Prevalence of Stress and Coping Strategies among Undergraduate Medical Students at Ridgeway Campus of The University of Zambia

Background: Stress is the way in which the body reacts to uncomfortable situations. The University Of Zambia School of Medicine (UNZASoM) is the first medical school in Zambia established in 1965 and is located at the Ridgeway Campus. Students at the campus face a number of challenges, including inadequate accommodation, struggling to pay university fees, demanding learning load and alcohol and substance abuse. Methods: The study was a quantitative cross-sectional design. Third to seventh year medical students were recruited using simple random sampling. The data collection instrument was a self-administered questionnaire. Results: The overall findings showed that 71.2% of all the respondents experienced some levels of stress, and the highest prevalence was among the third year students. Prevalence of stress among students who took alcohol was lower (43.3%) than among those who did not (61.1%). Academic pressure (93.94%), financial problems (68.94%) and lecturers' attitudes (72.72%) were the three most important sources of stress while attending church services (61.36%), watching movies (77.27%) and taking a walk (58.33%) were the three most common coping strategies. Conclusion: The prevalence of moderate to severe stress was 53.03% which was very high. Students in this category qualify for further clinical assessment and appropriate treatment. However, most of these students were not offered help in form of therapy. Students should be encouraged to employ more of the physically active coping mechanisms and encouraged to seek help from the university counseling services. The government should endeavor to include more students on government sponsorship programs and build more accommodation facilities on campus.


INTRODUCTION
Stress results when an individual is unable to cope 1 with perceived past, present or future situations. The University of Zambia School Of Medicine is the first medical school in Zambia established in 1965, located at the University Teaching Hospital (UTH) and the Ridgeway Campus within the greater city of Lusaka. The Campus accommodates three more schools under UNZA. Despite increase in the number of students, infrastructural development has not kept pace. Hence, one of the biggest challenges a m o n g m e d i c a l s t u d e n t s i s i n a d e q u a t e accommodation. The impact is worse on clinical students who are required to be in the UTH at awkward hours, even at night. Most students come from low income families and so are unable to afford alternative accommodation outside Ridgeway campus.
The Bachelor of Medicine and Bachelor of Surgery (MB ChB) curriculum at UNZASoM is designed to produce competent graduate doctors who value lifelong learning, ready to undertake specialist training programmes, and provide quality patient care and 2 leadership in medical research. However, this is bombarded with facts. Hence, there may be unintended negative consequences with respect to the students' health.
It is a well-recognized phenomenon that medical school is stressful because of many psychological 3 changes in students. Students face social, 4 emotional, physical and family problems. Studies have classified the sources of stress into three main 5 areas: academic, social and financial problems. It has also been postulated that burnout in newly graduated doctors and older physicians has its 6 origins in medical school. Frequent exposure to environmental stress may result into stress-like symptoms which can affect the well-being of health 7 professionals and health care provided.
Coping strategies are behavioral and psychological efforts that are used to tolerate stressful events. They 8 are classified into avoidant and active. Active coping' means exerting efforts to remove the stressor; 'acceptance' means accepting the occurrence of a stressful event while 'planning' consists of thinking about how to confront the stressor and planning one's coping efforts. 'Positive reframing' means making the best of the situation by seeing it in a more positive way; 'denial' is rejecting the reality of the stressful event while 'behavioral disengagement' means withdrawing efforts from the attempt to attain the goal with which the stressor is 9 interfering. Students in a study adopted active coping strategies (positive reframing, planning, acceptance, and active coping) rather than avoidant strategies (denial, alcohol/drug use and behavioral disengagement).In three British medical universities the prevalence was 31.2%, and it was 41.9% in a Malaysian school and 61.4% in a Thai 3 medical school.
High levels of stress impair students' general wellbeing and ability to learn. This ultimately affects health care provision in Zambia in future. At the time of the study the authors did not find any published work on prevalence of stress among medical students at UNZA-SoM. Hence, it was necessary to carry out such a study and to observe any possible correlations between stress and the following variables: age, gender, academic year, presence of physical problems, government or self-sponsorship, and substance use.
The objective of this study was to determine the prevalence of stress, associated factors and coping mechanisms among medical students at UNZA-SoM, Ridgeway campus.

METHODS
The study site was UNZA-SoM, Ridgeway Campus in Lusaka, Zambia. The study was a quantitative cross-sectional study design and the target population was all medical students at the named rd th institution from third (3 ) to seventh (7 ) years of study. All nonmedical students at the institution were excluded.
The sample size was calculated as 132 students and this was proportionately distributed according to the class size in every year, which gave 33 students from third year class, 28 students from the fourth year, 27 from the fifth year, 23 from the sixth year, and 21 from the seventh year class. A self-administered questionnaire was given to each of the picked students. Kessler 10 stress assessment system designed to measure anxiety and depression experienced in the most recent 4 week period through a 10-item questionnaire was the main part of the questionnaire (www.hcp.med.harvard. edu/ncs/K6-K10/index.html).
Ethics approval was obtained from the Ethics Committee School of Medicine, University of Zambia. Approval also obtained from the University of Zambia, Dean of students, Ridgeway Campus.
Consent was obtained from participants. A pre-test was carried out at UNZA-SoM among nonmedical students to test the data collection tool.
Data entry and analysis was done using STATA14 and Microsoft Excel. Kessler 10 was used. Numbers attached to the students 10 responses were added up and the total score was scored on the Kessler Psychological Distress Scale (K10). Scores ranged from 10 to 50 categorised as follows; 20 or belowlow level of stress; 20-24 -mild level of stress; 25-29 -moderate level of stress; and 30 and abovesevere level of stress. From this initial analysis, proportions were determined that were then used to study the relationships and/or influences of the individual variables on the levels of stress exhibited and then tabulated. Associations were analysed using Chi square test.

RESULTS
One hundred and thirty-two students from third to seventh year of study participated in this study. The prevalence of stress of all categories was 71.21% and of severe stress was 20.45%. The proportion of female students (76.09%) who were stressed was higher than male students (50.0%).The prevalence of stress (K10 score of 20 and above) was highest among the third-year students (90.6%) followed by fourth year class with 72.0%, 60.0% for fifth, 8.0% for sixth and 40.5% for seventh. This was statistically significant. The prevalence of stress was noted to be higher in those students who were not accommodated on campus (73.0%) compared to those who were (33.8%). This was also statistically significant. Among those who were GRZ-sponsored, prevalence of stress was lower (52.1%) than those who were not (55.6%). This was not statistically significant. Prevalence of stress among students who did not take alcohol was lower (43.3%) than among those who did (61.1%). There was no association between alcohol intake and stress levels.

Figure 1: Different categories of stress levels
The moderately stressed category scored the highest value (32.58%), followed by those not stressed (28.79%), then the severely stressed (20.45%).Those mildly stressed were 18.18%.

DISCUSSION
Prevalence of stress among medical students is essential because it predicts academic outcome as well as healthcare services provided. The overall prevalence of stress in the present study was 71.2%. This was lower than that obtained from a South 6 African study (78%). In another study done in Bangladesh, the overall prevalence of stress was 10 54%. This was lower .These variations might be attributed to differing academic atmosphere and stress assessment tools.
The prevalence of stress in female participants was higher (76.1%) in the present study than that obtained from among the male participants (50.0%).
A similar finding was obtained in a South African 6 study. However, a study conducted in Egypt 11 reported no gender differences for stress. The finding that the prevalence of stress is highest among the third year students (90.6 %) was, perhaps, the most predictable discovery of the present study ( p value-0.001,and was significant to conclude the finding). Third year is quite bulky and records a high number of repeating students. The prevalence of stress was lowest among the sixth year students. However, final year medical students were significantly stressed than other years in a certain 12 study. High values were recorded in the younger and older groups while the intermediate group recorded low values, due to the fact that the younger group has a large number of third and fourth who have a higher prevalence of stress.68.9% of respondents ticked financial problems as a source of stress. A study done in Scotland showed that students with financial burdens and accumulated debt during their studies performed less well in their 13 examinations than other students. Accommodation challenges also contributed significantly to the overall burden of stress as evidenced by the higher prevalence (73.4%) in those who are not accommodated compared to those who were (33.8%).The p value was 0.001 and was significant. Accommodation away from home was found to be an important determinant of stress in a study done in 14 India. Students who took alcohol were more likely to be stressed (43.3%) than those who did not (61.1%). A study from East Africa indicated that alcohol drinkers were 1.93 times more likely to have 15 stress than nondrinkers.
In this study, attending church services, watching movies and taking a walk were identified as being the top three coping mechanisms. Malaysian students adopted regular exercise, praying, counselling, watching movies, practising meditation, and soft music as common coping 16 strategies. Previous studies recommended student support systems, wellness, counseling and preventive mental health services, stress 17 management programmes and training workshops. In one university in the USA, a stress reduction course was offered to second year medical 18 students. An important premise on which the value of the current study partly stood was that high levels of stress (Kessler 10 score >20) have negative effects on academic performance. In future, it would be interesting to conduct a study designed to determine the effect of stress on academic performance.
Students should be encouraged to employ more of the physically active coping mechanisms and seek help from the University Counseling services. The government should endeavor to include more students on government sponsorship program, and to build more accommodation facilities on campus. The faculty should consider reviewing teaching styles in order to try and make them more comprehensive.

CONCLUSION
The prevalence of stress of all categories was determined by the present study to be at 71.2% while that of severe stress was 20.5%. The top three most important stressors identified were, in order of magnitude, academic pressure, lecturers' attitudes and financial problems. As coping mechanisms, attending church services, watching movies and taking a walk were identified as being the top three.
Prevalence of moderate to severe stress was 53.0%, which is very high. Students in this category qualify for further clinical assessment and appropriate treatment.