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Stress refers to the “sum of physical, mental and emotional strains or tensions on a person” [1]. It is defined as a condition typically characterized by symptoms of mental and physical tension or strain, as depression or hypertension, which can result from a reaction to a situation in which a person feels threatened or pressured or both [2]. The term stress was first employed, in the 1930’s, by the Endocrinologist Hans Selye [3] who published a model of stress. In this model stress is divided into eustress and distress. The stress which enhances function (physical or mental, such as through strength training or challenging work), is called eustress, while persistent stress that is not resolved through coping or adaptation and, may lead to anxiety or withdrawal (depression) behavior is known as distress [3].

Past research indicates that undergraduate medical students experience stress during their academic years [4,5]. This stress can be related to issues including, financial problems, health problems, social issues or academic difficulties [6]. Evidence indicates that first year medical student’s stress is related to more to academic factors rather than social factors [7]. Students who begin with relatively low academic grades are more likely to experience greater stress [8].

Compared to first year, stress increases in third year [9]. Among the sources reported as stressful for students include tests and examinations, wide range of content to be learnt, lack of time to do revision, poor marks, insufficient skill in medical practice, fail to follow the reading schedule, heavy workload and having difficulty in understanding the content [10].

Studies established that chronic and continued exposure to stressful condition leads to emotional, physical and mental disturbance of the students [11,12]. Persistent stress leads to low self-esteem of students, difficulty in handling different situation, sleep disorder, decreased attention and abnormal appetite which eventually effects the academic achievement and personal growth of students [13]. Stress can also lead to improved performance and one of the reasons for this could be students approach to coping with stress [14] and the other could be the environmental context [15].

There are multiple factors which influence stress among medical students [16] However, the causes and effect of stress on the performance of students has remained relatively unexplored. Considering that stress can either negatively or positively influence academic achievement, the aim of this study is to explore the relationship between stress and academic performance among medical students and identify sources of stress effecting academic performance. The objectives of the study are:

• To determine the sources of stress among undergraduate medical students.

• To determine the effect of stress on the academic performance of medical students.

• To determine the level of stress experienced by medical students

The study was conducted at Sheikh Zayed Medical College, Rahim Yar Khan, Pakistan. The Institutional Ethics Committee of Sheikh Zayed Medical College, Rahim Yar Khan approved the study. All the undergraduate third year medical students were invited to participate in the study. Informed consent was obtained from all participants. Participation in the study was voluntary.

For the present study Medical Student Stressor Questionnaire (MSSQ) was used to determine the effect of stress on the academics performance of the students [17]. It is a valid and reliable instrument which consists of 40 items representing the six stressor domains: Academic-related stressors (ARS); Intrapersonal and interpersonalrelated stressors (IRS); Teaching and learning-related stressors (TLRS); Social-related stressors (SRS); Drive and desire related stressors (DRS); Group activities related stressors (GARS). Respondents were asked to rate each source by choosing from five responses, “causing no stress at all’’, “causing mild stress’’, “causing moderate stress’’, “causing high stress’’ and “causing severe stress’’. The scoring method assigns marks from 0 (i.e. causing no stress) to 4 (i.e. causing severe stress) to each of the responses respectively [18].

Data was analyzed using descriptive statistics. Mean was calculated for each item. Cronbach coefficient alpha was calculated to assess the internal consistency of the instrument and for each of the six stressor domains.

A total of 200 undergraduate medical students participated in the study. Among them 90(45%) were male and 110(55%) were female. All the students responded to all the items in the scale (item response rate=100%). Table 1 shows Cronbach Alpha value for each stressor domain. Table 2 shows stress level before and after exams in students. Table 3 shows stressor domain distribution of high, moderate and mild stress. Table 4 shows item means causing high, moderate and mild stress

Table 1: Cronbach Alpha value for each stressor domain.

Table 2: Stress level before and after exams in students.

Table 3: Stressor domain distribution of high, moderate and mild stress.

Table 4: Domain items causing high, moderate and mild stress.

The study was conducted to determine the prevalence of stress among medical students and to observe an association between the levels of stress and academic performance. Findings from the study indicate that there is a relationship between stress and academics; they are inversely proportional to each other. Medical education is perceived as being stressful, and a high level of stress may have a negative effect on cognitive functioning and learning of medical students [19]. In the present study before exams, medical students showed higher level of stress than after exams. This finding is consistent with existing evidence in which level of stress is high before examination [20].

Females in our study demonstrated more stress as compared to male students. Misra and Castillo (2004) conducted a study, in which they concluded that perception and reaction to stress is different in both genders [21]. Female students show greater anxiety, changes in physiological states and increased emotional response to stress as compared to male students [22].

In the present study Medical Student Stress Questionnaire (MSSQ) was used to determine stress among medical students. In MSSQ six domains are used for the identification of sources of stress among students. In the present study academics (ARS) are the major source of stress, and the highest three sources are “getting poor marks”, “large amount of content to be learnt,” and “going through tests and examinations”. These findings are consistent with existing evidence that academic requirements substantially contribute to students stress levels [23-25].

In terms of teaching learning related stressors (TLRS) ‘inappropriate assignments,’ contributed significantly to students stress. This is consistent with existing literature that medical students are loaded with many assignments which lead to increased stress [26]. However, it would be assumed that these assignments would somehow contribute to their learning while in our study inappropriate assignments indicates that students’ learning is hindered by these assignments. This may imply that teachers need to be more thoughtful when giving assignments to students to ensure learning is take place.

Social related stressor (SRS) refers to any form of community and societal relationships that cause stress. In our study, ‘facing illness or death of the patients,’ contributed significantly to students stress. This finding is also consistent with existing evidence that students feel helpless in coping with illness and death [27]. This may imply that students need counseling and trained in managing such situations.

In the present study moderate stress was found in the domains of interpersonal and intrapersonal related stressor (IRS) and group activities related stressor (GRS). In these domains majority of the items are related to conflicts and group work which according to our study findings contribute less to students’ stress. Derive and desire related stressor (DRS) had the lowest prevalence, and less effect on the academic performance. It generally relates to unwillingness to study medicine due to various reasons including wrong choice by the student or parental wish to study medicine.

Overall findings of the present study indicate that students undergo considerable stress before examinations and females students more so. Our study found that ARS is the only stressor domain that scored more than 2.00 and this indicates that, it caused high stress to the students. Whereas, the other five domains; IRS (1.79), GARS (1.58), TLRS (1.87), SRS (1.66) and DRS (1.50) were causing moderate stress to the students. To solve problem of poor academic performance, the students may need to identify sources, levels of stress and a coping strategy to improve the poor performance.

The findings of the present study are from a single medical institution but factors inducing stress among medical students are consistent with existing evidence from other cultures. The effect of stress could have been further explored, but this can be a future longitudinal study in which students trained in managing stress effectively and its prolonged exposure could be studied.

Undergraduate medical students experience considerable stress in their third year. Academic related factors are the major cause of stress in students. It is important that students should be counseling and trained to manage stress effectively otherwise it can adversely influence their health and academic performance.