for male participants (95% CI: 1.15–7.02, p-value < 0.05). There was no significant association between religion and stress level or between nationality and stress level after adjusting for sociodemographic characteristics. There was a significant association between a participant's semester and stress level after adjusting for sociodemographic characteristics. The odds of having stress were 68% lower for the third-semester participants than for the second-semester participants (95% CI: 0.13–0.76, p-value < 0.05).

Table 5 Association between the level of stress and sociodemographic characteristics (n = 247)

There was a significant association between a participant's history of anxiety and stress level after adjusting for sociodemographic characteristics. The odds of experiencing stress were 5.29 times greater in participants with a history of anxiety than in participants with no history of anxiety (95% CI: 1.54–18.07, p-value < 0.05).

Discussion

In our study, several key patterns and associations were observed between self-perceived stress and socio-demographic factors. Most of the participants were male, Hindu, and Nepalese. Female participants and second-semester participants reported the highest level of stress. Another significant finding was that participants with a history of anxiety or depression had elevated levels of stress. Academic-related stressors such as a lack of time to review content and test examinations were among the top stressors for the participants. These findings suggest that gender, academic semester, and history of anxiety and depression play crucial roles in the stress levels of participants.

The overall prevalence of moderate to high stress in our study was 79.8%, with the highest prevalence observed in the second semester (88.2%) and the fourth semester (78.4%). The mean Perceived Stress Scale (PSS) score was 18.72 ± 5.93. This high prevalence could be due to the intense academic pressure faced by students during these semesters. This finding is consistent with another study where the mean PSS score was 19.45 ± 6.49 [4]. However, the prevalence of stress was lower in the study (37.7%) but with a higher mean PSS score (27.5 ± 4.76).² This difference may be due to the different academic environments and the study streams of the participants. Another study in India reported a lower prevalence of stress (48.8%), possibly because the participants were from various academic streams [3]

Our findings indicate that female participants were nearly three times more likely to experience moderate to severe stress compared to their male counterparts. This aligns with previous research demonstrating higher odds of stress among female undergraduates (OR = 1.99, 95% CI: 1.313–3.031)² and (OR = 2.35, 95% CI: 1.67–3.30) [4]. The increased vulnerability of female students to stress may be attributed to societal expectations, gender-specific academic pressures, and differences in coping mechanisms. Furthermore, compared to second–semester students, those in the third semester had 66% lower odds of experiencing moderate to severe stress. A similar pattern has been observed in prior studies where first-year graduates had higher odds of stress (OR = 2.383, 95% CI: 1.047–5.422)² likely due to academic adaptation challenges.

A history of anxiety or depression was found to be a strong predictor of stress, with affected students five times more likely to experience moderate to severe stress. This finding highlights the significant impact of pre-existing mental health conditions on students'stress levels. Consistent with our findings, prior research has shown that depression and stress levels varied significantly across semesters, underscoring the need for mental health support throughout academic careers [11]

Domain-specific stressor analysis revealed that moderate stress, except for drive- and desire-related stressors, caused mild stress. Among these, academic-related stress (ARS) was the major source of moderate stress, with top stressors including a lack of time to review content, test examinations, and large amounts of content. However, our study identified female gender and a history of anxiety as the key factors associated with stress, consistent with findings from previous research [11].

It is important to note that while the odds ratios (OR) for gender and history of anxiety or depression suggest significant effects, the wide confidence intervals observed, particularly for anxiety history (CI: 1.54–18.07), indicate that these estimates are less precise and should be interpreted with caution. The variability in these estimates suggests a need for more precise measurements or larger sample sizes in future studies to better understand these associations.

This study was conducted in a single medical college and focused on first- and second-year medical students, which may limit the generalizability of the findings to other institutions, academic years, or programs. Additionally, the use of self-reported measures could introduce reporting bias. Future research could expand this work by including multiple medical colleges across different regions and incorporating students from various academic programs and levels. Employing a mixed-method approach, such as integrating qualitative interviews, may also help reduce potential bias and provide a more comprehensive understanding of students’ stressors.

Conclusions

The prevalence of moderate to high stress among pre-clinical undergraduate medical participants is notably high, with academic-related stressors being the primary contributors. Female, second-semester participants and those with a history of anxiety or depression are more likely to experience higher stress levels. These findings underscore the need for targeted interventions to address academic-related stress with more focus on improving time management skills and organization during academic activities. Also, mental health support is required within medical education to improve participants’ well-being and academic performance.