INTRODUCTION:

In recent years, there has been a growing concern of the stressors faced by students undergoing tertiary medical education. Over and above the pressure caused by academics and the necessity to succeed, other factors such as the environmental stressors, uncertain future and difficulties of integrating into the system pose unintended negative consequences namely: physical and mental health and academic performance^1-4.

Stress, has been regarded as a relationship between the person and the environment, which results when an individual perceives the demands tax or exceed available coping resources^5,
6.

Studies on stress among medical students have reported prevalence of 20.1% in Nepal, 40.9% in Brazil, 88% symptoms of stress in Botswana, 61.4% in Thailand, 57% and 63.8 in Saudi Arabia, 29.6% in public university and 46.2% in a private university in Malaysia and 57% among USA medical students^{1-3, 7-13}.

Coping strategies are behavioural, emotional and cognitive efforts employed to control, tolerate, minimise or manage internal and external demands that exceed the available resources. Coping plays a central role in ensuring adaptation to stressful life events, be it work, family or academic^14-16.

Carver introduced the 28 items Brief Coping Inventory, explaining active coping as executing efforts or taking action to remove or handle the stressor; planning includes planning one’s efforts and thinking how to handle the stressor; acceptance is believing that the stressful event is real and occurred; positive reframing which enables one to see it in a positive note; while the avoidant strategies include denial where one rejects the reality of the stressful event having occurred; behavioural disengagement calls on withdrawing or giving up on the goals to be attained; venting causing awareness of the distressful situation leading to expressing those feelings while humour is used to joke on the stressor itself. Ethnic, cultural and socioeconomic characteristics influence coping strategies adapted where negative coping techniques like drug abuse, tobacco and alcohol have been undertaken by medical students in United Kingdom^17,
18.

A certain amount of stress is warranted in everyday life to ensure one performs at his or her best, beyond which the pressure exceeds the ability of the person to handle or cope with the situation or stressor leading to distress¹⁹. Such chronic stress can affect a student’s academic performance resulting in professional problems in their career, compromising patient care²⁰. Medical students, in addition to coping with stressors of everyday life, have to deal with stressors specific to the medical field, such as unfamiliar information and exposure to patients illness, input overload, frequent examinations, high likelihood of failure and lack of leisure time²¹. Due to high stress levels among medical students, certain coping strategies are required in order to stay functional.

Though there are several studies reporting on the prevalence of stress and coping strategies on individual medical schools and universities, comparison of stress and coping strategies between private and public universities are limited. The author having access to a private and public university which are the only 2 in the author’s working state/province, embarked on this study.

Comparing the stress prevalence and coping strategies practised by these 2 universities would pave the way for addressing effective and appropriate coping strategies unique to these universities and enable collaborative sharing of recommendations and experiences in this area. This would further assist in planning interventional measures to be instituted in future. This will enable the stakeholders to produce medical doctors who will be well adjusted to the medial environment and competent in their field to provide exemplary patient care in their career. The objective of this study is to compare the coping strategies practiced and its association with stress between medical students from a private and public university.

MATERIAL AND METHODS:

Study design and sampling:

This was a cross-sectional study conducted in a public university and private university namely, University Sultan Zainal Abidin (UniZSA) and UCSI University (UCSI) respectively. A total of 245 medical students from UniZSA and 315 medical students from UCSI, from year 1 to year 5 participated in this study. This study was carried out between 2015 till 2016. A universal sampling method was used due to accessibility and adequate resources to conduct the study. Inclusion criteria was all medical students from UniZSA and UCSI universities who gave voluntary consent and the exclusive criteria was those who absent on the day of data collection, refused to give consent and had known psychiatric illnesses.

Instruments:

A self-administered questionnaire comprising of 3 sections namely sociodemographic information, 12 item General Health Questionnaire (GHQ-12) and a 28 item Brief Cope Inventory was used in this study. This study is a part of a main study which looked at stress levels, types of stressors and their associations. Thus, the stress levels were estimated in the first part of the study using the GHQ-12 which is a useful tool used frequently to measure the psychological morbidity (stress) of medical students. This tool reported an internal consistency alpha value of 0.85 done on medical students. The items on the GHQ-12 represented 12 manifestations of stress, and the GHQ scoring method used was 0-0-1-1on a likert scale of 1-4 as; ‘not at all’, ‘no more than usual’, ‘rather more than usual’, and ‘much more than usual’. A binary scoring method was used to evaluate responses. This method assigns a score of zero to the two least symptomatic answers and a score of one to the two most symptomatic answers; thus, responses can only be scored as zero or one. Respondents with a score of 4 or greater on the GHQ-12 were considered to be under significant unfavourable stress, defined as ‘caseness’ in this study²².

Coping strategies were assessed using the Brief COPE scale, which is an abbreviated version of the COPE Inventory. The Brief COPE is used to assess a broad range of coping behaviours in managing stress among adults²³. It consists of 28 items, and each item is rated on a 4-point Likert scale ranging from “I have not been doing this at all-score 1” to “I have been doing this a lot-score 4” The higher score indicates greater coping by the respondents. The items were scored to produce 14 dimensions, each reflecting the use of a coping strategy: active coping, planning, acceptance, denial, self-distraction, use of substance, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, humour, religion, and self-blame. It is a validated instrument in which the Cronbach’s alpha values ranged 0.50–0.90.

It was ensured that the data was not collected close to examination dates, to avoid adding stress to the students, introducing measurement bias. The questionnaire was distributed to students in a lecture hall. A short briefing was done with information sheet also distributed to the students. Written informed consent was obtained from all the medical students in both universities and it took approximately 20-25 minutes to fill in the questionnaire. Students were assured of confidentiality. Approval was obtained from the UniZSA Medical Faculty to conduct the study among their students and ethical clearance was obtained from the UCSI University Research Ethics Committee.

Statistical Analysis:

Data were analysed using Statistical Package for Social Sciences (SPSS) version 20.0 software. All data were entered into SPSS and checked for data entry errors and cleaned. Descriptive statistics was applied for analysis of the demographic data, the students’ stress prevalence based on GHQ-12 score, and the coping strategies. Stress was dichotomised into 2 categories namely ‘stress’ and ‘no stress’. Chi-square test was used to test the association between stress and coping strategies. The researcher used alpha (α) set at 0.05 and confidence interval of 95% for interpretation of data.

RESULTS:

The response rate from UniZSA medical students was 90% (245 out of 273 students). The response rate from UCSI medical students was 100% and 4 responses were discarded, out of 319 responses, due to missing values.

Table:1 Socio-demographic characteristics of University Sultan Zainal Abidin and UCSI University medical students

	UniZSAMS (n=245)		UCSIMS (n=315)
Variables	Mean (SD)	Frequency (%)	Mean (SD)	Frequency (%)

Age	21.8 (1.50)		23.02 (1.78)
Gender Male Female		71 (29.0) 174 (71.0)		123 (39.0) 192 (61.0)
Ethnicity Malay Chinese Indian Others		163 (66.5) 42 (17.2) 36 (14.7) 4 (1.6)		83 (26.3) 164 (52.1) 53 (16.8) 15 (4.8)
Marital status Single Married		238 (97.1) 7 (2.9)		306 (97.1) 9 (2.9)
Year of study Year 1 Year 2 Year 3 Year 4 Year 5		61 (24.9) 57 (23.3) 37 (15.1) 51 (20.8) 39 (15.9)		52 (16.5) 64 (20.3) 49 (15.6) 77 (24.4) 73 (23.2)
Source of tuition fee Parents Scholarship Loan Combination		10 (4.0) 205 (83.7) 9 (3.7) 21 (8.6)		67 (21.2) 143 (45.4) 33 (10.5) 72 (22.9)

*Mean(SD): Mean and standard deviation

UniZSAMS-University Sultan Zainal Abidin medical students, UCSIMS–UCSI University medical students.

The UniZSA medical students comprised of 66.5% Malays (Muslims) compared to UCSI medical students who were more than half (52.1%) Chinese. The main sourse of tuition fee paid by UniZSA medical students came from scholarships (83.7) while only 45.4% medical students from UCSI received scholarships. (Table 1)

The stress prevalence reported among UCSI medical students was 42.2% while UniZSA medical students was 33.1%.

Table: 2 Comparison of coping strategies adapted by University Sultan Zainal Abidin and UCSI University medical students.

Universiti Sultan Zainal Abidin (n=245)

UCSI University (n=315)

Coping strategies

Frequency (%)

Rank by frequency of practice

Frequency (%)

Rank by frequency practice

Self-distraction

Not practised

Practised

131 (53.5)

114 (46.5)

164 (52.1)

151 (47.9)

Active coping

Not practised

Practised

116 (47.3)

129 (52.7)

126 (40.0)

189 (60.0)

Denial

Not practised

Practised

110 (44.9)

135 (55.1)

286 (90.8)

29 (9.2)

Substance abuse

Not practised

Practised

238 (97.1)

7 (2.9)

300 (95.2)

15 (4.8)

Emotional support

Not practised

Practised

171 (69.8)

74 (30.2)

185 (58.7)

130 (41.3)

Behaviour disengagement

Not practised

Practised

224 (91.4)

21 (8.6)

290 (92.1)

25 (7.9)

Venting

Not practised

Practised

196 (80.0)

49 (20.0)

242 (76.8)

73 (23.2)

Instrumental support

Not practised

Practised

149 (60.8)

96 (39.2)

182 (57.8)

133 (42.2)

Positive reframing

Not practised

Practised

99 (40.4)

146 (59.6)

147 (46.7)

168 (53.3)

Selfblame

Not practised

Practised

210 (85.7)

35 (14.3)

229 (72.7)

86 (27.3)

Planning

Not practised

Practised

106 (43.3)

139 (56.7)

146 (46.3)

169 (53.7)

Humor

Not practised

Practised

203 (82.9)

42 (17.1)

261 (82.9)

54 (17.1)

Acceptance

Not practised

Practised

84 (34.3)

161 (65.7)

136 (43.2)

179 (56.8)

Religion

Not practised

Practised

73 (29.8)

172 (70.2)

141 (44.8)

174 (55.2)

Table 3: Comparison of stress and associated coping strategies practiced by medical students between private and public university

	UniZSA			UCSI University
Variable	Having stress		X² (df)	P value	Having stress		X² (df)	P -value
	Yes	No			Yes	No
Self-distraction
Not practised	43 (32.8)	88 (67.2)	0.007 (1)	0.933	95 (57.9)	69 (42.1)	0.00 (1)	0.955
Practised	38( 33.3)	76 66.7)			87 (57.6)	64 (42.4)
Active coping
Not practised	35 (30.2)	81 (69.8)	0.831 (1)	0.362	75 (59.5)	51 (40.5)	0.26 (1)	0.608
Practised	46 (35.7)	83 (64.3)			107 (56.6)	82 (43.4)
Denial
Not practised	70 (31.0)	156 (69.0)	5.740 (1)	0.017*	156 (54.5)	130 (45.5)	13.31 (1)	<0.001**
Practised	11 (57.9)	8 (42.1)			26 (89.7)	3 (10.3)
Substance abuse
Not practised	78 32.8)	160 (67.2)	0.312 (1)	0.576	173 (57.7)	127 (42.3)	0.03 (1)	0.858
Practised	3 (42.9)	4 (57.1)			9 (60.0)	6 (40.0)
Emotional support
Not practised	56 (32.7)	115(67.3)	0.025 (1)	0.874	101 (54.6)	84 (45.4)	1.86 (1)	0.172
Practised	25 (33.8)	49 (66.2)			81 (62.3)	49 (37.7)
Behaviour disengagement
Not practised	65 (29.0)	159(71.0)	19.306(1)	< 0.001*	161 (55.5)	129 (44.5)	7.65 (1)	0.006*
Practised	16 (76.2)	5 (23.8)			21 (84)	4 (16)
Venting
Not practised	49 (25.0)	147(75.0)	28.776(1)	< 0.001*	129 (53.3)	113 (46.7)	8.56 (1)	0.003*
Practised	32 (65.3)	17 (34.7)			53 (72.6)	20 (27.4)
Instrumental support
Not practised	46 (30.9)	103(69.1)	0.823 (1)	0.364	97 (53.3)	85 (46.7)	3.55 (1)	0.060
Practised	35 (36.5)	61 (63.5)			85 (63.9)	48 (36.1)
Positive reframing
Not practised	35 (35.4)	64 (64.6)	0.394 (1)	0.530	91 (61.9)	56 (38.1)	1.92 (1)	0.165
Practised	46 (31.5)	100(68.5)			91 (54.2)	77 (45.8)
Self blame
Not practised	61 (29.0)	149(71.0)	10.700(1)	<0.001*	120 (52.4)	109 (47.6)	9.94 (1)	0.002*
Practised	20 (57.1)	15 (42.9)			62 (72.1)	24 (27.9)
Planning
Not practised	30 (28.3)	76 (71.7)	1.912 (1)	0.167	90 (61.6)	56 (38.4)	1.67 (1)	0.197
Practised	51 (36.7)	88 (63.3)			92 (54.4)	77 (45.6)
Humour
Not practised	69 (34.0)	134(66.0)	0.462(1)	0.497	145 (55.6)	116 (44.4)	3.08 (1)	0.079
Practised	12 (28.6)	30 (71.4)			37 (68.5)	17 (31.5)
Acceptance
Not practised	35 (41.7)	49 (58.3)	4.277(1)	0.039*	76 (55.9)	60 (44.1)	0.35 (1)	0.553
Practised	46 (28.6)	115 (71.4)			106 (59.2)	73 (40.8)
Religion
Not practised	24 (32.9)	49 (67.1)	0.002(1)	0.968	83 (58.9)	58 (41.1)	0.12 (1)	0.725
Practised	57 (33.1)	115 (66.9)			99 (56.9)	75 (43.1)

Chi-square test was used to test association between stress and coping strategies. *P<0.05: significant **p<0.001

Similar avoidant coping strategies namely; denial, behavioural disengagement, self-blame and venting were practiced by both university students as shown in Table 3.

DISCUSSION:

Though the response rate for this study was 90% from UniZSA medical students and 100% from UCSI medical students, the response rates were still very good. UCSI University students (private) reported a higher prevalence of stress compared to UniZSA (public university) medical students which could be explained by the fact that public university medical students had an added advantage of being fully (100) % sponsored by government unlike private university students, the public university students have the university and teaching hospital just across the road unlike UCSI medical students who have to travel between campus and hospital which is approximately 40 kilometres. The same teaching hospital is being used for teaching by both universities but UniZSA medical students may find it more conducive and comfortable being in public university unlike the UCSI private students. Another reason for the discrepancy in stress levels could be due to majority of UniZSA students being Malay adapt well in the state where the university is, which is more than 90% Malay majority population compared to UCSI which has more than half of the students being Chinese who may find it less conducive. Furthermore, the first 2 years of UCSI medical students’ preclinical education was in a mixed metropolitan city before they come to the east coast state for their clinical education. There have been no similar articles published comparing private and public university medical student stress within the same state with similar instruments, though a study done in another private university stationed in the west coast city of Malaysia reported 46% stress, while another public university in the same city reported 42% stress^4,
24. Contrary to findings in this study of UniZSA with a prevalence of 33% stress, a study done earlier in UniZSA reported 78.3% stress among year1 and year 2 preclinical medical student²⁵. However, the difference in stress prevalence could be due to only studying preclinical students in the previous study and using a different stress assessing instrument.

The first 5 coping strategies practised by both universities were the same: UnizSA medical students reported choosing religion as their first coping strategy while UCSI University students reported using active coping as their first choice. This could be explained by the fact that UniZSA has majority Malay students whose religious faith runs deeply as a Muslim, prayer a daily obligation; refuge in religion is frequently sought²⁶. Amongst students, religious beliefs, and spiritual orientation are linked to academic motivation and good academic performance. Students participating in spiritual activities claim to attain emotional well-being. The holy book, Quran also describes the concept of peace being a positive state of safety and security with oneself and religion being a complete way of life which teaches spiritual advancement and material progress which are extensively used by Muslims^27,28. The positive coping strategies planning and acceptance (fourth and second respectively) were similarly ranked in both universities. The 2 negative coping strategies, behavioural disengagement and substance abuse, were also ranked similarly as the last 2 coping strategies used in both these universities. Unlike the findings from a United Kingdom study that reported the use of alcohol, drugs and tobacco as common coping strategies among medical students, this was an encouraging finding in this study²⁹. This could be related to students’ religious beliefs, although under-reporting cannot be ruled out, as students could have hesitated to report unacceptable behaviours in the Malaysian context. The coping strategies significantly associated with stress reported in this study were also similar in both universities; behavioural disengagement, denial, venting, and self-blame as reported in other universities^24,
30-32. Avoidant coping strategies as reported namely; self blame, denial, behavioural disengagement can create stress and anxiety in the long run. These maladaptive coping strategies may not be helpful and may even enhance stressful situational³². An additional coping strategy ‘acceptance’ was a significantly associated coping strategy with stress among UniZSA medical students.

RECOMMENDATIONS:

Several studies have recommended counselling sessions but there is no evidence on the usefulness or take up rate of these sessions by medical students^3,30. Both universities should share their experiences and network to explore more promising stress management programme specific to medical students. A study was conducted in 2010 on medical students through a stress management program named “Medical Student Well-Being Workshop” to assess the impact of the workshop and acceptance of the medical students to this workshop. This was an intervention programme and workshop which dwelled with stress and coping strategies and reported evidence of positive impact in improving and reducing medical students’ stress level³³. Such workshops should be further explored and studied to add evidence to its usefulness. This study reported significant association between stress and avoidant coping strategies like denial, venting and behavioural disengagement where the stress management programme recommended above may be a venue for students to become aware of the avoidant strategies used and to inculcate positive coping strategies from the workshop.

LIMITATIONS:

The cross-sectional study design does not allow a study of the cause effect relationship of stress and coping strategies. The study was conducted only in one state in Malaysia, thus limiting the generalisation of the findings to medical students in other states and overall Malaysia. The medical students could have underscored the stress scales or provided socially desirable answers leading to response bias.

The strength of this study is the comparative nature of studying stress and coping strategies between private and public universities, including medical students from all years of study; year 1-5 with good response rate.

CONCLUSIONS:

Prevalence of stress was higher among UCSI University medical students compared to UniZSA medical students. UniZSA medical students practised religion as their highest ranked coping strategy compared to UCSI students who practised active coping. The last 2 ranked coping strategies practised; behavioural disengagement and substance abuse (negative strategies) were similar too. The coping strategies significantly associated with stress were also similar for both universities. Stress management programmes like “Medical Student Well-Being Workshops” should be conducted to further add evidence for the implementation of such interventions for reducing medical student stress.

ACKNOWLEDGMENTS:

We wish to thank the Dean of the Faculty of Medicine and Health Sciences, University of Sultan Zainal Abidin (UniZSA), Terengganu, for allowing us to conduct the study at the university.

This study was made possible with the University Research Grant from UCSI University–Proj-In-FMS-025.

CONFLICT OF INTEREST:

The Authors declare that there is no conflict of interest.

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4 Sherina M, Rampal L et al. Psychological stress among undergraduate medical students. Medical Journal of Malaysia. 2004;59(2):207-211.

5 Lazarus RS. Coping theory and research: Past, present, and future. Psychosomatic Medicine. 1993;55(3):234-247.

6 Krohne HW. Stress and coping theories. International Encyclopedia of the Social Behavioral Sciences. 2002;22:15163-15170.

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8 Abdulghani HM. Stress and depression among medical students: A cross sectional study at a medical college in Saudi Arabia. Pakistan Journal of Medical Sciences. 2008; 24(1):12-17.